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Wang EY, Girotto JE. Approaches to Reduce Use and Duration of Anti-MRSA Agents for Antimicrobial Stewardship Programs: A Review of Recent Literature. J Pharm Pract 2024; 37:448-466. [PMID: 36194825 DOI: 10.1177/08971900221130893] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Antimicrobial stewardship programs (ASPs) have the potential to effectively deescalate unnecessary methicillin-resistant Staphylococcus aureus (MRSA) coverage. This review summarizes literature published from 2014 through 2021 describing contemporary ASP methods and their resulting effectiveness at reducing anti-MRSA agent use (ie vancomycin, linezolid, daptomycin, ceftaroline, and clindamycin). This review of the literature examined the following strategies, which had reports of success in either decreasing the use or duration of anti-MRSA agents: prospective review and feedback, antibiotic timeouts, health system or department protocol changes, polymerase chain reaction (PCR) and rapid testing of patient samples. Most of the current literature continue to support most ASP interventions including antibiotic timeouts, pathways, and molecular testing including MRSA nasal PCRs and rapid diagnostic testing can be successful at reducing unnecessary anti-MRSA use.
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Affiliation(s)
- Ethan Y Wang
- Department of Pharmacy Practice, University of Connecticut, School of Pharmacy, Storrs, CT, USA
| | - Jennifer E Girotto
- Department of Pharmacy Practice, University of Connecticut, School of Pharmacy, Storrs, CT, USA
- Department of Pediatrics, Antimicrobial Stewardship Program Connecticut Children's, Hartford, CT, USA
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Lewis AD, Bridwell MR, Hambuchen MD, Clay TB, Orwig KW. Correlation of MRSA Polymerase Chain Reaction (PCR) Nasal Swab in Ventilator-Associated Pneumonia, Lung Abscess, and Empyema. Diagn Microbiol Infect Dis 2022; 105:115836. [DOI: 10.1016/j.diagmicrobio.2022.115836] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2022] [Revised: 09/26/2022] [Accepted: 10/12/2022] [Indexed: 11/03/2022]
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Marinucci V, Louzon PR, Carr AL, Hayes J, Lopez-Ruiz A, Sniffen J. Pharmacist-Driven Methicillin-Resistant S. aureus Polymerase Chain Reaction Testing for Pneumonia. Ann Pharmacother 2022; 57:560-569. [PMID: 36039495 DOI: 10.1177/10600280221121144] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Nasal colonization with methicillin-resistant Staphylococcus aureus (MRSA) can be detected using nasal swab polymerase chain reaction (PCR) assay and is associated with clinical MRSA infection. The MRSA nasal PCR has a rapid turnaround time and a negative predictive value for MRSA pneumonia of >98%; however, data are limited in critically ill patients. OBJECTIVE The purpose of this study is to determine the impact of a pharmacist-driven algorithm, utilizing MRSA PCR nasal screening on duration of anti-MRSA therapy in patients admitted to the intensive care unit (ICU) with suspected pneumonia. METHODS A single-center pre/post study was conducted in 4 ICUs at a large tertiary care community hospital. Adult patients admitted to the ICU initiated on vancomycin or linezolid for pneumonia managed using a pharmacist-driven MRSA PCR algorithm were included in the algorithm cohort. A historical cohort with standard management was matched 1:1 by age, type of pneumonia, and Acute Physiology and Chronic Health Evaluation II (APACHE II) score. The primary outcome was duration of anti-MRSA therapy. Secondary outcomes included MRSA rates, number of vancomycin levels, new onset of acute kidney injury (AKI), ICU length of stay (LOS), hospital LOS, and mortality. RESULTS Of the 245 patients screened, 50 patients met inclusion criteria for the algorithm cohort and were matched to 50 patients in the historical cohort. The duration of anti-MRSA therapy was significantly lower compared with the historical cohort (47 vs 95 hours; P < 0.001). Secondary outcomes were similar between groups for MRSA rates, new onset of AKI, LOS, and mortality. There were less vancomycin levels ordered in the algorithm cohort (2 vs 3, P = 0.026). CONCLUSIONS A pharmacist-driven MRSA PCR algorithm significantly reduced anti-MRSA duration of therapy in critically ill patients with pneumonia. Future studies should validate these results in critically ill populations and in settings where MRSA pneumonia is more prevalent.
