Impact of Vancomycin Exposure on Outcomes in Patients with Methicillin-Resistant Staphylococcus aureus Bacteremia: Support for Consensus Guidelines Suggested Targets
Impact of Vancomycin Exposure on Outcomes in Patients with Methicillin-Resistant Staphylococcus aureus Bacteremia: Support for Consensus Guidelines Suggested Targets
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DOI：
10.1093/cid/cir124
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发表时间：
2011-04-15
影响因子：
11.8
通讯作者：
Rybak, Michael J.
中科院分区：
文献类型：
--
作者：
Kullar, Ravina;Davis, Susan L.;Rybak, Michael J.
背景资料。随着时间的推移，耐甲氧西林金黄色葡萄球菌(MRSA)感染的万古霉素失败率越来越高。我们研究的主要目的是确定最初使用万古霉素治疗的MRSA菌血症患者暴露于万古霉素的影响和预后。这是一项单中心的回顾性分析，研究对象为从2005年1月到2010年4月，最初使用万古霉素治疗的320名有记录的MRSA菌血症患者。药敏试验采用Etest和微量肉汤稀释两种方法，以确定药敏试验与患者预后的相关性。在320名患者的队列中，超过一半(52.5%)的患者经历了万古霉素失败。Logistic回归分析万古霉素失效的独立预测因素包括感染性心内膜炎(调整后优势比4.55；95%可信区间2.26~9.15)、院内获得性感染(调整后优势比2.19；95%可信区间1.21~3.97)、ETEST万古霉素初始水平1 mg/L(调整后优势比1.52；95%可信区间1.09~2.49)。经分类回归树(CART)分析，24小时(AUC(24小时))万古霉素曲线下面积与MIC之比为421(61.2%比48.6%；P=.038)。鉴于与万古霉素相关的高失败率，应该考虑通过在选定的患者中选择较高的谷值15-20 mg/L和AUC(24小时)/MIC比值<gt；=400来优化万古霉素的药代动力学/药效学特性。
Background. High rates of vancomycin failure in methicillin-resistant Staphylococcus aureus (MRSA) infections have been increasingly reported over time. The primary objective of our study was to determine the impact of vancomycin exposure and outcomes in patients with MRSA bacteremia initially treated with vancomycin.Methods. This was a single-center retrospective analysis of 320 patients with documented MRSA bacteremia initially treated with vancomycin from January 2005 through April 2010. Two methods of susceptibility, Etest and broth microdilution, were performed for all isolates to determine the correlation of susceptibility testing to patient outcomes.Results. Among a cohort of 320 patients, more than half (52.5%) experienced vancomycin failure. Independent predictors of vancomycin failure in logistic regression included infective endocarditis (adjusted odds ratio [AOR], 4.55; 95% confidence interval [CI], 2.26-9.15), nosocomial-acquired infection (AOR, 2.19; 95% CI, 1.21-3.97), initial vancomycin trough 1 mg/L by Etest (AOR, 1.52; 95% CI, 1.09-2.49). With use of Classification and Regression Tree (CART) analysis, patients with vancomycin area under the curve at 24 h (AUC(24h)) to MIC ratios 421 (61.2% vs 48.6%; P = .038)Conclusions. In light of the high failure rates associated with this antimicrobial, optimizing the pharmacokinetic/pharmacodynamic properties of vancomycin by targeting higher trough values of 15-20 mg/L and AUC(24h)/MIC ratios >= 400 in selected patients should be considered.