Vancomycin Use In Pediatric Neurosurgery Patients - Statistical Data Included

AORN Journal, July, 2000 by Maryanne K. Coughlin

VANCOMYCIN USE IN PEDIATRIC NEUROSURGERY PATIENTS S Shah et al American Journal of Infection Control Vol 27 (December 1999) 482-487

One clear health risk to surgical patients is vancomycin-resistant enterococci (VRE). Increased use and prior exposure to vancomycin are factors that increase the probability of acquiring VRE. Vancomycin-resistant enterococci are especially problematic because they usually are resistant to multiple antimicrobials, are easily transmitted in the hospital setting, and may transfer vancomycin resistance to other gram-positive organisms. The clinical challenge is to decrease the use of vancomycin to help reduce VRE.

Limited data exist regarding the use of this agent in pediatric patients. This study reported 17.9% of all vancomycin doses ordered at Egleston Children's Hospital (ECH), Atlanta, a large tertiary hospital, were administered to pediatric patients undergoing neurosurgical procedures. In addition, an increase in use of the agent was found in the pediatric neurosurgery unit at this hospital between 1993 to 1995. Little information about indications for vancomycin use, however, is available. In this study, researchers reviewed medical records of a sample of pediatric patients undergoing neurosurgical procedures to whom vancomycin was administered, and they assessed the indications and appropriateness of its use.

Methods. A cross-sectional study of pediatric patients undergoing neurosurgical procedures at ECH was conducted between Jan 1 and Dec 31, 1996. Each patient reviewed received IV vancomycin. Data were obtained from the ECH pharmacy and the information systems department. Thirty patients were selected randomly from all neurosurgical patients who received vancomycin during the study period.

Medical records of these patients were screened to determine each patient's age, gender, underlying diagnoses, reason for admission, and duration of hospitalization. Patients also were screened for indwelling medical devices (eg, central venous catheters, central nervous system shunts) and for other categories of distinction (eg, first dose of vancomycin; neutropenia; immunosuppression as a result of chemotherapy, HIV, organ transplantation, antimicrobial treatment in the previous four weeks).

Vancomycin use was classified as prophylactic (ie, administered in the perioperative setting of a surgical procedure), empiric (ie, administered in the presence of signs and symptoms suggestive of infection before acquiring culture results), and therapeutic (ie, administered after a bacterial pathogen was identified and antimicrobial susceptibilities were known). Indications for the agent included a designation for appropriate use as recommended by the US Centers for Disease Control and Prevention Hospital Infection Control Practices Advisory Committee (HICPAC).

Results. Patients ranged in age from 2.4 months to 17.8 years, and 17 of the 30 patients were male. Hospitalization of patients ranged from one to 12 days with a median of two days. Neurosurgical procedures were performed on 29 patients and included

* cranial (n = 4),

* spinal (n = 2),

* cerebrospinal fluid (CSF) shunt insertion (n = 7), and

* CSF shunt revision (n = 16) procedures.

One patient received a central venous catheter, three received peripheral arterial catheters, and four underwent recent antimicrobial therapy.

Vancomycin was administered as a prophylaxis for cranial (n = 4), spinal (n = 2), and shunt (n = 22) procedures. The first dose was administered to 22 of the patients six minutes to one hour before the surgical procedure. Six patients received vancomycin after the incision was made. Two patients received vancomycin as empiric therapy for suspected meningitis, and no patients received vancomycin as a specific directed therapy based on positive culture results.

According to HICPAC, 28 of these patients received vancomycin as routine surgical prophylaxis. Two were treated empirically for suspected meningitis. The number of extra doses of vancomycin ranged from one to 11, for a total of 50 doses.

Discussion. Vancomycin is an important antimicrobial agent in the treatment of infections caused by gram-positive bacteria. Inappropriate use, however, contributes to a much bigger health risk--VRE. Furthermore, the recent isolation of strains of Staphylococcus aureus with intermediate resistance to vancomycin may be a warning sign of full resistance in the future. Many other antimicrobials have been used successfully as prophylaxis, including cephalosporins, clindamycin-gentamicin, and ampicillin. Given the risk of the emergence of vancomycin-resistant strains, other antibiotics for neurosurgical procedures must be considered. Researchers of this study noted that HICPAC recommendations were difficult to apply to pediatric patients undergoing neurosurgical procedures, and that future consideration should be given to patient population-specific guidelines.

Conclusion. Decreasing the risk of infections associated with multimedication-resistant organisms by reducing overuse and misuse of antimicrobials is a major challenge for clinicians. Implementing clinical guidelines or vancomycin restriction policies may encourage appropriate use of vancomycin.