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This report presents the case of an 18-year-old male with cystic fibrosis (CF) who developed septic shock due to methicillin-resistant Staphylococcus aureus (MRSA) bacteremia. He had a history of poor nutritional status and uncontrolled CF-related diabetes, both contributing to his rapidly declining condition. Despite aggressive treatment, including extracorporeal membrane oxygenation, his hospital course continued to deteriorate, including worsening respiratory failure and the need for lower extremity amputation secondary to ischemia. Ultimately, the decision to withdraw life support was made after it was determined the patient had unrecoverable respiratory failure. Our goal in presenting this case is to demonstrate the serious consequences of MRSA infection in patients with CF, who are often severely immunocompromised, and to emphasize the need for early detection and aggressive intervention among patients of this group.
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Nosocomial Methicillin-resistant Staphylococcus aureus (MRSA) bacteremia results in a significant increase in morbidity and mortality in hospitalized patients. We aimed to analyze the impact of applying 10% povidone iodine (PI) twice daily to both nares in addition to chlorhexidine (CHG) bathing on nosocomial (MRSA) bacteremia in critically ill patients. A quality improvement study was completed with pre and post-design. The study period was from January 2018 until February 2020 and February 2021 and June 2021. The control period (from January 2018 to May 2019) consisted of CHG bathing alone, and in the intervention period, we added 10% PI to the nares of critically ill patients. Our primary outcome is rates of nosocomial MRSA bacteremia, and our secondary outcome is central line associated blood stream infection (CLABSI) and potential cost savings. There were no significant differences in rates of MRSA bacteremia in critically ill patients. Nosocomial MRSA bacteremia was significantly lower during the intervention period on medical/surgical areas (MSA). CLABSIs were significantly lower during the intervention period in critically ill patients. There were no Staphylococcus aureus CLABSIs in critical care area (CCA)during the intervention period. The intervention showed potential significant cost savings. The application of 10% povidone iodine twice a day in addition to CHG bathing resulted in a significant decrease in CLABSIs in critically ill patients and a reduction in nosocomial MRSA in the non-intervention areas. Further trials are needed to tease out individual patients who will benefit from the intervention.
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Vancomycin remains the standard of care for treating methicillin-resistant Staphylococcus aureus (MRSA) bacteremia in pediatrics largely because no alternative antibiotic is definitively superior. Long-standing historical precedent and S. aureus' notable lack of vancomycin resistance are clear benefits, but vancomycin's use remains plagued by nephrotoxicity and the need for therapeutic drug monitoring, with inadequate consensus on how best to dose or monitor vancomycin in pediatrics. Daptomycin, ceftaroline, and linezolid are all promising alternatives, with improved safety relative to vancomycin. However, inadequate and variable efficacy data limit confidence in their use. Despite this, we contend that it is time for clinicians to reconsider vancomycin's place in clinical use. In this review, we summarize the supporting data for using vancomycin versus these other anti-MRSA antibiotics, present a framework for antibiotic decision-making that considers patient-specific factors, and discuss approaches to antibiotic selection for various etiologies of MRSA bacteremia. This review aims to help pediatric clinicians choose among the various treatment options for MRSA bacteremia, acknowledging that the optimal antibiotic choice is sometimes uncertain.
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Bacteriemia , Staphylococcus aureus Resistente a Meticilina , Infecciones Estafilocócicas , Humanos , Niño , Vancomicina/uso terapéutico , Staphylococcus aureus , Infecciones Estafilocócicas/tratamiento farmacológico , Antibacterianos/uso terapéutico , Bacteriemia/tratamiento farmacológicoRESUMEN
Emphysematous pyelonephritis is an acute necrotizing infection of the renal parenchyma, collecting system, and surrounding perinephric tissue, characterized by the presence of gas within these locations on imaging. It is associated with high mortality rates and is often found in diabetic patients. We present the case of a 60-year-old female, with a past history of Von Willebrand disease and hypertension, who presented to our emergency department complaining of acute-on-chronic right knee, left hip, and paraspinal lumbar back pain with an increased frequency of falling for approximately one week. She was found to have pursed-lip breathing on physical exam. Due to her vague clinical presentation, this condition was incidentally discovered on initial workup for a pulmonary embolus, found to have extensive air in the left renal collecting system on CT of the chest. Broad-spectrum antibiotics and monitoring of hemodynamics were part of the initial resuscitation with eventual percutaneous nephrostomy tube placement by interventional radiology. Post-operatively, she developed acute respiratory distress syndrome further complicated by methicillin-resistant Staphylococcus aureus bacteremia. It is important to keep emphysematous pyelonephritis in the differential even in the absence of risk factors and signs of urosepsis when a patient presents with vague signs and symptoms of this disease.
