Vancomycin use in a hospital with vancomycin restriction.

We evaluated vancomycin use in a hospital with endemic vancomycin-resistant enterococci and a vancomycin restriction program. Only 68% of vancomycin was prescribed appropriately. Inappropriate use was due primarily to empirical therapy. In the patients with a microbiological diagnosis following empirical therapy, 83% (25/30) had infections due to bacteria sensitive to an appropriate antibiotic other than vancomycin. However, only 60% (15/25) of these patients had their vancomycin orders changed.

Effect of pharmacist interventions on medication use and cost in hospitalized patients with or without HIV infection.

Pharmacotherapeutic interventions and drug acquisition costs in HIV-positive and HIV-negative patients on a hospital medical service were studied. In November and December 1995, HIV-positive and HIV-negative patients were randomly selected and matched on the basis of admission date. Pharmacotherapeutic interventions were recorded by a pharmacist until the time of discharge. Drug acquisition costs were obtained through records of medications ordered. The two patient groups were compared with respect to length of stay (LOS), number and cost of medications, and number of interventions. HIV-positive patients had significantly more medication orders and required more interventions than HIV-negative patients. Mean LOS was not significantly different. HIV status and number of medications were significantly associated with requiring five or more interventions. Drug acquisition costs were significantly higher in the HIV-positive group. The mean pharmacist-attributed cost saving per patient was $134 for HIV-positive patients and $27 for HIV-negative patients. HIV-positive patients required more interventions and consumed more medication resources than HIV-negative patients. Pharmacist interventions produced drug acquisition cost savings for both groups, with more savings being realized for positive patients.

Evaluating the cost of medications for ambulatory HIV-infected persons in association with landmark changes in antiretroviral therapy.

Costs of medications for ambulatory HIV-infected people increase as knowledge of antiretroviral therapy and therapy for opportunistic infection grows. We evaluated the evolution of drug costs for HIV-infected persons who attend a university clinic in Baltimore, Maryland. Cross-sectional abstracts of a cohort of patients for four periods, corresponding to landmark changes in therapy, who attended the clinic between June 1995 and September 1996 were obtained. Monthly medication costs for all patients were calculated. Mean costs increased significantly (p < .01) from period 1 ($447 U.S.) to period 4 ($1048 U.S.). Multivariate analysis only revealed higher costs for patients with a CD4+ count <200 cells/mm3 (p < .001). The proportion of costs attributable to antiretroviral therapy increased from 34% in period 1 to 53% in period 4. Combination therapy increased >10-fold, from 8% in period 1 to 94% in period 4. Protease inhibitor use also increased significantly, from 4% in period 2 to 53% in period 4. We quantified the increase in costs of medications from mid-1995 to late 1996. Increases in costs appear to be the result of increasing complexity of drug regimens, particularly antiretroviral therapy in combinations.

Enterococci resistant to multiple antimicrobial agents, including vancomycin. Establishment of endemicity in a university medical center.

OBJECTIVES: To determine the distribution of and risk factors for colonization and infection with vancomycin-resistant enterococci; to evaluate the molecular epidemiology of these strains; and to assess the effect of interventions, including 1) strict adherence to infection control procedures and 2) restricted use of vancomycin. DESIGN: Problem identification based on descriptive studies, point-prevalence surveys, and case-control studies and followed by specific interventions and evaluation of the response to these interventions. SETTING: University medical center. PARTICIPANTS: All patients hospitalized between May 1992 and June 1994 (59,196 admissions). MAIN RESULTS: 75 active infections attributed to vancomycin-resistant enterococci were identified. Thirty-one patients (41%) had bloodstream infections and 6 (8%) died. The incidence of active infection was highest in the organ transplantation unit (13.2 infections/1000 admissions). In the point-prevalence studies, vancomycin-resistant enterococci were isolated from 20% of a random sample of hospitalized patients in July, August, and September 1993 (adjusted prevalence, 16.9%). Case-control studies showed significant associations between colonization and infection and 1) receipt of antimicrobial agents, particularly vancomycin, and 2) severity of illness. Although several small case clusters had isolates with identical banding patterns on pulsed field gel electrophoresis, at least 45 different banding patterns were noted among medical center isolates. Interventions took place in November and December 1993. Vancomycin restriction policies resulted in a 59% decrease in intravenous vancomycin use and an 85% decrease in oral vancomycin use. Point-prevalence surveys done in April, May, and June 1994 showed a consistent 20% level of colonization with vancomycin-resistant enterococci strains (adjusted prevalence, 18.7%). No significant changes were seen in rates of vancomycin-resistant enterococci infection. CONCLUSIONS: Vancomycin-resistant enterococci are an important cause of illness and death in the study institution, particularly among organ transplant recipients and other seriously ill persons; they have also become a common intestinal colonizer among hospitalized patients. The diversity of isolates (based on molecular typing studies) suggests that resistant organisms have been introduced from multiple sources. Interventions that effectively lower the overall level of colonization with vancomycin-resistant enterococci must still be identified.