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February 3, 1993, Vol 269, No. 5 >
ARTICLE | February 3, 1993

The Epidemiology of Intravenous Vancomycin Usage in a University Hospital: Title and subTitle BreakA 10-Year Study FREE

Javier Ena, MD, PhD; Robert W. Dick, RPh; Ronald N. Jones, MD; Richard P. Wenzel, MD, MSc
[+] Author Affiliations

Reprint requests to Division of General Medicine, Clinical Epidemiology and Health Services Research, Department of Internal Medicine, C41 -GH, University of Iowa College of Medicine, Iowa City, IA 52242 (Dr Wenzel).


JAMA. 1993;269(5):598-602. doi:10.1001/jama.1993.03500050076029
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References

Objectives.  —To examine the trends of intravenous vancomycin usage during a 10-year period, to classify the indications for which physicians prescribed the antibiotic, and to identify the independent predictors for empirical use of vancomycin.

Design.  —A descriptive epidemiological study, a cross-sectional study, and a case-control study were performed.

Setting.  —A 900-bed university-teaching hospital.

Main Outcome Measures.  —The annual crude usage (grams) and incidence density (grams/1000 patient-days) of vancomycin were measured for 10 years (July 1981 to July 1991). In 109 randomly selected patient medical records, we evaluated the proportion of usage of vancomycin classified as prophylaxis, empirical therapy, or specifically directed therapy. Univariate and multivariate analyses were performed to identify determinants of empirical administration of vancomycin vs a penicillase-resistant penicillin to 64 case patients and 64 control patients.

Results.  —The rate of vancomycin usage increased 20-fold from 5.72 g/1000 patient-days in 1981 to 121.25 g/1000 patient-days in 1991. The use of vancomycin was significantly higher (P<.0001) in hematology-oncology areas compared with that in other hospital areas. The rates for each indication for vancomycin were 35.0% for prophylaxis, 31.8% for empirical therapy, and 33.2% for therapy specifically directed by culture results. In a multivariate analysis, the presence of "plastic" medical devices was the best independent predictor for patients receiving vancomycin: intravenous lines (odds ratio [OR], 6.23; 95% confidence interval [CI], 2.28 to 17.06; P<.001), Hickman catheters (OR, 76.12; 95% CI, 15.06 to 384.73; P<.001), and other medical devices (OR, 10.50; 95% CI, 2.54 to 43.38; P=.001).

Conclusions.  —Vancomycin use has increased linearly in the last decade primarily related to the presence of indwelling vascular devices in hematology-oncology patients. Use of vancomycin is equally divided among empirical therapy, prophylaxis, and specific therapy for a documented infection.(JAMA. 1993;269:598-602)

