Oral Step-Down Therapy With Levofloxacin for Febrile Neutropenia in Children With Cancer

Abstract Background Although febrile neutropenia (FN) is a frequent complication in children with cancer receiving chemotherapy, there remains significant variability in selection of route (intravenous [IV] vs oral) and length of therapy. We implemented a guideline with a goal to change practice from using IV antibiotics after hospital discharge to the use of step-down oral therapy with levofloxacin for most children with FN until absolute neutrophil count > 500. The objectives of this study were to determine the impact of this guideline on home IV antibiotic use, and to evaluate the safety of implementation of this guideline. Methods We performed a quasi-experimental, pre–post study of discharge FN treatment at a stand-alone children’s hospital in patients without bacteremia discharged between January 2013 and October 2018. In January 2015, a multidisciplinary team created a guideline to switch most children with FN to oral levofloxacin, which was formally implemented as of September 2017. Discharges during the postintervention period (after September 2017) were compared to discharges in the preintervention period (between January 2013 and December 2014). Results In adjusted multivariable regression analyses, the postimplementation period was associated with a decrease in home IV antibiotics (adjusted risk ratio [aRR], 0.07 [95% confidence interval {CI}, .03–.13]) and fewer IV antibiotic initiations within 24 hours of a new healthcare encounter up to 7 days after discharge (aRR, 0.39 [95% CI, .17–.93]) compared to the preintervention time period. Conclusions Step-down oral levofloxacin for children with FN who are afebrile with an ANC ≤ 500 at discharge is feasible and resulted in similar clinical outcomes compared to home IV antibiotics.

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Impact of Removal of Automatic 7-Day Stop Orders for Inpatient Antimicrobials

Infection Control and Hospital Epidemiology ◽

10.1017/ice.2020.831 ◽

2020 ◽

Vol 41 (S1) ◽

pp. s264-s265

Author(s):

Afia Adu-Gyamfi ◽

Keith Hamilton ◽

Leigh Cressman ◽

Ebbing Lautenbach ◽

Lauren Dutcher

Keyword(s):

Time Series ◽

Time Series Analysis ◽

Interrupted Time Series ◽

Antibiotic Use ◽

Interrupted Time Series Analysis ◽

Series Analysis ◽

Treatment Interruptions ◽

Days Of Therapy ◽

Quasi Experimental ◽

The Impact

Background: Automatic discontinuation of antimicrobial orders after a prespecified duration of therapy has been adopted as a strategy for reducing excess days of therapy (DOT) as part of antimicrobial stewardship efforts. Automatic stop orders have been shown to decrease antimicrobial DOT. However, inadvertent treatment interruptions may occur as a result, potentially contributing to adverse patient outcomes. To evaluate the effects of this practice, we examined the impact of the removal of an electronic 7-day ASO program on hospitalized patients. Methods: We performed a quasi-experimental study on inpatients in 3 acute-care academic hospitals. In the preintervention period (automatic stop orders present; January 1, 2016, to February 28, 2017), we had an electronic dashboard to identify and intervene on unintentionally missed doses. In the postintervention period (April 1, 2017, to March 31, 2018), the automatic stop orders were removed. We compared the primary outcome, DOT per 1,000 patient days (PD) per month, for patients in the automatic stop orders present and absent periods. The Wilcoxon rank-sum test was used to compare median monthly DOT/1,000 PD. Interrupted time series analysis (Prais-Winsten model) was used to compared trends in antibiotic DOT/1,000 PD and the immediate impact of the automatic stop order removal. Manual chart review on a subset of 300 patients, equally divided between the 2 periods, was performed to assess for unintentionally missed doses. Results: In the automatic stop order period, a monthly median of 644.5 antibiotic DOT/1,000 PD were administered, compared to 686.2 DOT/1,000 PD in the period without automatic stop orders (P < .001) (Fig. 1). Using interrupted time series analysis, there was a nonsignificant increase by 46.7 DOT/1,000 PD (95% CI, 40.8 to 134.3) in the month immediately following removal of automatic stop orders (P = .28) (Fig. 2). Even though the slope representing monthly change in DOT/1,000 PD increased in the period without automatic stop orders compared to the period with automatic stop orders, it was not statistically significant (P = .41). Manual chart abstraction revealed that in the period with automatic stop orders, 9 of 150 patients had 17 unintentionally missed days of therapy, whereas none (of 150 patients) in the period without automatic stop orders did. Conclusions: Following removal of the automatic stop orders, there was an overall increase in antibiotic use, although the change in monthly trend of antibiotic use was not significantly different. Even with a dashboard to identify missed doses, there was still a risk of unintentionally missed doses in the period with automatic stop orders. Therefore, this risk should be weighed against the modest difference in antibiotic utilization garnered from automatic stop orders.Funding: NoneDisclosures: None

