Improving Clinical Outcomes in Patients With Methicillin-Sensitive Staphylococcus aureus Bacteremia and Reported Penicillin Allergy
Improving Clinical Outcomes in Patients With Methicillin-Sensitive Staphylococcus aureus Bacteremia and Reported Penicillin Allergy
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DOI：
10.1093/cid/civ394
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发表时间：
2015-09-01
影响因子：
11.8
通讯作者：
Walensky, Rochelle P.
中科院分区：
文献类型：
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作者：
Blumenthal, Kimberly G.;Parker, Robert A.;Walensky, Rochelle P.
背景甲氧西林敏感金黄色葡萄球菌（MSSA）菌血症是一种病态感染。在10%报告青霉素（PCN）过敏的患者中，通常避免使用一线MSSA治疗（萘夫西林、苯唑西林、头孢唑林），但这些患者中的大多数并非真正过敏。我们使用了一个决策树与敏感性分析，以确定最佳的评估和治疗MSSA菌血症和报告PCN过敏的患者。我们的模型模拟了3种策略：（1）无过敏评估，给予万古霉素（Vanc）;（2）过敏史指导治疗：如果病史排除过敏特征，给予头孢唑啉（Hx-头孢唑啉）;（3）完整的过敏评估与病史适当的PCN皮肤试验：如果皮肤试验阴性，给予头孢唑啉（ST-头孢唑啉）。模型结果包括12周MSSA治愈、复发和死亡;过敏反应包括严重、轻微和潜在医源性;以及药物不良反应。VANC导致最少的患者达到MSSA治愈和最高的复发率（67.3%/14.8% vs 83.4%/9.3%，Hx-Cefaz和84.5%/8.9%，ST-Cefaz）以及过敏反应的最高频率（3.0% vs 2.4% Hx-头孢唑和1.7% ST-头孢唑）和最高的药物不良反应率（5.2% vs 4.6% Hx-头孢唑和4.7% ST-头孢唑）。即使在“Vanc的最佳情况”的情况下，Vanc也会产生最差的结果。ST-头孢是首选Hx-头孢，虽然敏感的输入变量。患有MSSA菌血症和报告的PCN过敏的患者应针对过敏进行最佳治疗。尽管需要更多的数据，但皮肤试验的全面过敏评估似乎是首选。
Background. Methicillin-sensitive Staphylococcus aureus (MSSA) bacteremia is a morbid infection. First-line MSSA therapies (nafcillin, oxacillin, cefazolin) are generally avoided in the 10% of patients reporting penicillin (PCN) allergy, but most of these patients are not truly allergic. We used a decision tree with sensitivity analyses to determine the optimal evaluation and treatment for patients with MSSA bacteremia and reported PCN allergy.Methods. Our model simulates 3 strategies: (1) no allergy evaluation, give vancomycin (Vanc); (2) allergy history-guided treatment: if history excludes anaphylactic features, give cefazolin (Hx-Cefaz); and (3) complete allergy evaluation with history-appropriate PCN skin testing: if skin test negative, give cefazolin (ST-Cefaz). Model outcomes included 12-week MSSA cure, recurrence, and death; allergic reactions including major, minor, and potentially iatrogenic; and adverse drug reactions.Results. Vanc results in the fewest patients achieving MSSA cure and the highest rate of recurrence (67.3%/14.8% vs 83.4%/9.3% for Hx-Cefaz and 84.5%/8.9% for ST-Cefaz) as well as the greatest frequency of allergic reactions (3.0% vs 2.4% for Hx-Cefaz and 1.7% for ST-Cefaz) and highest rates of adverse drug reactions (5.2% vs 4.6% for Hx-Cefaz and 4.7% for ST-Cefaz). Even in a "best case for Vanc" scenario, Vanc yields the poorest outcomes. ST-Cefaz is preferred to Hx-Cefaz although sensitive to input variations.Conclusions. Patients with MSSA bacteremia and a reported PCN allergy should have the allergy addressed for optimal treatment. Full allergy evaluation with skin testing seems to be preferred, although more data are needed.