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Decreasing Empiric Vancomycin

Usage for Late Onset Sepsis in


the NICU
Joshua Cooper, MD, Tinisha Lambeth, DNP,
Avinash Shetty, MD, Jennifer Holman, MD
Problem Description
• Both Novant Health Forsyth Medical Center and
Brenner Children’s Hospital traditionally used
Vancomycin as first-line empiric coverage for gram-
positive bacteria in infants greater than 72 hours old
with infectious concerns
• Baseline data for infants ≥72 hours of age from Oct-
Dec 2017:
• NHFMC: Vancomycin was initiated in 55.2% of
infectious workups
• BCH: Vancomycin was initiated in 57.9% of
infectious workups

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Available Knowledge

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Available knowledge continued:
Effectiveness of a Guideline to Reduce Vancomycin Use
in the NICU

• Brigham and Women’s and Mass General


Hospitals
• 6 months prospective data collection on infants
treated with Vanc b/w 2005-2006
• Intervention placed
• Data collected 11/06-11/07
• Antibiotic utilization patterns monitored through
12/08
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Rationale
• Vancomycin is still used in some NICUs as
part of empiric therapy for suspected late-
onset sepsis
• However, routine Vancomycin use in
neonates is associated with:
• increased burden of antibiotic-resistant
organisms
• eradication of normal healthy gut
microflora
• increased cost
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Setting
Novant Health Forsyth Medical Center (NHFMC)
• 56-bed magnet certified, level III neonatal intensive
care unit (NICU)
• Exclusively inborn, non-surgical infants for a 20-
county perinatal region in Northwest North
Carolina, USA
• Over 1,000 admissions annually (22 weeks and
greater)
• 2nd largest inpatient obstetric facility in the state of
North Carolina

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Setting
Brenner Children’s Hospital at Wake Forest
Baptist Health (BCH)
• 40-bed, level IV NICU
• Over 500 admissions annually (22 weeks and
greater)
• Primarily outborn, serves as primary neonatal
referral center for Northwest North Carolina,
Southwest Virginia, and parts of Eastern
Tennessee
• Provides all pediatric subspecialty services,
cardiothoracic surgery, and neurosurgery

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Smart Aim
• Decrease the percent of patients ≥72 hours of
age started on Vancomycin for infectious
concerns from 55.2% (NHFMC) and 57.9%
(BCH) to 10% or less by December 31, 2018 by
using Nafcillin at NHFMC and Oxacillin at BCH.

Global Aim
• Reduce Vancomycin use per 1,000 patient days
in order to prevent antibiotic resistant
organisms and patient morbidity (evaluation
ongoing).
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Strategies for Change
• Developed key drivers and interventions of change to
standardize empiric antibiotics for infants ≥72 hours of
age with infectious concerns
• Used the Model for Improvement with Plan Do Study
Act (PDSA) cycles to determine the impact of our
intervention on outcome measures
• Updated evidence-based practice guidelines and
communication tools were distributed to attendings,
nurse practitioners, and fellows via email and at
monthly staff meetings
• Obtained staff feedback at monthly staff meetings and
via email

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Key Driver Diagram: Vancomycin Reduction in Infants ≥72 Hours Old Who Have Infectious
Concerns
Aim Drivers Interventions
• Lecture for NNP/PA team outlining common organisms and their
Orders for treatment
Vancomycin only in • Create, present at faculty meeting, email, and post 4P in the NICUs
cases in which outlining the practice changes.
specifically indicated • Update EBP guidelines and share with providers via email.
To decrease the • Pharmacists will remind providers during medical rounds to use
percent of Nafcillin (NHFMC) or Oxacillin (BCH) instead of Vancomycin when
patients > 72 discussing initiation of therapy for suspected infections.
hours started on • Nafcillin “medication of the month” education sheet posted in the
Vancomycin for NHFMC NICU
Staff knowledge of
infectious • LOS medication reminders placed on “workplace on wheels” computers
organisms causing
concerns from LOS
50% to 10% by
Dec 31, 2018.
• Audit physician prescribing.
• Providers will document reason for ordering Vancomycin.
Reduce
Provider buy-in
Vancomycin use
per 1,000 patient
• Provide MRSA routine surveillance culture results to providers.
days in order to
• Create smart phrase for summarizing patient’s history of positive
prevent antibiotic
Staff knowledge of cultures.
resistant
clear evidence-based • Auto-populate positive cultures in daily progress note
organisms and
patient morbidity guideline practice
changes
• Hard stop in EMR with prior authorization from pharmacists for ordering
Vancomycin.
Reduced availability of
Vancomycin
Baseline Statistics
NHFMC BCH 2018 P-value
Total Patients 89 78
Gestational Age 27 weeks 1 day 30 weeks 1 day p<0.01
Birth Weight 954.5 grams 1603.8 grams p<0.01
Female (%) 55% 42% p<0.73
Race (%) p=0.77
Asian 1% 2%
Black 43% 44%
Hispanic 15% 18%
White 42% 36%

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Number of Workups
• NHFMC Oct-Nov: 31
• NHFMC Jan-Dec: 84

• BCH Oct-Nov: 44
• BCH Jan-Dec:102

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% of patients at NHFMC who were started on
vancomycin for infectious concerns

0
10
20
30
40
50
60
70
80
90
10/2-10/8 (n=01) 100
10/16-10/22 (n=04)
10/30-11/5 (n=01)
11/13-11/19 (n=01)
11/27-12/3 (n=05)
12/11-12/17 (n=01)

