Dadzie Precious, Dietrich Tyson, Ashurst John
Pharmacy, Kingman Regional Medical Center, Kingman, USA.
Pharmacy / Infectious Diseases, Kingman Regional Medical Center, Kingman, USA.
Cureus. 2019 Dec 13;11(12):e6378. doi: 10.7759/cureus.6378.
Introduction Pneumonia caused by methicillin-resistant (MRSA) carries a high rate of morbidity and mortality. Many clinicians empirically treat those at risk of developing MRSA pneumonia with vancomycin. Several studies have identified a high negative predictive value of the MRSA polymerase chain reaction (PCR) nasal swab test in lower respiratory tract infections, suggesting it can be used to guide the de-escalation of empiric anti-MRSA therapy. Objective To evaluate the impact of a pharmacist-driven MRSA PCR nasal swab protocol on the de-escalation of empiric vancomycin in patients with pneumonia in a rural healthcare setting. Secondarily, to assess the rate of hospital length of stay, the rate of vancomycin-associated acute kidney injury, and in-hospital mortality after pharmacist-driven de-escalation of empiric vancomycin in patients with pneumonia. Methods A retrospective, single-center, pre-post cohort study was conducted in patients after the implementation of a pharmacist-driven protocol allowing pharmacists to obtain nasal swabs and PCR testing for MRSA in those on empiric vancomycin therapy for suspected MRSA pneumonia. Based on negative test results, pharmacists recommended a de-escalation of empiric vancomycin to the physician. Patients were included if they were adults at least 18 years of age, had a physician diagnosis of suspected or confirmed pneumonia, and initiated on at least one dose of intravenous vancomycin within 48 hours of admission. Results A total of 79 patients were identified for inclusion in the pre-protocol group (n=32) or post-protocol group (n= 47). The mean duration of vancomycin therapy in the pre-protocol group was 3.1 days as compared to 1.7 days in the post-protocol group for a 1.4 days reduction (p=0.044). There was no significant impact on the number of vancomycin cases de-escalated within 24 hours (p=0.14) but there was a significant reduction at 48 hours (p=0.01). Protocol implementation was associated with a reduction in the average length of hospitalization (8 versus 5.20 days, p=0.006). Neither group had a vancomycin-associated acute kidney injury or in-hospital mortality. Conclusion Among patients with suspected MRSA pneumonia, a pharmacist-driven MRSA PCR nasal swab protocol resulted in a significant reduction of empiric vancomycin duration of therapy without an adverse impact on clinical outcomes in a rural healthcare setting.
引言 耐甲氧西林金黄色葡萄球菌（MRSA）引起的肺炎具有较高的发病率和死亡率。许多临床医生会凭经验用万古霉素治疗有发生MRSA肺炎风险的患者。多项研究已确定MRSA聚合酶链反应（PCR）鼻拭子检测在 lower respiratory tract infections中的阴性预测价值较高，这表明它可用于指导经验性抗MRSA治疗的降阶梯治疗。目的 评估药剂师主导的MRSA PCR鼻拭子检测方案对农村医疗机构中肺炎患者经验性使用万古霉素降阶梯治疗的影响。其次，评估在药剂师主导下对肺炎患者经验性使用万古霉素进行降阶梯治疗后的住院时间、万古霉素相关急性肾损伤发生率及院内死亡率。方法 开展一项回顾性、单中心、前后队列研究，研究对象为实施了药剂师主导方案后的患者，该方案允许药剂师为疑似MRSA肺炎且正在接受经验性万古霉素治疗的患者采集鼻拭子并进行MRSA的PCR检测。根据检测结果为阴性，药剂师建议医生对经验性使用的万古霉素进行降阶梯治疗。纳入标准为年龄至少18岁的成年人，经医生诊断为疑似或确诊肺炎，且在入院后48小时内开始使用至少一剂静脉万古霉素。结果 共确定79例患者纳入方案实施前组（n = 32）或方案实施后组（n = 47）。方案实施前组万古霉素治疗的平均时长为3.1天，而方案实施后组为1.7天，减少了1.4天（p = 0.044）。对24小时内降阶梯的万古霉素病例数无显著影响（p = 0.14），但在48小时时有显著减少（p = 0.01）。方案实施与平均住院时间缩短相关（8天对5.20天，p = 0.006）。两组均未发生万古霉素相关急性肾损伤或院内死亡。结论 在疑似MRSA肺炎患者中，药剂师主导的MRSA PCR鼻拭子检测方案可显著缩短经验性使用万古霉素的治疗时长，且在农村医疗机构中对临床结局无不良影响。
