IV Fluid Shortage Mitigation Actions

DUHS Antimicrobial Stewardship IV Fluid Shortage Mitigation Announcement

*** Updated 10/10/2024 ***

IV Vancomycin uses high volumes of IV fluid. Clinicians should vigilantly assess risk factors for resistant Gram-positive infections and need for anti-MRSA therapy for each patient. See below for general guidance regarding anti-MRSA agent alternatives. Always account for patient specific factors.
After initiation, clinicians should actively de-escalate empiric, broad-spectrum antibiotics to narrow, targeted agents as clinical data return.
- Use a negative MRSA nasal PCR to stop vancomycin in patients with suspected MRSA pneumonia.
- Use negative blood culture results at 48 hours to stop vancomycin for patients with suspected sepsis due to Gram positive pathogens.
Active Immediately
- All patients should be actively evaluated for IV to PO conversions for anti-infectives.
  - In particular, PO azithromycin is preferred over IV azithromycin to conserve fluids.
- (DUH-Durham) Linezolid restriction to ID consult/telephone approval has temporarily been removed for ADULT patients
  - LMA noting restriction has been removed in Maestro
  - Helpful education to carefully evaluate drug-drug interactions is on CustomID
- (DUH-Durham) Daptomycin restriction to ID consult has transitioned to telephone approval for ADULT patients
  - Restriction screens remain during order entry, however ID consultants have been alerted of this modification to use judgement in providing telephone/chart review approval versus bedside consults. This will be updated in Maestro after the system freeze.
- (DUH-Raleigh) Daptomycin restriction has been expanded to either ID consult OR antimicrobial stewardship approval. Linezolid use remains unrestricted.

Helpful Tips

Critically evaluate the need for Anti-MRSA coverage
- Avoid vancomycin in patients that are extremely low risk for MRSA:
  - Most UTIs
  - Intra-abdominal infection (IAI)
  - Non-purulent cellulitis (cefazolin preferred)
  - Non-severe CAP
- Among patients with pneumonia, assess risk factors BEFORE starting MRSA coverage:
  - Personal history of +MRSA respiratory culture in past 1 year
  - Prior hospitalization AND IV antibiotics in past 90 days
  - Pre-test probability of MRSA based on clinical characteristics (e.g. cavitary/necrotizing presentation, large effusion/empyema, severe disease with purulence and/or septic shock)
Use rapid diagnostics to help stop anti-MRSA agents quickly:
- MRSA nasal PCR can rule out MRSA pneumonia – find more information here
Indication-based Guidance for Vancomycin Alternatives during IV Fluid Shortage:

Indication for Resistant Gram Positive Coverage	Suggested alternative(s) to Vancomycin
Suspected or Confirmed MRSA Pneumonia	Linezolid If contraindication to linezolid: Ceftaroline* For otherwise stable patients, consider MRSA PCR nasal screen *prior* to initiating MRSA therapy and holding MRSA therapy if nasal screen is negative.
Gram Positive Bacteremia Including suspected or confirmed MRSA or Coagulase Negative Staphylococcus (CoNS), or suspected central line infection	Daptomycin ID consult required for S. aureus or S. lugdunensis bacteremia**
Skin and Soft Tissue Infection due to MRSA	Non-purulent: Cefazolin or cephalexin Purulent and little concern for bloodstream infection: doxycycline, sulfamethoxazole/trimethoprim, linezolid If concern for possible bloodstream infection: Daptomycin** If concern for necrotizing fasciitis: linezolid + ID consult Clindamycin is not ideal due to higher rates of MRSA resistance and C. difficile risk
CNS Infection	1st line: Vancomycin, until CSF and susceptibility data return Alternative: Linezolid + discussion with ID consultants, particularly for CNS infection due to Staphylococci Guidance Healthcare or Shunt-associated meningitis/ventriculitis guidance Community acquired meningitis guidance
Suspected Sepsis	Carefully evaluate the source and follow source-based guidance, including when MRSA therapy is not indicated (most UTI, IAI, non-purulent soft tissue infections) For true sepsis of unknown source, initiate vancomycin with plans to rapidly de-escalate with culture data at 48 hours.
Medical prophylaxis	ECMO Concentrated vancomycin via central line, when possible Alternative: Call ID for daptomycin approval or alternative recommendation Post-lung transplant: Discuss with transplant ID consultant
ID consult is required for ceftaroline at all DUHS hospitals *For daptomycin: At DUH Durham campus, ID telephone approval is required; at DUH Raleigh campus, ID consult OR antimicrobial stewardship approval is required.

Agent-based Guidance for Anti-MRSA Agents During IV Fluid Shortage

Drug	Currently impacted by IV fluid shortage? (i.e., diluent ≥250 mL)	Considerations
IV ceftaroline*	NO	Restricted to ID consult
IV clindamycin	NO	Linezolid is preferred as anti-MRSA + anti-toxin therapy for patients with necrotizing soft tissue infection
IV daptomycin*	NO	IV push; at DUH Raleigh, restricted to ID consult OR antimicrobial stewardship approval during the fluid shortage
IV doxycycline	YES, 200 mg doses	Oral formulation is preferred when feasible
IV linezolid	NO	Premix; oral formulation is preferred when feasible Drug interaction considerations for linezolid use
IV tedizolid*	YES	Oral formulation is preferred when feasible
IV trimethoprim/sulfamethoxazole	YES	Oral formulation is preferred when feasible
IV vancomycin	YES	For patients with central line access, vancomycin doses ≤ 1000 mg may be concentrated in 100 mL bags (max 10 mg/mL)
*Agents that currently require ID consult approval at DUH Raleigh campus

Questions/Concerns?

Center for Medication Policy: 919-684-5125
Site Specific Stewardship/ID Pharmacists
- DUH-Durham ASET: 970-6666 (pager) or Secure Chat Group: ASET Med or ASET Surgery
- DUH-Raleigh (Jessica Michal, usual hours M-F 0700-1530): phone 919-485-1736, pager 919-970-3521
- Duke Regional (John Boreyko): 919-470-4145 or Secure chat