REFERENCES

1 +
Centers for Disease Control.  Nosocomial infection surveillance, 1983. CDC Surveillance Summaries . 1984;;33( (suppl 2) ):922SS-955SS.
2 +
Morrison AJ Jr, Freer CV, Searcy MA, Landry SM, Wenzel RP.  Nosocomial bloodstream infections: secular trends in a statewide surveillance program in Virginia. Infect Control . 1986;;7:550-553.
3 +
Landry DL, Kaiser DL, Wenzel RP.  Hospital stay and mortality attributed to nosocomial enterococcal bacteremia: a controlled study. Am J Infect Control . 1989;;17:323-329.
4 +
Karp JE, Dick JD, Angelopulos C, et al.  Empiric use of vancomycin during prolonged treatment-induced granulocytopenia. Am J Med . 1986;;81:237-242.
5 +
Grubb WB, Townsend DE, Ashdown N, Tjia T, McGlashan C, Leng T.  Genetic analysis of methicillin-resistant Staphylococcus aureus from Singapore hospitals. Eur J Clin Microbiol Infect Dis . 1986;; 5:728-730.
6 +
French GL, Ling J, Ling T, Hui YW.  Susceptibility of Hong-Kong isolates of methicillin-resistant Staphylococcus aureus to antimicrobial agents. J Antimicrob Chemother . 1988;;21:581-588.
7 +
Veach LA, Pfaller MA, Barret, Koontz FP, Wenzel RP.  Vancomycin resistance in Staphylococcus hemolyticus causing colonization and bloodstream infection. J Clin Microbiol . 1990;;28:2064-2068.
8 +
Uttley AC, Collins CH, Naidoo J, George RC.  Vancomycin resistant enterococci. Lancet . 1988;;1: 57-58.
9 +
Broderick A, Mori M, Nettleman MD, Streed SA, Wenzel RP.  Nosocomial infections: validation of surveillance and computer modeling to identify patients at risk. Am J Epidemiol . 1990;;131:734-742.
10 +
Widmer AF, Pfaller MA, Wenzel RP.  Failure to isolate methicillin-resistant Staphylococcus aureus from stethoscopes in two hospitals with endemic strains. Eur J Clin Microbiol Infect Dis . 1991;;10:46.
11 +
McCabe WR, Jackson GG.  Gram-negative bacteremia. Arch Intern Med . 1962;;110:847-855.
12 +
Winston DJ, Murphy WY, Young LS, Hewitt WL.  Piperacillin therapy for serious bacterial infections. Am J Med . 1980;;69:255-261.
13 +
Farber BF, Karchmer AW, Buckley MJ, Moellering RC Jr.  Vancomycin prophylaxis in cardiac operations: determination of optimal dose regimen. J Thorac Cardiovasc Surg . 1983;;85:933-935.
14 +
Sandford JP. Guide to Antimicrobial Therapy 1991 . Bethesda, Md: Antimicrobial Therapy Inc; 1991;.
15 +
Kunin CM, Tupasi T, Craig WA.  Use of antimicrobials: a brief exposition of the problem and some tentative solutions. Ann Intern Med . 1973;; 79:555-560.
16 +
Kramer MS, Leventhal JM, Hutchinson TA, Feinstein AR.  An algorithm for the operational assessment of adverse drug reactions, I: background, description, and instructions for use. JAMA . 1979;; 242:623-632.
