Use of vancomycin or first-generation cephalosporins for the treatment of hemodialysis-dependent patients with methicillin-susceptible Staphylococcus aureus bacteremia
Use of vancomycin or first-generation cephalosporins for the treatment of hemodialysis-dependent patients with methicillin-susceptible Staphylococcus aureus bacteremia
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DOI：
10.1086/510386
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发表时间：
2007-01-15
影响因子：
11.8
通讯作者：
Fowler, Vance G., Jr.
中科院分区：
文献类型：
--
作者：
Stryjewski, Martin E.;Szczech, Lynda A.;Fowler, Vance G., Jr.
背景资料。由于给药容易，万古霉素通常用于治疗长期血液透析患者的甲氧西林敏感金黄色葡萄球菌(MSSA)菌血症。这种治疗策略导致的临床结果还没有很好的定义。我们前瞻性地确定了接受长期血液透析的患者，这些患者被诊断为MSSA菌血症。根据治疗期间接受的主要抗生素(万古霉素或第一代头孢菌素[头孢唑林])对临床结果进行分组。治疗失败(定义为死亡或复发感染)在最初阳性血培养结果后12周确定。使用多变量分析对混杂因素进行调整。在84个月的时间里，123名血液透析依赖的MSSA菌血症患者被确认。接受万古霉素治疗的患者(n=77)比接受头孢唑林治疗(n=46)的患者更年轻(51岁比57岁；P=.06)，并且出现转移并发症的比率较低(11.7%比36.7%；P=.001)。两组在急性生理学和慢性健康评估II评分、合并症、感染源、血液透析通路类型和通路去除率方面相似。治疗失败在接受万古霉素治疗的患者中更为常见(31.2%vs.13%；P=0.02)。在多变量分析中，与治疗失败独立相关的因素包括万古霉素的使用(优势比，3.53；95%可信区间，1.15-13.45)和保留血液透析途径(优势比，4.99；95%可信区间，1.89-13.76)。接受万古霉素治疗的依赖血液透析的MSSA菌血症患者发生治疗失败的风险比接受头孢唑林治疗的患者更高。在没有患者特定情况(例如，对β-内酰胺类过敏)的情况下，对于患有MSSA菌血症的血液透析依赖患者，在经验性治疗之后不应继续使用万古霉素。
Background. Because of its ease of dosing, vancomycin is commonly used to treat methicillin-susceptible Staphylococcus aureus (MSSA) bacteremia in patients undergoing long-term hemodialysis. Clinical outcomes resulting from such a therapeutic strategy have not been well defined.Methods. We prospectively identified patients undergoing long-term hemodialysis who received a diagnosis of MSSA bacteremia. Clinical outcomes were grouped according to the predominant antibiotic received during their therapy (vancomycin or a first-generation cephalosporin [cefazolin]). Treatment failure (defined as death or recurrent infection) was determined at 12 weeks after the initial positive blood culture results. A multivariable analysis was used to adjust for confounders.Results. During an 84-month period, 123 hemodialysis-dependent patients with MSSA bacteremia were identified. Patients receiving vancomycin (n = 77) tended to be younger (51 vs. 57 years; P = .06) and had lower rates of metastatic complications at presentation (11.7% vs. 36.7%; P = .001) than did those receiving cefazolin (n = 46). The 2 groups were similar with regard to Acute Physiology and Chronic Health Evaluation II scores, comorbidities, source of infection, type of hemodialysis access, and access removal rates. Treatment failure was more common among patients receiving vancomycin (31.2% vs. 13%; P = .02). In the multivariable analysis, factors independently associated with treatment failure included vancomycin use (odds ratio, 3.53; 95% confidence interval, 1.15-13.45) and retention of the hemodialysis access (odds ratio, 4.99; 95% confidence interval, 1.89-13.76).Conclusions. Hemodialysis-dependent patients with MSSA bacteremia treated with vancomycin are at a higher risk of experiencing treatment failure than are those receiving cefazolin. In the absence of patient specific circumstances (e.g., allergy to beta-lactams), vancomycin should not be continued beyond empirical therapy for hemodialysis-dependent patients with MSSA bacteremia.