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Hall RG, Thatcher M, Wei W, Varghese S, Varughese L, Ndiulor M, Payne KD. Dosing strategies to optimize currently available anti-MRSA treatment options (Part 1: IV options). Expert Rev Clin Pharmacol 2017; 10:493-508. [PMID: 28293964 DOI: 10.1080/17512433.2017.1300527] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
INTRODUCTION Methicillin-resistant Staphylococcus aureus (MRSA) continues to be a predominant pathogen resulting in significant morbidity and mortality. Optimal dosing of anti-MRSA agents is needed to help prevent the development of antimicrobial resistance and to increase the likelihood of a favorable clinical outcome. Areas covered: This review summarizes the available data for antimicrobials routinely used for MRSA infections that are not administered orally or topically. We make recommendations and highlight the current gaps in the literature. A PubMed (1966 - Present) search was performed to identify relevant literature for this review. Expert commentary: Improvements in MIC determination and therapeutic drug monitoring are needed to fully implement individualized dosing that optimizes antimicrobial pharmacodynamics.Additional data will become available for these agents in regards to effectiveness for severe MRSA infections and pharmacokinetic data for special patient populations.
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Affiliation(s)
- Ronald G Hall
- a Texas Tech University Health Sciences Center , Dallas , TX , USA.,b Dose Optimization and Outcomes Research (DOOR) program
| | - Michael Thatcher
- a Texas Tech University Health Sciences Center , Dallas , TX , USA
| | - Wei Wei
- a Texas Tech University Health Sciences Center , Dallas , TX , USA
| | - Shibin Varghese
- a Texas Tech University Health Sciences Center , Dallas , TX , USA
| | - Lincy Varughese
- a Texas Tech University Health Sciences Center , Dallas , TX , USA
| | - Michelle Ndiulor
- a Texas Tech University Health Sciences Center , Dallas , TX , USA
| | - Kenna D Payne
- a Texas Tech University Health Sciences Center , Dallas , TX , USA
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White BP, Barber KE, Stover KR. Ceftaroline for the treatment of methicillin-resistant Staphylococcus aureus bacteremia. Am J Health Syst Pharm 2017; 74:201-208. [PMID: 28179245 DOI: 10.2146/ajhp160006] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
PURPOSE The utility of ceftaroline for the treatment of methicillin-resistant Staphylococcus aureus bacteremia (MRSAB) is reviewed. SUMMARY Ceftaroline was originally approved for the treatment of community-acquired bacterial pneumonia (CABP) and acute bacterial skin and skin structure infections (ABSSSIs) but recently received an additional approval for the treatment of S. aureus bacteremia (SAB) associated with ABSSSIs. Ceftaroline has demonstrated efficacy for the treatment of MRSAB, including isolates with elevated minimum inhibitory concentrations to conventional therapy when used alone or in combination with other agents. In multiple studies, ceftaroline has displayed rapid bloodstream eradication, even in the setting of refractory MRSAB or infective endocarditis. The clinical resolution of MRSAB or SAB in patients who received ceftaroline ranged from 31.0% to 83.3%; studies used varying definitions for clinical resolution and included differing proportions of patients with endocarditis. The use of ceftaroline in treatment-refractory patients and assorted populations makes absolute effectiveness difficult to determine. Ceftaroline has been shown to be effective in patients who have not responded to other agents for MRSAB, making it an attractive option for such patients. Although the approved dosing regimen for ceftaroline fosamil is 600 mg every 12 hours for patients with normal renal function for the treatment of ABSSSIs and CABP, there is some debate about whether more frequent doses (i.e., every 8 hours) are needed for MRSAB. CONCLUSION Ceftaroline has been used to successfully treat SAB, including endocarditis. Therapy with ceftaroline may be considered when antibiotic resistance or previous treatment failure precludes the use of first-line agents.
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Affiliation(s)
| | - Katie E Barber
- University of Mississippi School of Pharmacy, Jackson, MS
| | - Kayla R Stover
- University of Mississippi School of Pharmacy, Jackson, MS
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Zasowski EJ, Trinh TD, Claeys KC, Casapao AM, Sabagha N, Lagnf AM, Klinker KP, Davis SL, Rybak MJ. Multicenter Observational Study of Ceftaroline Fosamil for Methicillin-Resistant Staphylococcus aureus Bloodstream Infections. Antimicrob Agents Chemother 2017; 61:e02015-16. [PMID: 27895012 PMCID: PMC5278749 DOI: 10.1128/aac.02015-16] [Citation(s) in RCA: 52] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2016] [Accepted: 11/20/2016] [Indexed: 01/28/2023] Open
Abstract
Novel therapies for methicillin-resistant Staphylococcus aureus (MRSA) bloodstream infection (BSI) are needed in the setting of reduced antibiotic susceptibilities and therapeutic failure. Ceftaroline is a cephalosporin antibiotic with MRSA activity. Although not FDA approved for MRSA BSI, ceftaroline has generated much interest as a potential treatment option. However, detailed descriptions of its use in this setting remain limited. To address this, we conducted a retrospective, multicenter, observational study of adult patients with MRSA BSI treated with at least 72 h of ceftaroline from 2011 to 2015. Safety outcomes were examined in the overall cohort, while efficacy outcomes were examined among patients who had not cleared their BSI prior to ceftaroline initiation. Data were also stratified by ceftaroline monotherapy or combination therapy. Predictors of clinical failure on ceftaroline treatment were also sought. Overall, 211 patients were included in the safety population; Clostridium difficile infection, rash, and neutropenia occurred in 6 patients (2.8%), 7 patients (3.3%), and 3 patients (1.4%), respectively. Clinical success was observed in 86 (68.3%) of the 126 patients included in the efficacy population. The monotherapy and combination therapy subgroups had similar proportions of patients experiencing success (69.7 and 64.9%, respectively). The median BSI durations post-ceftaroline treatment were 2 days (interquartile range, 1 to 4 days) for monotherapy and 3 days (interquartile range, 1.5 to 5 days) for combination therapy. Higher acute physiology and chronic health evaluation II scores and comorbid malignancy independently predicted treatment failure. Ceftaroline appears effective for MRSA BSI as both monotherapy and combination therapy. However, comparative studies are needed to further delineate the role of ceftaroline in MRSA BSI treatment.
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Affiliation(s)
- Evan J Zasowski
- Anti-Infective Research Laboratory, Department of Pharmacy Practice, Eugene Applebaum College of Pharmacy and Health Sciences, Wayne State University, Detroit, Michigan, USA
| | - Trang D Trinh
- Anti-Infective Research Laboratory, Department of Pharmacy Practice, Eugene Applebaum College of Pharmacy and Health Sciences, Wayne State University, Detroit, Michigan, USA
| | - Kimberly C Claeys
- Anti-Infective Research Laboratory, Department of Pharmacy Practice, Eugene Applebaum College of Pharmacy and Health Sciences, Wayne State University, Detroit, Michigan, USA
- Department of Pharmacy Practice, University of Maryland School of Pharmacy, Baltimore, Maryland, USA
| | - Anthony M Casapao
- Anti-Infective Research Laboratory, Department of Pharmacy Practice, Eugene Applebaum College of Pharmacy and Health Sciences, Wayne State University, Detroit, Michigan, USA
- Department of Pharmacy Practice, Husson University School of Pharmacy, Bangor, Maine, USA
| | - Noor Sabagha
- Anti-Infective Research Laboratory, Department of Pharmacy Practice, Eugene Applebaum College of Pharmacy and Health Sciences, Wayne State University, Detroit, Michigan, USA
| | - Abdalhamid M Lagnf
- Anti-Infective Research Laboratory, Department of Pharmacy Practice, Eugene Applebaum College of Pharmacy and Health Sciences, Wayne State University, Detroit, Michigan, USA
| | - Kenneth P Klinker
- University of Florida, College of Pharmacy, Gainesville, Florida, USA
| | - Susan L Davis
- Anti-Infective Research Laboratory, Department of Pharmacy Practice, Eugene Applebaum College of Pharmacy and Health Sciences, Wayne State University, Detroit, Michigan, USA
- Department of Pharmacy Services, Henry Ford Hospital, Detroit, Michigan, USA
| | - Michael J Rybak
- Anti-Infective Research Laboratory, Department of Pharmacy Practice, Eugene Applebaum College of Pharmacy and Health Sciences, Wayne State University, Detroit, Michigan, USA
- Department of Medicine, Division of Infectious Diseases, School of Medicine, Wayne State University, Detroit, Michigan, USA
- Department of Pharmacy Services, Detroit Medical Center, Detroit, Michigan, USA
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54
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Biedenbach DJ, Iaconis JP, Sahm DF. Comparative in vitro activities of ceftaroline and ceftriaxone against bacterial pathogens associated with respiratory tract infections: results from the AWARE surveillance study. J Antimicrob Chemother 2016; 71:3459-3464. [PMID: 27559120 DOI: 10.1093/jac/dkw315] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2016] [Revised: 07/06/2016] [Accepted: 07/07/2016] [Indexed: 08/30/2023] Open
Abstract
OBJECTIVES Ceftaroline fosamil is indicated for the treatment of community-acquired bacterial pneumonia and ceftriaxone has an indication for lower respiratory tract infections. This study was conducted to compare the relative in vitro activities of these two agents against bacterial species associated with community-associated respiratory tract infections. METHODS In all, 13 005 isolates of Staphylococcus aureus, Streptococcus pneumoniae, Moraxella catarrhalis and Haemophilus influenzae were collected in 2012-14 from 39 countries in the Asia-Pacific region, Europe, Latin America and Africa-Middle East from respiratory tract specimens. The identification was confirmed centrally by MALDI-TOF and broth microdilution susceptibility testing and interpretation was done according to CLSI guidelines. RESULTS Ceftaroline was 16-fold more potent against MSSA (MIC90 0.25 versus 4 mg/L) than ceftriaxone and ≥16-fold more potent against MRSA (MIC90 2 versus >32 mg/L). Ceftaroline was 16-fold more potent against S. pneumoniae (MIC90 0.12-0.25 mg/L) compared with ceftriaxone (MIC90 1-2 mg/L), with higher MIC values observed among penicillin-non-susceptible isolates for both agents. Similar activity (MIC90 ≤0.03 mg/L) was observed for ceftaroline and ceftriaxone against H. influenzae, with higher MIC values observed in the Asia-Pacific region for both agents compared with other regions. Ceftaroline was 4- to 8-fold more active against M. catarrhalis (MIC90 0.12-0.25 mg/L) compared with ceftriaxone (MIC90 1 mg/L). CONCLUSIONS These global MIC data demonstrated that ceftaroline exhibited superior in vitro activity compared with ceftriaxone against bacterial species that commonly cause community-associated respiratory tract infections.