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Endogenous bacterial endophthalmitis (EBE) is a rare but vision-threatening complication of bacteria spreading contiguously through the blood-ocular border. The condition is frequently associated with a poor visual prognosis and has even resulted in death. We present a case of a 48-year-old female with bilateral endogenous methicillin-resistant Staphylococcus aureus (MRSA)endophthalmitis further complicated by septic emboli, endocarditis, osteomyelitis, and septic polyarthralgia. Her vision did not return despite aggressive antibiotic therapy and urgent bilateral vitrectomy. This case presents an interesting and rare clinical vignette resulting in infection and damage of multiple organ systems that required aggressive management and carefully orchestrated multidisciplinary care.
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BACKGROUND: Methicillin-Resistant Staphylococcus aureus (MRSA) is a major cause of healthcare-associated infections (HAI). Contact isolation has been traditionally implemented to stop transmission but its impact is increasingly questioned. METHODS: A single center, retrospective, nonrandomized, observational, quasi-experimental study compared MRSA HAI rates between pre-/postdiscontinuation of MRSA contact isolation in a tertiary university hospital over 68 months. Data on primary outcomes, Central line-associated bloodstream infections and MRSA LabID bacteremia events, were analyzed by interrupted time series design using segmented Poisson regression modeling. As secondary outcomes catheter-associated urinary tract infections , ventilator-associated pneumonia , surgical site infections and hospital-associated pneumonia were compared using Fisher's exact tests. Current savings due to discontinuation were calculated based on gown use. RESULTS: Two hundred and ninty-five patients developed 399 HAIs. Infection rates between pre- and postinterventions were as follows: Central line-associated bloodstream infections: (0.02% vs 0.02%; P-value = .64), MRSA LabID events: (0.01% vs 0.02%; P-value = .32), hospital-associated pneumonia: (0.01% vs 0.01%; P-value = .64), catheter-associated urinary tract infections: (0% vs 0.01%; P-value = .56), ventilator-associated pneumonia: (0.01% vs 0.01%; P-value = .32), surgical site infections (0.55% vs 0.15%; P-value = .03). Savings amount to $139,228 annually. CONCLUSIONS: Discontinuing CP did not negatively impact endemic MRSA HAI rates between pre-postdiscontinuation periods and saved costs for isolation materials.
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Bacteriemia , Infección Hospitalaria , Staphylococcus aureus Resistente a Meticilina , Infecciones Estafilocócicas , Bacteriemia/epidemiología , Bacteriemia/prevención & control , Infección Hospitalaria/epidemiología , Infección Hospitalaria/prevención & control , Humanos , Control de Infecciones , Estudios Retrospectivos , Infecciones Estafilocócicas/epidemiología , Infecciones Estafilocócicas/prevención & controlRESUMEN
Spinal epidural and psoas abscesses have been found to occur together. Most cases described in the literature have been secondary to either hematogenous spread or direct invasion. Risk factors include intravenous drug use and immunosuppression. This case highlights the risk of the use of unsterile subcutaneous insulin injections leading to psoas abscess, which can be complicated by a spinal epidural abscess.
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BACKGROUND: Lower mortality has been observed with combination therapy compared to monotherapy for methicillin-resistant Staphylococcus aureus (MRSA) bacteremia; however, there is a lack of evidence for continued combination therapy over de-escalation to monotherapy following bacteremia clearance. METHODS: This was a single-center, retrospective study evaluating patients with MRSA bacteremia hospitalized from November 1, 2011, through July 31, 2019. Patients who received three to ten days of combination therapy followed by de-escalation to monotherapy were directly compared to patients retained on combination therapy. The primary composite outcome included inpatient infection-related mortality, 60-day readmission, and 60-day bacteremia recurrence. RESULTS: A total of 286 patients with MRSA bacteremia were identified, with 146 patients omitted based on exclusion criteria. The study population included 66 in the combination therapy group and 74 in the monotherapy group. Study population was 51% female (n = 71) and 78% white (n = 109) with median age of 46 years (IQR 34.5-61). No significant difference was observed in the primary composite outcome (21% combination therapy group vs 24% monotherapy group; P =.66), with retained observations after controlling for confounders. Within this outcome, there was no significant difference in 60-day readmission (20% combination therapy group vs 18% monotherapy group; P =.75), bacteremia recurrence (3% combination therapy group vs 7% monotherapy group; P =.45), or inpatient infection-related mortality (2% combination therapy group vs 5% monotherapy group; P = 1.00). CONCLUSIONS: No difference was found in the composite outcome of 60-day bacteremia recurrence, readmission, or inpatient infection-related mortality for patients with MRSA bacteremia retained on combination therapy versus those de-escalated to monotherapy.
