Research In Practice Blog
Critically ill children are often started on antibiotics when doctors suspect a serious infection, even before the exact cause is known. This approach helps ensure potentially dangerous bacterial infections are treated as quickly as possible. Vancomycin remains among the most commonly prescribed antibiotics in pediatric intensive care units (PICUs) and provides coverage for methicillin-resistant Staphylococcus aureus (MRSA) and several lower-virulence gram-positive organisms.
However, several studies have found that MRSA is uncommon among children receiving antibiotics for suspected serious bacterial infections. As a result, starting anti-MRSA treatment right away may not be necessary in some cases. Overuse of vancomycin for suspected serious bacterial infection in critically ill children is a concern as vancomycin has been associated with acute kidney injury, infusion-related reactions, and the development of vancomycin-resistant Enterococcus. Despite these risks, efforts to improve vancomycin prescribing practices have largely been limited to individual hospitals.
Study Design and Methods
In their recent multicenter interrupted time series study, researchers, including Clinical Futures experts Kathleen Chiotos, MD, MSCE, Rebecca Same, MD, Yun Li, PhD, Julia E. Szymczak, PhD, and Jeffrey S. Gerber, MD, PhD, examined the impact of a multifaceted antimicrobial stewardship intervention to reduce empiric vancomycin overuse for suspected serious bacterial infection in children admitted to the PICU. The study, 'Reducing Empiric Vancomycin Use in the Pediatric Intensive Care Unit: a Multicenter Study', included five PICUs at three pediatric hospitals across the United States. The intervention was implemented between August and October 2023. Researchers compared antibiotic use during the 18 months afterward.
The stewardship program included 3 key components:
- Development of a consensus-based guideline for empiric vancomycin use
- Clinician education
- Group-level audit and feedback reports
Clinicians received training on when vancomycin was most appropriate, while each hospital was able to tailor the program to fit its needs and available resources. Researchers focused on episodes when children were evaluated for a suspected series of bacterial infection.
To measure the intervention's impact, researchers looked at two primary outcomes:
- The proportion of episodes in which vancomycin was administered within 12 hours of the evaluation for suspected serious bacterial infection and
- The number of consecutive days vancomycin was administered during the first three days following the evaluation for suspected serious bacterial infection.
Findings
Among the 4549 infection evaluations included in this study, researchers observed an immediate decline in vancomycin use after the intervention was introduced. The likelihood of a child receiving vancomycin within 12 hours of suspected serious bacterial infection onset decreased by 29% immediately after implementation. Empiric vancomycin days of therapy after suspected serious bacterial infection onset decreased by 24% immediately after the intervention. There were no increases in mortality, organ dysfunction, or missed MRSA infections postintervention. Vancomycin days of therapy per 1000 patient days for PICU patients across all sites decreased from 97 to 80 in the postintervention period.
The data revealed a decrease in both the proportion of suspected infection episodes receiving empiric vancomycin and the number of vancomycin days administered during the first 3 days after serious bacterial infection evaluation, as well as a decrease in the overall unit-level vancomycin use over time in the postintervention period. The observed reductions in vancomycin use were not associated with increased use of alternative anti-MRSA agents, adverse clinical outcomes, or missed opportunities to empirically treat invasive MRSA infections.
Clinical Implications
Implementation of this multifaceted antimicrobial stewardship intervention was associated with a reduction in empiric vancomycin use without evidence of harm to patients. These findings support the safety and feasibility of reducing empiric vancomycin use in the PICU population, particularly for children empiric vancomycin in the PICU population, particularly for children unlikely to have MRSA infection.
For pediatric patients, reducing vancomycin exposure can decrease the risk of acute kidney injury and other adverse drug events. The study also demonstrates that stewardship efforts can be effective when they focus on the point at which antibiotics are first prescribed, even in a complex, high acuity environment like the PICU.
During the study period, sites with stronger feedback processes appeared to achieve larger reductions in vancomycin use, highlighting the value of providing clinicians with regular performance feedback. By combining evidence-based guidelines, clinical education, and ongoing feedback, this intervention offers a potential framework for future stewardship interventions to evaluate routine empiric anti-MSRA prescribing and safely reduce unnecessary antibiotic use.
Clinical Futures author(s): Kathleen Chiotos, MD, MSCE, Rebecca G Same, MD, Yun Li, PhD, Julia E Szymczak, PhD, Jeffrey S Gerber, MD, PhD