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Affiliation(s)
| | - J P Iaconis
- AstraZeneca Pharmaceuticals LP, Waltham, MA, USA
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Athans V, Kenney RM, Wong J, Davis SL. Outpatient use of ceftaroline fosamil versus vancomycin for osteoarticular infection: a matched cohort study. J Antimicrob Chemother 2016; 71:3568-3574. [PMID: 27530754 DOI: 10.1093/jac/dkw326] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2016] [Revised: 07/13/2016] [Accepted: 07/14/2016] [Indexed: 12/16/2023] Open
Abstract
OBJECTIVES There are few convenient intravenous options for long-term outpatient treatment of osteoarticular infection (OAI) and limited effectiveness and safety data exist for this off-label use of ceftaroline. The objective of this study was to describe the long-term effectiveness and safety of ceftaroline for the treatment of OAI. METHODS This was a matched retrospective cohort study of patients receiving ceftaroline- or vancomycin-based therapy for OAI in the outpatient setting. Patients were matched according to infection subtype, anatomical site and microbiology. The primary endpoint was 180 day infection-related readmission (IRR). Secondary endpoints included all-cause readmission, time-to-IRR and adverse event incidence. RESULTS The final matched cohort consisted of 50 ceftaroline-treated patients and 50 vancomycin-treated patients. The IRR incidence was 22% for ceftaroline patients and 30% for vancomycin patients; OR = 0.66 (95% CI = 0.27-1.62; P = 0.362). There was no significant difference between groups in all-cause readmission or time-to-IRR. Attributable adverse event incidences were 24% and 18% for ceftaroline and vancomycin, respectively. Rash (10%) and nausea (6%) were the most common ceftaroline adverse events, while acute kidney injury (6%) and rash (4%) were the most common vancomycin adverse events. CONCLUSIONS Attributable readmission and adverse events were common among patients treated with outpatient intravenous antimicrobials for OAI. This study found no appreciable difference in effectiveness or tolerability between ceftaroline- or vancomycin-treated patients. Although further research will be important to delineate the role of ceftaroline in the management of OAI, data derived from this study may aid clinicians in determining therapy when limited options exist.
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Affiliation(s)
- Vasilios Athans
- Department of Pharmacy Services, Henry Ford Hospital, 2799 W. Grand Boulevard, Detroit, MI 48202, USA
- Department of Pharmacy Services, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195, USA
| | - Rachel M Kenney
- Department of Pharmacy Services, Henry Ford Hospital, 2799 W. Grand Boulevard, Detroit, MI 48202, USA
| | - Jacob Wong
- Henry Ford Home Infusion, Henry Ford Health System, 21298 Melrose Avenue, Southfield, MI 48075, USA
| | - Susan L Davis
- Department of Pharmacy Services, Henry Ford Hospital, 2799 W. Grand Boulevard, Detroit, MI 48202, USA
- Eugene Applebaum College of Pharmacy and Health Sciences, Wayne State University, 259 Mack Avenue, Detroit, MI 48201, USA
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Burnett YJ, Echevarria K, Traugott KA. Ceftaroline as Salvage Monotherapy for Persistent MRSA Bacteremia. Ann Pharmacother 2016; 50:1051-1059. [PMID: 27520326 DOI: 10.1177/1060028016664361] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVE To summarize published data regarding the use of ceftaroline as salvage monotherapy for persistent methicillin-resistant Staphylococcus aureus (MRSA) bacteremia. DATA SOURCES PubMed (January 1980-June 2016) was searched using combinations of the search terms methicillin-resistant Staphylococcus aureus, MRSA, bacteremia, ceftaroline, refractory, and persistent Supplemental references were generated through review of identified literature citations. STUDY SELECTION AND DATA EXTRACTION Available English-language, full-text articles pertaining to the use of ceftaroline for persistent MRSA bacteremia (MRSAB) were included. DATA SYNTHESIS The PubMed search yielded 23 articles for evaluation. There are no randomized controlled trials to date-only case series and reports. Four retrospective case series detailing the use of ceftaroline as monotherapy for persistent MRSAB were included. Most patients received at least 4 days of an appropriate anti-MRSA antimicrobial prior to ceftaroline and were able to clear bacteremia within 3 days. The most common rationales for ceftaroline use were progression of disease or nonresponse to current therapy. Higher off-label dosing of ceftaroline is often utilized to achieve optimal pharmacokinetic/pharmacodynamic parameters. Adverse events are not well described due to lack of follow-up; however, neutropenia has been associated with prolonged use. CONCLUSIONS Treatment options for persistent MRSAB remain few and far between. Ceftaroline is an effective agent for the salvage treatment of MRSAB. Off-label doses up to 600 mg every 8 hours are often used to achieve optimal pharmacokinetic/pharmacodynamic parameters. Because of lack of follow-up in these reports, the incidence of adverse effects of prolonged use of ceftaroline is not well defined.
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Affiliation(s)
- Yvonne J Burnett
- St. Louis College of Pharmacy, MO, USA
- Washington University School of Medicine, St. Louis, MO, USA
| | - Kelly Echevarria
- South Texas Veterans Health Care System, San Antonio, TX, USA
- University of Texas at Austin, TX, USA
- University of Texas Health Science Center at San Antonio, TX, USA
| | - Kristi A Traugott
- University of Texas at Austin, TX, USA
- University of Texas Health Science Center at San Antonio, TX, USA
- University Health System, San Antonio, TX, USA
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Abstract
Infective endocarditis (IE) is a rare, life-threatening disease that has long-lasting effects even among patients who survive and are cured. IE disproportionately affects those with underlying structural heart disease and is increasingly associated with health care contact, particularly in patients who have intravascular prosthetic material. In the setting of bacteraemia with a pathogenic organism, an infected vegetation may form as the end result of complex interactions between invading microorganisms and the host immune system. Once established, IE can involve almost any organ system in the body. The diagnosis of IE may be difficult to establish and a strategy that combines clinical, microbiological and echocardiography results has been codified in the modified Duke criteria. In cases of blood culture-negative IE, the diagnosis may be especially challenging, and novel microbiological and imaging techniques have been developed to establish its presence. Once diagnosed, IE is best managed by a multidisciplinary team with expertise in infectious diseases, cardiology and cardiac surgery. Antibiotic prophylaxis for the prevention of IE remains controversial. Efforts to develop a vaccine that targets common bacterial causes of IE are ongoing, but have not yet yielded a commercially available product.