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Aims: Several in vitro and in vivo studies demonstrated that adding a ß-lactam to vancomycin (VAN) or daptomycin (DAP) can provide synergy against methicillin-resistant Staphylococcus aureus (MRSA). However, the results from clinical studies were controversial. The objective of this systematic review and meta-analysis was to compare the efficacy and safety of using VAN or DAP plus a ß-lactam (combination therapy) and using VAN or DAP alone (monotherapy) in MRSA bloodstream infections. Methods: We included randomized controlled trials and observational studies evaluating whether combination therapy can improve clinical and microbiological outcomes and safety compared to monotherapy with VAN or DAP in MRSA-related bacteremia. Results: Literature search identified 3 randomized clinical trials and 10 observational studies involving at least 1,796 patients. There were no significant associations between the combination therapy and risk of mortality within 30 days (risk ratios [RRs], 1.10, 95% confidence interval [CI], 0.82-1.46), in-hospital mortality (RR, 0.59, 95% CI, 0.31-1.13) and mortality within 60-90 days (RR, 0.91, 95% CI, 0.64-1.29). There was also no evidence that there was a difference in length of hospital stay between the combination therapy and monotherapy (mean difference, -0.41 days, 95% CI, -3.41 to 2.59). However, compared with monotherapy, combination therapy seemed to have a shorter duration of bacteremia(mean difference, -1.06 days, 95% CI, -1.53 to -0.60), a lower risk of persistent bacteremia (RR, 0.63, 95% CI, 0.51-0.79) and a lower risk of bacteremia recurrence within 60-90 days (RR, 0.61, 95% CI, 0.40-0.92). There were no statistically significant differences in the total number of adverse events, including acute kidney injury (AKI) (RR, 1.52, 95% CI, 0.84-2.73), thrombocytopenia (RR, 1.13, 95% CI, 0.74-1.73), and diarrhea (RR, 1.36, 95% CI, 0.70-2.65), between patients with combination therapy and monotherapy. In subgroup analysis, when the analysis was limited to the studies comparing using DAP plus ceftaroline with monotherapy, we found that the former had a lower risk of mortality within 30 days. In addition, a subgroup analysis limited to randomized clinical trials showed that the combination therapy was associated with a higher risk of AKI compared with using VAN or DAP alone. Conclusions: Although adding a ß-lactam to standard therapy seemed to experience a higher clearance compared with monotherapy in patients with MRSA bacteremia, the combination therapy did not increase survival benefits. Based on the available evidence, the combination therapy was not supported as the routine management of MRSA-related bacteremia, and both its harms and benefits should be taken into account.
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Antibacterianos/uso terapéutico , Bacteriemia/tratamiento farmacológico , Staphylococcus aureus Resistente a Meticilina/efectos de los fármacos , Infecciones Estafilocócicas/tratamiento farmacológico , Antibacterianos/administración & dosificación , Antibacterianos/efectos adversos , Bacteriemia/mortalidad , Daptomicina/uso terapéutico , Quimioterapia Combinada , Humanos , Tiempo de Internación , Estudios Observacionales como Asunto , Ensayos Clínicos Controlados Aleatorios como Asunto , Infecciones Estafilocócicas/mortalidad , Vancomicina/uso terapéutico , beta-Lactamas/uso terapéuticoRESUMEN
Among patients with methicillin-resistant Staphylococcus aureus (MRSA) bacteremia from a prospective randomized clinical trial, acute kidney injury (AKI) rates increased with increasing vancomycin exposure, even within the therapeutic range. AKI was independently more common for the (flu)cloxacillin group. Day 2 vancomycin AUCâ ≥470 mg·h/L was significantly associated with AKI, independent of (flu)cloxacillin receipt.
