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Kuo CF, Lio CF, Chen HT, Wang YTT, Ma KSK, Chou YT, Chang FC, Tsai SY. Discordance of vancomycin minimum inhibitory concentration for methicillin-resistant Staphylococcus aureus at 2 μg/mL between Vitek II, E-test, and Broth Microdilution. PeerJ 2020; 8:e8963. [PMID: 32435531 PMCID: PMC7224226 DOI: 10.7717/peerj.8963] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2018] [Accepted: 03/23/2020] [Indexed: 12/28/2022] Open
Abstract
Background Vancomycin, the first line antibiotic for methicillin-resistant Staphylococcus aureus (MRSA) bacteremia, is often administered inappropriately when MIC is greater than 2 µg/mL, including ‘susceptible’ strains. This study assessed the discordance of vancomycin minimum inhibitory concentration (MIC) for methicillin-resistant Staphylococcus aureus (MRSA). Methods In total, 229 MRSA isolates from blood cultures collected between 2009 and 2015 at a tertiary hospital in Taiwan were examined. The MICs of vancomycin were measured using Vitek 2, E-test, and standard broth microdilution at the level of 2 µg/mL. Results The geometric mean of the MICs of hospital-acquired MRSA was higher than that of community-acquired MRSA (P < 0.001), with the exact agreement rates (with broth microdilution) at 2 µg/mL being 53.6% in Vitek 2 and 86.7% in E-test. Overall, E-test (98.1%) had more categorical accordance than did Vitek 2 (94.0%; P = 0.026). Vitek 2 had a tendency to overestimate MRSA in high-MIC isolates, whereas E-test inclined underestimation in low-MIC isolates. Surprisingly, the discordance rates of MRSA vancomycin MICs were higher in hospital-acquired isolates (13.3%–17.0%) than in community-acquired isolates (6.2%–7.0%). Conclusion The Infectious Diseases Society of America recommends the use of alternative antimicrobial agents when vancomycin MIC is ≥ 2 µg/mL; in this study, only 53.6% of the isolates tested using Vitek 2 showed a high MIC in the broth microdilution method. Accurate identification of the resistance profile is a key component of antimicrobial stewardship programs. Therefore, to reduce inappropriate antibiotic use and mitigate the emergence of resistant strains, we recommend using complementary tests such as E-test or Broth microdilution to verify the MIC before administering second-line antibiotics. Strengths (1) We compared the categorical agreement between different methods measuring MRSA MICs level. (2) Physicians should incorporate this information and consider a complementary test to verify the appropriateness of the decision of shifting vancomycin to second-line antibiotic treatment to improve patients’ prognosis. (3) MRSA-vancomycin MICs at a cutoff of 2 µg/mL obtained using Vitek II exhibited a higher sensitivity level and negative predictive value than those obtained using E-test in the prediction of categorical agreement with standard broth microdilution. Limitation (1) Our research was based on a single hospital-based study. (2) The MRSA strains in this study were stored for more than 12 months after isolation. (3) We did not collect information on clinical prognosis.