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Affiliation(s)
- Thomas L Holland
- Department of Medicine, Division of Infectious Diseases, Duke University Medical Center, Room 185 Hanes Building, 315 Trent Drive, Durham, North Carolina 27710, USA
- Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina, USA
| | - Larry M Baddour
- Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Arnold S Bayer
- Department of Medicine, David Geffen School of Medicine at UCLA, Torrance, California, USA
| | - Bruno Hoen
- Department of Infectious Diseases, University Hospital of Pointe-Pitre, Pointe-Pitre, France
| | - Jose M Miro
- Infectious Diseases Service, Hospital Clinic - IDIBAPS, University of Barcelona, Barcelona, Spain
| | - Vance G Fowler
- Department of Medicine, Division of Infectious Diseases, Duke University Medical Center, Room 185 Hanes Building, 315 Trent Drive, Durham, North Carolina 27710, USA
- Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina, USA
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Abstract
PURPOSE OF REVIEW To highlight the importance of escalating pathogen resistance in ventilator-associated pneumonia (VAP) along with diagnostic and treatment implications. RECENT FINDINGS In a period of rising bacterial resistance, VAP remains an important infection occurring in critically ill patients. Risk factors for multidrug-resistant pathogens depend on both local epidemiology and host factors. New diagnostic techniques and antimicrobials can help with rapid bacterial identification and timely and appropriate treatment while avoiding emergence of bacterial resistance. SUMMARY Clinicians should be aware of risk factors for multidrug-resistant pathogens causing VAP and also of particularities of diagnosis and treatment of this important clinical entity.
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Blumenthal KG, Kuhlen JL, Weil AA, Varughese CA, Kubiak DW, Banerji A, Shenoy ES. Adverse Drug Reactions Associated with Ceftaroline Use: A 2-Center Retrospective Cohort. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2016; 4:740-6. [PMID: 27130709 PMCID: PMC4939098 DOI: 10.1016/j.jaip.2016.03.008] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/16/2015] [Revised: 02/26/2016] [Accepted: 03/18/2016] [Indexed: 01/10/2023]
Abstract
BACKGROUND Ceftaroline fosamil is a cephalosporin approved for treating skin and soft tissue infections (SSTIs), including those caused by methicillin-resistant Staphylococcus aureus and community-acquired pneumonia (CAP). OBJECTIVES We aimed to study ceftaroline use and associated adverse drug reactions (ADRs), including hypersensitivity reactions (HSRs), among inpatients. METHODS We performed a retrospective electronic health record review of inpatients from Massachusetts General Hospital and Brigham and Women's Hospital who received ceftaroline between May 2012 and February 2015. ADRs diagnosed by clinical providers during the course of clinical care were subsequently verified and classified. Risk factors for ADRs were identified. RESULTS Among 96 patients (median age, 57 years; 54% females) who received a median of 28 (interquartile range, 6-63) ceftaroline doses, 54% were being treated for methicillin-resistant Staphylococcus aureus and treatment indications other than SSTI and CAP comprised 59% of care. There were 31 ADRs observed in 20 (21%) patients; hematologic (n = 15) and cutaneous (n = 9) findings were most common. Observed HSRs included rash with mucosal lesions (n = 1), rash with skin desquamation (n = 1), and possible organ-specific HSRs (n = 2). Patients who suffered an ADR received more doses of ceftaroline (median, 46 vs 21; P = .013). There was no increased risk of ceftaroline ADR among patients with reported beta-lactam allergy history (P > .5). CONCLUSIONS Ceftaroline is used to treat a range of infections beyond SSTI and CAP. We observed a high rate of ADRs from ceftaroline, including signs of severe HSRs. More data are needed to understand the frequency and predictors of ceftaroline ADRs and HSRs.
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Affiliation(s)
- Kimberly G Blumenthal
- Division of Rheumatology, Allergy, and Immunology, Department of Medicine, Massachusetts General Hospital, Boston, Mass; Department of Medicine, Harvard Medical School, Boston, Mass; Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, Mass.
| | - James L Kuhlen
- Acadia Allergy and Immunology, Department of Medicine, University of South Carolina School of Medicine, Greenville, SC
| | - Ana A Weil
- Department of Medicine, Harvard Medical School, Boston, Mass; Division of Infectious Diseases, Department of Medicine, Massachusetts General Hospital, Boston, Mass
| | | | - David W Kubiak
- Division of Infectious Diseases, Department of Medicine, Brigham and Women's Hospital, Boston, Mass; Department of Pharmacy, Brigham and Women's Hospital, Boston, Mass
| | - Aleena Banerji
- Division of Rheumatology, Allergy, and Immunology, Department of Medicine, Massachusetts General Hospital, Boston, Mass; Department of Medicine, Harvard Medical School, Boston, Mass
| | - Erica S Shenoy
- Department of Medicine, Harvard Medical School, Boston, Mass; Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, Mass; Division of Infectious Diseases, Department of Medicine, Massachusetts General Hospital, Boston, Mass; Infection Control Unit, Massachusetts General Hospital, Boston, Mass
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PBP 4 Mediates High-Level Resistance to New-Generation Cephalosporins in Staphylococcus aureus. Antimicrob Agents Chemother 2016; 60:3934-41. [PMID: 27067335 DOI: 10.1128/aac.00358-16] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2016] [Accepted: 04/08/2016] [Indexed: 12/21/2022] Open
Abstract
Staphylococcus aureus is an important cause of both hospital- and community-associated methicillin-resistant S. aureus (MRSA) infections worldwide. β-Lactam antibiotics are the drugs of choice to treat S. aureus infections, but resistance to these and other antibiotics make treatment problematic. High-level β-lactam resistance of S. aureus has always been attributed to the horizontally acquired penicillin binding protein 2a (PBP 2a) encoded by the mecA gene. Here, we show that S. aureus can also express high-level resistance to β-lactams, including new-generation broad-spectrum cephalosporins that are active against methicillin-resistant strains, through an uncanonical core genome-encoded penicillin binding protein, PBP 4, a nonessential enzyme previously considered not to be important for staphylococcal β-lactam resistance. Our results show that PBP 4 can mediate high-level resistance to β-lactams.
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Matzneller P, Lackner E, Lagler H, Wulkersdorfer B, Österreicher Z, Zeitlinger M. Single- and Repeated-Dose Pharmacokinetics of Ceftaroline in Plasma and Soft Tissues of Healthy Volunteers for Two Different Dosing Regimens of Ceftaroline Fosamil. Antimicrob Agents Chemother 2016; 60:3617-25. [PMID: 27044549 PMCID: PMC4879389 DOI: 10.1128/aac.00097-16] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2016] [Accepted: 03/26/2016] [Indexed: 12/17/2022] Open
Abstract
Ceftaroline fosamil (CPT-F) is currently approved for use for the treatment of complicated skin and soft tissue infections and community-acquired pneumonia at 600 mg twice daily (q12h), but other dosing regimens are under evaluation. To date, very limited data on the soft tissue pharmacokinetics (PK) of the active compound, ceftaroline (CPT), are available. CPT concentrations in the plasma, muscle, and subcutis of 12 male healthy volunteers were measured by microdialysis after single and repeated intravenous administration of 600 mg CPT-F q12h or three times daily (q8h) in two groups of 6 subjects each. Relevant PK and PK/pharmacodynamic (PD) parameters were calculated and compared between groups. In plasma, the area under the concentration-time curve (AUC) from 0 to 24 h for total CPT and the cumulative percentage of the dosing interval during which the free drug concentrations exceeded the MIC (fTMIC) for unbound CPT for the currently established threshold of 1 mg/liter were significantly higher in the group receiving CPT-F q8h. Exposure to free drug in soft tissues was higher in the group receiving CPT-F q8h, but high interindividual variability in relevant PK parameters was observed. The mean ratios of the AUC from time zero to the end of the dosing interval (AUC0-τ) for free CPT in soft tissues and the AUC0-τ for the calculated free fraction in plasma at steady state ranged from 0.66 to 0.75. Administration of CPT-F q8h led to higher levels of drug exposure in all investigated compartments. When MIC values above 1 mg/liter were assumed, the calculated fTMIC after dosing q12h was markedly lower than that after dosing q8h. The clinical implications of these differences are discussed in light of recently completed clinical phase III and PK/PD studies.