17 +
Hutchinson TA, Leventhal JM, Kramer MS, Karch FE, Lipman AG, Feinstein AR.  An algorithm for the operational assessment of adverse drug reactions, II: demonstration of reproducibility and validity. JAMA . 1979;;242:633-638.
18 +
Wilkinson L. SYSTAT: The System for Statistics . Evanston, Ill: SYSTAT Inc; 1990;.
19 +
Fleiss JL. Statistical Methods for Rates and Proportions . New York, NY: John Wiley & Sons Inc; 1981;:14.
20 +
EGRET: Epidemiological Graphics Estimation and Testing Package . Seattle, Wash: Statistics and Epidemiology Reseach Corporation and Cytel Software Corporation; 1990;.
21 +
Martin MA, Pfaller MA, Wenzel RP.  Coagulase-negative staphylococcal bacteremia: mortality and hospital stay. Ann Intern Med . 1989;;110:9-16.
22 +
Archer GL.  Staphylococcus epidermidis and other coagulase-negative staphylococci.  In: Mandell GL, Douglas RG, Bennett JE, eds. Principles and Practice of Infectious Diseases . New York, NY: John Wiley & Sons Inc; 1990;:1511-1518.
23 +
European Organization for Research and Treatment of Cancer (EORTC) International Antimicrobial Therapy Cooperative Group and the National Cancer Institute of Canada-Clinical Trials Group.  Vancomycin added to empirical combination antibiotic therapy for fever in granulocytopenic cancer patients. J Infect Dis . 1991;;163:951-958.
24 +
Hughes WT, Armstrong D, Bodey GP, et al.  Guidelines for the use of antimicrobial agents in neutropenic patients with unexplained fever. J Infect Dis . 1990;;161:381-396.
25 +
Scheckler WE, Bennett JV.  Antibiotic usage in seven community hospitals. JAMA . 1970;;213:264-267.
26 +
Roberts AW, Visconti JA.  The rational and irrational use of systemic antimicrobial drugs. Am J Hosp Pharm . 1972;;29:828-834.
27 +
Castle M, Wilfert CM, Cate TR, Osterhout S.  Antimicrobial use at Duke University Medical Center. JAMA . 1977;;237:2819-2833.
28 +
Maki DG, Schuna AA.  A study of antimicrobial misuse in a university hospital. Am J Med Sci . 1978;;275:271-282.
29 +
Jones SR, Barks J, Bratton T, et al.  The effect of an educational program upon hospital antimicrobial use. Am J Med Sci . 1977;;273:79-85.
30 +
Farber BF, Moellering RC Jr.  Retrospective study of the toxicity of preparations of vancomycin from 1974 to 1981. Antimicrob Agents Chemother . 1983;;23:138-141.
31 +
Sorrell TC, Collignon PJ.  A prospective study of adverse reactions associated with vancomycin therapy. J Antimicrob Chemother . 1985;;16:235-241.
32 +
Marr JJ, Moffet HL, Kunin CM.  Guidelines for improving the use of antimicrobial agents in hospitals: a statement by the Infectious Disease Society of America. J Infect Dis . 1988;;157:869-876.