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Tai CH, Liu WL, Pan SC, Ku SC, Lin FJ, Wu CC. Evaluation of the Negative Predictive Value of Methicillin-Resistant Staphylococcus aureus Nasal Swab Screening in the Medical Intensive Care Units and Its Effect on Antibiotic Duration. Infect Drug Resist 2022; 15:1259-1266. [PMID: 35355623 PMCID: PMC8959872 DOI: 10.2147/idr.s351832] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Accepted: 03/11/2022] [Indexed: 11/23/2022] Open
Abstract
Background In addition to active surveillance of methicillin-resistant Staphylococcus aureus (MRSA) carrier, MRSA nasal screening can be valuable for antibiotic de-escalation. This study aimed to assess the correlations between the MRSA nasal swab and subsequent culture results in patients admitted to medical intensive care units (MICU). The impact of MRSA nasal swab on the antibiotic duration was also evaluated. Materials and Methods This retrospective study enrolled patients who received glycopeptides in the MICU of a medical center in 2019. Patients treated with glycopeptides for over 2 days before MICU admission were excluded. The associated data were collected through the electronic medical record system. The negative predictive value (NPV) of MRSA nasal swabs for MRSA infection was calculated, and their influence on empirical glycopeptide treatment duration was analyzed. Results Of the 338 patients who met the inclusion criteria, 277 underwent MRSA nasal screening. The NPV of MRSA-negative nasal swab for subsequent MRSA infection was 98.4%. The glycopeptide treatment duration of the patients with and without nasal screening was not significantly different (4.2 ± 2.8 vs 4.4 ± 3.0 days, p = 0.577). Of the 120 patients with MRSA-negative nasal swab and no subsequent MRSA infection, 75 continued empirical glycopeptides therapy. The additional treatment time was 3 days (interquartile range: 2–6 days). Conclusion The MRSA nasal swabs have high NPV for MRSA infection in critically ill patients. However, it has no impact on the empirical glycopeptide treatment duration. The value of MRSA nasal swabs should be advocated to optimize antibiotic therapy.
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Affiliation(s)
- Chih-Hsun Tai
- Department of Pharmacy, National Taiwan University Hospital, College of Medicine, National Taiwan University, Taipei, Taiwan.,School of Pharmacy, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Wei-Ling Liu
- School of Pharmacy, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Sung-Ching Pan
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Shih-Chi Ku
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Fang-Ju Lin
- Department of Pharmacy, National Taiwan University Hospital, College of Medicine, National Taiwan University, Taipei, Taiwan.,School of Pharmacy, College of Medicine, National Taiwan University, Taipei, Taiwan.,Graduate Institute of Clinical Pharmacy, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Chien-Chih Wu
- Department of Pharmacy, National Taiwan University Hospital, College of Medicine, National Taiwan University, Taipei, Taiwan.,School of Pharmacy, College of Medicine, National Taiwan University, Taipei, Taiwan
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Elliott BP, Tang MM, Madden JA, Markert RJ, Burdette SD, Pleiman CM, Speelmon EC. A retrospective cohort study assessing acute kidney injury and renal recovery among septic patients empirically treated with vancomycin piperacillin-tazobactam versus vancomycin cefepime. Intern Emerg Med 2022; 17:91-99. [PMID: 34089468 PMCID: PMC8178657 DOI: 10.1007/s11739-021-02772-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2021] [Accepted: 05/21/2021] [Indexed: 12/29/2022]
Abstract
Vancomycin plus piperacillin-tazobactam (VPT) is a commonly used antimicrobial regimen for septic patients. VPT is more nephrotoxic than other regimens such as vancomycin plus cefepime (VC) when given over several days. This risk of nephrotoxicity is less clear when VPT is given for initial empiric therapy in sepsis and de-escalated quickly based on evolving clinical information. The objective of this study was to assess nephrotoxicity among septic patients empirically treated with either VPT or VC at initial clinical presentation. We conducted a retrospective study of septic patients who received VPT or VC within 12 h of presentation to the emergency department. The primary outcomes were acute kidney injury (AKI) and renal recovery 72 h after presentation. For the total of 418 patients, 306 received VPT and 112 received VC. Rates of AKI at 72 h were 15.2% for VPT patients and 11.0% for VC patients [p = 0.44]. Among patients with AKI at presentation, 16.3% of VPT patients had AKI at 72 h compared to 8.9% of VC patients [p = 0.19]. Among those without AKI at presentation, 14.2% VPT patients and 16.7% VC patients had AKI at 72 h [p = 0.71]. Renal recovery rates for patients with AKI at presentation were 42.3% for VPT patients versus 40.3% for VC patients [p = 0.78]. In-hospital renal replacement therapy occurred in 6.2% VPT patients and 0.9% VC patients [p = 0.024]. Therefore, initial empiric therapy with VPT in sepsis may not confer increased risk of AKI when de-escalated appropriately.