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Affiliation(s)
- Peter Matzneller
- Department of Clinical Pharmacology, Medical University of Vienna, Vienna, Austria
| | - Edith Lackner
- Department of Clinical Pharmacology, Medical University of Vienna, Vienna, Austria
| | - Heimo Lagler
- Department of Clinical Pharmacology, Medical University of Vienna, Vienna, Austria Clinical Division of Infectious Diseases and Tropical Medicine, Department of Medicine I, Medical University of Vienna, Vienna, Austria
| | | | - Zoe Österreicher
- Department of Clinical Pharmacology, Medical University of Vienna, Vienna, Austria
| | - Markus Zeitlinger
- Department of Clinical Pharmacology, Medical University of Vienna, Vienna, Austria
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Holubar M, Meng L, Deresinski S. Bacteremia due to Methicillin-Resistant Staphylococcus aureus: New Therapeutic Approaches. Infect Dis Clin North Am 2016; 30:491-507. [PMID: 27208769 DOI: 10.1016/j.idc.2016.02.009] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
This article reviews recent clinical evidence for the treatment of methicillin-resistant Staphylococcus aureus (MRSA) bacteremia. Vancomycin remains the initial antibiotic of choice for the treatment of patients with MRSA bacteremia and endocarditis due to isolates with vancomycin minimum inhibitory concentration ≤2 μg/mL, whereas daptomycin is an effective alternative, and ceftaroline seems promising. Treatment options for persistent MRSA bacteremia or bacteremia due to vancomycin-intermediate or vancomycin-resistant strains include daptomycin, ceftaroline, and combination therapies. There is a critical need for high-level evidence from clinical trials to allow optimally informed decisions in the treatment of MRSA bacteremia and endocarditis.
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Affiliation(s)
- Marisa Holubar
- Division of Infectious Diseases and Geographic Medicine, Stanford University School of Medicine, 300 Pasteur Drive, Room L-134, Stanford, CA 94305-5105, USA.
| | - Lina Meng
- Department of Pharmacy, Stanford Health Care, 300 Pasteur Drive, M/C 5616 Room H0301, Stanford, CA 94305-5105, USA
| | - Stan Deresinski
- Division of Infectious Diseases and Geographic Medicine, Stanford University School of Medicine, 300 Pasteur Drive, Room L-134, Stanford, CA 94305-5105, USA
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Alternative Treatment Options for Methicillin-Resistant Staphylococcus aureus Nosocomial Pneumonia. INFECTIOUS DISEASES IN CLINICAL PRACTICE 2016. [DOI: 10.1097/ipc.0000000000000377] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Bassetti M, Righi E. Safety profiles of old and new antimicrobials for the treatment of MRSA infections. Expert Opin Drug Saf 2016; 15:467-81. [PMID: 26764972 DOI: 10.1517/14740338.2016.1142528] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
INTRODUCTION Methicillin-resistant Staphylococcus aureus (MRSA) is a frequent cause of severe nosocomial and community-acquired infections. Various adverse effects have been associated with compounds that are commonly used in the treatment of MRSA. AREAS COVERED Prolonged use of high-dose vancomycin has been linked with nephrotoxicity. Linezolid use has been associated with lactic acidosis in regimens longer than 14 days and occurrence of thrombocytopenia in patients with renal impairment. Daptomycin use correlates with reversible and often asymptomatic myopathy. Among new compounds, telavancin has shown increased toxicity compared to vancomycin, especially in patients with severe renal impairment, while a low rate of adverse effects was reported others glycolipopeptides such as dalbavancin and oritavancin and for new cephalosporins. Recently studied oxazolidinones (tedizolid and radezolid) also showed mild adverse effects in Phase 2 and 3 clinical trials. EXPERT OPINION Due to the constant increase in antimicrobial resistance, the use of higher doses and prolonged regimens of antibiotics employed in the treatment of Gram-positive infections has become more common and linked to increased toxicity. Furthermore, new compounds with MRSA activity have been recently approved and will be regularly employed in clinical practice. The knowledge of the adverse effects and risk factors for the development of toxicity associated with anti-MRSA antimicrobials is paramount for the correct use of old and new compounds, especially in the treatment of severe infections.
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Affiliation(s)
- Matteo Bassetti
- a Infectious Diseases Division , Santa Maria Misericordia Hospital , Udine , Italy
| | - Elda Righi
- a Infectious Diseases Division , Santa Maria Misericordia Hospital , Udine , Italy
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Park KH, Greenwood-Quaintance KE, Patel R. In vitro activity of ceftaroline against staphylococci from prosthetic joint infection. Diagn Microbiol Infect Dis 2016; 84:141-3. [PMID: 26602948 DOI: 10.1016/j.diagmicrobio.2015.10.012] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2015] [Revised: 10/14/2015] [Accepted: 10/18/2015] [Indexed: 01/20/2023]
Abstract
We tested the in vitro activity of ceftaroline by Etest against staphylococci recovered from patients with prosthetic joint infection, including 97 Staphylococcus aureus isolates (36%, oxacillin resistant) and 74 Staphylococcus epidermidis isolates (74%, oxacillin resistant). Ceftaroline inhibited all staphylococci at ≤0.5 μg/mL. The ceftaroline MIC(90/50) values for methicillin-susceptible S. aureus, methicillin-susceptible S. epidermidis, methicillin-resistant S. aureus, and methicillin-resistant S. epidermidis were 0.19/0.125, 0.094/0.047, 0.5/0.38, and 0.38/0.19 μg/mL, respectively. Based on these in vitro findings, ceftaroline should be further evaluated as a potential therapeutic option for the treatment of prosthetic joint infection caused by methicillin-susceptible and methicillin-resistant S. aureus and S. epidermidis.
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Affiliation(s)
- Kyung-Hwa Park
- Division of Clinical Microbiology, Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN 55905; Department of Infectious Diseases, Chonnam National University Medical School, Gwangju, South Korea
| | - Kerryl E Greenwood-Quaintance
- Division of Clinical Microbiology, Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN 55905
| | - Robin Patel
- Division of Clinical Microbiology, Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN 55905; Division of Infectious Diseases, Department of Medicine, Mayo Clinic, Rochester, MN 55905.
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Choo EJ, Chambers HF. Treatment of Methicillin-Resistant Staphylococcus aureus Bacteremia. Infect Chemother 2016; 48:267-273. [PMID: 28032484 PMCID: PMC5204005 DOI: 10.3947/ic.2016.48.4.267] [Citation(s) in RCA: 95] [Impact Index Per Article: 11.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2016] [Indexed: 01/08/2023] Open
Abstract
Methicillin-resistant Staphylococcus aureus (MRSA) is a significant cause of health care-associated infections. Vancomycin remains an acceptable treatment option. There has been a welcome increase in the number of agents available for the treatment of MRSA infection. These drugs have certain differentiating attributes and may offer some advantages over vancomycin, but they also have significant limitations. These agents provide some alternative when no other options are available.
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Affiliation(s)
- Eun Ju Choo
- Division of Infectious Diseases, Department of Medicine, Soonchunhyang University Hospital, Bucheon, Korea
| | - Henry F Chambers
- Division of Infectious Diseases, Department of Medicine, San Francisco General Hospital, University of California, San Francisco, San Francisco, CA, USA.
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Biedenbach DJ, Alm RA, Lahiri SD, Reiszner E, Hoban DJ, Sahm DF, Bouchillon SK, Ambler JE. In Vitro Activity of Ceftaroline against Staphylococcus aureus Isolated in 2012 from Asia-Pacific Countries as Part of the AWARE Surveillance Program. Antimicrob Agents Chemother 2016; 60:343-7. [PMID: 26503659 PMCID: PMC4704164 DOI: 10.1128/aac.01867-15] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2015] [Accepted: 10/20/2015] [Indexed: 12/16/2022] Open
Abstract
Ceftaroline, the active metabolite of the prodrug ceftaroline-fosamil, is an advanced-generation cephalosporin with activity against methicillin-resistant Staphylococcus aureus (MRSA). This investigation provides in vitro susceptibility data for ceftaroline against 1,971 S. aureus isolates collected in 2012 from seven countries (26 centers) in the Asia-Pacific region as part of the Assessing Worldwide Antimicrobial Resistance and Evaluation (AWARE) program. Broth microdilution as recommended by the CLSI was used to determine susceptibility. In all, 62% of the isolates studied were MRSA, and the ceftaroline MIC90 for all S. aureus isolates was 2 μg/ml (interpretive criteria: susceptible, ≤1 μg/ml). The overall ceftaroline susceptibility rate for S. aureus was 86.9%, with 100% of methicillin-sensitive S. aureus isolates and 78.8% of MRSA isolates susceptible to this agent. The highest percentages of ceftaroline-nonsusceptible MRSA isolates came from China (47.6%), all of which showed intermediate susceptibility, and Thailand (37.1%), where over half (52.8%) of isolates were resistant to ceftaroline (MIC, 4 μg/ml). Thirty-eight ceftaroline-nonsusceptible isolates (MIC values of 2 to 4 μg/ml) were selected for molecular characterization. Among the isolates analyzed, sequence type 5 (ST-5) was the most common sequence type encountered; however, all isolates analyzed from Thailand were ST-228. Penicillin-binding protein 2a (PBP2a) substitution patterns varied by country, but all isolates from Thailand had the Glu239Lys substitution, and 12 of these also carried an additional Glu447Lys substitution. Ceftaroline-fosamil is a useful addition to the antimicrobial agents that can be used to treat S. aureus infections. However, with the capability of this species to develop resistance to new agents, it is important to recognize and monitor regional differences in trends as they emerge.