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O12 Circulating concentrations of broad-spectrum beta-lactams in children with cancer: beware of glomerular hyperfiltration!

Archives of Disease in Childhood ◽

10.1136/archdischild-2019-esdppp.12 ◽

2019 ◽

Vol 104 (6) ◽

pp. e5.2-e6

Author(s):

P André ◽

L Diezi ◽

LA Decosterd ◽

PA Crisinel ◽

K Dao ◽

...

Keyword(s):

Febrile Neutropenia ◽

Broad Spectrum ◽

Large Fraction ◽

Glomerular Hyperfiltration ◽

List Type ◽

Beta Lactams ◽

Children With Cancer ◽

Therapeutic Success ◽

The Impact ◽

Trough Levels

BackgroundBroad-spectrum beta-lactams such as meropenem (MER) and piperacillin-tazobactam (PIP) are commonly prescribed in children with cancer having febrile neutropenia. They are introduced at intensive dosage, unless decreased renal function calls for dose reduction. Recently, glomerular hyperfiltration (HF) was recognized to be frequent among children with cancer during initial cycles of chemotherapy.1 We evaluated the impact of HF on therapeutic exposure to MER and PIP.MethodsWe retrieved retrospectively all MER and PIP plasma levels measured in children with cancer in our hospital between 2012 and 2018. We compared trough levels with usual therapeutic ranges (derived from reference values of minimum inhibitory concentrations). We classified the children according to plasma creatinine and estimated glomerular filtration rate (Schwartz formula) as either altered-normal (< 160 mL/min/1.73 m2) or increased (i.e. HF, ≥160). Neutropenia was defined as absolute neutrophil count < 500 cells/µL.ResultsWe collected 120 concentration values (53 MER, 67 PIP) measured in 50 children with cancer. Among them, 74 (62%) had concomitant creatinine values suggestive of HF, and 80 (67%) were neutropenic. Overall, 67% of trough levels were below usual therapeutic ranges (MER: 2–8 mg/L, PIP 8–30 mg/L). This was more often the case in presence of concomitant HF (MER: 92%, PIP: 83%), often associated with neutropenia. Low exposure was observed not only at initial intensive dosage (MER: 120 mg/kg/day, PIP: 400 mg/kg/day)2 but tended to persist despite dosage readjustment based on concentration monitoring. Moreover, bacteremia was diagnosed in 38 cases.ConclusionCurrent recommended doses of MER and PIP do not provide optimal concentration coverage throughout the dosing interval in a large fraction of children with cancer and febrile neutropenia as a result of HF. Monitoring of beta-lactams should be offered to all children with cancer to ensure best therapeutic success and avoid the development of resistance.ReferencesKwatra NS, Meany HJ, Ghelani SJ, Zahavi D, Pandya N, Majd M. Glomerular hyperfiltration in children with cancer: prevalence and a hypothesis. Pediatr Radiol 2017;47(2):221–226.The Lexicomp Pediatric & Neonatal Dosage Handbook, 21st edition, Lexicomp, USA.Disclosure(s)Nothing to disclose

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Periconceptional Folic Acid Supplementation and the Risk of Spontaneous Abortion among Women Who Prepared to Conceive: Impact of Supplementation Initiation Timing

Nutrients ◽

10.3390/nu12082264 ◽

2020 ◽

Vol 12 (8) ◽

pp. 2264

Author(s):

Yan-Yan Mao ◽

Liu Yang ◽

Min Li ◽

Jun Liu ◽

Qian-Xi Zhu ◽

...

