Resident Physician Joseph M. Sanzari Children's Hospital Hackensack University Medical Center Hackensack, New Jersey, United States
Background: Vancomycin is often used for empiric treatment of Gram-positive infections in infants with late-onset sepsis (LOS). Given resistance and toxicity, the American Academy of Pediatrics and Pediatric Infectious Disease Society recommend a vancomycin-sparing regimen based on methicillin-resistant Staphylococcus aureus (MRSA) risk (known colonization, prior history). However, variability exists in recommendation uptake. In 2022, all infants with suspected LOS in our NICU received vancomycin, resulting in an antibiotic utilization rate (AUR) of 29 days of therapy (DOT) per 1000 patient days. Objective: To decrease the mean vancomycin AUR from 29 to 20 DOT per 1000 patient days (30% decrease) in 12 months. Design/Methods: This QI project is in a one year intervention period (3/23-2/24) and institutional review board exempt. Our level 3b, 40 bed NICU is part of an academic children’s hospital associated with a large medical center and integrated health network. Infants admitted to the NICU and treated for LOS (after 72 hours of life) are included; those with necrotizing enterocolitis are excluded. A multidisciplinary team is using the Model for Improvement to design and execute the project. Interventions tested using Plan, Do, Study, Act cycles include: education sessions, real-time audits of patients on vancomycin for 48+ hours, provider feedback, and clinical practice guideline (CPG) implementation. Variables collected include: gestational age, antibiotics received, MRSA status, culture results, diagnoses, central lines, and mortality. The outcome measure is the vancomycin AUR (DOT/1000 patient days). The AUR is plotted monthly on a statistical process control U-chart and analyzed for special cause variation. The main process measure is adherence to the CPG. Balancing measures include: Gram positive sepsis-related mortality and delayed onset of effective antimicrobial treatment. Process and balancing measures are plotted monthly on run charts. Over the project’s first six months, the vancomycin AUR is 19 DOT/1000 patient days.