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Affiliation(s)
| | | | | | | | - Daryl J Hoban
- International Health Management Associates, Inc., Schaumburg, Illinois, USA
| | - Daniel F Sahm
- International Health Management Associates, Inc., Schaumburg, Illinois, USA
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Biedenbach DJ, Hoban DJ, Reiszner E, Lahiri SD, Alm RA, Sahm DF, Bouchillon SK, Ambler JE. In Vitro Activity of Ceftaroline against Staphylococcus aureus Isolates Collected in 2012 from Latin American Countries as Part of the AWARE Surveillance Program. Antimicrob Agents Chemother 2015; 59:7873-7. [PMID: 26416860 PMCID: PMC4649166 DOI: 10.1128/aac.01833-15] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2015] [Accepted: 09/23/2015] [Indexed: 12/18/2022] Open
Abstract
The in vitro activities of ceftaroline and comparators, using broth microdilution, were determined against 1,066 Staphylococcus aureus isolates from hospitalized patients. Seventeen medical centers from Latin American countries contributed isolates. Methicillin-resistant S. aureus (MRSA) percentages ranged from 46% (Brazil) to 62% (Argentina). All methicillin-susceptible S. aureus (MSSA) isolates were susceptible to ceftaroline. Ceftaroline activity against MRSA varied with MIC90s of 0.5 (Venezuela) to 2 (Brazil, Chile, and Colombia) μg/ml, which was the highest MIC value. ST-5 was the most common sequence type.
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Affiliation(s)
| | - Daryl J Hoban
- International Health Management Associates, Inc., Schaumburg, Illinois, USA
| | - Edina Reiszner
- AstraZeneca Pharmaceuticals, Waltham, Massachusetts, USA
| | | | - Richard A Alm
- AstraZeneca Pharmaceuticals, Waltham, Massachusetts, USA
| | - Daniel F Sahm
- International Health Management Associates, Inc., Schaumburg, Illinois, USA
| | | | - Jane E Ambler
- AstraZeneca Pharmaceuticals, Waltham, Massachusetts, USA
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Faris J, Mynatt RP, Hall Snyder AD, Rybak MJ. Treatment of Methicillin-Resistant Staphylococcus aureus (MRSA) Pneumonia with Ceftaroline Fosamil in a Patient with Inhalational Thermal Injury. Infect Dis Ther 2015; 4:519-28. [PMID: 26541469 PMCID: PMC4675765 DOI: 10.1007/s40121-015-0096-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2015] [Indexed: 11/30/2022] Open
Abstract
A 48-year-old female, who was found unresponsive and suffered inhalation injury secondary to a house fire, was transferred to our burn center for definitive treatment. Post tracheostomy, the patient became febrile and tachycardic. On hospital day (HD) 5, the patient expressed thick yellow secretions during suctioning and diffuse rhonchi was noted on physical exam. Blood cultures and a culture from the broncheo-alvelolar lavage grew Gram-positive cocci in clusters and the patient was started on empiric vancomycin. Despite aggressive vancomycin dosing (1750 mg intravenously every 6 h), the patient's status continued to deteriorate. The organism was identified as methicillin-resistant Staphylococcus aureus (MRSA) with a vancomycin minimum inhibitory concentration (MIC) of 2 mg/L. Based on the potential for drug-drug interactions with linezolid, the patient was started on ceftaroline fosamil (MIC = 0.5 mg/L) 600 mg intravenously every 8 h with a prolonged 2-h infusion to anticipate suboptimal concentrations secondary to thermal burn injury. Post change in antibiotic therapy, a rapid clinical improvement was observed with the patient becoming afebrile at 48 h after initiation of ceftaroline. The patient completed a total of 14 days of ceftaroline therapy and was subsequently weaned from the ventilator on HD 22 and decannulated 2 days later. To our knowledge, this is the first report of the use of ceftaroline for the treatment of MRSA pneumonia in a patient with thermal injury.
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Affiliation(s)
- Janie Faris
- Trauma Surgery Critical Care, Department of Pharmacy, Carilion Roanoke Memorial Hospital, 1906 Belleview Avenue, Roanoke, VA, 24014, USA
| | - Ryan P Mynatt
- Detroit Receiving Hospital, Wayne State University, Detroit, MI, USA
| | - Ashley D Hall Snyder
- Anti-Infective Research Laboratory, Eugene Applebaum College of Pharmacy and Health Sciences, Wayne State University, Detroit, MI, USA
| | - Michael J Rybak
- Anti-Infective Research Laboratory, Eugene Applebaum College of Pharmacy and Health Sciences, Wayne State University, Detroit, MI, USA.
- School of Medicine, Wayne State University, Detroit, MI, USA.
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Kullar R, Sakoulas G, Deresinski S, van Hal SJ. When sepsis persists: a review of MRSA bacteraemia salvage therapy. J Antimicrob Chemother 2015; 71:576-86. [PMID: 26565015 DOI: 10.1093/jac/dkv368] [Citation(s) in RCA: 57] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
MRSA bacteraemia (MRSAB), including infective endocarditis, carries a high mortality rate, with up to 50% of patients failing initial therapy with vancomycin and requiring salvage therapy. Persistent MRSAB can be difficult to successfully eliminate, especially when source control is not possible due to an irremovable focus or the bacteraemia still persists despite surgical intervention. Although vancomycin and daptomycin are the only two antibiotics approved by the US FDA for the treatment of patients with MRSAB as monotherapy, the employment of novel strategies is required to effectively treat patients with persistent MRSAB and these may frequently involve combination drug therapy. Treatment strategies that are reviewed in this manuscript include vancomycin combined with a β-lactam, daptomycin-based therapy, ceftaroline-based therapy, linezolid-based therapy, quinupristin/dalfopristin, telavancin, trimethoprim/sulfamethoxazole-based therapy and fosfomycin-based therapy. We recommend that combination antibiotic therapy be considered for use in MRSAB salvage treatment.
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Affiliation(s)
- Ravina Kullar
- Global Center for Scientific Affairs, Merck Research Laboratories, Merck & Co., Inc., Kenilworth, NJ, USA
| | - George Sakoulas
- Division of Paediatric Pharmacology & Drug Discovery, University of California San Diego School of Medicine, La Jolla, CA, USA Sharp Rees-Stealy Medical Group, San Diego, CA, USA
| | - Stan Deresinski
- Department of Medicine, Division of Infectious Diseases, Stanford University School of Medicine, Stanford, CA, USA
| | - Sebastiaan J van Hal
- Department of Microbiology & Infectious Diseases, Royal Prince Alfred Hospital, Camperdown, Australia
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What is the best therapeutic approach to methicillin-resistant Staphylococcus aureus pneumonia? Curr Opin Infect Dis 2015; 28:164-70. [PMID: 25692268 DOI: 10.1097/qco.0000000000000149] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
PURPOSE OF REVIEW The purpose of this review is to define what the best therapeutic approach is for the treatment of methicillin-resistant Staphylococcus aureus (MRSA) pneumonia. RECENT FINDINGS Although two meta-analyses reported conflicting findings, recent retrospective studies reported higher success rates in patients with MRSA pneumonia treated with linezolid when compared to vancomycin. Only registration trials are available for some anti-MRSA antibiotics, such as telavancin, ceftaroline, and ceftobiprole. Scarce information is available regarding the best therapeutic approach for MRSA community-acquired pneumonia. SUMMARY Linezolid seems to be a better choice than vancomycin for the treatment of MRSA ventilator-associated pneumonia. It is still unclear whether this affirmation holds for other forms of MRSA pneumonia. Further research is needed to define whether newer antibiotics are better alternatives than currently recommended agents.