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Affiliation(s)
- Brian Pacca Elliott
- Department of Critical Care Medicine, Miami Valley Hospital, Dayton, OH, USA.
- Department of Internal Medicine, Wright Patterson Air Force Base, Dayton, OH, USA.
- Department of Internal Medicine and Neurology, Boonshoft School of Medicine, Wright State University, 128 E Apple St, Weber CHE Building, Dayton, OH, 45409, USA.
| | - Michael M Tang
- Department of Critical Care Medicine, Miami Valley Hospital, Dayton, OH, USA
- Department of Internal Medicine, Wright Patterson Air Force Base, Dayton, OH, USA
- Department of Internal Medicine and Neurology, Boonshoft School of Medicine, Wright State University, 128 E Apple St, Weber CHE Building, Dayton, OH, 45409, USA
| | - Joshua Alexander Madden
- Department of Critical Care Medicine, Miami Valley Hospital, Dayton, OH, USA
- Department of Internal Medicine and Neurology, Boonshoft School of Medicine, Wright State University, 128 E Apple St, Weber CHE Building, Dayton, OH, 45409, USA
| | - Ronald James Markert
- Department of Internal Medicine and Neurology, Boonshoft School of Medicine, Wright State University, 128 E Apple St, Weber CHE Building, Dayton, OH, 45409, USA
| | - Steven Dale Burdette
- Department of Internal Medicine and Neurology, Boonshoft School of Medicine, Wright State University, 128 E Apple St, Weber CHE Building, Dayton, OH, 45409, USA
- Department of Infectious Diseases, Miami Valley Hospital, Dayton, OH, USA
| | - Craig Matthew Pleiman
- Department of Infectious Diseases, Miami Valley Hospital, Dayton, OH, USA
- Department of Pharmacy, Miami Valley Hospital, Dayton, OH, USA
| | - Emily Claire Speelmon
- Department of Critical Care Medicine, Miami Valley Hospital, Dayton, OH, USA
- Department of Internal Medicine and Neurology, Boonshoft School of Medicine, Wright State University, 128 E Apple St, Weber CHE Building, Dayton, OH, 45409, USA
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Utility of Methicillin-Resistant Staphylococcus aureus Nares Screening in Hospitalized Children with Acute Infectious Disease Syndromes. Antibiotics (Basel) 2021; 10:antibiotics10121434. [PMID: 34943646 PMCID: PMC8697957 DOI: 10.3390/antibiotics10121434] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2021] [Revised: 11/02/2021] [Accepted: 11/20/2021] [Indexed: 11/17/2022] Open
Abstract
Studies in adults support the use of a negative methicillin-resistant Staphylococcus aureus (MRSA) nares screening (MNS) to help limit empiric anti-MRSA antibiotic therapy. We aimed to evaluate the use of MNS for anti-MRSA antibiotic de-escalation in hospitalized children (<18 years). Records of patients admitted between 1 January 2015 and 31 December 2020 with a presumed infectious diagnosis who were started on anti-MRSA antibiotics, had a PCR-based MNS, and a clinical culture performed were retrospectively reviewed. A total of 95 children were included with a median age (range) of 2 (0–17) years. The top three diagnosis groups were skin and soft tissue infections (n = 38, 40%), toxin-mediated syndromes (n = 17, 17.9%), and osteoarticular infections (n = 14, 14.7%). Nasal MRSA colonization and growth of MRSA in clinical cultures was found in seven patients (7.4%) each. The specificity and the negative predictive value (NPV) of the MNS to predict a clinical MRSA infection were both 95.5%. About half (n = 55, 57.9%) had anti-MRSA antibiotics discontinued in-house. A quarter (n = 14, 25.5%) were de-escalated based on the negative MNS test alone, and another third (n = 21, 38.2%) after negative MNS test and negative culture results became available. A high NPV suggests that MNS may be useful for limiting unnecessary anti-MRSA therapy and thereby a useful antimicrobial stewardship tool for hospitalized children. Prospective studies are needed to further characterize the utility of MNS for specific infectious diagnoses.
