• This research was supported by the Oregon Clinical and Translational Research Institute funded by National Center for Advancing Translational Sciences (UL1TR000128).

• Further work is required to determine the impact of these findings on patientso Determine if excessive vancomycin use increased rates of adverse events or

treatment failure • Explore opportunities to reduce vancomycin use such as rapid intervention and de-

escalation of therapy

Vancomycin Use in Community-Acquired Pneumonia: Assessing Inappropriate TherapyTimothy G. Shan, BS1; Sara J. Gore, MD2; Caitlin M. McCracken, MA1; Gregory B. Tallman, PharmD MS

BCPS3; Haley K. Holmer, MPH4; David T. Bearden, PharmD FSIDP1,5; Jessina C. McGregor, PhD FSHEA1

INTRODUCTION

OBJECTIVES

RESULTS

ACKNOWLEDGEMENTS & DISCLOSURES

REFERENCES

CONCLUSIONS

• Empiric therapy with anti-methicillin-resistant Staphylococcus aureus (MRSA) agents for treatment of community-acquired pneumonia (CAP) is recommended only in high-risk patients1

• MRSA is a relatively rare causative pathogen of CAP, accounting for only 0.7% of cases in hospitalized patients2

• Vancomycin is the first line agent for empiric MRSA coverage in most inpatients and may often be used excessively

• There is limited data on duration of vancomycin use that is appropriate in hospitalized patients with CAP

• To evaluate the excess use of vancomycin among patients admitted for CAP

METHODSDesign & Setting• Retrospective, single-center cohort study of hospitalized adults with CAP• IRB approved study • Oregon Health & Science University (OHSU) hospital Inclusion Criteria• Inpatient adults ≥ 18 years old treated with IV vancomycin for CAP between 08/01/2017

and 07/31/2018• Pneumonia encounter ICD-9 diagnosis code • CAP defined as pneumonia acquired outside of the hospital Exclusion Criteria• Hospital acquired pneumonia (HAP)

o defined as pneumonia occurring 48 hours or more after admission, not associated with endotracheal intubation, and not incubating at time of admission

• Ventilator associated pneumonia (VAP)o defined as pneumonia occurring >48 hours or more after endotracheal intubation

Data Collection• Demographics, diagnostic codes, laboratory and pharmacy data were obtained from the

Pharmacy Research Repository • CAP patients, appropriateness, and duration of inappropriate therapy identified

through manual chart review Outcome• Inappropriate vancomycin use was determined as follows:

o Culture positive for gram negative organism, yeast, or funguso Narrower spectrum therapy available based on the lack of MRSA risk factors or

culture with methicillin susceptible Staphylococcus aureus o Duration of therapy exceeding the recommended duration set by IDSA guidelines for

CAP o Redundant therapy including more than one anti MRSA agent o Lack of infectious process

Analysis • Inappropriate vancomycin use was reported as days of therapy per patient-day • Patient characteristics and reasons for inappropriate use were summarized

• 52 patients were identified for inclusion o 11/52 (21%) patients had risk factors warranting empiric vancomycin therapy o 22/52 (42%) patients had sepsis at the time of admission

• Median duration of therapy was 2 days (interquartile range: 1-3) • 9/52 (17%) patients received inappropriate courses of vancomycin

o Median duration of inappropriate therapy was 1 day (IQR: 1-2.25)o 20/125 (16%) of vancomycin days of therapy were inappropriate o 7/9 (78%) patients had positive cultures

• 51/52 (98%) of patients had cultures performedo 23/52 (44%) grew no organism

Total Cohort (n=52)Age, mean (SD) 68 (17.5)Male 32 (61.5)Race

White 45 (86.5)Black/African American 1 (1.9)Asian/Pacific Islander 3 (5.8)More than one race 3 (5.8)

EthnicityHispanic or Latino 7 (13.5)Not Hispanic or Latino 45 (86.5)

Route of admissionClinic or physician 3 (5.8)Non-healthcare facility 30 (58)Transfer from hospital 17 (33)Transfer from SNF 2 (3.8)

Culture results 51 (98)No organism identified 23 (44)

Risk factorsHistory of MRSA 4 (7.7)History of IV drug use 3 (5.7)Recent IV antibiotics 4 (7.7)

Appropriate(n = 43)

Inappropriate(n = 9)

Route of admissionClinic or physician 3 (7) 0Non-healthcare facility 26 (60.5) 4 (44.4)Transfer from hospital 13 (30.2) 4 (44.4)Transfer from SNF 1 (2.3) 1 (11.1)

Average length of stay (d) 10 16Average length of therapy (d) 2.5 3.3

1. Mandell LA, Wunderink RG, Anzueto A, et al. Infectious Diseases Society of America/American Thoracic Society Consensus Guidelines on the Management of Community-Acquired Pneumonia in Adults. Clinical Infectious Diseases. 2007;44(Supplement_2):S27-S72.

2. 1. Self WH, Wunderink RG, Williams DJ, et al. Staphylococcus aureus Community-acquired Pneumonia: Prevalence, Clinical Characteristics, and Outcomes. Clinical infectious diseases : an official publication of the Infectious Diseases Society of America. 2016;63(3):300-309.

Table 1: Patient characteristics

Table 2: Characteristics based on appropriateness

• CAP patients accounted for a small number of pneumonia patients who received vancomycin

• The median inappropriate DOT was short• Concomitant sepsis was the most common reason for appropriate empiric vancomycin

therapy• Continuation of vancomycin after organism identification from a culture was the most

frequent reason for inappropriate therapy• Admission from a non-healthcare facility or outside hospital accounted for the majority

of inappropriate therapy which may present as another opportunity for intervention • Rapid identification and intervention may help further reduce the duration of

inappropriate therapy

FUTURE OPPORTUNITIES

Total Inappropriate (n =9)Reason for Inappropriate therapy

Culture positive for gram negative organism, yeast, or fungus 6 (66.7)Narrower spectrum antibiotic therapy 2 (22.2)Longer treatment duration than indicated 1 (11.1)Redundant therapy 0Lack of infectious process 0

Entire course inappropriate 1 (11)Partial course inappropriate 8 (89)

Table 3: Reason for inappropriate therapy

Timothy Shan: shant@oregonstate.edu