ABSTRACT
BACKGROUND: Patients in the Intensive Care Unit (ICU) often have sub-therapeutic vancomycin levels in the initial stages of therapy. Loading doses have been demonstrated to overcome this problem. AIM: The aim of this study was to determine the impact of a standardised loading dose and increased clinician awareness of under-dosing on the achievement of early therapeutic vancomycin trough concentrations in the ICU. METHODS: A pre- and post-intervention observational study was conducted in the ICU following the introduction of a 2-g vancomycin loading dose and demonstration of local under-dosing. All initial vancomycin trough levels were examined, except those from neurosurgical patients. Primary outcome measures were the proportion of patients achieving therapeutic vancomycin levels and mean trough concentrations. A year after introduction, a review was conducted to further assess the impact and sustainability of the intervention. RESULTS: There were 31 courses of vancomycin in the pre-intervention period (no loading doses given) and 21 courses in the post-intervention period, of which 11 had a loading dose. In the pre-intervention group, 13% of courses achieved therapeutic concentrations. This increased to 33% in the post-intervention group (P= 0.08). A statistically significant increase in mean trough concentration, from 9.8 ± 6.6 mg/L to 14.9 ± 6.3 mg/L (P= 0.01), between the pre- and post-intervention groups was observed. During the follow-up period, results were similar to the post-intervention audit. CONCLUSION: A standardised loading dose is a simple and sustainable intervention that may improve early achievement of therapeutic vancomycin levels in critically ill patients. The clinical significance of this requires further study.
Subject(s)
Anti-Bacterial Agents/administration & dosage , Critical Care/methods , Vancomycin/administration & dosage , Adult , Aged , Anti-Bacterial Agents/blood , Anti-Bacterial Agents/pharmacokinetics , Anti-Bacterial Agents/therapeutic use , Burns/drug therapy , Critical Illness , Dose-Response Relationship, Drug , Drug Administration Schedule , Drug Monitoring , Female , Follow-Up Studies , Hospitals, University , Humans , Intensive Care Units , Male , Medical Audit , Middle Aged , Postoperative Complications/drug therapy , Practice Guidelines as Topic , Quality Improvement , Standard of Care , Staphylococcal Infections/drug therapy , Vancomycin/blood , Vancomycin/pharmacokinetics , Vancomycin/therapeutic use , VictoriaABSTRACT
A point-prevalence survey performed among residents of eight nursing homes in Melbourne, Australia, found a rate of fecal VRE colonization of 3.1% (9/292; 95% confidence interval, 1.1-5.1), all vanB Enterococcusfaecium. This is a higher rate than in the general community (3.1% vs 0.2%). Many residents (16%) had been inpatients in acute-care hospitals in the previous 3 months.
Subject(s)
Enterococcus faecalis/isolation & purification , Enterococcus faecium/isolation & purification , Feces/microbiology , Gram-Positive Bacterial Infections/epidemiology , Nursing Homes/statistics & numerical data , Vancomycin Resistance , Aged , Aged, 80 and over , Anti-Bacterial Agents/pharmacology , Disease Outbreaks , Enterococcus faecalis/drug effects , Enterococcus faecium/drug effects , Female , Humans , Male , Microbial Sensitivity Tests , Prevalence , Vancomycin/pharmacology , Victoria/epidemiologyABSTRACT
To assess the rate of fecal vancomycin-resistant enterococci (VRE) colon ization in Austalia, we examined specimens from 1,085 healthy volunteers. VRE was cultured from 2(0.2%) of 1,085 specimens; both were vanB Enter ococcus faecium, identical by pulsed-field gel electrophoresis, but with a pattern rare in Melbourne hospitals.
Subject(s)
Enterococcus faecalis/drug effects , Feces/microbiology , Vancomycin Resistance , Adult , Australia , Electrophoresis, Gel, Pulsed-Field , Enterococcus faecalis/isolation & purification , Female , Humans , Male , Microbial Sensitivity TestsABSTRACT
OBJECTIVE: To describe the level of activity, independence and demographics of elderly people hospitalised with community-acquired pneumococcal pneumonia. DESIGN: Prospective descriptive study. SETTING: Seven university-affiliated hospitals and three community hospitals. PATIENTS: People aged over 55 years admitted to hospital with a clinical history consistent with pneumococcal pneumonia, a Streptococcus pneumoniae isolate in blood or sputum, and a chest x-ray consistent with pneumonia. Significant immunosuppression or certain comorbidities (parenchymal lung disease and end-stage renal failure) were exclusion criteria. MAIN OUTCOME MEASURE: Level of independence, assessed by participation in a range of standardised activities before the patient's illness. RESULTS: 82 patients met our case definition. Five refused to participate, leaving 77 evaluable patients. The patients had high levels of independence: 64 (83%; 95% confidence interval [CI], 73%-91%) lived in their own home and 69 (90%; 95% CI, 81%-95%) participated in regular hobbies. Exercise tolerance was good, with 43 (56%; 95% CI, 45%-68%) able to climb a flight of stairs and 59 (76%; 95% CI, 65%-85%) able to walk more than 50 m without stopping; 41 (53%; 95% CI, 41%-64%) could continue further than a kilometre. Mortality was low (9 patients; 12%) despite a high rate of bacteraemia (43 patients; 56%). Within the past five years, 59 (77%) had been hospitalised and 53 (69%) vaccinated with influenza vaccine. Only 7% had ever received pneumococcal vaccination. CONCLUSION: Pneumococcal pneumonia is not the "old man's friend". It represents a major cause of morbidity and mortality in otherwise well, active and independent older Australians. Hospitalisation and attendance for influenza vaccination may represent opportunities for pneumococcal vaccination.