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Baddour LM, Wilson WR, Bayer AS, Fowler VG, Tleyjeh IM, Rybak MJ, Barsic B, Lockhart PB, Gewitz MH, Levison ME, Bolger AF, Steckelberg JM, Baltimore RS, Fink AM, O'Gara P, Taubert KA. Infective Endocarditis in Adults: Diagnosis, Antimicrobial Therapy, and Management of Complications: A Scientific Statement for Healthcare Professionals From the American Heart Association. Circulation 2015; 132:1435-86. [PMID: 26373316 DOI: 10.1161/cir.0000000000000296] [Citation(s) in RCA: 1861] [Impact Index Per Article: 206.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Infective endocarditis is a potentially lethal disease that has undergone major changes in both host and pathogen. The epidemiology of infective endocarditis has become more complex with today's myriad healthcare-associated factors that predispose to infection. Moreover, changes in pathogen prevalence, in particular a more common staphylococcal origin, have affected outcomes, which have not improved despite medical and surgical advances. METHODS AND RESULTS This statement updates the 2005 iteration, both of which were developed by the American Heart Association under the auspices of the Committee on Rheumatic Fever, Endocarditis, and Kawasaki Disease, Council on Cardiovascular Disease of the Young. It includes an evidence-based system for diagnostic and treatment recommendations used by the American College of Cardiology and the American Heart Association for treatment recommendations. CONCLUSIONS Infective endocarditis is a complex disease, and patients with this disease generally require management by a team of physicians and allied health providers with a variety of areas of expertise. The recommendations provided in this document are intended to assist in the management of this uncommon but potentially deadly infection. The clinical variability and complexity in infective endocarditis, however, dictate that these recommendations be used to support and not supplant decisions in individual patient management.
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Kiang TKL, Wilby KJ, Ensom MHH. A critical review on the clinical pharmacokinetics, pharmacodynamics, and clinical trials of ceftaroline. Clin Pharmacokinet 2015; 54:915-31. [PMID: 25940827 DOI: 10.1007/s40262-015-0281-3] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Only a parenteral formulation of ceftaroline is commercially available, and the prodrug, ceftaroline fosamil, is hydrolyzed quickly and completely upon intravenous administration. Ceftaroline is relatively minimally bound to plasma proteins (15-28 %), with a volume of distribution of 30-40 L. Ceftaroline undergoes minimal metabolism and does not appear to be a cytochrome P450 substrate. Its renal clearance (e.g. 4-7 L/h after multiple dosing) approximates glomerular filtration rate, with a terminal half-life of ~2.6 h in healthy subjects. The pharmacokinetics of ceftaroline have been described thoroughly in clinical investigations primarily conducted by the manufacturer. Despite its indications for treating skin and skin structure infections (SSSI) or community-acquired pneumonia (CAP), some studies that contributed data to the final drug labelling were conducted only in healthy volunteers. A significant amount of data have been contributed by the drug maker, and the overall quality of the pharmacodynamics and clinical data, based on our critical analysis provided in this review, is strong. Ceftaroline can be considered as a therapeutic alternative for complicated SSSI and CAP (Pneumonia Outcome Research Team Class III-IV). The current dosing regimen of ceftaroline 600 mg intravenously every 12 h appears sufficient to establish pharmacokinetic-pharmacodynamic relationships and achieve optimal clinical efficacy. More clinical studies are needed to define the place of ceftaroline in therapy for SSSI, CAP, and other indications such as osteomyelitis, endocarditis, and other types of pneumonia. Moreover, continued development in population modelling incorporating more patient-specific data would allow further analysis to identify intrinsic and extrinsic factors that influence the pharmacokinetics of ceftaroline in humans.
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Affiliation(s)
- Tony K L Kiang
- Faculty of Pharmaceutical Sciences, The University of British Columbia, Vancouver, BC, Canada
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Abstract
PURPOSE OF REVIEW To highlight the clinical importance of ventilator-associated pneumonia (VAP) in an era of escalating antimicrobial resistance. RECENT FINDINGS VAP continues to be an important infection in the critically ill. The development of rapid microbiologic diagnostics and new antimicrobial agents offer opportunities for improved treatment strategies for VAP balancing the need to treat effectively in a timely manner and antimicrobial stewardship. Additionally, the new surveillance definitions for assessing the quality of care in critically ill patients (ventilator-associated events, ventilator-associated conditions, and infection-related ventilator-associated conditions) do not appear to be adequate surrogates for the identification of VAP. SUMMARY Clinicians caring for critically ill patients should be aware of the importance of correctly treating VAP. As new diagnostic technologies and antimicrobials become available for VAP, their incorporation into routine patient management should occur in a way that optimizes patient outcomes wherein minimizing further emergence of antimicrobial resistance.
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Abstract
PURPOSE OF REVIEW Vancomycin has been the cornerstone of treatment for methicillin-resistant Staphylococcus aureus (MRSA) infections. This review describes new MRSA-active antibiotics that have recently been introduced and highlights emerging resistance. RECENT FINDINGS Elevations in the vancomycin minimum inhibitory concentration within the susceptible range are associated with treatment failure and mortality in the treatment of MRSA infections. Ceftaroline and ceftobiprole are anti-MRSA cephalosporins and are noninferior to comparator agents in the treatment of acute bacterial skin and skin structure infections (ABSSSIs) and pneumonia. Tedizolid is more potent than linezolid, has improved pharmacokinetics and reduced toxicity and is active against cfr-containing S. aureus. Telavancin now has approval for treatment of hospital-acquired pneumonia, and recent phase 2 trial data showed similar cure rates in S. aureus bacteremia. Dalbavancin and oritavancin are administered once weekly and are noninferior to comparators for acute bacterial skin and skin structure infections. Resistance has emerged against many new anti-MRSA antimicrobials including ceftaroline. Combination therapy of β-lactams with vancomycin or daptomycin is increasing. SUMMARY Several new MRSA-active agents are now approved for use, although much of the data is derived from treatment of acute bacterial skin and skin structure infections or pneumonia. Further studies are required for more invasive infections, such as bacteremia and endocarditis.
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Mpenge MA, MacGowan AP. Ceftaroline in the management of complicated skin and soft tissue infections and community acquired pneumonia. Ther Clin Risk Manag 2015; 11:565-79. [PMID: 25897241 PMCID: PMC4396454 DOI: 10.2147/tcrm.s75412] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
Ceftaroline is a new parenteral cephalosporin approved by the European Medicines Agency (EMA) and the US Food and Drug Administration (FDA) for the treatment of complicated skin and soft tissue infections (cSSTIs) including those due to methicillin-resistant Staphylococcus aureus (MRSA), and community-acquired pneumonia (CAP). Ceftaroline has broad-spectrum activity against gram-positive and gram-negative bacteria and exerts its bactericidal effects by binding to penicillin-binding proteins (PBPs), resulting in inhibition of bacterial cell wall synthesis. It binds to PBP 2a of MRSA with high affinity and also binds to all six PBPs in Streptococcus pneumoniae. In in vitro studies, ceftaroline demonstrated potent activity against Staphylococcus aureus (including MRSA and vancomycin-intermediate isolates), Streptococcus pneumoniae (including multidrug resistant isolates), Haemophilus influenzae, Moraxella catarrhalis, and many common gram-negative pathogens, excluding extended spectrum beta-lactamase (ESBL)-producing Enterobacteriaceae and Pseudomonas aeruginosa. In Phase II and Phase III clinical trials, ceftaroline was noninferior to its comparator agents and demonstrated high clinical cure rates in the treatment of cSSTIs and CAP. It demonstrated favorable outcomes in patients treated for both regulatory-approved indications and unlicensed indications in a retrospective analysis. Ceftaroline is a safe and effective option for treatment in specific patient populations in which its efficacy and safety have been proven. This article reviews the challenges in the treatment of cSSTI and CAP, ceftaroline and its microbiology, pharmacology, efficacy, and safety data which support its use in treatment of cSSTIs and CAP.