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Hemophagocytic lymphohistiocytosis (HLH) is a rare disease that occurs due to unregulated immune system activation induced by various causes including infection and cancer. In this article, we report a case of a 67-year-old male with history of small cell lung cancer who developed HLH triggered by methicillin-resistant Staphylococcus aureus (MRSA) bacteremia. The patient was initially admitted for septic shock and gastrointestinal bleed. Further workup showed that the patient met criteria for HLH diagnosis as he was positive for 5 of the 8 parameters. Unfortunately, the patient's condition worsened and he eventually expired. With this case, we wish to draw attention to the fact that sepsis due to MRSA bacteremia can be a trigger for HLH.
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Bacteriemia/complicaciones , Linfohistiocitosis Hemofagocítica/etiología , Staphylococcus aureus Resistente a Meticilina/aislamiento & purificación , Choque Séptico/complicaciones , Anciano , Resultado Fatal , Humanos , Linfohistiocitosis Hemofagocítica/diagnóstico , MasculinoRESUMEN
BACKGROUND: Whole-genome sequencing (WGS) is increasingly used to map the spread of bacterial and viral pathogens in nosocomial settings. A limiting factor for more widespread adoption of WGS for hospital infection prevention practices is the availability of standardized tools for genomic epidemiology. METHODS: We developed the Pathogen Sequencing Phylogenomic Outbreak Toolkit (PathoSPOT) to automate integration of genomic and medical record data for rapid detection and tracing of nosocomial outbreaks. To demonstrate its capabilities, we applied PathoSPOT to complete genome surveillance data of 197 MRSA bacteremia cases from two hospitals during a 2-year period. RESULTS: PathoSPOT identified 8 clonal clusters encompassing 33 patients (16.8% of cases), none of which had been recognized by standard practices. The largest cluster corresponded to a prolonged outbreak of a hospital-associated MRSA clone among 16 adults, spanning 9 wards over a period of 21 months. Analysis of precise timeline and location data with our toolkit suggested that an initial exposure event in a single ward led to infection and long-term colonization of multiple patients, followed by transmissions to other patients during recurrent hospitalizations. CONCLUSIONS: We demonstrate that PathoSPOT genomic surveillance enables the detection of complex transmission chains that are not readily apparent from epidemiological data and that contribute significantly to morbidity and mortality, enabling more effective intervention strategies.
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Infección Hospitalaria/epidemiología , Brotes de Enfermedades , Genómica , Epidemiología Molecular , Adolescente , Adulto , Anciano , Bacteriemia/microbiología , Infección Hospitalaria/microbiología , Infección Hospitalaria/prevención & control , Infección Hospitalaria/transmisión , Brotes de Enfermedades/prevención & control , Femenino , Genoma Bacteriano , Hospitales , Humanos , Masculino , Staphylococcus aureus Resistente a Meticilina/genética , Staphylococcus aureus Resistente a Meticilina/aislamiento & purificación , Persona de Mediana Edad , Filogenia , Infecciones Estafilocócicas/epidemiología , Infecciones Estafilocócicas/transmisión , Secuenciación Completa del Genoma , Adulto JovenRESUMEN
BACKGROUND: Methicillin-resistant Staphylococcus aureus bacteremia (MRSA-B) may fail to improve with standard monotherapy, particularly in patients with multifocal infection, incomplete source control, or persistent bacteremia. Synergy observed in vitro between ceftaroline (CPT) and daptomycin (DAP) or vancomycin (VAN) may translate into clinical benefit. Here, we describe our experience with DAP/CPT and VAN/CPT for complicated MRSA-B after monotherapy failure. METHODS: Single-center, retrospective review of consecutive patients treated with DAP/CPT or VAN/CPT for MRSA-B after monotherapy failure from 1 January 2016 to 30 November 2018. RESULTS: We identified 11 instances of combination therapy in 10 patients (DAP/CPT = 6, VAN/CPT = 5) with 1 patient receiving VAN/CPT followed by DAP/CPT. Rates of multifocal infection, incomplete source control, persistent bacteremia, and infective endocarditis were high (100%, 80%, 60%, and 60%, respectively). Combination therapy was initiated most commonly for persistent bacteremia (60%). When patients were persistently bacteremic, median preceding duration was 13 days and median time to clearance was 3 days. Total microbiologic cure rate was 100%. There were zero instances of bacteremia relapse at 30 days (30D) or 60 days (60D). All-cause 30D and 60D mortality rates were 11.1% and 33.3%, respectively. CONCLUSIONS: Combination therapy demonstrated success in diverse cases of refractory MRSA-B, including instances of persistent bacteremia paired with incomplete source control. Optimal timing and therapeutic cadence for combination therapy remain unclear. Our findings suggest that DAP/CPT and VAN/CPT can be considered for complicated MRSA bacteremia when other treatment options fail or are unavailable. We propose persistent bacteremia with incomplete source control to be a clinical niche particularly worthy of further investigation.
