Tag Archive for: MRSA

Staphylococcus aureus

Microbiological diagnoses and clinical outcomes for acute hematogenous osteomyelitis

Staphylococcus aureus

Acute hematogenous osteomyelitis is an infection that occurs in the bone and is most commonly caused by the pathogen Staphylococcus aureus.

Hospital length of stay (LOS) was shorter and odds of receiving three or more unique antibiotics for acute hematogenous osteomyelitis (AHO) was lower in culture-negative patients versus culture-positive patients, according to findings presented by researchers at Children’s National Hospital. The data was presented as part of a poster presentation at the ID Week 2022 conference.

AHO is an infection that occurs in the bone and is most commonly caused by the pathogen Staphylococcus aureus. AHO affects about 2-13 children per 100,000 in developed countries each year.

“For most patients with acute hematogenous osteomyelitis, the antibiotics we treat them with are empiric antibiotics – that is, our “best guess” at what antibiotic they should be on – as opposed to “definitive” antibiotics based on microbiologic results,” says Rana Hamdy, M.D., M.S.C.E., M.P.H., director of the Antimicrobial Stewardship Program at Children’s National Hospital and one of the authors of the study. “But with increasing antibiotic resistance, sometimes our “best guess” is wrong and that could lead to longer hospital length of stay and multiple changes in antibiotic regimens for some patients.”

She continues, “For this reason, the 2021 Pediatric Infectious Diseases Society clinical practice guidelines for patients with bone and joint infections suggest performing a bone biopsy when feasible to be able to have culture results to help guide the antibiotic choices.”

Blood and bone cultures may identify causative pathogens and determine antibiotic susceptibilities but obtaining bone cultures is an invasive procedure that carries risks including bleeding and the risk of sedation for the procedure.

The retrospective study included 367 patients under age 21 admitted to Children’s National Hospital from January 2010 – June 2020 with a final clinician’s diagnosis of AHO. Of the 367 patients, 210 (57.2%) had at least one positive culture result, 151 patients (41.1%) had all negative cultures, and 6 (1.6%) patients had no blood, bone or synovial fluid cultures obtained. About 83% of patients with positive culture were identified as having Staphylococcus aureus infections. Specifically, about 24% of identified pathogens were methicillin-resistant Staphylococcus aureus (MRSA).

In this population being culture-negative was associated with shorter LOS and lower odds of receiving three or more unique antibiotics.

“Our study disproved our hypothesis that patients without positive cultures would have longer hospital length of stay; however, because it was a retrospective study, there was the potential for additional confounding factors that we may not have been able to adjust for,” Dr. Hamdy adds.

Baby in the NICU

Quality improvement initiative reduces vancomycin use in NICU

Baby in the NICU

A quality improvement initiative in the Neonatal Intensive Care Unit (NICU) at Children’s National Hospital led to a significant reduction in treatment with intravenous vancomycin, an antibiotic used for resistant gram positive infections, which is often associated with acute kidney injury.

A quality improvement initiative in the Neonatal Intensive Care Unit (NICU) at Children’s National Hospital led to a significant reduction in treatment with intravenous vancomycin, an antibiotic used for resistant gram positive infections, which is often associated with acute kidney injury. The findings, published in the journal Pediatrics, show the initiative reduced vancomycin use in patients by 66%, and the NICU has sustained the reduction for more than a year.

Vancomycin is a broad-spectrum antibiotic often used to treat methicillin-resistant Staphylococcus aureus (MRSA) infection. It’s one of the most commonly prescribed antibiotics in NICUs, but its overuse poses an increased risk of morbidity. Benchmarking data showed that in 2017, vancomycin use at Children’s National Hospital was significantly higher than use at peer institutions, suggesting there was likely an opportunity to optimize use of this drug.

The intervention program was led by Rana Hamdy, M.D., M.S.C.E., M.P.H., an infectious diseases specialist at Children’s National, Lamia Soghier, M.D., medical unit director of the Children’s National NICU, and other team members from neonatology, infectious diseases, pharmacy, nursing and quality improvement. The team accomplished the prescribing reduction by sequentially implementing a four-step approach involving interdisciplinary team building and provider education, pharmacist-initiated 48-hour time-outs, clinical pathway development and prospective audit with feedback.

“Our interdisciplinary quality improvement team was devoted to this project and implemented interventions that, early on, led not only to reduction in vancomycin use, but to better outcomes in our patients with fewer episodes of vancomycin-associated acute kidney injury,” said Dr. Hamdy. “This led to early buy-in from the prescribers, ultimately changing the culture of antibiotic prescribing in the NICU.”

Following the NICU’s intervention program to improve patient safety, vancomycin use in patients decreased from 112 days of therapy per 1,000 patient-days to 38 days of therapy per 1,000 patient-days. During the intervention program, the researchers noted that this was “the first work to show a significant change in vancomycin-associated acute kidney injury in neonates.”

Four key interventions were sequentially implemented to successfully achieve and sustain the reduction in vancomycin use. Intervention 1 was the development of an interdisciplinary and provider education team that addressed institutional antibiotic prescribing practices. Intervention 2, a pharmacist-initiated 48-hour time-out, involved clinical pharmacists identifying patients who have been on antibiotics for ≥ 48 hours and encouraged their providers to either discontinue vancomycin or to switch to a narrow-spectrum antibiotic. Intervention 3 consisted of the development of new clinical pathways including discontinuing vancomycin in infants at low risk for MRSA. Lastly, intervention 4, antimicrobial stewardship program (ASP) prospective audit and feedback, involved an ASP member reviewing all NICU vancomycin orders and issuing appropriate recommendations for NICU providers and pharmacists to be carried out within 24 hours.

This project was taken on as part of Children’s National Quality Improvement and Leadership Training (QuILT) course sponsored by the Quality & Safety Department. This notable work was highlighted in the 2019 annual Quality and Safety report and by the Magnet® program as an exemplary example of nursing-physician partnership working to improve patient care.

The associated article, “Reducing Vancomycin Use in a Level IV Neonatal Intensive Care Unit,” will be published July 1 in Pediatrics. The lead author is Dr. Rana Hamdy, an infectious diseases specialist and director of the Antimicrobial Stewardship Program. Twenty notable co-authors are also from Children’s National.