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12/25-12/31 (n=03) 55.2%
1/8-1/14 (n=00)

Average
1/22-1/28 (n=01)
2/5-2/11 (n=03)
2/19-2/25 (n=02)

4.8%
3/5-3/11 (n=01)
3/19-3/25 (n=02)
4/2-4/8 (n=02)
4/16-4/22 (n=00)
4/30-5/6 (n=03)

Week
5/14-5/20 (n=00)
5/28-6/3 (n=00)
6/11-6/17 (n=03)
6/25-7/1 (n=02)
7/9-7/15 (n=03)
7/23-7/29 (n=02)
% of patients who were started on vancomycin 8/6-8/12 (n=00)
8/20-8/26 (n=02)
9/3-9/9 (n=00)
late onset infectious concerns

9/17-9/23 (n=02)
10/1-10/7 (n=01)
Center percentage of patients started on vancomycin

10/15-10/21 (n=02)
10/29-11/4 (n=00)
11/12-11/18 (n=05)
72 hours who were started on vancomycin for
% of patients at NHFMC greater than or equal to

11/26-12/2 (n=02)
12/10-12/16 (n=03)
12/24-12/31 (n=00)
% of patients at BCH who were started on
vancomycin for infectious concerns

0
10
20
30
40
50
60
70
80
90
10/2-10/8 (n=03) 100
10/16-10/22 (n=03)
10/30-11/5 (n=01)
11/13-11/19 (n=04)
11/27-12/3 (n=03)
12/11-12/17 (n=04)

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12/25-12/31 (n=06)
1/8-1/14 (n=01)

Average
1/22-1/28 (n=01)
2/5-2/11 (n=01)
57.8%

2/19-2/25 (n=01)
3/5-3/11 (n=05) 18.4%
3/19-3/25 (n=03)
4/2-4/8 (n=01)
4/16-4/22 (n=02)
4/30-5/6 (n=00)

Week
5/14-5/20 (n=01)
5/28-6/3 (n=03)
6/11-6/17 (n=00)
6/25-7/1 (n=01)
7/9-7/15 (n=00)
7/23-7/29 (n=03)
% of patients who were started on vancomycin 8/6-8/12 (n=02)
8/20-8/26 (n=02)
9/3-9/9 (n=03)
onset infectious concerns

9/17-9/23 (n=00)
10/1-10/7 (n=03)
Center percentage of patients started on vancomycin

10/15-10/21 (n=02)
10/29-11/4 (n=00)
11/12-11/18 (n=02)
11/26-12/2 (n=01)
hours who were started on vancomycin for late
% of patients at BCH greater than or equal to 72

12/10-12/16 (n=04)
12/24-12/31 (n=02)
Appropriate Vancomycin Starts
• NHFMC Nov-Dec 2017: 0/16
• NHFMC Jan-Dec 2018: 2/4
• BCH Nov-Dec 2017: 1/22
• BCH Jan-Dec 2018: 8/20
• 7 patients switched to Vanc at NHFMC and 3 switched
to Vanc at BCH after cultures positive (and later found
to be MRSA). None of these patients had
decompensation/morbidity.

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NHFMC Recommended Empiric Antibiotics Selected?
12

10

0
Oct '17 Nov '17 Dec '17 Jan '18 Feb '18 Mar '18 Apr '18 May '18 Jun '18 Jul '18 Aug '18 Sep '18 Oct '18 Nov '18 Dec '18

Wake Forest Baptist Medical Center Yes No "Narrow" 18


BCH Recommended Empiric Antibiotics Selected?
12

10

0
Oct '17 Nov '17 Dec '17 Jan '18 Feb '18 Mar '18 Apr '18 May '18 Jun '18 Jul '18 Aug '18 Sep '18 Oct '18 Nov '18 Dec '18

Wake Forest Baptist Medical Center Yes No "Narrow" 19


NHFMC Blood Cultures Obtained on Workup

12

10

0
Oct '17 Nov '17 Dec '17 Jan '18 Feb '18 Mar '18 Apr '18 May '18 Jun '18 Jul '18 Aug '18 Sep '18 Oct '18 Nov '18 Dec '18

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BCH Blood Cultures Obtained on Workup

16

14

12

10

0
Oct '17 Nov '17 Dec '17 Jan '18 Feb '18 Mar '18 Apr '18 May '18 Jun '18 Jul '18 Aug '18 Sep '18 Oct '18 Nov '18 Dec '18

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Discussion
• Decreased empiric Vancomycin usage at both
institutions (reached goal of <10% at NHFMC)
• While empiric vancomycin use was reduced,
oftentimes non-narrow antibiotics were still chosen as
first-line
• More workups included two blood cultures as study
progressed

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Discussion
• Beyond December 2018, it appears both institutions
are continuing to use primarily narrow-spectrum
antibiotics in conjunction for late onset sepsis workups
• Greater buy-in at NHFMC likely related to recent
implementation of other antibiotic reduction strategies
(Kaiser Sepsis, guidelines for VLBW infants)
• Overall, staff at both institutions readily accepted
recommendations for change in empiric antibiotics after
education, but on occasion did use Vancomycin first
line in “sicker” infants

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Future Plans
• Continue to push for two cultures to be obtained during
LOS workups and include more discussion on when
CSF cultures should be obtained
• Work to ensure that other broad-spectrum antibiotics
(cephalosporins, meropenem) are used more
judiciously and less frequently as empiric LOS
antibiotics
• Work on shortening courses of therapy

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