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Radiofrequency ablation has become one of the most commonly used interventions in the treatment of chronic venous insufficiency. It is performed with minimal analgesic use, tolerable postprocedural pain, and prompt return to activities of daily living. Typical complications, though rare, include failure of total venous occlusion, deep venous thrombosis, skin hyperpigmentation, infection, and skin burn. Here, we report the case of a patient who developed suppurative thrombophlebitis with methicillin-resistant Staphylococcus aureus bacteremia, requiring surgical resection.
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OBJECTIVE: The objective of this review is to describe the outcomes of patients treated with ceftaroline in the non-Food and Drug Administration (FDA) approved indication of methicillin-resistant Staphylococcus aureus (MRSA) infections in both pediatric and adult populations. DATA SOURCES: A systematic overview was conducted by searching PubMed, Medline, and The Cochrane Library up to January 2019. STUDY SELECTION AND DATA EXTRACTION: All English-language clinical trials and case reports related to the efficacy of ceftaroline in new, not-yet-approved FDA indications in MRSA infections in pediatric or adult populations. DATA SYNTHESIS: In the case of MRSA bacteremia (MRSAB) infections, three different randomized studies in pediatric patients showed effectiveness of ceftaroline. When used in the case of adult populations with MRSA bacteremia, a small trial of 16 patients showed 50% clinical success in patients with acute bacterial skin and skin structure infections versus 63% clinical success in patients with community-acquired bacterial pneumonia. Another case series of six refractory case reports showed 50% clinical success of ceftaroline in patients with MRSA. CONCLUSIONS: Although there are few case reports and limited data to date, ceftaroline fosamil should continue to be studied as an alternative therapy in MRSA infections in both pediatric and adult populations. Clinical success rates of ceftaroline were, in most cases, considered high when treating patients with MRSA infection. More clinical trials need to be studied. In the specific case of MRSA bacteremia, the treatment options remain few and ceftaroline should be extensively studied for the salvage treatment of MRSAB.
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BACKGROUND: Methicillin-resistant Staphylococcus aureus (MRSA) is frequently implicated in health care-associated outbreaks in burn intensive care units, incurring substantial morbidity and mortality to these high-risk patients and excess costs to health care systems. METHODS: MRSA health care-associated infections (HAIs) were noted before and after the implementation of basic infection prevention measures and the subsequent implementation of universal decolonization with intranasal mupirocin. Pulsed-field gel electrophoresis was used to determine the relatedness of clinical isolates. A case-control study was conducted to characterize the risk factors for MRSA HAIs. RESULTS: Basic interventions failed to decrease the rate of MRSA HAIs, although compliance with these interventions was high throughout the study. MRSA HAIs decreased from 8.53 HAIs per 1,000 patient days before the implementation of intranasal mupirocin to 3.61 HAIs per 1,000 patient days after the implementation of intranasal mupirocin (Pâ¯=â¯.033). Pulsed-field gel electrophoresis disclosed 10 unique clones with no large clusters. The case-control study revealed a significant association between MRSA HAIs and lengths of stay, body surface area burned, intubation, pressor requirement, leukocytosis, lactic acidosis, development of pneumonia, MRSA colonization, and death. CONCLUSIONS: Basic environmental and behavioral interventions fell short of controlling a low-count, sporadic, and multiclonal MRSA outbreak in the burn intensive care unit of a tertiary medical center. However, the added implementation of universal decolonization with intranasal mupirocin was effective. Burn victims with greater disease severity were at higher risk for MRSA HAIs.