Keyword(s):

Folic Acid ◽

Spontaneous Abortion ◽

Lower Risk ◽

Folic Acid Supplementation ◽

Health Examination ◽

Adjusted Risk ◽

Adjusted Risk Ratio ◽

Periconceptional Period ◽

Utilization Of Healthcare ◽

The Impact

It is unclear whether periconceptional folic acid (FA) supplementation decreases the risk of spontaneous abortion (SA). The impact of supplementation initiation timing has not been ascertained. This cohort study aimed to investigate the association between maternal periconceptional FA supplementation and risk of SA, with due consideration of the supplementation initiation timing. Through the National Free Pre-conception Health Examination Project (NFPHEP), we identified 65,643 pregnancies on FA supplementation in Chongqing, China between 2010 and 2015. After adjusting for covariates, maternal periconceptional FA supplementation was associated with a lower risk of SA (adjusted risk ratio [aRR]: 0.52; 95% confidence interval [CI]: 0.48–0.56). Pregnant women with FA supplementation initiated at least 3 months before conception had a 10% lower risk of SA (aRR: 0.46; 95% CI: 0.42–0.50) than those with FA supplementation initiated 1–2 months before conception (aRR: 0.56; 95% CI: 0.50–0.62) or after conception (aRR: 0.56; 95% CI: 0.51–0.61). These associations might not thoroughly account for FA supplementation, and to some extent our findings confirm the role of the utilization of healthcare in preventing SAs. Women who initiated healthcare, including taking FA earlier during the periconceptional period, could have a lower risk of SA.

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The Urine-culturing Cascade: Variation in Nursing Home Urine Culturing and Association With Antibiotic Use and Clostridiodes difficile Infection

Clinical Infectious Diseases ◽

10.1093/cid/ciz482 ◽

2019 ◽

Vol 70 (8) ◽

pp. 1620-1627 ◽

Cited By ~ 5

Author(s):

Kevin Antoine Brown ◽

Nick Daneman ◽

Kevin L Schwartz ◽

Bradley Langford ◽

Allison McGeer ◽

...

Keyword(s):

Nursing Home ◽

Nursing Homes ◽

Regression Models ◽

Urine Culture ◽

Nursing Home Residents ◽

Antibiotic Use ◽

Antibiotic Prescribing ◽

Adjusted Risk ◽

Adjusted Risk Ratio ◽

Before And After

Abstract Background Rates of antibiotic use vary widely across nursing homes and cannot be explained by resident characteristics. Antibiotic prescribing for a presumed urinary tract infection is often preceded by inappropriate urine culturing. We examined nursing home urine-culturing practices and their association with antibiotic use. Methods We conducted a longitudinal, multilevel, retrospective cohort study based on quarterly nursing home assessments between April 2014 and January 2017 in 591 nursing homes and covering >90% of nursing home residents in Ontario, Canada. Nursing home urine culturing was measured as the proportion of residents with a urine culture in the prior 14 days. Outcomes included receipt of any systemic antibiotic and any urinary antibiotic (eg, nitrofurantoin, trimethoprim/sulfonamides, ciprofloxacin) in the 30 days after the assessment and Clostridiodes difficile infection in the 90 days after the assessment. Adjusted Poisson regression models accounted for 14 resident covariates. Results A total of 131 218 residents in 591 nursing homes were included; 7.9% of resident assessments had a urine culture in the prior 14 days; this proportion was highly variable across the 591 nursing homes (10th percentile = 3.4%, 90th percentile = 14.3%). Before and after adjusting for 14 resident characteristics, nursing home urine culturing predicted total antibiotic use (adjusted risk ratio [RR] per doubling of urine culturing, 1.21; 95% confidence interval [CI], 1.18–1.23), urinary antibiotic use (RR, 1.33; 95% CI, 1.28–1.38), and C. difficile infection (incidence rate ratio, 1.18; 95% CI, 1.07–1.31). Conclusions Nursing homes have highly divergent urine culturing rates; this variability is associated with higher antibiotic use and rates of C. difficile infection.