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Affiliation(s)
- Chien-Feng Kuo
- Division of Infectious Disease, Mackay Memorial Hospital, Taipei, Taiwan
| | - Chon Fu Lio
- Department of Laboratory Medicine, Mackay Memorial Hospital, Taipei, Taiwan
| | - Hsiang-Ting Chen
- Division of Infectious Disease, Mackay Memorial Hospital, Taipei, Taiwan.,Department of Medicine, Mackay Medical College, Taipei, Taiwan
| | - Yu-Ting Tina Wang
- Department of Laboratory Medicine, Mackay Memorial Hospital, Taipei, Taiwan
| | - Kevin Sheng-Kai Ma
- Department of Laboratory Medicine, Mackay Memorial Hospital, Taipei, Taiwan.,Department of Pathology, School of Dental Medicine, University of Pennsylvania, Philadelphia, USA
| | - Yi Ting Chou
- Department of Laboratory Medicine, Mackay Memorial Hospital, Taipei, Taiwan
| | - Fu-Chieh Chang
- Infection control center, Mackay Memorial Hospital, Taipei, Taiwan
| | - Shin-Yi Tsai
- Department of Laboratory Medicine, Mackay Memorial Hospital, Taipei, Taiwan.,Department of Medicine, Mackay Medical College, Taipei, Taiwan.,Department of Health Policy and Management, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, U.S.,Graduate Institute of Long-Term Care, Graduate Institute of Biomedical Sciences, Mackay Medical College, New Taipei City, Taiwan
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2
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Novel bio compactable silver nanowires and nanocubes: An effective treatment against carbapenem and vancomycin resistant strains isolated from cancer patients. JOURNAL OF SAUDI CHEMICAL SOCIETY 2019. [DOI: 10.1016/j.jscs.2019.06.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
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3
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Bader JC, Lakota EA, Andes DR, Rubino CM, Ambrose PG, Bhavnani SM. Time for Precision: A World Without Susceptibility Breakpoints. Open Forum Infect Dis 2018; 5:ofy282. [PMID: 30581880 PMCID: PMC6297858 DOI: 10.1093/ofid/ofy282] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2018] [Accepted: 10/29/2018] [Indexed: 12/16/2022] Open
Abstract
Interpretive criteria for in vitro susceptibility testing criteria, "susceptibility breakpoints," underpin the evaluation and selection of antimicrobial regimens. However, despite their strengths, susceptibility breakpoints are a relatively blunt instrument employed to address an extremely complex question-what is the likelihood of treatment success for individual patients? With regard to evaluating patients on a case-by-case basis, breakpoints merely allow us to account for pathogen susceptibility. This approach precludes consideration of drug exposures achieved in patients, thus overlooking half of the equation for predicting treatment success. Herein, we propose the framework for considering both pathogen- and patient-specific information to provide clinicians a means of evaluating antimicrobial regimens for individual patients through tools automating pharmacokinetic-pharmacodynamic target attainment analyses. Implementing these tools along with their acceptance by professional organizations will allow for a shift in the paradigm for how antimicrobials are selected and dosed-toward patient-centered care through precision medicine.
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Affiliation(s)
- Justin C Bader
- Institute for Clinical Pharmacodynamics, Schenectady, New York
| | | | | | | | - Paul G Ambrose
- Institute for Clinical Pharmacodynamics, Schenectady, New York
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4
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Naylor NR, Atun R, Zhu N, Kulasabanathan K, Silva S, Chatterjee A, Knight GM, Robotham JV. Estimating the burden of antimicrobial resistance: a systematic literature review. Antimicrob Resist Infect Control 2018; 7:58. [PMID: 29713465 PMCID: PMC5918775 DOI: 10.1186/s13756-018-0336-y] [Citation(s) in RCA: 283] [Impact Index Per Article: 47.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2017] [Accepted: 03/14/2018] [Indexed: 01/02/2023] Open
Abstract
Background Accurate estimates of the burden of antimicrobial resistance (AMR) are needed to establish the magnitude of this global threat in terms of both health and cost, and to paramaterise cost-effectiveness evaluations of interventions aiming to tackle the problem. This review aimed to establish the alternative methodologies used in estimating AMR burden in order to appraise the current evidence base. Methods MEDLINE, EMBASE, Scopus, EconLit, PubMed and grey literature were searched. English language studies evaluating the impact of AMR (from any microbe) on patient, payer/provider and economic burden published between January 2013 and December 2015 were included. Independent screening of title/abstracts followed by full texts was performed using pre-specified criteria. A study quality score (from zero to one) was derived using Newcastle-Ottawa and Philips checklists. Extracted study data were used to compare study method and resulting burden estimate, according to perspective. Monetary costs were converted into 2013 USD. Results Out of 5187 unique retrievals, 214 studies were included. One hundred eighty-seven studies estimated patient health, 75 studies estimated payer/provider and 11 studies estimated economic burden. 64% of included studies were single centre. The majority of studies estimating patient or provider/payer burden used regression techniques. 48% of studies estimating mortality burden found a significant impact from resistance, excess healthcare system costs ranged from non-significance to $1 billion per year, whilst economic burden ranged from $21,832 per case to over $3 trillion in GDP loss. Median quality scores (interquartile range) for patient, payer/provider and economic burden studies were 0.67 (0.56-0.67), 0.56 (0.46-0.67) and 0.53 (0.44-0.60) respectively. Conclusions This study highlights what methodological assumptions and biases can occur dependent on chosen outcome and perspective. Currently, there is considerable variability in burden estimates, which can lead in-turn to inaccurate intervention evaluations and poor policy/investment decisions. Future research should utilise the recommendations presented in this review. Trial registration This systematic review is registered with PROSPERO (PROSPERO CRD42016037510).
