Keyserling Harry L, Sinkowitz-Cochran Ronda L, Harris James M, Levine Gail L, Siegel Jane D, Stover Beth H, Lau Sharon A, Jarvis William R
Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia 30322, USA.
Pediatrics. 2003 Aug;112(2):e104-11. doi: 10.1542/peds.112.2.e104.
To assess vancomycin utilization at children's hospitals, to determine risk factors for vancomycin use and length of therapy, and to facilitate adapting recommendations to optimize vancomycin prescribing practices in pediatric patients.
Two surveys were conducted at Pediatric Prevention Network hospitals. The first (Survey I) evaluated vancomycin control programs. The second (Survey II) prospectively reviewed individual patient records. Each hospital was asked to complete questionnaires on 25 consecutive patients or all patients for whom vancomycin was prescribed during a 1-month period.
In Survey I, 55 of 65 (85%) hospitals reported their vancomycin control policies. Three quarters had specific policies in place to restrict vancomycin use. One half had at least 3 vancomycin restriction measures. In Survey II, personnel at 22 hospitals reviewed 416 vancomycin courses, with 2 to 25 (median = 12) patients tracked per hospital. Eighty-two percent of the vancomycin prescribed was for treatment of neonatal sepsis, fever/neutropenia, fever of unknown origin, positive blood culture, pneumonia, or meningitis. In an additional 6% (26/416), vancomycin was prescribed for patients with beta-lactam allergies and in 13% (56/416) for prophylaxis. Median duration of prophylaxis was 2 days (range: 1-15 days). Almost half (196, 47%) of the patients who received vancomycin were in intensive care units; 27% of the vancomycin courses were initiated by neonatologists and 19% by hematologists/oncologists. The predominant risk factor at the time of vancomycin initiation was the presence of vascular catheters (322, 77%); other host factors included cancer chemotherapy (55, 13%), transplant (30, 7%), shock (24, 6%), other immunosuppressant therapy (17, 4%), or hyposplenic state (2, <1%). Other clinical considerations were severity of illness (96, 23%), uncertainty about diagnosis (51, 12%), patient not responding to current antibiotic therapy (40, 10%), or implant infection (13, 3%). When vancomycin was initiated, blood cultures were positive in 85 patients (20%); cultures from other sites were positive in 45 (11%), and Gram stains of body fluids were positive in 37 (9%). In 29 (7%) patients, organisms sensitive only to vancomycin were isolated before vancomycin initiation. Reasons for discontinuing vancomycin included: therapeutic course completed (125, 30%), negative cultures (106, 25%), alternative antibiotics initiated (75, 18%), illness resolved (14, 3%), or patient expired (13, 3%). Final results of blood culture isolates resistant to beta-lactam antibiotics included 48 coagulase-negative staphylococcus, 5 Staphylococcus aureus, and 10 other species.
At children's hospitals, vancomycin is initiated for therapy in patients who have vascular catheters and compromised host factors. Only 7% had laboratory-confirmed beta-lactam-resistant organisms isolated at the time vancomycin was prescribed. Efforts to modify empiric vancomycin use in children's hospitals should be targeted at intensivists, neonatologists, and hematologists. Initiatives to decrease length of therapy by decreasing the number of surgical prophylaxis doses and days of therapy before laboratory results may decrease vancomycin exposure.
评估儿童医院万古霉素的使用情况，确定万古霉素使用及治疗疗程的危险因素，并促进调整建议以优化儿科患者万古霉素的处方实践。
对儿科预防网络医院进行了两项调查。第一项（调查I）评估万古霉素控制项目。第二项（调查II）前瞻性地审查了个体患者记录。要求每家医院填写25例连续患者或在1个月期间内所有使用万古霉素患者的问卷。
在调查I中，65家医院中的55家（85%）报告了其万古霉素控制政策。四分之三的医院制定了限制万古霉素使用的具体政策。一半的医院至少有3项万古霉素限制措施。在调查II中，22家医院的人员审查了416个万古霉素疗程，每家医院跟踪2至25例患者（中位数 = 12例）。所开万古霉素的82%用于治疗新生儿败血症、发热/中性粒细胞减少症、不明原因发热、血培养阳性、肺炎或脑膜炎。另外6%（26/416）的患者因对β-内酰胺类过敏而使用万古霉素，13%（56/416）用于预防。预防的中位疗程为2天（范围：1 - 15天）。接受万古霉素治疗的患者中近一半（196例，47%）在重症监护病房；27%的万古霉素疗程由新生儿科医生启动，19%由血液科医生/肿瘤科医生启动。开始使用万古霉素时的主要危险因素是存在血管导管（322例，77%）；其他宿主因素包括癌症化疗（55例，13%）、移植（30例，7%）、休克（24例，6%）、其他免疫抑制治疗（17例，4%）或脾功能低下状态（2例，<1%）。其他临床考虑因素包括疾病严重程度（96例，23%）、诊断不确定（51例，12%）、患者对当前抗生素治疗无反应（40例，10%）或植入物感染（13例，3%）。开始使用万古霉素时，85例患者（20%）血培养阳性；其他部位培养阳性45例（11%），体液革兰氏染色阳性37例（9%）。在29例（7%）患者中，在开始使用万古霉素之前分离出仅对万古霉素敏感的微生物。停用万古霉素的原因包括：治疗疗程完成（125例，30%）、培养阴性（106例，25%）、开始使用替代抗生素（75例，18%）、疾病缓解（14例，3%）或患者死亡（13例，3%）。对β-内酰胺类抗生素耐药的血培养分离株的最终结果包括48株凝固酶阴性葡萄球菌、5株金黄色葡萄球菌和10株其他菌种。
在儿童医院，万古霉素用于有血管导管和宿主因素受损的患者进行治疗。在开具万古霉素处方时，只有7%的患者分离出实验室确认的对β-内酰胺类耐药的微生物。在儿童医院改变经验性使用万古霉素的努力应针对重症监护医生、新生儿科医生和血液科医生。通过减少手术预防剂量的数量和在实验室结果出来之前的治疗天数来缩短治疗疗程的举措可能会减少万古霉素的暴露。
