さまよう薬剤師のブログ

学位を持っても、センスのない、感染制御専門薬剤師のブログ.  I have Ph.D. but less sense ID pharmacist.

Decreased mortality in patients prescribed vancomycin after implementation of antimicrobial stewardship program

2017年にAJICに報告された、Veteran Affairs Western New York Healthcare System

におけるレトロスペなASP論文。

 

 

 

BACKGROUND:

The impact of an antimicrobial stewardship program (ASP) on 30-day mortality rates was evaluated in patients prescribed vancomycin in a Veterans Affairs hospital.

 

METHODS:

A retrospective chart review of patients receiving a minimum of 48 hours of vancomycin during October 2006-July 2014. A multivariate logistic regression analysis was used to determine predictors of mortality. Interventions of the ASP consist of appropriate antibiotic selection, dosing, microbiology, and treatment duration.

RESULTS:

Death occurred in 12.4% of 453 patients. Of the 56 deaths, 64.3% occurred during prestewardship versus 35.7% during stewardship (P = .021). Increased mortality was associated with pre-ASP (odds ratio [OR], 2.17; 95% confidence interval [CI], 1.13-4.27), age (unit OR, 1.08; 95% CI, 1.05-1.12), nephrotoxicity (OR, 3.24; 95% CI, 1.27-8.01), and hypotension (OR, 3.28; 95% CI, 1.42-7.44). Patients treated in the intensive care unit were associated with increased mortality. Patients in the stewardship group experienced lower rates of mortality, which may be caused by interventions initiated by the stewardship team, including minimizing nephrotoxicity and individualized chart review.

CONCLUSIONS:

Mortality in patients treated with vancomycin was decreased after antimicrobial stewardship was implemented. As anticipated, older age, hypotension, nephrotoxicity, and intensive care unit admission were associated with an increased incidence of mortality.

 

CQ

We aimed to evaluate the impact of an ASP on 30-day mortality rates of patient treated with intravenous (IV) vancomycin therapy at a Veterans Affairs hospital.

A secondary outcome was to determine significant risk factors for mortality associated with vancomycin.

 

 

Setting and study design

 

This was a single-center, institutional review board–approved, retrospective chart review of patients that received IV vancomycin at the Veteran Affairs Western New York Healthcare System, Buffalo, New York.

Patients were obtained via medication administration reports of IV vancomycin during the 2 designated time periods of October 1, 2006-July 31, 2008 (pre-ASP) and August 1, 2011-July 31, 2014 (ASP). The time gap between pre-ASP and ASP included a development period of the ASP program during which staffing was inconsistent.

The ASP is a patient-centered design that includes an infectious diseases pharmacist with the support of infectious diseases physicians.

The ASP does not use any automated protocols or guidelines; there is individualized chart review, microbiology review, and consultation with an infectious disease physician as needed. Interventions of the ASP consist of prospective audit and feedback, including appropriate antibiotic selection and dosing, microbiology, and duration of treatment.

The ASP provides monthly education to medical house staff to educate on antimicrobial stewardship and local antimicrobial resistance patterns.

To further limit inappropriate antimicrobial use within the facility, a restricted antibiotic policy is enforced that requires infectious diseases service approval of preselected antimicrobial agents.

The restricted antibiotic policy has been in place during the entire study period—both pre-ASP and during ASP.

 

Outcome measures

 

The primary outcome was to evaluate the 30-day mortality rate in patients that received IV vancomycin therapy. Mortality was assessed via chart review. Secondary outcomes included any significant risk factors for mortality and the impact of the ASP on vancomycin mortality rates. Baseline demographics included age, sex, race, height, weight, body mass index, serum creatinine, RIFLE (Risk, Injury, Failure, Loss of function, End-Stage Renal Disease) criteria,15 methicillin-resistant S aureus colonization nasally, and Charlson Comorbidity Index score.16 Additional data collection included service admitted to, indication for vancomycin treatment, microbiology cultures, total duration of vancomycin treatment, initial vancomycin trough, and maximum vancomycin trough. Total duration of therapy, total length of stay, and readmission to hospital within 30 days were also collected for each patient included. An initial vancomycin trough concentration was defined as a trough concentration obtained within the first 96 hours of starting vancomycin therapy. Vancomycin trough concentration is a laboratory value of serum concentration of vancomycin obtained 30 minutes prior to a dose of vancomycin. All troughs were taken within 30 minutes of the next scheduled dose of vancomycin. Nephrotoxicity was defined as an increase in serum creatinine of at least 0.5 mg/dL from baseline or a 50% increase from baseline for 2 consecutive days.

 

Pre-ASP versus ASP

  

The pre-ASP and ASP groups had similar baseline characteristics of age, height, weight, vancomycin troughs, and Charlson Comorbidity Index scores.

Patients in the ASP group had higher creatinine clearance (79.9 ± 33.1 vs 66.8 ± 29.3 mL/min; P < .0001).

There were more patients admitted to medicine service during the stewardship time frame and more patients admitted to the surgical service during the pre-ASP time frame.

There were fewer hypotensive patients in the ASP group (n = 14, 6.2%) compared with the pre-ASP group (n = 30, 13.3%; P = .01).

Patients in the ASP group had less nephrotoxicity than those in the pre-ASP group: 17 pa- tients (7.5%) in contrast with 31 patients (13.7%; P = .03).

 

Pharmacy interventions

 

Regarding vancomycin, the stewardship program made on average 4.12 ± 2.4 recommendations per patient. Patients in the stewardship program had an average of 1.93 ± 1.31 pharmacokinetic levels. Doses were adjusted 1.74 ± 1.06 per patient. Additional recommen- dations included imaging or echocardiogram; cultures; and initiation, discontinuation, or change in therapy.

 

limitations

 

The retrospective quasiexperimental study design relies on the accuracy of the electronic medical record, and selection bias must be a consideration.

General improvements in clinical practice over time and other confounders not included in the design of the study could impact mortality rates outside of ASP interventions.

Because this study was conducted at a single institution and in a veteran population with a relatively small sample size, its external validity may be limited.

The generalizability to high-risk sicker patients is limited because of the exclusion of patients on vasopressors. Additionally, it must be acknowledged that the data compared was not concurrent time periods.

 

CONCLUSIONS

 

Decreased mortality rates in patients treated with vancomycin were observed after implementation of the ASP. A bundled stewardship approach with multidisciplinary interventions has proven to be effective in the reduction of mortality. Safer use of antibiot- ics, especially a prevalently used antibiotic such as vancomycin, may be one mechanism for reduction of mortality.

 

f:id:akinohanayuki:20170813080317p:plain

f:id:akinohanayuki:20170813080336p:plain

 

感想

 

よい結果で良かったです。レトロですが。

新規性はありません。ただ、日本もアメリカも方向性が同じようだなっと思いました。

 

今日の一曲 

 

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