Vancomycin De-escalation Before and After Integration of Pre-specified Hold Instructions Based on MRSA Nasal PCR Result in the Electronic Medical Record

Background: Methicillin resistant Staphylococcus aureus (MRSA) nasal polymerase chain reaction (PCR) testing can support early de-escalation of empiric vancomycin in patients with suspected pneumonia; however, data evaluating electronic medical record (EMR) based enhancement interventions are limited. Objective: To evaluate the impact of an EMR-integrated MRSA PCR-based vancomycin hold or discontinuation option for suspected pneumonia or sepsis from a pneumonia source. Methods: This single-center, retrospective, pre-post study evaluated adults with a pharmacy vancomycin dosing consult before and after implementation of an EMR-integrated MRSA PCR-based hold or discontinuation intervention. The primary outcome was duration of vancomycin therapy between the pre-implementation and post-implementation groups. Secondary outcomes included acute kidney injury (AKI), same-day vancomycin discontinuation, reinitiation during the same visit, hospital length of stay, number of vancomycin levels obtained, and estimated pharmacist time. Results: In total, 398 patients were included: 200 in the pre-implementation group and 198 in the post-implementation group. Both the initial vancomycin duration and the total vancomycin duration, including reinitiation duration, was significantly reduced in the post-implementation group, with a median of 2 days versus 1 day ( P = 0.013) and 2 days versus 2 days ( P = 0.036), respectively. There were no significant differences in AKI, same-day vancomycin discontinuation, reinitiation during the same visit, hospital length of stay, and estimated pharmacist time. Total vancomycin levels obtained were significantly reduced in the post-implementation group ( P = 0.0165). Conclusion: Implementation of an EMR-based MRSA nasal PCR hold or discontinuation option modestly decreased vancomycin duration without negatively affecting patient outcomes.