The impact of a vancomycin intervention on vancomycin‐associated nephrotoxicity in children: a quality improvement initiative

Abstract Background Vancomycin is first‐line treatment for methicillin‐resistant Staphylococcus aureus (MRSA) infections. However, despite guideline recommendations, there is no evidence that targeting vancomycin trough concentrations of ≥15 mg/L in children confers clinical benefit and is associated with vancomycin‐associated nephrotoxicity (VAN). Aim This study aimed to evaluate the impact of a vancomycin safety bundle on VAN and vancomycin utilisation in hospitalised paediatric inpatients. Method A pre–post‐intervention study was conducted in a tertiary paediatric hospital comparing January–December 2018 (pre‐intervention) to May 2019–April 2020 (post‐intervention). Hospitalised children, aged 30 days to <18 years, that received intravenous vancomycin with at least one trough concentration were included. The intervention bundle comprised: (1) lowered empiric vancomycin trough targets (5–15 mg/L), (2) enhanced creatinine monitoring (concomitant serum creatinine with vancomycin trough), (3) guideline modification (reduced pre‐authorised indications for empiric vancomycin use), and (4) prescriber education initiatives. Ethical approval was granted by the WA Child and Adolescent Health Service Research Ethics Committee, Governance Evidence Knowledge Outcomes Program (Reference no: 41830) and the study conforms with the National Health and Medical Research Council's Ethical considerations in quality assistance and evaluation activities. Results A total of 314 vancomycin prescriptions were analysed (n = 204 pre‐intervention; n = 110 post‐intervention). Post‐intervention, VAN incidence decreased almost twofold from 0. 46 to 0. 25 episodes per 1000 patient bed days (p ≤ 0. 01), and vancomycin prescription days decreased by 19%. Total hospital drug costs for vancomycin decreased by AUD 16 033. Overall, and for paediatric invasive MRSA, no significant difference in clinical outcomes or 30‐day mortality was observed between study periods. Conclusion This study demonstrated the implementation of a vancomycin safety bundle significantly reduced paediatric VAN and vancomycin utilisation without compromising clinical outcomes. These data support antimicrobial stewardship interventions to improve medication safety for children.