434 - Barriers and Facilitators for Vancomycin Reduction in Preterm Infants: A Survey of Neonatal Clinicians

Publication Number: 2422.434

Pooja S. Yerram, Childrens Hospital of Philadelphia, Philadelphia, PA, United States; Hanna Rosewood, Childrens Hospital of Philadelphia, Philadelphia, PA, United States; Michael W. Kuzniewicz, Kaiser Permanente Northern California, Los Gatos, CA, United States; Jeffrey S. Gerber, Childrens Hospital of Philadelphia, Philadelphia, PA, United States; Karen M. Puopolo, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, United States; Julia E.. Szymczak, University of Utah School of Medicine, Salt Lake City, UT, United States; Melissa Schmatz, Children's Hospital of Philadelphia, Philadelphia, PA, United States; Chris Bonafide, Childrens Hospital of Philadelphia, Philadelphia, PA, United States; Canita R.. Brent, Childrens Hospital of Philadelphia, Philadelphia, PA, United States; Lori Christ, Childrens Hospital of Philadelphia, Philadelphia, PA, United States; El Noh, Children’s Hospital of Philadelphia, West Chester, PA, United States; Catherine K. Muhumuza, PennMedicine at Princeton University Hospital, Plainsboro, NJ, United States; Alina Ivashchuk, Women’s and Babies Hospital/Penn Medicine, Lancaster, PA, United States; Crystal Bass, CHOP Newborn Care at AtlantiCare, Galloway, NJ, United States; Joshua Bress, Global Strategies, Albany, CA, United States; Catherine Myers, Childrens Hospital of Philadelphia, Pomona, NJ, United States; Miren B. Dhudasia, Childrens Hospital of Philadelphia, Philadelphia, PA, United States; Samuel Garber, Perelman School of Medicine at the University of Pennsylvania, Voorhees, NJ, United States; Sagori Mukhopadhyay, Childrens Hospital of Philadelphia, Philadelphia, PA, United States

Background: Vancomycin is an antibiotic effective against multidrug-resistant bacteria for which few alternatives exist. National guidelines advise against the use of empiric vancomycin, reserving it for confirmed infections requiring vancomycin. Yet, it remains a common empirical antibiotic used in the late-onset sepsis evaluation among preterm infants. To address this, we identified three practices for starting, adding, and stopping vancomycin, collectively referred to as Vancomycin Reduction Practice (VRP) and incorporated them into a guideline for late-onset sepsis evaluations (Figure).

Objective: To identify factors influencing VRP implementation and compare responses by baseline site-specific vancomycin use.

Design/Methods: Cross-sectional survey was administered via REDCap to 386 neonatal clinicians at 14 Level 3 NICUs. Vancomycin use in infants born at ≤35 weeks' gestation was collected over 18 months, and use based on VRP was projected for each site. Sites were categorized as "at-goal" and "high-use" when baseline use rate was ≤10% and >10% of projected use, respectively. Barriers to the three practice recommendations were assessed in the knowledge, work environment, and patient-related domains and compared by site type. Descriptive statistics and the chi-square test were used for analysis.

Results: Of 176 (46%) respondents, 78 (44%) were from high-use and 98 (56%) from at-goal sites. Most (57%) were neonatologists, followed by nurses (14%), advanced practice providers (11%), pharmacists (9%) and trainees (7%). More high-use site responders rated their sites' vancomycin use as "too high" (62% vs. 8%, p < 0.001). Although clinicians from both site types identified similar benefits of using oxacillin/nafcillin as a first-line antibiotic, reasons for vancomycin use differed: "standard practice" (62% vs. 2%, p < 0.001) and "peer consistency" (35% vs. 5%, p < 0.001) were more common in high-use sites (Table 1). Similar work-related barriers were also identified for VRP-based vancomycin initiation or addition in high-use sites (Table 2). While most respondents identified no barriers to stopping vancomycin when cultures were negative, 19-34% responders in both groups cited medicolegal concerns and fear of missed infections as barriers.

Conclusion(s): Clinicians at high-use sites more often cite practice norms, infant vulnerability, and medicolegal concerns as drivers of empiric vancomycin use compared to those from at-goal sites. Tailored, site-specific education and culture change initiatives are required to overcome these barriers and optimize vancomycin use in preterm infants.

Figure: An example of a late-onset sepsis evaluation guideline incorporating vancomycin reducing practices (VRP)
Bolded sections in the guideline identify the three components of VRP

Table 1. Selecting first-line empiric antibiotics in late-onset sepsis evaluations.
Factors influencing antibiotic selection for late-onset sepsis, comparing perceived advantages of oxacillin/nafcillin and reasons for empiric vancomycin use.

Table 2. Barriers to Implementing the three VRP recommendations
Comparison of barriers to implementing vancomycin reduction practices across knowledge, work, and patient/family domains by site type.