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Antibacterianos/administración & dosificación , Quemaduras/complicaciones , Infección Hospitalaria/epidemiología , Brotes de Enfermedades , Staphylococcus aureus Resistente a Meticilina/aislamiento & purificación , Mupirocina/administración & dosificación , Infecciones Estafilocócicas/epidemiología , Administración Intranasal , Adulto , Anciano , Anciano de 80 o más Años , Bacteriemia/epidemiología , Bacteriemia/microbiología , Bacteriemia/prevención & control , Unidades de Quemados , Infección Hospitalaria/prevención & control , Femenino , Humanos , Unidades de Cuidados Intensivos , Masculino , Staphylococcus aureus Resistente a Meticilina/clasificación , Staphylococcus aureus Resistente a Meticilina/genética , Persona de Mediana Edad , Infecciones Estafilocócicas/microbiología , Infecciones Estafilocócicas/prevención & control , Centros de Atención Terciaria , Resultado del Tratamiento , Adulto JovenRESUMEN
Patients with an indwelling tunneled dialysis catheter (TDC) for hemodialysis access are at a high risk of developing methicillin-resistant Staphylococcus aureus (MRSA) infection. MRSA bacteremia complications rarely include infected aneurysm. Here, we report the first case of an infected thoracic aneurysm associated with TDC-related MRSA bacteremia. An 86-year-old Japanese male with a TDC for hemodialysis access developed TDC-related MRSA bacteremia. Intravenous vancomycin was initiated, and the TDC was removed on day 3. Despite removal of the catheter and initiation of vancomycin treatment, MRSA bacteremia persisted. Chest computed tomography (CT) showed no aneurysm; however, calcification of the thoracic aorta was detected on admission. The patient subsequently developed hemosputum. CT revealed a thoracic aneurysm, which turned out to be caused by MRSA bacteremia. The patient eventually died because of the rupture of the infected aneurysm, as confirmed by autopsy. This report demonstrates TDC management in a patient with TDC-related MRSA bacteremia and the importance of investigating a metastatic infection to a calcified artery if bacteremia persists.
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Aneurisma Infectado/complicaciones , Aorta Torácica/patología , Catéteres de Permanencia/efectos adversos , Catéteres Venosos Centrales/efectos adversos , Administración Intravenosa , Anciano de 80 o más Años , Aneurisma Infectado/diagnóstico por imagen , Antibacterianos/uso terapéutico , Aorta Torácica/diagnóstico por imagen , Aorta Torácica/microbiología , Pueblo Asiatico/etnología , Bacteriemia/complicaciones , Catéteres de Permanencia/microbiología , Catéteres Venosos Centrales/microbiología , Resultado Fatal , Humanos , Masculino , Staphylococcus aureus Resistente a Meticilina , Diálisis Renal/efectos adversos , Rotura , Infecciones Estafilocócicas/complicaciones , Infecciones Estafilocócicas/microbiología , Tomografía Computarizada por Rayos X , Vancomicina/administración & dosificación , Vancomicina/uso terapéuticoRESUMEN
Methicillin-resistant Staphylococcus aureus (MRSA) bacteremia is a serious infection that can result in significant morbidity and mortality. A retrospective cohort study was conducted to determine the predictors of mortality in patient with MRSA bacteremia correlating with clinical, phenotypic and genotypic characteristics of the relevant strains. Most of the bacteremia cases were healthcare-associated (Pâ¯<â¯0.0001). Older age (Pâ¯<â¯0.0001) and comorbidities (diabetes mellitus, hypertension and chronic kidney disease) were identified as the risk factors for MRSA bacteremia. All the strains were sensitive to vancomycin. Most MRSA strains causing bacteremia belonged to SCCmec type III-ST239 and exhibited pulsotype H. According to the multivariate analysis, ageâ¯≥â¯60â¯years old (Pâ¯=â¯0.022), female gender (Pâ¯=â¯0.0003), pneumonia (Pâ¯=â¯0.011) as source of infection as well as high APACHE II, Charlson comorbidity Index and Pitt's bacteremia scores were significantly associated with patient's mortality. There were emergence of MRSA clones such as SCCmec type I-ST152, SCCmec type V-ST45 and SCCmec type V-ST951 that was discovered for the first time in Malaysia. To our knowledge, this is the first study correlating the clinical, phenotypic and genotypic characteristics of patients with MRSA bacteremia as well as determining the risk factors for mortality in Malaysian hospital.
