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Study Indicates Vancomycin Overuse: Presented at ASHP

By Maury M. Breecher, PhD, MPH

SAN DIEGO, CA -- June 11, 2003 --Although vancomycin is one of the few antibiotics that remains effective against antibiotic-resistant, gram-positive enterococci, its indiscriminate use threatens its long-term effectiveness, says one of the authors of a study presented here at the American Society of Health-System Pharmacists annual summer meeting held May 31-June 4.

"Up until 3 to 4 years ago, vancomycin was the antibiotic of last resort for gram positive infection," said Lena Kang-Birken, PharmD, an associate professor in the School of Pharmacy, University of the Pacific, in Stockton, California. "Now, there are at least two other effective antibiotic agents. But for years and years vancomycin was the one and only antibiotic for this type of gram-positive infection."

"In 1995, the U.S. Centres for Disease Control and Prevention issued guidelines describing areas that would be considered appropriate for use of vancomycin. At that time, there was heightened recognition of the importance of using it appropriately," Dr. Kang-Birken said. "However, as time passed, that heightened recognition has faded and today, the use of vancomycin is largely inconsistent with those guidelines."

Dr. Kang-Birken and her colleagues studied 100 hospitalised patients -- 18 were paediatric cases; 67 patients had positive cultures for gram positive or gram negative microorganisms.

The researchers categorised the reasons the patients were given vancomycin as follows: 12 patients received empirical treatment on suspicion of infection, 24 patients had documented infection, 64 patients had surgical prophylaxis.

"These patients didn't have any documented infections, but since they were going into surgery there were prophylactically treated to prevent infections," she explained. "However, the use of vancomycin was consistent with the CDC recommendations in less than half of the cases. Of the 100 patients, we studied, usage of vancomycin was consistent with CDC guidelines in only 39% of the cases."

Positive cultures were found in 37 cases, 8 in the empirical group, 19 in the DI group, and 10 in the surgical group. After treatment, microbiological failure – persistence of the original organism and/or superinfection, that is another infection arising in addition to the original organism – occurred in seven cases, two from the empirical group, 2 in the DI cohort, and 1 of the surgical patients. A combination of antibiotic agents was then used to successfully treat those patients.

Still, Dr. Kang-Birken says the study shows an "indiscriminate" use of vancomycin that needs to be addressed. She also believes her team's study results are generalisable to hospitals throughout the United States.

"We need to reach the pharmacists and the physicians again to remind them that there is a guideline published by the CDC that we all respect so that vancomycin is used only when indicated," she told Doctor's Guide.

[Study Title: Prospective Evaluation of Clinical Impact of Appropriate Usage of Vancomycin Based on the Centres for Disease Control and Prevention Guidelines, S. Lena Kang-Birken and Jamie Yee (University of the Pacific, Stockton, California. Abstract P-46E]

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