Improving clinician adherence to vancomycin-use guidelines: Results of a pharmacist-based strategy at an Academic Medical Center

Vancomycin (vanc) is the only licensed antibiotic effective against several highly resistant bacteria. Unfortunately, its use has contributed to the emergence of vancomycin-resistant enterococci (VRE). The first VRE was isolated at Duke in 1992; by 1995, 10% of our enterococcal isolates were VRE. Simultaneously, participation in the CDC ICARE program suggested that vane usage was higher at Duke than at similar institutions. In the Fall of 1995, the Duke Antibiotic Decision Support Team used 3 separate point-prevalence surveys (PPS) to characterize vane usage relative to published CDC criteria. Vane was used empirically in 33% of the cases; adult patients (pts) receiving >3 days of vane for empiric therapy met CDC guidelines only 20% of the time. Therefore, we developed a Vancomycin Intervention Project that focused on empiric vane use in adults. This Project took place in the context of other vane and VRE-focused educational efforts as well as heightened Infection Control activities. The project was pharmacist-based and began with an educational note placed in each patient's chart on the first day of empiric vane therapy. Of 428 courses of empiric vane initiated, 250 (56%) were discontinued by day 3. On day 4, pharmacists initiated a computer-based review of patient drug allergies and micro results and progressed to pt chart review, if necessary, and discussions with clinicians to determine the prescriber's rationale for continued therapy. In only 20 cases was "inappropriate" vane documented by this point, and in 14 instances (3.3% of original courses), vane was discontinued as a result of a pharmacist's intervention. A follow-up PPS one year later substantiated improvement in guideline adherence for empiric vanc therapy (100% "appropriate"). We conclude that patient-specific chart reminders, combined with institutional education, correlate with improved clinician adherence to guideline-based restrictions on therapy We are refining our efforts to find the most enduring, cost-effective way to optimize appropriate vane therapy.

Duke Scholars

Author Carol Dukes Hamilton Medicine, Infectious Diseases

Author Richard Howard Drew Medicine, Infectious Diseases