T Kwan1, F Lin, B Ngai, M Loeb. 1. Department of Medicine, McMaster University, Hamilton, Ont.
Abstract
OBJECTIVE: Use of vancomycin is a risk factor for acquiring vancomycin-resistant enterococci (VRE). To optimize the use of vancomycin in hospitals, the Hospital Infection Control Practices Advisory Committee (HICPAC) published recommendations in 1995. The objectives of this study were to determine the frequency, indications, and risk factors for inappropriate inpatient vancomycin prescriptions before and after publication of the HICPAC recommendations. DESIGN: Cross-sectional study. SETTING: Two tertiary care hospitals in Ontario. INTERVENTIONS: Vancomycin prescriptions were randomly sampled and hospital chart view performed for two 12-month periods, one before and one after publication of the HICPAC recommendations on vancomycin use. RESULTS: Based on the review of 189 charts from hospital A and 190 from hospital B, there was no significant change in the proportion of inappropriate vancomycin prescriptions at either hospital from before publication of the HICPAC recommendations to afterward (63% v. 71% at hospital A, p = 0.21; 48% v. 37% at hospital B, p = 0.11). In 51% of all vancomycin prescriptions, the drug was prescribed instead of another antibiotic because of a recorded penicillin allergy. Surgical prophylaxis with more than 1 or 2 doses of vancomycin accounted for 66% (hospital A) and 58% (hospital B) of inappropriate prescriptions. In a multivariate analysis, surgical prophylaxis remained a significant risk factor for inappropriate use of vancomycin at both hospitals (odds ratio [OR] 5.6, 95% confidence interval [CI] 2.8 to 11.3, p = 0.01 for hospital A; OR 13.9, 95% CI 4.9 to 39.5, p = 0.01 for hospital B). Prescription by the orthopedic service also remained a significant risk factor in the final logistic regression model for hospital B (OR 3.9, 95% CI 1.1 to 13.9, p = 0.01). CONCLUSIONS: A high proportion of vancomycin prescriptions, surveyed before and after publication of the HICPAC recommendations on vancomycin use, were inappropriate. Excessive vancomycin use in surgical prophylaxis was an important factor. Our findings suggest that the use of standardized peri-operative order forms and of penicillin-allergy testing may help optimize vancomycin use in tertiary care hospitals.
OBJECTIVE: Use of vancomycin is a risk factor for acquiring vancomycin-resistant enterococci (VRE). To optimize the use of vancomycin in hospitals, the Hospital Infection Control Practices Advisory Committee (HICPAC) published recommendations in 1995. The objectives of this study were to determine the frequency, indications, and risk factors for inappropriate inpatient vancomycin prescriptions before and after publication of the HICPAC recommendations. DESIGN: Cross-sectional study. SETTING: Two tertiary care hospitals in Ontario. INTERVENTIONS:Vancomycin prescriptions were randomly sampled and hospital chart view performed for two 12-month periods, one before and one after publication of the HICPAC recommendations on vancomycin use. RESULTS: Based on the review of 189 charts from hospital A and 190 from hospital B, there was no significant change in the proportion of inappropriate vancomycin prescriptions at either hospital from before publication of the HICPAC recommendations to afterward (63% v. 71% at hospital A, p = 0.21; 48% v. 37% at hospital B, p = 0.11). In 51% of all vancomycin prescriptions, the drug was prescribed instead of another antibiotic because of a recorded penicillinallergy. Surgical prophylaxis with more than 1 or 2 doses of vancomycin accounted for 66% (hospital A) and 58% (hospital B) of inappropriate prescriptions. In a multivariate analysis, surgical prophylaxis remained a significant risk factor for inappropriate use of vancomycin at both hospitals (odds ratio [OR] 5.6, 95% confidence interval [CI] 2.8 to 11.3, p = 0.01 for hospital A; OR 13.9, 95% CI 4.9 to 39.5, p = 0.01 for hospital B). Prescription by the orthopedic service also remained a significant risk factor in the final logistic regression model for hospital B (OR 3.9, 95% CI 1.1 to 13.9, p = 0.01). CONCLUSIONS: A high proportion of vancomycin prescriptions, surveyed before and after publication of the HICPAC recommendations on vancomycin use, were inappropriate. Excessive vancomycin use in surgical prophylaxis was an important factor. Our findings suggest that the use of standardized peri-operative order forms and of penicillin-allergy testing may help optimize vancomycin use in tertiary care hospitals.