The impact of a multimodal approach to vancomycin discontinuation in hematopoietic stem cell transplant recipients (HSCT) with febrile neutropenia (FN)

Abstract

Background Current guidelines recommend adding vancomycin to empiric treatment of FN in patients who meet specific criteria. After 48 hours, the guidelines recommend discontinuing vancomycin if resistant Gram‐positive organisms are not identified. Based on these recommendations, a vancomycin stewardship team defined criteria for discontinuation of vancomycin at 48 hours and increased surveillance of vancomycin usage through a multimodal approach. The purpose of this retrospective analysis is to assess the impact of this multimodal approach on the discontinuation of empiric vancomycin at 48 hours in FN. Methods This retrospective analysis included a pre‐ and post‐intervention cohort of 200 HSCT recipients with FN from 2015 to 2018. Criteria for continued vancomycin use beyond 48 hours included culture‐documented resistant Gram‐positive infection, positive Methicillin‐Resistant S aureus (MRSA) nasal swab with evidence of pneumonia, or hemodynamic instability with concern for sepsis. The following patient characteristics were collected: previous MRSA infection, MRSA nasal swab collection and results, culture results, duration of vancomycin use, rationale for continuation of vancomycin beyond 48 hours, and re‐initiation of vancomycin. Results In the post‐intervention cohort, vancomycin discontinuation at 48 hours increased from 31% (95% CI 21.94‐40.05) to 70% (95% CI 61.02‐78.97; P < 0.0001). An additional 23% of vancomycin orders were discontinued at 72 hours. Off criteria vancomycin use decreased from 33% in pre to 1% in the post‐implementation cohort. Conclusion Establishing define criteria for vancomycin use in FN patients with a multimodal approach of physicians from hematology and infectious diseases, clinical pharmacists and the antibiotic stewardship team significantly improved vancomycin discontinuation.

Inpatient Antibiotic Stewardship Interventions in the Adult Oncology and Hematopoietic Stem Cell Transplant Population: A Review of the Literature

“…Perreault et al 16 conducted a retrospective, quasi-experimental study evaluating discontinuation of vancomycin at 48 hours in patients with febrile neutropenia (FN) meeting criteria to discontinue. A multimodal approach was utilized involving both education and PAF.…”

“…There were no differences noted in length of stay (LOS), in-hospital mortality, or Clostridioides difficile infection (CDI) rates. 15 Perreault et al 16 conducted a retrospective, quasi-experimental study evaluating discontinuation of vancomycin at 48 hours in patients with febrile neutropenia (FN) meeting criteria to discontinue. A multimodal approach was utilized involving both education and PAF.…”

“…This study did not evaluate clinical outcomes. 16 Two studies focused specifically on targeting carbapenem use. Ko et al 17 implemented an intervention in oncology patients receiving empirical cefepime for FN who remained hemodynamically unstable after 72 hours.…”

Evaluation of the negative predictive value of methicillin-resistant Staphylococcus aureus nasal swab screening in patients with acute myeloid leukemia

“…The MRSA nasal swab in conjunction with microbiologic cultures to identify both MRSA, along with other organisms like Streptococcus spp, Enterococcus spp, and CoNS that would require continuation of anti-MRSA therapy, given their performance characteristics, provide assurance to clinicians that stopping empiric anti-MRSA coverage in febrile neutropenia is safe and enhances antibiotic stewardship efforts. 3 Historically, risk factors for hospital-acquired MRSA infection have included ICU admission, mechanical ventilation, admission from an outside facility, and/or initiation of renal replacement therapy. 10,11 However, in our study, these known risk factors for hospital-acquired MRSA infections did not appear to correlate to our patient population.…”

“…Moreover, MRSA nasal swabs have proven to be useful in the de-escalation of anti-MRSA therapy. 3 The supporting data for de-escalation of therapy based on a negative MRSA nasal swab was validated in patients with pneumonia, but it has also been expanded to include nonpulmonary infections. The negative predictive value (NPV) of MRSA nasal swabs for pneumonia and nonpulmonary infections approaches 99%.…”