Abstract
Staphylococcus aureus is one of the most virulent Gram-positive organisms responsible for a multitude of infections, including bacteremia. Methicillin-resistant Staphylococcus aureus (MRSA) is of special concern in patients with bacteremia. Due to its associated poor clinical outcomes, morbidity, and mortality, the superlative salvage regimen for persistent MRSA bacteremia remains uncertain. An 85-year-old white female presented with persistent methicillin-resistant Staphylococcus aureus (MRSA) bacteremia. Empiric antibiotic therapy with linezolid was initiated prior to blood culture results. Once MRSA bacteremia was confirmed, alternative antibiotic therapy with daptomycin was initiated. Blood cultures remained positive for MRSA despite three days of daptomycin therapy after which ceftaroline was added to the antibiotic regimen. Blood cultures remained positive for MRSA despite seven days of combination therapy with daptomycin and ceftaroline. Salvage therapy was then initiated with daptomycin, linezolid, and meropenem. One day following initiation of salvage therapy, blood cultures revealed no bacterial growth for the remainder of the length of stay. This report supports the effectiveness of salvage therapy consisting of daptomycin, linezolid, and meropenem in patients with persistent MRSA bacteremia.
Highlights
Methicillin-resistant Staphylococcus aureus (MRSA) is concerning in patients with bacteremia and infective endocarditis, due to poor clinical outcomes associated with crude mortality rates as high as 22.3%, increased lengths of stay of 11.1 ± 10.7 days, and median total charges of $36,109 [1, 2]. e current Infectious Diseases Society of America (IDSA) clinical practice guidelines for the treatment of MRSA infections currently recommend vancomycin or daptomycin as the first-line treatment strategies for MRSA bacteremia; ambiguity in current practice raises specific challenges for treatment failure and persistent disease [1]
One day following daptomycin initiation, C-reactive protein (188.3 mg/L) and procalcitonin (0.60 ng/mL) were elevated and transthoracic echocardiogram (TTE) was negative for endocarditis vegetation; blood cultures remained positive for MRSA. ree days following daptomycin initiation, blood cultures remained positive for MRSA; consequentially, intravenous ceftaroline 400 mg every 12 hours was added to the antibiotic regimen
Blood cultures remained positive for MRSA after a total of thirteen days of appropriate intravenous antibiotics and escalation of the regimen. e patient’s bacteremia cleared one day following the initiation of salvage therapy consisting of daptomycin, linezolid, and meropenem
Summary
Methicillin-resistant Staphylococcus aureus (MRSA) is concerning in patients with bacteremia and infective endocarditis, due to poor clinical outcomes associated with crude mortality rates as high as 22.3%, increased lengths of stay of 11.1 ± 10.7 days, and median total charges of $36,109 [1, 2]. e current Infectious Diseases Society of America (IDSA) clinical practice guidelines for the treatment of MRSA infections currently recommend vancomycin or daptomycin as the first-line treatment strategies for MRSA bacteremia; ambiguity in current practice raises specific challenges for treatment failure and persistent disease [1]. E current Infectious Diseases Society of America (IDSA) clinical practice guidelines for the treatment of MRSA infections currently recommend vancomycin or daptomycin as the first-line treatment strategies for MRSA bacteremia; ambiguity in current practice raises specific challenges for treatment failure and persistent disease [1]. Persistent MRSA bacteremia is defined by the IDSA guidelines as positive blood cultures past seven days of adequate therapy at effective doses of appropriate antibiotics [1]. Guidance in situations of persistent MRSA bacteremia is currently directed solely through case-series and case reports involving daptomycin and vancomycin in combination with salvage antibiotics for clearance of blood cultures [4–10]. A patient is presented here with persistent MRSA bacteremia and clearance of blood cultures following escalation to salvage therapy with daptomycin, linezolid, and meropenem
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