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Bacteriemia/microbiología , Staphylococcus aureus Resistente a Meticilina , Infecciones Estafilocócicas/microbiología , Adulto , Anciano , Anciano de 80 o más Años , Bacteriemia/epidemiología , Bacteriemia/mortalidad , Infección Hospitalaria/epidemiología , Infección Hospitalaria/microbiología , Infección Hospitalaria/mortalidad , Femenino , Hospitales de Enseñanza , Humanos , Malasia/epidemiología , Masculino , Staphylococcus aureus Resistente a Meticilina/genética , Staphylococcus aureus Resistente a Meticilina/aislamiento & purificación , Staphylococcus aureus Resistente a Meticilina/patogenicidad , Persona de Mediana Edad , Estudios Retrospectivos , Factores de Riesgo , Infecciones Estafilocócicas/epidemiología , Infecciones Estafilocócicas/mortalidad , Centros de Atención TerciariaRESUMEN
Methicillin-resistant Staphylococcus aureus (MRSA) is a leading cause of bacteremia and is associated with significant morbidity and mortality. Prior studies evaluating the association of vancomycin MICs with clinical outcomes in patients with MRSA bacteremia have been inconsistent. This study evaluated the association between vancomycin MICs and 30-day in-hospital mortality rates for patients with MRSA bacteremia. This was a retrospective cohort study of patients with MRSA bacteremia treated with vancomycin for ≥72 h from January 2013 to August 2016. Vancomycin MICs were determined by broth microdilution via automated susceptibility testing methods. Study groups consisted of patients with MRSA isolates that had vancomycin MICs of <2 µg/ml and those with vancomycin MICs of 2 µg/ml. Covariates included demographics, severity of illness, comorbidities, intensive-care unit (ICU) admission, infectious disease consultation, infectious sources, and hospital onset of bacteremia. The primary outcome was 30-day in-hospital mortality. Secondary outcomes included the duration of bacteremia, persistent bacteremia for ≥7 days, recurrence within 30 days, change to alternative antibiotic therapy, and length of hospital stay. Multivariate logistic regression models were analyzed to control for potential confounding variables. A total of 166 patients were included for analysis: 91 patients with vancomycin MICs of <2 µg/ml and 75 patients with vancomycin MICs of 2 µg/ml. In the multivariate logistic regression model, a vancomycin MIC of 2 µg/ml, compared to a MIC of <2 µg/ml, was not significantly associated with 30-day in-hospital mortality after adjustment for confounders. Additionally, all secondary outcomes were not statistically significantly different between study groups. In patients with MRSA bacteremia treated with vancomycin, the vancomycin MIC was not associated with differences in clinical outcomes.
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Antibacterianos/uso terapéutico , Vancomicina/uso terapéutico , Anciano , Anciano de 80 o más Años , Bacteriemia/tratamiento farmacológico , Femenino , Humanos , Unidades de Cuidados Intensivos/estadística & datos numéricos , Modelos Logísticos , Masculino , Staphylococcus aureus Resistente a Meticilina/efectos de los fármacos , Pruebas de Sensibilidad Microbiana , Persona de Mediana Edad , Análisis Multivariante , Estudios Retrospectivos , Resultado del TratamientoRESUMEN
It is important to use vancomycin in a proper manner to ensure optimal drug exposure. Despite extensive use of vancomycin in children, studies on its optimal trough concentration (Ctrough) in the pediatric population remained rare. This retrospective study included children < 18 years old with culture-confirmed methicillin-resistant Staphylococcus aureus (MRSA) bacteremia who were hospitalized in our institute from January 2010 to April 2014. Clinical characteristics, initial vancomycin dose, Ctrough and clinical/microbiological outcomes were retrospectively collected from medical records. Forty-six MRSA bacteremia cases occurring to the patients with a mean age of 22.0 ± 46.9 months were included and all of them were healthcare-associated. Severe diseases requiring intensive care unit (ICU) stay, mechanical ventilation and/or resulting in death were observed in 57.8% (26/45); all-cause 30-day fatality was 11.1% (5/45). An initial Ctrough ≥ 15 µg/mL was achieved in only 4 (8.7%) cases with an average vancomycin dosage of 40.6 ± 7.9 mg/kg/day. Persistent bacteremia at 48 hours after initiation of vancomycin was observed more frequently in children with initial Ctrough < 10 µg/mL than in those with Ctrough ≥ 10 µg/mL (P = 0.032). However, there was no statistically significant difference between the two groups in terms of 30-day mortality and recurrent bacteremia (P = 0.899, and P = 0.754, respectively). Although initial Ctrough may be a useful parameter for minimizing early microbiological failure, it does not predict 30-day fatality or recurrence in pediatric MRSA bacteremia. Further prospective data on vancomycin dosing are needed to find the optimal drug exposure and clarify its impact on clinical outcomes in pediatric populations.