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1 +
Centers for Disease Control.  Nosocomial infection surveillance, 1983. CDC Surveillance Summaries . 1984;;33( (suppl 2) ):922SS-955SS.
2 +
Morrison AJ Jr, Freer CV, Searcy MA, Landry SM, Wenzel RP.  Nosocomial bloodstream infections: secular trends in a statewide surveillance program in Virginia. Infect Control . 1986;;7:550-553.
3 +
Landry DL, Kaiser DL, Wenzel RP.  Hospital stay and mortality attributed to nosocomial enterococcal bacteremia: a controlled study. Am J Infect Control . 1989;;17:323-329.
4 +
Karp JE, Dick JD, Angelopulos C, et al.  Empiric use of vancomycin during prolonged treatment-induced granulocytopenia. Am J Med . 1986;;81:237-242.
5 +
Grubb WB, Townsend DE, Ashdown N, Tjia T, McGlashan C, Leng T.  Genetic analysis of methicillin-resistant Staphylococcus aureus from Singapore hospitals. Eur J Clin Microbiol Infect Dis . 1986;; 5:728-730.
6 +
French GL, Ling J, Ling T, Hui YW.  Susceptibility of Hong-Kong isolates of methicillin-resistant Staphylococcus aureus to antimicrobial agents. J Antimicrob Chemother . 1988;;21:581-588.
7 +
Veach LA, Pfaller MA, Barret, Koontz FP, Wenzel RP.  Vancomycin resistance in Staphylococcus hemolyticus causing colonization and bloodstream infection. J Clin Microbiol . 1990;;28:2064-2068.
8 +
Uttley AC, Collins CH, Naidoo J, George RC.  Vancomycin resistant enterococci. Lancet . 1988;;1: 57-58.
9 +
Broderick A, Mori M, Nettleman MD, Streed SA, Wenzel RP.  Nosocomial infections: validation of surveillance and computer modeling to identify patients at risk. Am J Epidemiol . 1990;;131:734-742.
10 +
Widmer AF, Pfaller MA, Wenzel RP.  Failure to isolate methicillin-resistant Staphylococcus aureus from stethoscopes in two hospitals with endemic strains. Eur J Clin Microbiol Infect Dis . 1991;;10:46.
11 +
McCabe WR, Jackson GG.  Gram-negative bacteremia. Arch Intern Med . 1962;;110:847-855.
12 +
Winston DJ, Murphy WY, Young LS, Hewitt WL.  Piperacillin therapy for serious bacterial infections. Am J Med . 1980;;69:255-261.
13 +
Farber BF, Karchmer AW, Buckley MJ, Moellering RC Jr.  Vancomycin prophylaxis in cardiac operations: determination of optimal dose regimen. J Thorac Cardiovasc Surg . 1983;;85:933-935.
14 +
Sandford JP. Guide to Antimicrobial Therapy 1991 . Bethesda, Md: Antimicrobial Therapy Inc; 1991;.
15 +
Kunin CM, Tupasi T, Craig WA.  Use of antimicrobials: a brief exposition of the problem and some tentative solutions. Ann Intern Med . 1973;; 79:555-560.
16 +
Kramer MS, Leventhal JM, Hutchinson TA, Feinstein AR.  An algorithm for the operational assessment of adverse drug reactions, I: background, description, and instructions for use. JAMA . 1979;; 242:623-632.
17 +
Hutchinson TA, Leventhal JM, Kramer MS, Karch FE, Lipman AG, Feinstein AR.  An algorithm for the operational assessment of adverse drug reactions, II: demonstration of reproducibility and validity. JAMA . 1979;;242:633-638.
18 +
Wilkinson L. SYSTAT: The System for Statistics . Evanston, Ill: SYSTAT Inc; 1990;.
19 +
Fleiss JL. Statistical Methods for Rates and Proportions . New York, NY: John Wiley & Sons Inc; 1981;:14.
20 +
EGRET: Epidemiological Graphics Estimation and Testing Package . Seattle, Wash: Statistics and Epidemiology Reseach Corporation and Cytel Software Corporation; 1990;.
21 +
Martin MA, Pfaller MA, Wenzel RP.  Coagulase-negative staphylococcal bacteremia: mortality and hospital stay. Ann Intern Med . 1989;;110:9-16.
22 +
Archer GL.  Staphylococcus epidermidis and other coagulase-negative staphylococci.  In: Mandell GL, Douglas RG, Bennett JE, eds. Principles and Practice of Infectious Diseases . New York, NY: John Wiley & Sons Inc; 1990;:1511-1518.
23 +
European Organization for Research and Treatment of Cancer (EORTC) International Antimicrobial Therapy Cooperative Group and the National Cancer Institute of Canada-Clinical Trials Group.  Vancomycin added to empirical combination antibiotic therapy for fever in granulocytopenic cancer patients. J Infect Dis . 1991;;163:951-958.
24 +
Hughes WT, Armstrong D, Bodey GP, et al.  Guidelines for the use of antimicrobial agents in neutropenic patients with unexplained fever. J Infect Dis . 1990;;161:381-396.
25 +
Scheckler WE, Bennett JV.  Antibiotic usage in seven community hospitals. JAMA . 1970;;213:264-267.
26 +
Roberts AW, Visconti JA.  The rational and irrational use of systemic antimicrobial drugs. Am J Hosp Pharm . 1972;;29:828-834.
27 +
Castle M, Wilfert CM, Cate TR, Osterhout S.  Antimicrobial use at Duke University Medical Center. JAMA . 1977;;237:2819-2833.
28 +
Maki DG, Schuna AA.  A study of antimicrobial misuse in a university hospital. Am J Med Sci . 1978;;275:271-282.
29 +
Jones SR, Barks J, Bratton T, et al.  The effect of an educational program upon hospital antimicrobial use. Am J Med Sci . 1977;;273:79-85.
30 +
Farber BF, Moellering RC Jr.  Retrospective study of the toxicity of preparations of vancomycin from 1974 to 1981. Antimicrob Agents Chemother . 1983;;23:138-141.
31 +
Sorrell TC, Collignon PJ.  A prospective study of adverse reactions associated with vancomycin therapy. J Antimicrob Chemother . 1985;;16:235-241.
32 +
Marr JJ, Moffet HL, Kunin CM.  Guidelines for improving the use of antimicrobial agents in hospitals: a statement by the Infectious Disease Society of America. J Infect Dis . 1988;;157:869-876.

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