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INFECTIOUS DISEASES

Tolerance of Vancomycin for Surgical Prophylaxis in Patients Undergoing Cardiac Surgery and Incidence of Vancomycin-Resistant Enterococcus Colonization

Graduate Student, Department of Clinical Sciences and Administration, College of Pharmacy, University of Houston, Houston, TX

Thanh Dao, MT

Infection Control Practitioner, Infection Control Department, St. Luke's Episcopal Hospital, Houston

Firas Zabaneh, MT

Infection Control Practitioner, Infection Control Department, St. Luke's Episcopal Hospital

Margaret Reiter, RN

Manager, Patient Safety and Outcomes, St. Luke's Episcopal Hospital

Mark T LaRocco, PhD

Director, Clinical Microbiology Laboratory, St. Luke's Episcopal Hospital

Layne O Gentry, MD

Chief, Section of Infectious Diseases, St. Luke's Episcopal Hospital

Kevin W Garey, PharmD

Assistant Professor, Department of Clinical Sciences and Administration, College of Pharmacy, University of Houston

Reprints: Dr. Garey, Department of Clinical Sciences and Administration, College of Pharmacy, University of Houston, 1441 Moursund St., Houston, TX 77030-3047, fax 713/795-8383, kgarey{at}uh.edu

BACKGROUND: In 2001, vancomycin replaced cefuroxime for antibiotic prophylaxis in patients undergoing cardiac surgery at our institution due to high rates of surgical site infections caused by methicillin-resistant Staphylococcus spp. However, few data supported the use of vancomycin for surgical prophylaxis.

OBJECTIVE: To determine the tolerance of vancomycin for antibiotic prophylaxis and incidence of vancomycin-resistant Enterococcus (VRE) in cardiac surgery patients.

METHODS: In 2 separate studies, we assessed the adverse effects in patients given perioperative vancomycin (study 1) and the incidence of VRE in patients given perioperative vancomycin (study 2). Study 1 was a prospective cohort study of patients undergoing coronary artery bypass graft (CABG) or valve replacement surgery given vancomycin (1 dose preoperatively/2 doses postoperatively) for antibiotic prophylaxis between October 2003 and December 2004. Patients were assessed for tolerance to the antibiotic regimen. In study 2, cardiac surgery patients receiving perioperative vancomycin were screened for VRE before therapy and at day 7 of hospitalization. VRE was detected using standard microbiologic procedures.

RESULTS: In study 1, 1161 patients (CABG = 75%; valve = 19%; both = 6%) were evaluated. All patients but one (99.9%) were prescribed preoperative vancomycin. Therapy was changed for 34 (2.9%) patients, of which 20 changes were due to physician preference for another antibiotic. The only toxicity that required a change in the vancomycin regimen was red man's syndrome, which was experienced by 9 (0.8%) patients. Four patients did not receive a second postoperative dose due to prior renal insufficiency. Patients were most commonly switched to cefuroxime (n = 26), linezolid (n = 2), cefepime (n = 2), gatifloxacin, cefazolin, levofloxacin, or ceftriaxone (n = 1, each). In study 2, 100 patients were screened for the emergence of VRE colonization. No patient was VRE positive at baseline and 4 (4%) were positive at day 7.

CONCLUSIONS: Surgical antibiotic prophylaxis with vancomycin was reasonably well tolerated in CABG and valve replacement surgery, with a 4% incidence of VRE colonization.

Key Words: red man's syndrome, vancomycin, vancomycin-resistant Enterococcus

Published Online, February 14, 2006. www.theannals.com, DOI 10.1345/aph.1G565

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				K. W. Garey, D. Lai, T. K. Dao-Tran, L. O. Gentry, L. Y. Hwang, and B. R. Davis Interrupted Time Series Analysis of Vancomycin Compared to Cefuroxime for Surgical Prophylaxis in Patients Undergoing Cardiac Surgery Antimicrob. Agents Chemother., February 1, 2008; 52(2): 446 - 451. [Abstract] [Full Text] [PDF]

				K. W. Garey, T. Dao, H. Chen, P. Amrutkar, N. Kumar, M. Reiter, and L. O. Gentry Timing of vancomycin prophylaxis for cardiac surgery patients and the risk of surgical site infections J. Antimicrob. Chemother., September 1, 2006; 58(3): 645 - 650. [Abstract] [Full Text] [PDF]