KiDrug Alert Journal Club. A Critical Review of: "Impact of Antimicrobial Stewardship Program on Vancomycin use in a Pediatric Teaching Hospital"

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Anne Matlow




Antimicrobial stewardship programs (ASP) are important for cost-effective antimicrobial utilization and reduction in antibiotic resistance. There has been little written about ASPs in pediatric settings.

This study took place at Alfred I DuPont Hospital for Children in Wilmington Delaware, an academic tertiary care pediatric hospital where a computerized prescriber order entry system (CPOE) was in place, and focused on vancomycin utilization.

The ASP included development of guidelines and indications for use of vancomycin, prospective monitoring of prescribing and adherence to indications and hospital policy (displayed as a mandatory field in the CPOE system), and real time prescriber feedback. The major outcome measure was the density of vancomycin use (number of doses administered/ 1000 patient days). The number of interventions by the ASP were monitored and classified. In the first year of the stewardship program errors in vancomycin use and prescribing were identified by review of an automated report of patients on antimicrobials. After baseline data were collected, two interventions, automatic stop orders and targeted decision support were implemented. Vancomycin utilization decreased significantly (378 to 255 doses /1000 patient days) despite a significant rise in S. aureus, including MRSA infections. Vancomycin prescription errors, primarily premature stop and dosing errors, decreased significantly (1.8 to 1.4 errors/ 1000 patient days). However even after three years, 8% of vancomycin orders did not meet the approved indications. As a result, a restriction policy was introduced for preauthorization by the infectious diseases consultant to use vancomycin beyond 2 doses.

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