"One and done" vancomycin dosing disparaged
By M. ALEXANDER OTTO
At the 2013 ACEP Acientific Assembly
SEATTLE—One-and-done vancomycin dosing in the emergency department was associated with a high rate of ED returns for the same infection within 3 months, based on a single-center, retrospective study.
From Dec. 2008 to June 2010, 526 ED patients got vancomycin, mostly for cellulitis and abscesses, at the Barnes-Jewish Hospital ED in St. Louis, Mo., an academic ED that annually serves almost 100,000 patients; 67.9% got one dose, 26.6% got two, and 5.5% received three doses. Weight-based doses were too low in 73%, and too high in 3.4%. Less than half of the patients were sent home on an oral antibiotic; about one-third were back in the ED within 3 months for the same infection.
"It was very common just to order a dose of vancomycin and send people home, [but] none of the guidelines" from the Infectious Diseases Society of America and other groups "support the use of vancomycin in patients who have uncomplicated infections before going home" from the ED, said lead investigator Dr Kristen Mueller, a fourth-year emergency medicine resident at Barnes-Jewish. A single dose doesn’t keep inhibitory concentrations high enough for long enough to knock out infections entirely; although sensitive strains may die off, more robust and virulent ones are left to proliferate. Patients end up colonized by more resistant bacteria.
Several emergency physicians at the meeting said that they’ve noticed vancomycin dosing problems in their EDs, as well. Vancomycin dosing problems also were reported in a study published earlier this year by researchers from Christiana Care Health System in Newark Delaware (J Emerg Med. 2013;44[5]:979-984).
Vancomycin-intermediate Staphylococcus aureus was isolated from about 170 Barnes-Jewish patients in 2009. "It’s not as common as MRSA, but it’s there. What’s more concerning is that frank vancomycin resistant S. aureus is starting to establish itself in the US," and inappropriate use of vancomycin will just fuel the problem, she said.
Concerns about nephrotoxicity may be behind the low-dosing issue, but the hospital’s EHR system might also contribute to dosing inaccuracy, Dr Mueller said. At Barnes-Jewish, "our easiest order dose is 1 gram of vancomycin; it’s a one-click order in our order set. Whereas, to order a weight-appropriate dose, you actually have to calculate it out and type in the dose you want."
In response to the findings, Dr Mueller and her colleagues are adding a skin and soft tissue order set to the EHR system, with different tabs based on infection type and sub-tabs for patient disposition. Patients discharged home or to the observation unit will only have oral antibiotic options. Only inpatients will eligible for weight-based vancomycin dosing.
In an earlier study, Dr Mueller and her colleagues found that ED doses of vancomycin are frequently continued when patients are admitted, even if they’re wrong; 71% of the 2,560 inpatients in the earlier investigation were underdosed (J Emerg Med. 2013;44[5]:910-918).
Dr Mueller had no relevant disclosures.
Prehospital bivalirudin reduced bleeding with PCI
BY SHERRY BOSCHERT
At TCT 2013
SAN FRANCISCO – Giving bivalirudin in the ambulance to patients with ST-segment elevation MI before primary percutaneous coronary intervention significantly improved 30-day bleeding outcomes in a randomized controlled European trial in 2,218 patients, compared with giving unfractionated or low-molecular-weight heparin and optional glycoprotein IIb/IIIa inhibitors.
In Europe, anticoagulation commonly is started in the ambulance. The practice has not yet caught on in most of the United States.
Compared with the control group, the bivalirudin group had a nearly 40% decrease in a composite outcome of death or major bleeding not associated with coronary artery bypass grafting (CABG). Rates
for the primary outcome were 5% in the bivalirudin group and over 8% in the control group at 30 days,
Dr Philippe Gabriel Steg and his associates reported at the Transcatheter Cardiovascular Therapeutics annual meeting.
The rates of the main secondary outcome – a composite of death, reinfarction, or non-CABG major bleeding at 30 days – also were significantly lower in the bivalirudin group (6.7%) than in the control group (9.1%), said Dr Steg, professor of cardiology at Université Paris-Diderot and director of the coronary care unit at Hôpital Bichat, Paris.
The 30-day rate of acute stent thrombosis was nearly sixfold higher in the bivalirudin group (1.1%) than in the control group (0.2%), but that did not translate into an increased risk of infarction, which occurred in 1.7% in the bivalirudin group and 0.9% in the control group (0.9%).
The study was published online simultaneously with the presentation (N Engl J Med. October 30, 2013 [doi: 10.1056/NEJMoa1311096]).