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Affiliation(s)
- Mbiye A Mpenge
- Department of Medical Microbiology, University Hospitals Bristol NHS Trust, Bristol Royal Infirmary, Bristol, England
| | - Alasdair P MacGowan
- Department of Medical Microbiology, North Bristol NHS Trust, Southmead Hospital, Bristol, England
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Jones RN, Holliday NM, Critchley IA. Accuracy of the Thermo Fisher Scientific (Sensititre™) dry-form broth microdilution MIC product when testing ceftaroline. Diagn Microbiol Infect Dis 2015; 81:280-2. [PMID: 25623933 DOI: 10.1016/j.diagmicrobio.2014.12.010] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2014] [Revised: 12/22/2014] [Accepted: 12/24/2014] [Indexed: 11/23/2022]
Abstract
Ceftaroline, the active metabolite of the ceftaroline fosamil pro-drug, was the first advanced-spectrum cephalosporin with potent activity against methicillin-resistant Staphylococcus aureus to be approved by the US Food and Drug Administration for acute bacterial skin and skin structure infections. After 4 years of clinical use, few ceftaroline commercial susceptibility testing devices other than agar diffusion methods (disks and stable gradient) are available. Here, we validate a broth microdilution product (Sensititre™; Thermo Fisher Scientific, Cleveland, OH, USA) that achieved 99.2% essential agreement (manual and automated reading) and 95.3-100.0% categorical agreement, with high reproducibility (98.0-100.0%). Sensititre™ MIC values for ceftaroline, however, were slightly skewed toward an elevated value (0.5 × log2 dilution step), greatest when testing for streptococci and Enterobacteriaceae.
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Espedido BA, Jensen SO, van Hal SJ. Ceftaroline fosamil salvage therapy: an option for reduced-vancomycin-susceptible MRSA bacteraemia. J Antimicrob Chemother 2015; 70:797-801. [PMID: 25406295 DOI: 10.1093/jac/dku455] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2023] Open
Abstract
OBJECTIVES To examine the activity of ceftaroline against reduced-vancomycin-susceptible MRSA isolates. METHODS One-hundred and three MRSA blood culture isolates (predominantly ST239-MRSA-III), with varying vancomycin phenotypes, had their ceftaroline MICs determined by broth microdilution and MIC Evaluator strip (Oxoid-Thermo Fisher). Statistical analyses were performed that examined relationships with vancomycin and daptomycin MICs. Mutations in mecA were also examined. RESULTS All 103 isolates (including 60 heteroresistant vancomycin-intermediate Staphylococcus aureus/vancomycin-intermediate S. aureus) were susceptible to ceftaroline, with one isolate displaying heteroresistance that may be related to a mecA mutation. Higher ceftaroline MICs were associated with vancomycin-susceptible S. aureus isolates. CONCLUSIONS This study highlights that ceftaroline fosamil is an option for salvage therapy based on in vitro activity.
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Affiliation(s)
- Björn A Espedido
- Molecular Medicine Research Group, School of Medicine, University of Western Sydney, Sydney, NSW, Australia Antibiotic Resistance and Mobile Elements Group, Ingham Institute for Applied Medical Research, Sydney, NSW, Australia South Western Sydney Clinical School, University of New South Wales, Sydney, NSW, Australia
| | - Slade O Jensen
- Molecular Medicine Research Group, School of Medicine, University of Western Sydney, Sydney, NSW, Australia Antibiotic Resistance and Mobile Elements Group, Ingham Institute for Applied Medical Research, Sydney, NSW, Australia South Western Sydney Clinical School, University of New South Wales, Sydney, NSW, Australia
| | - Sebastiaan J van Hal
- Antibiotic Resistance and Mobile Elements Group, Ingham Institute for Applied Medical Research, Sydney, NSW, Australia Department of Microbiology and Infectious Diseases, Royal Prince Alfred Hospital, Sydney, NSW, Australia
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Stryjewski ME, Jones RN, Corey GR. Ceftaroline: clinical and microbiology experience with focus on methicillin-resistant Staphylococcus aureus after regulatory approval in the USA. Diagn Microbiol Infect Dis 2015; 81:183-8. [PMID: 25583130 DOI: 10.1016/j.diagmicrobio.2014.11.016] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2014] [Revised: 10/24/2014] [Accepted: 11/23/2014] [Indexed: 01/12/2023]
Abstract
Ceftaroline fosamil was approved in 2010 by the United States Food and Drug Administration (USA-FDA) for the treatment of patients with acute bacterial skin and skin structure infections (ABSSSIs) and community-acquired bacterial pneumonia (CABP). After approval, several studies and case reports have described the postmarketing clinical experience with ceftaroline in ABSSSIs and CABP and in patients with invasive methicillin-resistant Staphylococcus aureus (MRSA) infections, many of whom had failed prior antibiotics. Successful clinical outcomes observed among the majority of these patients were supported by preapproval and postapproval in vitro surveillance of ceftaroline activity using breakpoint criteria that have been harmonized between the USA-FDA and CLSI. MIC90 values/percentage of strains susceptible to ceftaroline has remained stable over the period 2009-2012. Taken together, these postapproval studies support the use of ceftaroline for ABSSSI as well as CABP. Importantly, these data also suggest that ceftaroline can be effective in patients with serious invasive MRSA infections who have failed other therapies.
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Affiliation(s)
- Martin E Stryjewski
- Department of Medicine and Division of Infectious Diseases, Centro de Educación Médica e Investigaciones Clínicas (CEMIC), Buenos Aires, Argentina.
| | | | - G Ralph Corey
- Division of Infectious Diseases, Duke Clinical Research Institute, Durham, NC, USA; Duke University Medical Center, Durham, NC, USA.
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Scott LJ, Frampton JE. Ceftaroline fosamil: a guide to its use in complicated skin and soft tissue infections and community-acquired pneumonia in the EU. DRUGS & THERAPY PERSPECTIVES 2015. [DOI: 10.1007/s40267-014-0174-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Bergin SP, Holland TL, Fowler VG, Tong SYC. Bacteremia, Sepsis, and Infective Endocarditis Associated with Staphylococcus aureus. Curr Top Microbiol Immunol 2015; 409:263-296. [PMID: 26659121 DOI: 10.1007/82_2015_5001] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Bacteremia and infective endocarditis (IE) are important causes of morbidity and mortality associated with Staphylococcus aureus infections. Increasing exposure to healthcare, invasive procedures, and prosthetic implants has been associated with a rising incidence of S. aureus bacteremia (SAB) and IE since the late twentieth century. S. aureus is now the most common cause of bacteremia and IE in industrialized nations worldwide and is associated with excess mortality when compared to other pathogens. Central tenets of management include identification of complicated bacteremia, eradicating foci of infection, and, for many, prolonged antimicrobial therapy. Evolving multidrug resistance and limited therapeutic options highlight the many unanswered clinical questions and urgent need for further high-quality clinical research.
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Kuhlen JL, Blumenthal KG, Sokol CL, Balekian DS, Weil AA, Varughese CA, Shenoy ES, Banerji A. Ceftaroline desensitization procedure in a pregnant patient with multiple drug allergies. Open Forum Infect Dis 2015; 2:ofv027. [PMID: 26034776 PMCID: PMC4438906 DOI: 10.1093/ofid/ofv027] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2014] [Accepted: 02/27/2015] [Indexed: 01/26/2023] Open
Abstract
Validated skin testing is lacking for many drugs, including ceftaroline. The cross-reactivity between ceftaroline and other β-lactam antibiotics is unknown. We report a case of a pregnant patient with cystic fibrosis and multiple drug allergies who required ceftaroline for methicillin-resistant Staphylococcus aureus pneumonia and underwent an uncomplicated empiric desensitization procedure.
