Relationship between vancomycin tolerance and clinical outcomes in Staphylococcus aureus bacteraemia
Relationship between vancomycin tolerance and clinical outcomes in Staphylococcus aureus bacteraemia
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DOI：
10.1093/jac/dkw453
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发表时间：
2017-02-01
影响因子：
5.2
通讯作者：
Steed, Molly E.
中科院分区：
文献类型：
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作者：
Britt, Nicholas S.;Patel, Nimish;Steed, Molly E.
背景：先前的数据已经证明万古霉素MIC值在金黄色葡萄球菌菌血症（SAB）中的临床重要性；然而，万古霉素耐受性（VT）的影响尚不清楚。目的：比较SAB中室性心动过速和非室性心动过速患者临床失败的频率。方法：这是一项针对SAB患者的回顾性队列研究，不包括治疗< 48小时或多微生物菌血症。主要结局是临床失败（包括30天死亡率、无法缓解的体征和症状以及60天复发）。用微量肉汤稀释法测定万古霉素MIC和MBC。采用多变量泊松回归评价VT （MBC/MIC >= 32）与临床失败的关系。结果：225例患者中有26.7%分离出VT。在未调整分析中，VT与临床失败相关（总体48.0%）[68.3% （n = 41/60）对40.6% (n = 67/165)]；P < 0.001]，这种关系在多变量分析中仍然存在（校正风险比，1.74;95% CI, 1.36-2.24; P < 0.001）。在甲氧西林敏感层内，VT与临床失败之间的关联也一致[甲氧西林敏感（n = 125，风险比1.67;95% CI, 1.20-2.32; P = 0.002）；甲氧西林耐药（n = 100，风险比1.69;95% CI, 1.14-2.51; P = 0.010）]。在接受β -内酰胺治疗的甲氧西林敏感SAB病例中，VT仍与临床失败相关（风险比1.77;95% CI, 1.19-2.61; P = 0.004）。结论：VT与SAB的临床失败相关，与甲氧西林敏感性或最终治疗无关。VT可能降低细胞壁活性治疗的有效性，或作为与不良预后相关的其他病原体特异性因素的替代标志物。未来的研究应评估抗菌非细胞壁活性药物是否能改善VT SAB的预后。
Background: Previous data have demonstrated the clinical importance of vancomycin MIC values in Staphylococcus aureus bacteraemia (SAB); however, the impact of vancomycin tolerance (VT) is unknown.Objectives: To compare the frequency of clinical failure between patients with VT and non-VT isolates in SAB.Methods: This was a retrospective cohort study of patients with SAB, excluding treatment < 48 h or polymicrobial bacteraemia. The primary outcome was clinical failure (composite of 30 day mortality, non-resolving signs and symptoms, and 60 day recurrence). Vancomycin MIC and MBC were determined by broth microdilution. The association between VT (MBC/MIC >= 32) and clinical failure was evaluated by multivariable Poisson regression.Results: Of the 225 patients, 26.7% had VT isolates. VT was associated with clinical failure (48.0% overall) in unadjusted analysis [68.3% (n = 41/60) versus 40.6% (n = 67/165); P < 0.001] and this relationship persisted in multivariable analysis (adjusted risk ratio, 1.74; 95% CI, 1.36-2.24; P < 0.001). The association between VT and clinical failure was also consistent within strata of methicillin susceptibility [methicillin susceptible (n = 125, risk ratio, 1.67; 95% CI, 1.20-2.32; P = 0.002); methicillin resistant (n = 100, risk ratio, 1.69; 95% CI, 1.14-2.51; P = 0.010)]. Among methicillin-susceptible SAB cases treated with beta-lactam therapy, VT remained associated with clinical failure (risk ratio, 1.77; 95% CI, 1.19-2.61; P = 0.004).Conclusions: VT was associated with clinical failure in SAB, irrespective of methicillin susceptibility or definitive treatment. VT may decrease the effectiveness of cell-wall-active therapy or be a surrogate marker of some other pathogen-specific factor associated with poor outcomes. Future research should evaluate if bactericidal non-cell-wall-active agents improve outcomes in VT SAB.