Louise-Marie Oleksiuk , PharmD, BCPS UPMC Presbyterian Shadyside – Shadyside Campus

1. Use of negative MRSA nares swabs to support discontinuation of vancomycin in patients with pneumonia Louise-Marie Oleksiuk, PharmD, BCPS UPMC Presbyterian Shadyside – Shadyside Campus Antimicrobial Stewardship Program Email: gillislm@upmc.edu Saturday, March 9th, 2019 Three Rivers Antimicrobial Stewardship Symposium

2. Learning Objectives • Describe how MRSA nares swabs can be used to help de-escalate intravenous vancomycin in patients being treated for pneumonia • List some shortcomings of using MRSA nares swabs to de-escalate vancomycin therapy

3. Local Rationale HIGH vancomycin utilization

4. Local Vancomycin Utilization Pneumonia treated with vancomycin Vancomycin utilization for alternate indications Pneumonia treated with alternate antibiotics Of vancomycin use: ~30% pneumonia Of patients with pneumonia: ~45% receive vancomycin

5. Vancomycin Utilization for Pneumonia(non-ICU) Adequate respiratory samples: ~1%

6. Can a negativeMRSA-nasal swab be used to rule-out MRSA pneumonia?

7. Definition – Negative Predictive Value (NPV) Test versus disease table

8. Definition – Negative Predictive Value (NPV) Test versus disease table • The percentage of patients with a negative test who do not have the disease = (D / [C+D]) x 100 • Influenced by prevalence of disease in population being tested • Prevalence ↑, NPV ↓

9. Clinical Utility of MRSA Nasal Screening • 2018 meta-analysis • Evaluate diagnostic value of MRSA nasal screening in MRSA pneumonia • N = 22 studies (5,163 patients) • Pneumonia classification (n=11) • VAP = 5 • CAP, HCAP, VAP = 3 • CAP, HCAP = 2 • “Nosocomial” = 1 • Nares screening • PCR (2 hours, $26) = 11 • Chromogenic agar (2 days, $7) = 4 Parente DM, et al. Clin Infect Dis 2018;67(1):1-7

10. Results • Pooled prevalence of MRSA pneumonia: 10% Parente DM, et al. Clin Infect Dis 2018;67(1):1-7

11. UPMC Shadyside Experience

12. Local Prevalence (2016) MRSA detected in respiratory culture

13. Local NPV MRSA nasal swab result within 7 days before respiratory culture • NPV: 96.9% • ICU: 95.8% • Non-ICU: 98.2%

14. Antimicrobial Stewardship Intervention • Educate pharmacists and prescribers • Vancomycin utilization rates vs prevalence • NPV of MRSA nasal swab • Recommend ordering MRSA nasal swab (and respiratory culture) when starting empiric vancomycin for pneumonia • Prospective audit with intervention and feedback (“timeouts”) • Antimicrobial stewardship, decentralized, rounding, pharmacokinetics pharmacists

15. Vancomycin De-escalation • Within 7 days of onset of pneumonia • Results from adequate respiratory specimens should always supersede MRSA swab findings • MRSA nasal swab should not be used to guide antibiotic de-escalation in patients with: • Concurrent indication for vancomycin/anti-MRSA therapy • Recent nasal decolonization before screening • MRSA infection within 30 days before onset of pneumonia • Clinical findings associated with higher prevalence of S. aureus pneumonia • Empyema, lung abscess, necrotizing or cavitary infiltrates, preceding or concurrent viral pneumonia (e.g. influenza), history of MRSA pneumonia (including Cystic Fibrosis).

16. Q. Which of the following represents a scenario where an MRSA nares swab should NOTbe used to guide vancomycin de-escalation in patients with pneumonia? • Local prevalence of MRSA pneumonia ~5% • Pulmonary culture growing S.pneumoniae • No other indication for intravenous vancomycin (aside from pneumonia) • No clinical findings associated with higher prevalence of S.aureuspneumonia (e.g. empyema, lung abscess, necrotizing or cavitary infiltrates, preceding or concurrent viral pneumonia)

17. Q. Which of the following represent(s) shortcomings of using MRSA nares swabs to guide vancomycin de-escalation? • Negative predictive value is influenced by prevalence of disease in population • Time associated with specimen processing if using chromogenic agar • Unclear utility in patients presenting with clinical findings associated with higher prevalence of S.aureuspneumonia (e.g. preceding or concurrent viral pneumonia) • All of the above represent shortcomings

18. Local Impact (Results) UPMC Presbyterian Shadyside Quality Fair (2019) 1st Place in Quality

19. Local Impact (Results continued)Vancomycin Utilization for Pneumonia *Time from MRSA nasal swab collection to results (days), median (range): 2 (1-3)

20. Project Timeline

21. Barriers and Lessons Learned Barriers Lessons Learned Use of MRSA nasal swabs was a well-accepted (required few repeat interventions) Successfully used “antibiotic timeouts” as recommended by the new Joint Commission medication management standard on antimicrobial stewardship • Limited impact on inappropriate empiric vancomycin initiation (outdated treatment guidelines) • Ensuring timely MRSA nasal swab ordering (initially) • MRSA sample collection required reminders • MRSA nasal swab processing time: 48 hours • Prospective audit with intervention and feedback is time-consuming

22. Future Research • Added experience using it as antimicrobial stewardship tool • Evaluate utility of MRSA nares screen in patients with pneumonia and concomitant risk factors or clinical presentations suggestive for MRSA pneumonia • Clinical utility in other infections Carr AL, et al. Pharmacotherapy 2018;doi:10.1002/phar.2188

23. Acknowledgements Physicians • David R. Weber, MD • Robert L. Volosky, MD • John Zisko, MD • Maria Guyette, MD • Nathan Shively, MD Pharmacists • Frances Youschak, PharmD • Erica Gray, PharmD • Brian Tuttle, RPh

24. Use of negative MRSA nares swabs to support discontinuation of vancomycin in patients with pneumonia Three Rivers Antimicrobial Stewardship Symposium Louise-Marie Oleksiuk, PharmD, BCPS UPMC Presbyterian Shadyside – Shadyside Campus Antimicrobial Stewardship Program Email: gillislm@upmc.edu