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Affiliation(s)
- Nichola R. Naylor
- National Institute for Health Research Health Protection Research Unit in Healthcare Associated Infection and Antimicrobial Resistance at Imperial College, Hammersmith Campus, London, W12 0NN UK
| | - Rifat Atun
- National Institute for Health Research Health Protection Research Unit in Healthcare Associated Infection and Antimicrobial Resistance at Imperial College, Hammersmith Campus, London, W12 0NN UK
- Harvard University, 665 Huntington Avenue, Boston, MA 02115 USA
| | - Nina Zhu
- National Institute for Health Research Health Protection Research Unit in Healthcare Associated Infection and Antimicrobial Resistance at Imperial College, Hammersmith Campus, London, W12 0NN UK
| | - Kavian Kulasabanathan
- Imperial College London, Sir Alexander Fleming Building, South Kensington Campus, London, UK
| | - Sachin Silva
- Harvard University, 665 Huntington Avenue, Boston, MA 02115 USA
| | - Anuja Chatterjee
- National Institute for Health Research Health Protection Research Unit in Healthcare Associated Infection and Antimicrobial Resistance at Imperial College, Hammersmith Campus, London, W12 0NN UK
| | - Gwenan M. Knight
- National Institute for Health Research Health Protection Research Unit in Healthcare Associated Infection and Antimicrobial Resistance at Imperial College, Hammersmith Campus, London, W12 0NN UK
| | - Julie V. Robotham
- National Institute for Health Research Health Protection Research Unit in Healthcare Associated Infection and Antimicrobial Resistance at Imperial College, Hammersmith Campus, London, W12 0NN UK
- Modelling and Economics Unit, National Infection Service, Public Health England, 61 Colindale Avenue, London, NW9 5EQ UK
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5
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Diaz R, Afreixo V, Ramalheira E, Rodrigues C, Gago B. Evaluation of vancomycin MIC creep in methicillin-resistant Staphylococcus aureus infections—a systematic review and meta-analysis. Clin Microbiol Infect 2018. [DOI: 10.1016/j.cmi.2017.06.017] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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6
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Hos NJ, Jazmati N, Stefanik D, Hellmich M, AlSael H, Kern WV, Rieg S, Wisplinghoff H, Seifert H, Kaasch AJ. Determining vancomycin Etest MICs in patients with MRSA bloodstream infection does not support switching antimicrobials. J Infect 2016; 74:248-259. [PMID: 28017826 DOI: 10.1016/j.jinf.2016.12.007] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2016] [Revised: 12/16/2016] [Accepted: 12/18/2016] [Indexed: 10/20/2022]
Abstract
