Abstract
BackgroundThe purported value of empirical therapy to cover methicillin-resistant Staphylococcus aureus (MRSA) has been debated for decades. The purpose of this study was to evaluate the effects of inappropriate empirical antibiotic therapy on clinical outcomes in patients with healthcare-associated MRSA bacteremia (HA-MRSAB).MethodsA prospective, multicenter, observational study was conducted in 15 teaching hospitals in the Republic of Korea from February 2010 to July 2011. The study subjects included adult patients with HA-MRSAB. Covariate adjustment using the propensity score was performed to control for bias in treatment assignment. The predictors of in-hospital mortality were determined by multivariate logistic regression analyses.ResultsIn total, 345 patients with HA-MRSAB were analyzed. The overall in-hospital mortality rate was 33.0 %. Appropriate empirical antibiotic therapy was given to 154 (44.6 %) patients. The vancomycin minimum inhibitory concentrations of the MRSA isolates ranged from 0.5 to 2 mg/L by E-test. There was no significant difference in mortality between propensity-matched patient pairs receiving inappropriate or appropriate empirical antibiotics (odds ratio [OR] = 1.20; 95 % confidence interval [CI] = 0.71–2.03). Among patients with severe sepsis or septic shock, there was no significant difference in mortality between the treatment groups. In multivariate analyses, severe sepsis or septic shock (OR = 5.45; 95 % CI = 2.14–13.87), Charlson’s comorbidity index (per 1-point increment; OR = 1.52; 95 % CI = 1.27–1.83), and prior receipt of glycopeptides (OR = 3.24; 95 % CI = 1.08–9.67) were independent risk factors for mortality.ConclusionInappropriate empirical antibiotic therapy was not associated with clinical outcome in patients with HA-MRSAB. Prudent use of empirical glycopeptide therapy should be justified even in hospitals with high MRSA prevalence.
Highlights
The purported value of empirical therapy to cover methicillin-resistant Staphylococcus aureus (MRSA) has been debated for decades
Cases were defined as the patients treated with inappropriate empirical antibiotics, and controls were defined as those with HA-MRSA bacteremia (MRSAB) who were treated with appropriate empirical antibiotics
An in-hospital mortality rate of at least 25 % was noted for pneumonia (55 %), central nervous system infections, MRSAB of unknown origin (44.4 %), intra-abdominal infections (38.1 %), catheter-related bloodstream infection (CR-BSI) (33.3 %), and cardiovascular infections (28.6 %), whereas mortality rates of less than 25 % were observed for urinary tract infections, surgical wound infections, skin and soft tissue infections, bone and joint infections, and head and neck infections
Summary
The purported value of empirical therapy to cover methicillin-resistant Staphylococcus aureus (MRSA) has been debated for decades. The purpose of this study was to evaluate the effects of inappropriate empirical antibiotic therapy on clinical outcomes in patients with healthcare-associated MRSA bacteremia (HA-MRSAB). Methicillin-resistant Staphylococcus aureus (MRSA) has been a major cause of healthcare-associated bacteremia [1, 2]. Studies evaluating the presence of relationships between clinical outcome and inappropriate empirical antibiotic therapies in patients with MRSAB have yielded conflicting results [10,11,12,13,14,15,16]. The conflicting results on the benefits of early empirical antibiotic therapy are probably due to differing definitions of “inappropriate” therapy on the basis of in vitro susceptibility data, impact of potentially confounding variables, and selection or information biases such as the baseline severity of illness [17, 18]. Empirical glycopeptides use for MRSAB should be guided on the basis of scientific data
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