Reducing Vancomycin Use in a Level IV NICU.

BACKGROUND AND OBJECTIVES: Vancomycin remains one of the most commonly prescribed antibiotics in NICUs despite recommendations to limit its use for known resistant infections. Baseline data revealing substantially higher vancomycin use in our NICU compared to peer institutions informed our quality improvement initiative. Our aim was to reduce the vancomycin prescribing rate in neonates hospitalized in our NICU by 50% within 1 year and sustain for 1 year. METHODS: In the 60-bed level IV NICU of an academic referral center, we used a quality improvement framework to develop key drivers and interventions including (1) physician education with benchmarking antibiotic prescribing rates; (2) pharmacy-initiated 48-hour antibiotic time-outs on rounds; (3) development of clinical pathways to standardize empirical antibiotic choices for early-onset sepsis, late-onset sepsis, and necrotizing enterocolitis; coupled with (4) daily prospective audit with feedback from the antimicrobial stewardship program. RESULTS: We used statistical process u-charts to show vancomycin use declined from 112 to 38 days of therapy per 1000 patient-days. After education, pharmacy-initiated 48-hour time-outs, and development of clinical pathways, vancomycin use declined by 29%, and by an additional 52% after implementation of prospective audit with feedback. Vancomycin-associated acute kidney injury also declined from 1.4 to 0.1 events per 1000 patient-days. CONCLUSIONS: Through a sequential implementation approach of education, standardization of care with clinical pathways, pharmacist-initiated 48-hour time-outs, and prospective audit with feedback, vancomycin days of therapy declined by 66% over a 1-year period and has been sustained for 1 year.

What is the appropriate intravenous dose of vitamin E for very-low-birth-weight infants?

The Committee on Fetus and Newborn of the American Academy of Pediatrics (AAP) has endorsed 1 to 2 mg/dl as the normal range of serum tocopherol level. Our Cochrane review has shown that vitamin E supplementation resulting in levels >3.5 mg/dl, but not < or =3.5 mg/dl, significantly reduces the risk for severe retinopathy among very-low-birth-weight (VLBW) infants examined but increases the risks of sepsis and of necrotizing enterocolitis among infants treated for >1 week. As a fixed daily intravenous dose of vitamin E results in an inverse relationship between serum level and birth weight and is a risk for both low and high serum tocopherol levels, a dose adjusted for current weight appears more judicious than a fixed dose per day. Based on currently available data the AAP and the American Society for Clinical Nutrition currently recommend a routine intake of 2 ml/kg/day of MVI Pediatric (2.8 IU/kg/day) in VLBW infants (maximum of 5 ml/day or 7 IU/day).