OBJECTIVES Elevated vancomycin minimum inhibitory concentrations (MIC) have been reported to adversely affect clinical outcome in methicillin-resistant Staphylococcus aureus (MRSA) bloodstream infection (BSI). We therefore examined the association between vancomycin MIC and outcome considering various potential confounders. METHODS Clinical data and bacterial isolates were prospectively collected from patients with MRSA BSI from 2006 to 2012 as part of the Invasive Staphylococcus aureus Infection Cohort (INSTINCT) study. Antimicrobial susceptibility was assessed by Etest, broth microdilution (BMD) and VITEK 2. Bacterial genotypes were determined by spa typing. Using univariate and Cox regression analyses, we investigated the impact of low (≤1.0 mg/L) and high (≥1.5 mg/L) vancomycin Etest MIC on clinical outcomes. RESULTS Ninety-one MRSA BSI episodes were included, of which 79 (86.8%) were caused by spa types t003, t032 and t045. High vancomycin MICs were seen only if using Etest but not confirmed using standard reference BMD. When episodes were stratified into low and high vancomycin Etest MIC groups, 30-day overall mortality was 34.5% and 27.3%, respectively (P = 0.64, OR 0.71; 95% confidence interval [CI] 0.27-1.79). Variables significantly associated with all-cause mortality in the Cox model were age (P = 0.003), acute physiology score (P = 0.0006), and Charlson comorbidity index (P = 0.018). CONCLUSIONS Vancomycin MICs may vary dependent on testing methodologies and local MRSA epidemiology. The patients' underlying disease and individual comorbidities rather than elevated vancomycin MICs determine adverse clinical outcomes in MRSA BSI. Routine Etest MIC testing of MRSA isolates is of limited value for treatment decisions.
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Affiliation(s)
- Nina J Hos
- Institute for Medical Microbiology, Immunology and Hygiene, University of Cologne, Goldenfelsstr. 19-21, 50935 Cologne, Germany; Cologne Cluster of Excellence in Cellular Stress Responses in Aging-associated Diseases, University of Cologne, Joseph-Stelzmann-Str. 26, 50931 Cologne, Germany; German Centre for Infection Research, Partner Site Bonn-Cologne, Germany
| | - Nathalie Jazmati
- Institute for Medical Microbiology, Immunology and Hygiene, University of Cologne, Goldenfelsstr. 19-21, 50935 Cologne, Germany
| | - Danuta Stefanik
- Institute for Medical Microbiology, Immunology and Hygiene, University of Cologne, Goldenfelsstr. 19-21, 50935 Cologne, Germany
| | - Martin Hellmich
- Institute of Medical Statistics, Informatics and Epidemiology, University of Cologne, Kerpener Str. 62, 50937 Cologne, Germany
| | - Halil AlSael
- Institute for Medical Microbiology, Immunology and Hygiene, University of Cologne, Goldenfelsstr. 19-21, 50935 Cologne, Germany
| | - Winfried V Kern
- Division of Infectious Diseases, Department of Medicine II, University Medical Center Freiburg, Hugstetter Str. 55, 79106 Freiburg, Germany
| | - Siegbert Rieg
- Division of Infectious Diseases, Department of Medicine II, University Medical Center Freiburg, Hugstetter Str. 55, 79106 Freiburg, Germany
| | - Hilmar Wisplinghoff
- Institute for Medical Microbiology, Immunology and Hygiene, University of Cologne, Goldenfelsstr. 19-21, 50935 Cologne, Germany
| | - Harald Seifert
- Institute for Medical Microbiology, Immunology and Hygiene, University of Cologne, Goldenfelsstr. 19-21, 50935 Cologne, Germany; German Centre for Infection Research, Partner Site Bonn-Cologne, Germany.