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1003. Impact of a Standardized Pharmacist-led Β-lactam Allergy Interview on the Quality of Allergy Documentation

Open Forum Infectious Diseases ◽

10.1093/ofid/ofz360.867 ◽

2019 ◽

Vol 6 (Supplement_2) ◽

pp. S353-S353

Author(s):

Cynthia T Nguyen ◽

Oumaima Sahbani ◽

Jennifer Pisano ◽

Ken Pursell ◽

Natasha N Pettit

Keyword(s):

Primary Outcome ◽

Skin Testing ◽

Hospital Costs ◽

Antibiotic Use ◽

Pharmacist Intervention ◽

Lactam Antibiotic ◽

Quasi Experimental ◽

Secondary Endpoints ◽

The Impact

Abstract Background Reported β-lactam allergies are common and are associated with inappropriate antibiotic therapy, poor clinical outcomes, and increased hospital costs. Documentation of β-lactam reactions is often incomplete and many patients with a reported allergy can tolerate a β-lactam antibiotic. This study aims to evaluate the impact of a standardized interviewing tool used by pharmacists on the quality of β-lactam allergy documentation. Methods This is a single-center, prospective, quasi-experimental study of adult inpatients. Patients were included if they had a documented β-lactam allergy, were interviewed by a pharmacist utilizing a standardized tool, and had the β-lactam allergy updated in the electronic medical record. The primary outcome was the percentage of patients with a complete allergy history documented. A complete allergy history was defined as including a description of the type of reaction, time of the reaction, and timing of the reaction. Secondary endpoints included the documentation of individual allergy history components, including if interventions were required to manage the reaction, tolerance of other β-lactams and receipt of penicillin skin testing in the past. A subgroup analysis was also performed among patients who received antibiotics during the admission evaluating antibiotic use, length of stay, mortality, and readmission. Results The study included 107 patients. The average time to complete an interview was 14.8 minutes. After the interview, 11 (10%) patients had the β-lactam allergy label removed. Consequently 107 allergy labels were evaluated in the pre-interview arm and 96 allergy labels in the post-interview arm. More patients had a documented complete allergy history after pharmacist intervention (39% vs. 0%, P < 0.001). Documentation of all components of the allergy history improved after the interview (Table 1). Additionally, the amount of patients with an unknown reaction significantly declined (21% vs. 6%, P = 0.004). Conclusion The use of a standardized β-lactam allergy interview tool improved the quality of allergy documentation, led to de-labeling of β-lactam allergies, and reduced the amount of unknown reactions. Disclosures All authors: No reported disclosures.

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Limiting Vancomycin Exposure in Pediatric Oncology Patients With Febrile Neutropenia May Be Associated With Decreased Vancomycin-Resistant Enterococcus Incidence

Journal of the Pediatric Infectious Diseases Society ◽

10.1093/jpids/piz064 ◽

2019 ◽

Vol 9 (4) ◽

pp. 428-436 ◽

Cited By ~ 1

Author(s):

Manjiree V Karandikar ◽

Carly E Milliren ◽

Robin Zaboulian ◽

Poornima Peiris ◽

Tanvi Sharma ◽

...

