Di Pentima
Impact of antimicrobial stewardship program on vancomycin use in a pediatric teaching hospital
Pediatr Infect Dis J
Epub ahead of print 2010 Feb 23
; doi:

Investigators from Alfred I. duPont Hospital for Children, Wilmington, DE, performed a prospective single-hospital intervention study of the impact of an antimicrobial stewardship program (ASP) on intravenous vancomycin use. The intervention consisted of: 1) implementing guidelines and indications for each antimicrobial into a computerized prescriber order entry (CPOE) system; 2) prospective monitoring of antimicrobial prescribing and adherence to policies; and 3) real-time feedback to prescribers. The intervention period covered all prescriptions from April 2004 through May 2007. Data from April 2003 through March 2004 was used as a baseline. All medication orders were entered electronically.

Guidelines and approved indications for vancomycin were provided at hospital workstation downloads and pocket-size print versions distributed prior to the intervention. CPOE entry required selection of an approved indication prior to ordering. Prospective monitoring included daily ASP team review of all antimicrobial usage and microbiology (culture) data and discussion with the primary provider. Subsequent interventions included daily reports of patients due to stop vancomycin (with communication to primary providers) and vancomycin-specific CPOE order sets to help guide prescribers in dosing.

Vancomycin use declined from 378 doses administered/1,000 patient-days at baseline to 255 during the last year of the study despite increasing rates of methicillin-resistant Staphylococcus aureus (MRSA). Decreased vancomycin use was not associated with increases in use of other agents against S aureus. Vancomycin prescribing errors were primarily related to dosing (101/190) and premature stop (45/190). Prescription errors dropped significantly from 1.8 to 1.4 errors/1,000 patient days, with the main reduction coming from a decrease in premature stop errors. Central venous catheter infections were the most common source of infection associated with vancomycin prescription errors.

Over the course of the study, non-approved vancomycin indications were selected in 28% of vancomycin doses administered. The rate of approval of ASP recommendations on vancomycin utilization increased from 80% during the first year of the study to 92% for the third year (P<.001). The authors conclude that an ASP reduced vancomycin use and vancomycin prescribing errors, and thereby improved the quality of care.

Computerized provider order entry (CPOE) is an electronic system by which prescribers enter orders for patient care.1 CPOE transmits medication orders to the pharmacy for dispensing drug doses which are delivered to care units for administration to patients. Two ways CPOE can improve medication use are to: 1) guide prescriber behaviors (via effective user interfaces) to adhere to institutional policies; and 2) capture order content (electronically) to understand clinician behaviors.2 To reap these benefits, CPOE must be used for all medication orders within a care unit. Successful CPOE implementation is multi-factorial.3 

The ASP described by Di Pentima, et al, demonstrates a transformative journey that combines health information technology and adaptive leadership. Recent reports from other pediatric tertiary institutions have also demonstrated improvements in...

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