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Kunming P, Can C, Zhangzhang C, Wei W, Qing X, Xiaoqiang D, Xiaoyu L, Qianzhou L. Vancomycin Associated Acute Kidney Injury: A Longitudinal Study in China. Front Pharmacol 2021; 12:632107. [PMID: 33762952 PMCID: PMC7982802 DOI: 10.3389/fphar.2021.632107] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2020] [Accepted: 02/01/2021] [Indexed: 12/29/2022] Open
Abstract
Background: Vancomycin-associated acute kidney injury (VA-AKI) is a recognizable condition with known risk factors. However, the use of vancomycin in clinical practices in China is distinct from other countries. We conducted this longitudinal study to show the characteristics of VA-AKI and how to manage it in clinical practice. Patients and Methods: We included patients admitted to hospital, who received vancomycin therapy between January 1, 2016 and June 2019. VA-AKI was defined as a patient having developed AKI during vancomycin therapy or within 48 h following the withdrawal of vancomycin therapy. Results: A total of 3719 patients from 7058 possible participants were included in the study. 998 patients were excluded because of lacking of serum creatinine measurement. The incidence of VA-AKI was 14.3%. Only 32.3% (963/2990) of recommended patients performed therapeutic drug monitoring of vancomycin. Patients with VA-AKI were more likely to concomitant administration of cephalosporin (OR 1.55, 95% CI 1.08–2.21, p = 0.017), carbapenems (OR 1.46, 95% CI 1.11–1.91, p = 0.006) and piperacillin-tazobactam (OR 3.12, 95% CI 1.50–6.49, p = 0.002). Full renal recovery (OR 0.208, p = 0.005) was independent protective factors for mortality. Compared with acute kidney injury stage 1, AKI stage 2 (OR 2.174, p = 0.005) and AKI stage 3 (OR 2.210, p = 0.005) were independent risk factors for fail to full renal recovery. Conclusion: Lack of a serum creatinine measurement for the diagnosis of AKI and lack of standardization of vancomycin therapeutic drug monitoring should be improved. Patient concomitant with piperacillin-tazobactam are at higher risk. Full renal recovery was associated with a significantly reduced morality.
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Affiliation(s)
- Pan Kunming
- Department of Pharmacy, Zhongshan Hospital Fudan University, Shanghai, China
| | - Chen Can
- Department of Pharmacy, Zhongshan Hospital Fudan University, Shanghai, China
| | - Chen Zhangzhang
- Department of Pharmacy, Zhongshan Hospital Fudan University, Shanghai, China
| | - Wu Wei
- Department of Pharmacy, Zhongshan Hospital Fudan University, Shanghai, China
| | - Xu Qing
- Department of Pharmacy, Zhongshan Hospital Fudan University, Shanghai, China
| | - Ding Xiaoqiang
- Department of Nephrology, Zhongshan Hospital Fudan University, Shanghai, China
| | - Li Xiaoyu
- Department of Pharmacy, Zhongshan Hospital Fudan University, Shanghai, China
| | - Lv Qianzhou
- Department of Pharmacy, Zhongshan Hospital Fudan University, Shanghai, China
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Impact of Nasal Swabs on Empiric Treatment of Respiratory Tract Infections (INSERT-RTI). PHARMACY 2020; 8:pharmacy8020101. [PMID: 32545231 PMCID: PMC7356089 DOI: 10.3390/pharmacy8020101] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Revised: 06/01/2020] [Accepted: 06/08/2020] [Indexed: 11/17/2022] Open
Abstract
Methicillin-resistant Staphylococcusaureus (MRSA) polymerase-chain-reaction nasal swabs (PCRNS) are a rapid diagnostic tool with a high negative predictive value. A PCRNS plus education “bundle” was implemented to inform clinicians on the utility of PCRNS for anti-MRSA therapy de-escalation in respiratory tract infections (RTI). The study included patients started on vancomycin with a PCRNS order three months before and after bundle implementation. The primary objective was the difference in duration of anti-MRSA therapy (DOT) for RTI. Secondary objectives included hospital length of stay (LOS), anti-MRSA therapy reinitiation, 30-day readmission, in-hospital mortality, and cost. We analyzed 62 of 110 patients screened, 20 in the preintervention and 42 in the postintervention arms. Mean DOT decreased after bundle implementation by 30.3 h (p = 0.039); mean DOT for patients with a negative PCRNS decreased by 39.7 h (p = 0.014). Median cost was lower after intervention [USD$51.69 versus USD$75.30 (p < 0.01)]. No significant difference in LOS, mortality, or readmission existed. The bundle implementation decreased vancomycin therapy and cost without negatively impacting patient outcomes.
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