Keyword(s):

Antibiotic Resistance ◽

High Risk ◽

Febrile Neutropenia ◽

Pediatric Oncology ◽

Antibiotic Use ◽

Vancomycin Resistant Enterococcus ◽

Post Intervention ◽

Oncology Patients ◽

Vancomycin Resistant ◽

The Impact

Abstract Background Limited data exists regarding the effects of empiric antibiotic use in pediatric oncology patients with febrile neutropenia (FN) on the development of antibiotic resistance. We evaluated the impact of a change in our empiric FN guideline limiting vancomycin exposure on the development of vancomycin-resistant Enterococcus in pediatric oncology patients. Methods Retrospective, quasi-experimental, single-center study using interrupted timeseries analysis in oncology patients aged ≤18 years with at least 1 admission for FN between 2009 and 2015. Risk strata incorporated diagnosis, chemotherapy phase, Down syndrome, septic shock, and typhlitis. Microbiologic data and inpatient antibiotic use were obtained by chart review. Segmented Poisson regression was used to compare VRE incidence and antibiotic days of therapy (DOT) before and after the intervention. Results We identified 285 patients with 697 FN episodes pre-intervention and 309 patients with 691 FN episodes postintervention. The proportion of high-risk episodes was similar in both periods (49% vs 48%). Empiric vancomycin DOT/1000 FN days decreased from 315 pre-intervention to 164 post-intervention (P < .01) in high-risk episodes and from 199 to 115 in standard risk episodes (P < .01). Incidence of VRE/1000 patient-days decreased significantly from 2.53 pre-intervention to 0.90 post-intervention (incidence rate ratio, 0.14; 95% confidence interval, 0.04–0.47; P = .002). Conclusions A FN guideline limiting empiric vancomycin exposure was associated with a decreased incidence of VRE among pediatric oncology patients. Antimicrobial stewardship interventions are feasible in immunocompromised patients and can impact antibiotic resistance.

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993. Pharmacist-driven Penicillin Allergy Assessment in the Emergency Department – Antimicrobial Stewardship at the Point of Prescription

Open Forum Infectious Diseases ◽

10.1093/ofid/ofz360.857 ◽

2019 ◽

Vol 6 (Supplement_2) ◽

pp. S349-S350

Author(s):

Samantha Campbell ◽

Pavithra Srinivas ◽

Gregory Hauler ◽

Ellen Immler ◽

Susan Seiti ◽

...

Keyword(s):

Emergency Department ◽

Antimicrobial Stewardship ◽

Primary Outcome ◽

Antibiotic Use ◽

Assessment Process ◽

Allergic Reactions ◽

Post Intervention ◽

Quasi Experimental ◽

Tract Infections ◽

The Impact

Abstract Background Β-lactam allergy assessment is endorsed by the IDSA as an antimicrobial stewardship tool to enhance the use of first-line agents. We evaluated the impact of pharmacist-driven penicillin (PCN) allergy assessment at the point of prescription on antibiotic use in our emergency department (ED). Methods Retrospective, quasi-experimental study of adult patients with a PCN allergy receiving antibiotics at a community hospital ED. The intervention comprised an ED pharmacist performing allergy assessment and discussing therapy options with providers at the point of prescription. The primary outcome was to evaluate impact on guideline-preferred antibiotic prescription in the ED pre-intervention (March 1, 2017–August 31, 2017) vs. post-intervention (March 1, 2018–August 31, 2018). Secondary outcomes included types of reported allergic reactions, safety of allergy assessment process, and impact on downstream antibiotic use. Results Overall, 381 patients were evaluated (256 pre-intervention, 125 post-intervention). The median age was similar between groups and 85% of patients presented to the ED from the community. Most common infectious syndromes encountered in the ED were UTIs (35%), respiratory tract infections (25%), and skin/soft-tissue infections (18%). The proportion of guideline-preferred antibiotic prescriptions in the ED increased from 37% pre to 44% post (P = 0.171). Proportion of fluoroquinolone (FQ) prescriptions in the ED was reduced from 37.5% pre to 26% post (P = 0.021). Proportion of cephalosporin prescriptions increased from 26% pre to 42% post (P = 0.002). Types of reported allergic reactions were similar between groups and 55% of patients had tolerated a β-lactam agent since the listed allergy. Overall, 70% of patients were hospitalized from the ED. Similar trends in antibiotic use were observed at admission – decreased FQs (38% pre vs. 27% post, P = 0.059), increased cephalosporins (24% pre vs. 38.4% post, P = 0.021). Two patients (1.6%) experienced a nonsevere reaction within 24 hours of β-lactam administration post-allergy assessment. Conclusion Pharmacist-driven PCN allergy assessment at the point of prescription in the ED was safe and effective at improving the use of guideline-preferred antibiotics and reducing FQ use. Disclosures All authors: No reported disclosures.

