Effect of rapid methicillin-resistant Staphylococcus aureus nasal polymerase chain reaction screening on vancomycin use in the intensive care unit

Abstract

Purpose To determine the impact of a pharmacist-driven methicillin-resistant Staphylococcus aureus (MRSA) nasal polymerase chain reaction (PCR) screen on vancomycin duration in critically ill patients with suspected pneumonia. Methods This was a retrospective, quasi-experimental study at a 613-bed academic medical center with 67 intensive care beds. Adult patients admitted to the intensive care unit (ICU) between 2017 and 2019 for 24 hours or longer and empirically started on intravenous vancomycin for pneumonia were included. The primary intervention was the implementation of a MRSA nasal PCR screen protocol. The primary outcome was duration of empiric vancomycin therapy. Secondary outcomes included the rate of acute kidney injury (AKI), the number of vancomycin levels obtained, the rate of resumption of vancomycin for treatment of pneumonia, ICU length of stay, hospital length of stay, the rate of ICU readmission, and the rate of in-hospital mortality. Results A total of 418 patients were included in the final analysis. The median vancomycin duration was 2.59 days in the preprotocol group and 1.44 days in the postprotocol group, a reduction of approximately 1.00 day (P < 0.01). There were significantly fewer vancomycin levels measured in the postprotocol group than in the preprotocol group. Secondary outcomes were similar between the 2 groups, except that there was lower AKI and fewer vancomycin levels obtained in the postprotocol group (despite implementation of area under the curve–based vancomycin dosing) as compared to the preprotocol group. Conclusion The implementation of a pharmacist-driven MRSA nasal PCR screen was associated with a decrease in vancomycin duration and the number of vancomycin levels obtained in critically ill patients with suspected pneumonia.

Pharmacist-Driven Methicillin-Resistant S. aureus Polymerase Chain Reaction Testing for Pneumonia

“…19,20 Although these findings are similar to our study, the most common pneumonia classification in Raush et al 19 was CAP and most patients received linezolid or ceftaroline as anti-MRSA therapy. Our study found more patients with HAP and receiving vancomycin, which is more consistent with the findings from Diep et al 20 In addition, Diep et al 20 did not report any critical care scoring systems to grade the severity of illness. Our study only included critically ill patients, with a mean APACHE II score of approximately 17, indicating a 25% nonoperative mortality rate.…”

Utility of Methicillin-Resistant Staphylococcus aureus Nares Screening in Hospitalized Children with Acute Infectious Disease Syndromes

“…In our study of pediatric patients hospitalized for a presumed infectious diagnosis and started on empiric broad-spectrum antimicrobial treatment including anti-MRSA antibiotics, an MNS test, when correlated with clinical cultures, was found to have a high NPV for a clinical MRSA infection. Similar to previous analyses in adults that are promoting MNS as a potentially powerful stewardship tool for de-escalation and avoidance of empirical anti-MRSA therapy [3][4][5][6][7], our findings suggest that MNS could also be a useful tool in limiting anti-MRSA antimicrobials in pediatric patients.…”

“…In adult studies, the downstream effects of avoiding or stopping anti-MRSA antibiotics early because of a negative MNS have been manifold, including decreased length of anti-MRSA antibiotics, fewer drug-monitoring labs, decreased nephrotoxicity, and decreased length of stay [ 3 , 4 , 5 ]. In this context, we took great interest to see that the decision to discontinue the anti-MRSA antimicrobial treatment was supported by a negative MNS alone, or by a negative MNS in combination with a negative clinical culture in a quarter and about a third of those children in whom treatment was stopped during hospitalization.…”

“…While it has been recognized that carriage of S. aureus is an important risk factor for developing a subsequent clinical infection, the nares, in particular, were noted as the most frequent carriage site for S. aureus [2]. Consequently, multiple clinical studies in adult patients, especially with pneumonia, have demonstrated the usefulness of a negative MRSA nares screening (MNS) test in aiding the de-escalation of anti-MRSA antimicrobials [3][4][5][6].…”

“…While it has been recognized that carriage of S. aureus is an important risk factor for developing a subsequent clinical infection, the nares, in particular, were noted as the most frequent carriage site for S. aureus [ 2 ]. Consequently, multiple clinical studies in adult patients, especially with pneumonia, have demonstrated the usefulness of a negative MRSA nares screening (MNS) test in aiding the de-escalation of anti-MRSA antimicrobials [ 3 , 4 , 5 , 6 ]. Moreover, it has been demonstrated that MNS is a valuable antimicrobial stewardship tool with potential applications beyond lower respiratory tract infections, including patients with bloodstream, abdominal, and skin and soft tissue infections [ 7 ].…”