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Affiliation(s)
- James L. Kuhlen
- Division of Rheumatology, Allergy, and Immunology, Department of Medicine, Massachusetts General Hospital
- Harvard Medical School
| | - Kimberly G. Blumenthal
- Division of Rheumatology, Allergy, and Immunology, Department of Medicine, Massachusetts General Hospital
- Harvard Medical School
- Medical Practice Evaluation Center, Massachusetts General Hospital
| | - Caroline L. Sokol
- Division of Rheumatology, Allergy, and Immunology, Department of Medicine, Massachusetts General Hospital
- Harvard Medical School
- Center for Immunology and Inflammatory Diseases, Division of Rheumatology, Allergy and Immunology, Department of Medicine, Massachusetts General Hospital
| | - Diana S. Balekian
- Division of Rheumatology, Allergy, and Immunology, Department of Medicine, Massachusetts General Hospital
- Harvard Medical School
| | - Ana A. Weil
- Harvard Medical School
- Division of Infectious Diseases, Department of Medicine, Massachusetts General Hospital
| | - Christy A. Varughese
- Division of Infectious Diseases, Department of Medicine, Massachusetts General Hospital
- Department of Pharmacy, Massachusetts General Hospital
| | - Erica S. Shenoy
- Harvard Medical School
- Medical Practice Evaluation Center, Massachusetts General Hospital
- Division of Infectious Diseases, Department of Medicine, Massachusetts General Hospital
- Infection Control Unit, Massachusetts General Hospital, Boston
| | - Aleena Banerji
- Division of Rheumatology, Allergy, and Immunology, Department of Medicine, Massachusetts General Hospital
- Harvard Medical School
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Merker A, Danziger LH, Rodvold KA, Glowacki RC. Pharmacokinetic and pharmacodynamic evaluation of ceftaroline fosamil. Expert Opin Drug Metab Toxicol 2014; 10:1741-50. [PMID: 25347329 DOI: 10.1517/17425255.2014.972932] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
INTRODUCTION Ceftaroline fosamil is a 5th generation cephalosporin with an in vitro spectrum of activity including Streptococcus agalactiae, penicillin- and cephalosporin-resistant S. pneumoniae, S. pyogenes, methicillin-susceptible S. aureus and methicillin-resistant S. aureus, Haemophilus influenzae, Klebsiella oxytoca, K. pneumoniae and Moraxella catarrhalis. It is currently approved by the FDA for the treatment of acute bacterial skin and skin structure infections (ABSSSI) and community-acquired bacterial pneumonia (CABP) in adults. AREAS COVERED This review covers the mechanism of action; bacterial resistance; pharmacokinetic characteristics in various patient populations; pharmacodynamic data in animal and in vitro models as well as human studies; efficacy observed in clinical trials for ABSSSI and CABP; and adverse effects. EXPERT OPINION Ceftaroline provides in vitro bactericidal activity against methicillin-, vancomycin-, daptomycin-, and linezolid-resistant Gram-positive organisms and select Gram-negative pathogens. The pharmacodynamics of ceftaroline is similar to other β-lactam agents. Ceftaroline exhibits a favorable adverse effect profile and is generally well tolerated. There is little data on clinical success of ceftaroline in patients with bacteremia or endocarditis other than what has been published in a small series of case reports. Randomized-control studies are needed to establish clinical outcomes and safety in these patient populations.
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Affiliation(s)
- Andrew Merker
- HIV PGY2 Resident,University of Illinois at Chicago, College of Pharmacy , 833 South Wood Street, Chicago, 60612 , USA
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Abstract
IMPORTANCE Several management strategies may improve outcomes in patients with Staphylococcus aureus bacteremia. OBJECTIVES To review evidence of management strategies for S. aureus bacteremia to determine whether transesophageal echocardiography is necessary in all adult cases and what is the optimal antibiotic therapy for methicillin-resistant S. aureus (MRSA) bacteremia. EVIDENCE REVIEW A PubMed search from inception through May 2014 was performed to identify studies addressing the role of transesophageal echocardiography in S. aureus bacteremia. A second search of PubMed, EMBASE, and the Cochrane Library from January 1990 through May 2014 was performed to find studies addressing antibiotic treatment for MRSA bacteremia. Studies reporting outcomes from antibiotic therapy for MRSA bacteremia were included. All searches, which were limited to English and focused on adults, were augmented by review of bibliographic references from included studies. The quality of evidence was assessed using the Grades of Recommendation, Assessment, Development and Evaluation system with consensus of independent evaluations by at least 2 of the authors. FINDINGS In 9 studies with a total of 4050 patients, use of transesophageal echocardiography was associated with higher rates of a diagnosis of endocarditis (14%-28%) compared with transthoracic echocardiography (2%-15%). In 4 studies, clinical or transthoracic echocardiography findings did not predict subsequent transesophageal echocardiography findings of endocarditis. Five studies identified clinical or transthoracic echocardiography characteristics associated with low risk of endocarditis (negative predictive values from 93% to 100%). Characteristics associated with a low risk of endocarditis include absence of a permanent intracardiac device, sterile follow-up blood cultures within 4 days after the initial set, no hemodialysis dependence, nosocomial acquisition of S. aureus bacteremia, absence of secondary foci of infection, and no clinical signs of infective endocarditis. Of 81 studies of antibiotic therapy for MRSA bacteremia, only 1 high-quality trial was identified. In that study of 246 patients with S. aureus bacteremia, daptomycin was not inferior to vancomycin or an antistaphylococcal penicillin, each in combination with low-dose, short-course gentamicin (clinical success rate, 44.2% [53/120] vs 41.7% [48/115]; absolute difference, 2.4% [95% CI, -10.2% to 15.1%]). CONCLUSIONS AND RELEVANCE All adult patients with S. aureus bacteremia should undergo echocardiography. Characteristics of low-risk patients with S. aureus bacteremia for whom transesophageal echocardiography can be safely avoided have been identified. Vancomycin and daptomycin are the first-line antibiotic choices for MRSA bacteremia. Well-designed studies to address the management of S. aureus bacteremia are needed.
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Affiliation(s)
- Thomas L. Holland
- Division of Infectious Diseases & International Health, Department of Medicine, Duke University School of Medicine, Durham, NC 27710, USA
- Duke Clinical Research Institute, Duke University, Durham, NC
| | - Christopher Arnold
- Division of Infectious Diseases & International Health, Department of Medicine, Duke University School of Medicine, Durham, NC 27710, USA
| | - Vance G. Fowler
- Division of Infectious Diseases & International Health, Department of Medicine, Duke University School of Medicine, Durham, NC 27710, USA
- Duke Clinical Research Institute, Duke University, Durham, NC
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Kullar R, McKinnell JA, Sakoulas G. Avoiding the perfect storm: the biologic and clinical case for reevaluating the 7-day expectation for methicillin-resistant Staphylococcus aureus bacteremia before switching therapy. Clin Infect Dis 2014; 59:1455-61. [PMID: 25048852 DOI: 10.1093/cid/ciu583] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Persistent methicillin-resistant Staphylococcus aureus (MRSA) bacteremia (MRSAB) is associated with poor outcomes and serious complications. The MRSA guidelines define treatment failure and persistent bacteremia as lasting ≥7 days; however, this definition requires reevaluation. Aggressively reducing the bacterial inoculum promptly is critical because factors already in place before clinical presentation are driving resistance to the few antibiotics that are available to treat MRSAB. Alternative approaches to treat MRSAB should be considered within 3-4 days of persistent MRSAB. With rapid molecular diagnostics emerging in clinical microbiology laboratories and biomarkers as a potential for early patient risk stratification, a future shorter threshold may become possible.
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Affiliation(s)
- Ravina Kullar
- Department of Medical Affairs, Cubist Pharmaceuticals, Lexington, Massachusetts
| | - James A McKinnell
- Infectious Disease Clinical Outcomes Unit (ID-CORE), Los Angeles Biomedical Research Institute, David Geffen School of Medicine, University of California Department of Medicine, Torrance Memorial Medical Center
| | - George Sakoulas
- Division of Pediatric Pharmacology and Drug Discovery, University of California San Diego School of Medicine, La Jolla
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Fabre V, Ferrada M, Buckel WR, Avdic E, Cosgrove SE. Ceftaroline in Combination With Trimethoprim-Sulfamethoxazole for Salvage Therapy of Methicillin-Resistant Staphylococcus aureus Bacteremia and Endocarditis. Open Forum Infect Dis 2014; 1:ofu046. [PMID: 25734118 PMCID: PMC4281789 DOI: 10.1093/ofid/ofu046] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2014] [Accepted: 06/09/2014] [Indexed: 11/15/2022] Open
Abstract
No clinical trials have investigated the use of ceftaroline fosamil for salvage therapy of methicillin-resistant Staphylococcus aureus bacteremia and endocarditis. We report data on 29 patients who received ceftaroline ± another antimicrobial for this indication. Ninety percent of patients had microbiologic cure and 31% had treatment success with a median follow-up of 6 months.
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Affiliation(s)
- Valeria Fabre
- Division of Infectious Diseases , Johns Hopkins University School of Medicine , Baltimore, Maryland
| | - Marcela Ferrada
- Division of Infectious Diseases , Johns Hopkins University School of Medicine , Baltimore, Maryland ; Critical Care Medicine Department, National Institutes of Health, Bethesda, Maryland
| | - Whitney R Buckel
- Department of Pharmacy , Intermountain Medical Center , Murray, Utah
| | - Edina Avdic
- Department of Pharmacy , Johns Hopkins Hospital , Baltimore, Maryland
| | - Sara E Cosgrove
- Division of Infectious Diseases , Johns Hopkins University School of Medicine , Baltimore, Maryland
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