Fear of resistance spurs development of antibiotic wound protocol

Team outlines alternative antibiotic use

A hospital-based continuous quality improvement team in El Paso, TX, has developed a protocol designed to help home health wound care patients avoid an aggressive new antibiotic-resistant organism.

Most such teams focus only on enhancing processes that result in variations, lower-than-average outcomes, or higher-than-average costs, and processes that directly involve hospital patients.

Medicare has strict reimbursement rules about home-infused antibiotics for wound care treatment. It will pay only for the antibiotic vancomycin, and it limits the dosage to 500 mg/day. So when Enid Seguinot, RN, BSN, CIC, infection control director at Columbia Medical Center West in El Paso, read about some documented cases of a vancomycin-resistant organism on the East Coast, she was concerned.

"That’s where methicillin-resistant Staphylococcus aureus (MRSA) and antibiotic-resistant tuberculosis started, and they moved West," she says. "With the high use of vancomycin here, we were afraid the resistant organism would start occurring here."

The hospital formed a team that included Seguinot; the physician-chairman of infection control; the physician-director and the nurse-director of the hospital’s wound care center; the pharmacy manager, the pharmacist-director of the outpatient infusion therapy center; a staff clinical pharmacist; and a staff nurse from the infusion center. Their goal was to design a protocol for antibiotic therapy that could be given once a day on an outpatient basis, to avoid the Medicare home health rule regarding vancomycin, says Chuck McDow, pharmacy manager. Team members also wanted to improve the outcomes for wound care patients.

"We came up with the idea that we would develop a once-a-day antibiotic service to manage those patients coming out of wound care, rather than send them home," McDow says. "Since we weren’t getting good outcomes in these wound care patients because we couldn’t give them the appropriate antibiotic therapy on the outside, and we couldn’t have these patients admitted to the hospital for the 30 days they needed to have therapy, we had to develop a drug regimen that could be conducted in a controlled environment in an outpatient setting."

Before the changes, patient care generally followed a standard course:

• admission to the wound care center, where staff debrided the wound and administered Procuren, an autologous-generated growth factor;

• Hyperbaric oxygenation (HBO) therapy, with patient returning to the infusion center for daily treatments;

• intravenous antibiotic therapy at home three times a day.

Team members reasoned that patients could receive once-daily antibiotic treatments while at the infusion center for their daily HBO treatments, McDow explains. "That means we had to develop a drug regimen that was given only once a day."

Not much to go on

Team members attacked their task by conducting a literature search. "There were a lot of publications on once-a-day dosing of antibiotics in inpatient settings but not too many outpatient programs," McDow says. They also looked at recommendations developed by Centers for Disease Control and Prevention (CDC) in Atlanta.

"The CDC recommendations deter the use of vancomycin," Seguinot says. "We used them to show the physicians some evidence for our thinking."

Team members also used the process of brainstorming and drew from the experience of the various disciplines represented on the team, she says. This technique uncovered the fact that home health care patients were receiving only 500 mg of vancomycin a day, which is not high enough to treat the infection.

Their solution was to put together a pharmacy-based kinetic dosing service. Kinetic dosing of drugs is based on the patient’s physical status, such as kidney and liver function. The pharmacists use a software-based mathematical model to dose each patient individually based on his or her weight, height, and liver and kidney function.

Vancomycin used selectively

Next, team members developed protocols for recommended antibiotics. "Initially, we use Rocephin, and if that’s not effective, we go to an aminoglycoside such as tobramycin or gentamicin," McDow explains. "We found out that we would need to use vancomycin, but it’s reserved for documented cases of MRSA and enterococci. We use a high enough dose in the therapeutic level so that we would prevent the emergence of resistant organisms. If you dose it subtherapeutically, you increase the chance of there being an organism that [is able to grow]. If you use the appropriate dose, you kill most of the bacteria. We are not using vancomycin unless we determine that that’s the only alternative."

The team also designed a three-step multidisciplinary approach to wound care:

1. Physicians admit patients to the infusion center with the recommended initial empiric antibiotic therapy.

2. Pharmacists dose the antibiotic based on the determined protocol. Dosing is based on patient’s renal and hepatic functions, and size.

3. Nurses administer the antibiotics.

"Through that team effort, we’re able to improve outcomes, as well," McDow says. "At home, the environment is not controlled, there is no kinetic service, no one is calculating what the dosages should be, and drug levels are not monitored appropriately."

If patients are not able to come to the infusion center, however, the wound care team will dose and monitor patients for home health, McDow adds.

The result of the team’s work is that outcomes have improved dramatically. Before the team’s recommendations were put into effect, the wound center had a rate of about 50% healed or improved, Seguinot says. Afterward, that rate rose to 88%.

The team continues to track every patient’s wound size. As it heals, they conduct cultures of the infection and monitor patients’ serum drug blood levels to determine if the dosing calculations achieved the desired drug levels within a nontoxic range. Failures and reasons for those failures are documented and reported to practitioners and the infection control department. Every failure is reviewed by the medical staff, McDow says.

Team members also interview patients to determine their level of satisfaction. "Most are satisfied with the therapy," McDow says. "Some prefer not to come in every day; that’s why we started providing the kinetic service through home health. We’ve even started providing transportation to and from the clinic to increase satisfaction. Patients have to come in every day for HBO therapy anyway, so it works out well."