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Procalcitonin and Interleukin-10 May Assist in Early Prediction of Bacteraemia in Children With Cancer and Febrile Neutropenia

Frontiers in Immunology ◽

10.3389/fimmu.2021.641879 ◽

2021 ◽

Vol 12 ◽

Author(s):

Marcel Doerflinger ◽

Gabrielle M. Haeusler ◽

Connie S. N. Li-Wai-Suen ◽

Julia E. Clark ◽

Monica Slavin ◽

...

Keyword(s):

Febrile Neutropenia ◽

Predictive Ability ◽

Fold Increase ◽

Interleukin 10 ◽

Service Utilisation ◽

Children With Cancer ◽

Clinical Variables ◽

Reactive Protein ◽

Plasma Cytokines ◽

The Impact

ObjectivesFebrile neutropenia (FN) causes treatment disruption and unplanned hospitalization in children with cancer. Serum biomarkers are infrequently used to stratify these patients into high or low risk for serious infection. This study investigated plasma abundance of cytokines in children with FN and their ability to predict bacteraemia.MethodsThirty-three plasma cytokines, C-reactive protein (CRP) and procalcitonin (PCT) were measured using ELISA assays in samples taken at FN presentation (n = 79) and within 8–24 h (Day 2; n = 31). Optimal thresholds for prediction of bacteraemia were identified and the predictive ability of biomarkers in addition to routinely available clinical variables was assessed.ResultsThe median age of included FN episodes was 6.0 years and eight (10%) had a bacteraemia. On presentation, elevated PCT, IL-10 and Mip1-beta were significantly associated with bacteraemia, while CRP, IL-6 and IL-8 were not. The combination of PCT (≥0.425 ng/ml) and IL-10 (≥4.37 pg/ml) had a sensitivity of 100% (95% CI 68.8–100%) and specificity of 89% (95% CI 80.0–95.0%) for prediction of bacteraemia, correctly identifying all eight bacteraemia episodes and classifying 16 FN episodes as high-risk. There was limited additive benefit of incorporating clinical variables to this model. On Day 2, there was an 11-fold increase in PCT in episodes with a bacteraemia which was significantly higher than that observed in the non-bacteraemia episodes.ConclusionElevated PCT and IL-10 accurately identified all bacteraemia episodes in our FN cohort and may enhance the early risk stratification process in this population. Prospective validation and implementation is required to determine the impact on health service utilisation.

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Pediatric Telehealth Expansion in Response to COVID-19

Frontiers in Pediatrics ◽

10.3389/fped.2021.642089 ◽

2021 ◽

Vol 9 ◽

Author(s):

Stormee Williams ◽

Kristina Hill ◽

Luyu Xie ◽

M. Sunil Mathew ◽

Ashley Ofori ◽

...