| | - Achim J Kaasch
- Institute for Medical Microbiology, Immunology and Hygiene, University of Cologne, Goldenfelsstr. 19-21, 50935 Cologne, Germany; Institute of Medical Microbiology and Hospital Hygiene, Heinrich-Heine University Düsseldorf, Universitätsstr. 1, 40225 Düsseldorf, Germany
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7
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Kent A, Kortsalioudaki C, Monahan IM, Bielicki J, Planche TD, Heath PT, Sharland M. Neonatal gram-negative infections, antibiotic susceptibility and clinical outcome: an observational study. Arch Dis Child Fetal Neonatal Ed 2016; 101:F507-F512. [PMID: 26951742 DOI: 10.1136/archdischild-2015-309554] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2015] [Revised: 02/10/2016] [Accepted: 02/12/2016] [Indexed: 11/03/2022]
Abstract
BACKGROUND Neonatal gram-negative (GN) infections are associated with high mortality and morbidity. Early appropriate antibiotic treatment is vital and gentamicin is the most frequently used antibiotic on neonatal units (NNUs). Antimicrobial breakpoints are predominantly based on adult data and the relationship between minimum inhibitory concentrations (MICs) and outcome in neonates is unclear. We aimed to determine the MIC of GN pathogens causing neonatal infections and relate this to clinical outcomes. METHODS MICs for eight antibiotics plus extended spectrum β-lactamase (ESBL) production were determined for invasive GN bacterial isolates from eight UK NNUs. European Committee on Antimicrobial Susceptibility Testing breakpoints were applied. MIC was correlated with clinical outcome using multivariable regression analysis. RESULTS 118 isolates from 116 patients were analysed. The median birth gestation and postnatal age was 27 weeks (IQR 24.6-32.3) and 20 days (IQR 5-44), respectively. Pathogens included Escherichia coli (51%), Klebsiella spp (23%) and Enterobacter spp (22%). 10-day attributable mortality was 18.1% (21 patients) with the highest mortality from Pseudomonas aeruginosa infections. ESBL producers accounted for 13.8% of the isolates. In regression analysis, increasing gentamicin MIC was associated with increased mortality in gentamicin treated patients across the full MIC range (OR per loge increase in MIC: 2.29; 95% CI 1.23 to 4.26, p=0.009), including susceptible isolates only (MIC ≤4) (OR 3.05; 95% CI 1.10 to 8.46, p=0.032). CONCLUSIONS Neonatal mortality from GN infections remains high and is associated with increasing gentamicin MIC, even for isolates deemed susceptible. A better understanding of population-specific MICs and aminoglycoside dosing is required to guide empiric antibiotic treatment.
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Affiliation(s)
- Alison Kent
- Paediatric Infectious Disease Research Group, St George's, University of London, London, UK
| | | | - Irene M Monahan
- Institute of Infection and Immunity, St George's, University of London, London, UK
| | - Julia Bielicki
- Paediatric Infectious Disease Research Group, St George's, University of London, London, UK
| | - Timothy D Planche
- Institute of Infection and Immunity, St George's, University of London, London, UK.,Department of Medical Microbiology, St George's Healthcare NHS Trust, London, UK
| | - Paul T Heath
- Paediatric Infectious Disease Research Group, St George's, University of London, London, UK
| | - Mike Sharland
- Paediatric Infectious Disease Research Group, St George's, University of London, London, UK
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8
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Antonanzas F, Lozano C, Torres C. Economic features of antibiotic resistance: the case of methicillin-resistant Staphylococcus aureus. PHARMACOECONOMICS 2015; 33:285-325. [PMID: 25447195 DOI: 10.1007/s40273-014-0242-y] [Citation(s) in RCA: 48] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
This paper analyses and updates the economic information regarding methicillin-resistant Staphylococcus aureus (MRSA), including information that has been previously reviewed by other authors, and new information, for the purpose of facilitating health management and clinical decisions. The analysed articles reveal great disparity in the economic burden on MRSA patients; this is mainly due to the diversity of the designs of the studies, as well as the variability of the patients and the differences in health care systems. Regarding prophylactic strategies, the studies do not provide conclusive results that could unambiguously orientate health management. The studies addressing treatments noted that linezolid seems to be a cost-effective treatment for MRSA, mostly because it is associated with a shorter length of stay (LOS) in hospital. However, important variables such as antimicrobial susceptibility, infection type and resistance emergence should be included in these analyses before a conclusion is reached regarding which treatment is the best (most efficient). The reviewed studies found that rapid MRSA detection, using molecular techniques, is an efficient technique to control MRSA. As a general conclusion, the management of MRSA infections implicates important economic costs for hospitals, as they result in higher direct costs and longer LOS than those related to methicillin-susceptible S. aureus (MSSA) patients or MRSA-free patients; there is wide variability in those increased costs, depending on different variables. Moreover, the research reveals a lack of studies on other related topics, such as the economic implications of changes in MRSA epidemiology (community patients and lineages associated with farm animals).
