title: A trial of discontinuation of empiric vancomycin therapy in patients with suspected methicillin-resistant Staphylococcus aureus health care-associated pneumonia.
abstract: Healthcare-associated pneumonia (HCAP) guidelines recommend de-escalating initial antibiotic therapy based on results from lower-respiratory-tract cultures. In the absence of adequate lower respiratory cultures, physicians are sometimes reluctant to discontinue empirical vancomycin, which is given for suspected methicillin-resistant Staphylococcus aureus (MRSA) HCAP. We evaluated a strategy of discontinuing vancomycin if both nasal and throat cultures were negative for MRSA when lower-respiratory-tract cultures were not available. An antimicrobial stewardship team identified patients receiving empirical vancomycin for suspected or proven HCAP but for whom adequate lower-respiratory-tract cultures were not available. Nasal and throat swab specimens were obtained and plated on MRSA selective media. If both nasal and throat MRSA cultures were negative, the stewardship team recommended discontinuation of empirical vancomycin. Demographic and clinical aspects, a clinical pulmonary infection score (CPIS) on the day of the stewardship recommendation, and mortality of patients for whom vancomycin was discontinued were obtained by retrospective chart review. A convenience sample of 91 patients with nasal and throat cultures negative for MRSA in the absence of adequate respiratory cultures had empirical vancomycin therapy discontinued. A retrospective review revealed that 88 (97%) patients had a CPIS of ≤6 on the day of the stewardship recommendation. In-hospital mortality (7.7%) was similar to that of a previous study of de-escalation of antibiotics in pneumonia patients without adequate cultures. In the absence of adequate lower-respiratory-tract cultures, it is reasonable to discontinue empirical vancomycin HCAP therapy in patients with negative MRSA nasal and throat cultures and a CPIS of <6.
authors.affiliation: Hospital Epidemiology and Infection Control Program, Yale-New Haven Hospital, New Haven, CT, USA. John.Boyce@ynhh.org
authors.forename: John M
authors.initials: JM
authors.lastname: Boyce
authors.forename: Olivia-Fabiola
authors.initials: OF
authors.lastname: Pop
authors.forename: Odaliz
authors.initials: O
authors.lastname: Abreu-Lanfranco
authors.forename: Whitney Y
authors.initials: WY
authors.lastname: Hung
authors.forename: Ann
authors.initials: A
authors.lastname: Fisher
authors.forename: Afshin
authors.initials: A
authors.lastname: Karjoo
authors.forename: Benjamin
authors.initials: B
authors.lastname: Thompson
authors.forename: Zenon
authors.initials: Z
authors.lastname: Protopapas
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000900:Anti-Bacterial Agents / Q000627:therapeutic use; D003428:Cross Infection / Q000175:diagnosis* / Q000188:drug therapy* / Q000401:mortality; D003470:Culture Media; D005260:Female; D006801:Humans; D008297:Male; D055624:Methicillin-Resistant Staphylococcus aureus; D008875:Middle Aged; D009296:Nasal Cavity / Q000382:microbiology; D010614:Pharynx / Q000382:microbiology; D011014:Pneumonia / Q000175:diagnosis* / Q000188:drug therapy* / Q000401:mortality; D012189:Retrospective Studies; D016019:Survival Analysis; D014640:Vancomycin / Q000627:therapeutic use
chemical_list: D000900:Anti-Bacterial Agents; D003470:Culture Media; D014640:Vancomycin