Keyword(s):

Underserved Populations ◽

Standard Of Care ◽

Fort Worth ◽

Chi Square ◽

Time Period ◽

Quasi Experimental ◽

Pediatric Populations ◽

Pediatric Healthcare ◽

The Impact

Introduction: Telehealth utilization has been steadily increasing for the past two decades and has been recognized for its ability to access rural and underserved populations. The advent of COVID-19 in March 2020 limited the feasibility of in-person healthcare visits which in turn increased telehealth demand and use. However, the long-term impacts of COVID-19 on the telehealth sector of the healthcare industry, and particularly on pediatric healthcare volume demand and subsequent expansion, are yet to be determined.Objective and Methods: To understand the impact of COVID-19 on telehealth utilization, volume demand, and expansion in one large pediatric healthcare system serving greater Dallas-Fort Worth, Texas, data on telehealth clinic visits by month, pre-COVID and post/current-COVID were compared. A quasi-experimental pretest-posttest design analysis compared telehealth visit counts from 54 ambulatory pediatric health specialties. Pre-post new patient counts were also analyzed via chi square.Results: Total telehealth visit counts significantly increased between March–October 2019 (2,033 visits) compared to March-October 2020 (54,276 visits). Mean monthly telehealth visits increased by 6,530 visits, or 2,569.75% over the same time period (p < 0.0001). In October 2020, total telehealth visits were still 1,194.78% above 2019 levels (345 visits in 2019 vs. 4467 visits in 2020).Discussion: Results here show a substantial volume increase in telehealth-delivered pediatric healthcare and resource utilization as a response to COVID-19. This provides a template for permanent adoption of pediatric telehealth delivery post pandemic. Further investigation is needed to determine impacts upon resource allocation, processes, and general models and standard of care to assist facilities and programs to better address the needs of the pediatric populations they serve in the post-COVID era.

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Multidisciplinary Tool Kit for Febrile Neutropenia: Stewardship Guidelines, Staphylococcus aureus Epidemiology, and Antibiotic Use Ratios

JCO Oncology Practice ◽

10.1200/jop.19.00492 ◽

2020 ◽

Vol 16 (7) ◽

pp. e563-e572

Author(s):

Rachel Bartash ◽

Kelsie Cowman ◽

Wendy Szymczak ◽

Yi Guo ◽

Belinda Ostrowsky ◽

...

Keyword(s):

Staphylococcus Aureus ◽

Febrile Neutropenia ◽

Predictive Value ◽

Retrospective Chart Review ◽

Antibiotic Use ◽

Post Intervention ◽

Days Of Therapy ◽

Before And After ◽

Quasi Experimental ◽

Mrsa Colonization

PURPOSE: Inappropriate vancomycin for febrile neutropenia (FN) is an ideal antimicrobial stewardship target. To improve vancomycin prescribing, we instituted a multifaceted intervention, including an educational guideline with audit for compliance; an antibiotic use audit; and an assessment of local burden of methicillin-resistant Staphylococcus aureus (MRSA) colonization and infection. MATERIALS AND METHODS: We conducted a quasi-experimental pre-post intervention review of vancomycin initiation for FN on a 32-bed hematology/oncology unit. A retrospective chart review was conducted from November 2015 to May 2016 (preintervention period). In January 2017, we implemented an institutional FN guideline emphasizing criteria for appropriate use. Vancomycin audit was conducted from February 2017 to October 2017 (postintervention period). The primary outcome was appropriateness of vancomycin initiation. We then compared average antibiotic use (days of therapy per 1,000 patient days) for vancomycin and cefepime before and after intervention. Finally, unit-wide MRSA screening cultures were obtained upon admission and bimonthly for 6 weeks (October 2, 2017, to November 9, 2017). Screened patients were followed for 12 months for clinical MRSA infection. RESULTS: Forty-three (49%) of 88 preintervention patients were started on empiric vancomycin appropriately, compared with 59 (66%) of 90 postintervention patients ( P = .02). There was a significant decrease in vancomycin use after intervention. Six (7.1%) of 85 patients screened positive for MRSA colonization. During the 12-month follow-up, no colonized patients developed clinical MRSA infections (positive predictive value, 0.0%). Of the 79 noncolonized patients, 2 developed a clinically significant infection (negative predictive value, 97.5%). CONCLUSION: Guideline-focused education can improve vancomycin appropriateness in FN and should be bundled with education and feedback about local MRSA epidemiology and antibiotic use rates for maximal stewardship impact.

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