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9
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Genetic and molecular predictors of high vancomycin MIC in Staphylococcus aureus bacteremia isolates. J Clin Microbiol 2014; 52:3384-93. [PMID: 25031442 DOI: 10.1128/jcm.01320-14] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
An elevated vancomycin MIC is associated with poor outcomes in Staphylococcus aureus bacteremia (SAB) and is reported in patients with methicillin-susceptible S. aureus (MSSA) bacteremia in the absence of vancomycin treatment. Here, using DNA microarray and phenotype analysis, we investigated the genetic predictors and accessory gene regulator (agr) function and their relationship with elevated vancomycin MIC using blood culture isolates from a multicenter binational cohort of patients with SAB. Specific clonal complexes were associated with elevated (clonal complex 8 [CC8] [P < 0.001]) or low (CC22 [P < 0.001], CC88 [P < 0.001], and CC188 [P = 0.002]) vancomycin MIC. agr dysfunction (P = 0.014) or agr genotype II (P = 0.043) were also associated with an elevated vancomycin MIC. Specific resistance and virulence genes were also linked to an elevated vancomycin MIC, including blaZ (P = 0.002), sea (P < 0.001), clfA (P < 0.001), splA (P = 0.001), and the arginine catabolic mobile element (ACME) locus (P = 0.02). These data suggest that inherent organism characteristics may explain the link between elevated vancomycin MICs and poor outcomes in patients with SAB, regardless of the antibiotic treatment received. A consideration of clonal specificity should be included in future research when attempting to ascertain treatment effects or clinical outcomes.
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10
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Edwards B, Andini R, Esposito S, Grossi P, Lew D, Mazzei T, Novelli A, Soriano A, Gould IM. Treatment options for methicillin-resistant Staphylococcus aureus (MRSA) infection: Where are we now? J Glob Antimicrob Resist 2014; 2:133-140. [PMID: 27873719 DOI: 10.1016/j.jgar.2014.03.009] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2013] [Revised: 03/28/2014] [Accepted: 03/31/2014] [Indexed: 01/05/2023] Open
Abstract
Methicillin-resistant Staphylococcus aureus (MRSA) infection continues to be a substantial global problem with significant associated morbidity and mortality. This review summarises the discussions that took place at the 4th MRSA Consensus Conference in relation to the current treatment options for serious MRSA infections and how to optimise whichever therapy is embarked upon. It highlights the many challenges faced by both the laboratory and clinicians in the diagnosis and treatment of MRSA infections.
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Affiliation(s)
- B Edwards
- Medical Microbiology Department, Royal Infirmary of Edinburgh, 51 Little France Crescent, Dalkeith Road, Edinburgh EH16 4SA, UK.
| | - R Andini
- Second University of Naples, UOC Transplant and Infectious Disease Medicine, AORN Monaldi, Naples, Italy
| | - S Esposito
- Department of Medicine, University of Salerno, Salerno, Italy
| | - P Grossi
- Department of Surgical and Morphological Studies, University of Unisubria, Varese, Italy
| | - D Lew
- Chief Infectious Diseases Division, Chief Department of Specialties of Internal Medicine, Geneva University Hospital, Geneva, Switzerland
| | - T Mazzei
- Department of Health Sciences, Clinical Pharmacology and Oncology Section, University of Firenze, Firenze, Italy
| | - A Novelli
- Department of Health Sciences, Clinical Pharmacology and Oncology Section, University of Firenze, Firenze, Italy
| | - A Soriano
- Department of Infectious Diseases, IDIBAPS, Hospital Clinic of Barcelona, Spain
| | - I M Gould
- Medical Microbiology Department, Aberdeen Royal Infirmary, Aberdeen, UK
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