In this episode, I’ll discuss the impact of compounded oral vancomycin liquid on hospital readmission for C diff infection.
The drug acquisition cost for oral vancomycin capsules is several orders of magnitude larger than for liquid vancomycin prepared from the IV formulation and given via the oral route. This causes inpatient pharmacies to automatically substitute the compounded liquid formulation for all orders for vancomycin capsules.
While this works great in the controlled inpatient environment, it has the potential to cause problems if a discharge prescription for oral vancomycin is written for the liquid formulation. Community pharmacies do not typically compound oral vancomycin solution, and insurance companies may not even cover a non-capsule form of oral vancomycin. The time it takes to resolve this issue once the patient has presented a prescription to a community pharmacy could cause an oral vancomycin prescription to go unfilled or delayed, and this might have an impact on patient outcomes.
To study the impact of prescribing vancomycin capsules vs liquid at discharge on readmissions for C. difficile infection, a group of authors published in American Journal of Health-System Pharmacy a retrospective cohort study.
Data from 440 patients were analyzed. The primary outcomes were all-cause and CDI-specific readmission rates within 30 days of discharge, and secondary outcomes included readmission rates within 60 and 90 days.
The primary outcome trended towards an increase in readmission rates with a prescription for liquid vancomycin but did not reach statistical significance. However with the secondary outcome of the 60-day readmission rate, patients prescribed liquid vancomycin were significantly more likely to be readmitted, with an adjusted hazard ratio for all-cause readmission of 1.87 and 2.84 for CDI-specific readmission.
The authors concluded:
A hospital pharmacy practice implemented to reduce medication costs may impact vancomycin prescribing at discharge and, in turn, may negatively impact readmission rates for patients with CDI treated with oral vancomycin.
Even though this was a small single-center study, hospital pharmacists should note the potential unforeseen consequence of using liquid oral vancomycin. Efforts should be made to guide providers on avoiding liquid vancomycin in favor of capsules during the discharge prescription process. Ideally, the electronic health record can be leveraged to make this guidance available to providers without requiring pharmacists to intervene manually.
The article in this episode is a selection from my Hospital Pharmacy Academy’s weekly literature digest. Have you ever felt like your physician colleagues are one step ahead of you with new literature developments? Every week, Academy members are provided a summary curated and explained by me of the top hospital pharmacy-related articles published that week from over 20 major journals and sources to save you time and keep you up to date with the literature. To get immediate access, go to pharmacyjoe.com/academy.
If you like this post, check out my book – A Pharmacist’s Guide to Inpatient Medical Emergencies: How to respond to code blue, rapid response calls, and other medical emergencies.
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