Vancomycin update

ECHO

Antibiotic Stewardship Program

Charles Krasner, M.D.

August 16, 2018

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Vancomycin blocks

bacterial cell wall

production

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Cell wall of gram positive

bacteria disrupted by vancomycin

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Gram positive cocci in clusters

(Staph) and in cha

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Only effective

against gram bacteria

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Active in a wide variety of infections

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Histamine release causes

transient itchy rash

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Red Man urticarial Rash

NOT a true allergy- slow

infusion down!

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Can also get a typical drug rash with vancomycin -usually not urticarial in

appearance and doesn’t resolve quickly with anti-

histamines. Do not re-challenge these patients!

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Some studies have suggested nephrotoxicity

related to Vancomycin trough levels

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“Nephrotoxicity during Vancomycin therapy in combination with Pip-Tazobactam or Cefepime” Rutter,W.C. et al. Antimicrob. Agents Chemother: Feb 2017 Univ Kentucky Healthcare

• 4,193 patients - retrospective, matched cohort study over 4 year period (2010-4). Did not include patients on dialysis, preg, CKD, cystic fibrosis.

• When patients were matched on multiple factors-age, sex, contrast exposure, severity of illness, trough concentrations and multiple other confounding factors:

• Adjusted AKI – Zosyn/vanco- 21.4 %• Adjusted AKI- Cefep/vanco – 12.6%

(P.<0001)• “reinforces the need for judicious use of

combination empirical anti-microbial therapy”

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Consequences of vancomycin toxicity

• Studies have demonstrated:• increased LOS in patients with acute

kidney injury (AKI) in patients with MRSA bacteremia compared to those without AKI (20 versus 13 days)

• longer time in ICU in those with AKI than those without(17 days versus 12 days)

• Slight increased risk of needing hemodialysis in AKI patients

• Increased hospital costs in AKI- LOS, dialysis, etc

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“Staphylococcus aureus Community-acquired Pneumonia: Prevalence, Clinical Characteristics, and Outcomes” W.E. Self et al Clinical Inf Diseases May, 2016

• Vanderbilt University study that looked at prevalence of MRSA pneumonia in CAP patients (eliminated most HCAP type patients- recent hosp, dialysis, cancer, SNF etc) in 5 hospitals over 2 ½ year period

• 2259 patients

• Approx 30%of patients received initial anti-MRSA antibiotics – (vancomycin or linezolid)

• 1.6% had Staph aureus or MRSA pna- only 0.9% had MRSA

• If admitted to ICU- 2.7% had MRSA

• If admitted to floor only 0.1% had MRSA!

• Bottom line- only 1 of 30 patients given empiric MRSA coverage for CAP actually had MRSA

• If a CAP patient is not sick enough for ICU, very unlikely to have MRSA pneumonia

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Cellulitis case

67 year old overweight ,diabetic male admitted with cellulitis and severe sepsis.

Has hx of peripheral vascular disease, neuropathy and ulcers on his feet. Seeing wound care at hospital clinic

Develops confusion , fever, rapidly progressive rash moving up leg.

Febrile to 102 F, HR112 and BP 100/68

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ER physician starts vancomycin and pip/tazobactam

(Zosyn) for severe sepsis diagnosis

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If cultures are negative for MRSA-stop the

vancomycin!

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Spell out in your sputum culture result

there is no MRSA present

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A few pointers to reduce vancomycin use

• A patient with CAP who isn’t in the ICU, isn’t spiking high feversand doesn’t have cavities on CXR, is very unlikely to have MRSApneumonia. Go with IDSA guidelines – ceftriaxone/azithromycinor doxycycline . Don’t use empiric vancomycin for thesepatients.

• If in ICU with pneumonia, and blood and sputum cultures donot show MRSA after 48 hours- stop the vancomycin. Theydon’t have MRSA pneumonia

• Don’t use vancomycin for non-purulent cellulitis- almostcertainly strep. Try cefazolin, amp-sulbactam or simplyampicillin iv

• Remember ECHO talk on pseudo-cellulitis- 40% of “cellulitis”cases are not infectious- particularly if no fever and bilateral

• Try not to use vanco/zosyn- too high risk for nephrotoxicity

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