Outcomes of Ceftriaxone Compared With Cefazolin or Nafcillin/Oxacillin for Outpatient Therapy for Methicillin-Sensitive Staphylococcus aureus Bloodstream Infections: Results From a Large United States Claims Database

Background

Ceftriaxone is a convenient option for methicillin-sensitive Staphylococcus aureus (MSSA) outpatient parenteral antimicrobial therapy (OPAT), but population-based studies for its effectiveness are lacking.

Methods

In this retrospective cohort, a large insurance claims database was queried from 2010 to 2018 for adults with MSSA bloodstream infection (BSI). Patients discharged on OPAT on cefazolin or oxacillin/nafcillin were compared with ceftriaxone with respect to 90-day hospital readmission with the same infection category and 90-day all-cause readmission using logistic regression models.

Results

Of 1895 patients with MSSA BSI, 1435 (75.7%) patients received cefazolin, oxacillin, or nafcillin and 460 (24.3%) ceftriaxone. Readmission due to the same infection category occurred in 366 (19.3%), and all-cause readmission occurred in 535 (28.3%) within 90 days. Risk factors significantly associated with readmission with the same infection category were the oldest sampled age group (61-64 years: adjusted odds ratio [aOR], 1.47 [95% confidence interval {CI}, 1.01-2.14]), intensive care unit stay during index admission (aOR, 2.33 [95% CI, 1.81-3.01]), prosthetic joint infection (aOR, 1.96 [95% CI, 1.18-2.23]), central line-associated BSI (aOR, 1.72 [95% CI, 1.33-2.94]), and endocarditis (aOR, 1.63 [95% CI, 1.18-2.23]). Ceftriaxone was not associated with increased risk of readmission with the same infection category (aOR, 0.89 [95% CI, .67-1.18]), or 90-day all-cause readmission (aOR, 0.86 [95% CI, .66-1.10]) when compared with oxacillin/nafcillin/cefazolin.

Conclusions

In this cohort of MSSA BSI patients discharged on OPAT, there were no differences in outcomes of readmission with the same infection and 90-day all-cause readmission in patients treated with ceftriaxone compared to oxacillin/nafcillin or cefazolin. Patients with complicated BSIs such as endocarditis and epidural abscess were more likely to be prescribed cefazolin or oxacillin/nafcillin.

Impact of viral detection in patients with community-acquired pneumonia: An observational cohort study

PURPOSE

The presence of a respiratory virus in patients with community-acquired pneumonia (CAP) may have an impact on the bacterial etiology and clinical presentation. In this study we aimed to assess the role of viral infection in the bacterial etiology and outcomes of patients with CAP.

METHODS

We performed a retrospective study of all adults hospitalized with CAP between November 2017 and October 2018. Patients were classified according to the presence of viral infection. An unvaried and a multivaried analysis were performed to identify variables associated with viral infection and clinical outcomes.

RESULTS

Overall 590 patients were included. A microorganism was documented in 375 cases (63.5%). A viral infection was demonstrated in 118 (20%). The main pathogens were Streptococcus pneumoniae (35.8%), Staphylococcus aureus (2.9%) and influenza virus (10.8%). A trend to a higher rate of S. aureus (p=0.06) in patients with viral infection was observed. Patients with viral infection had more often bilateral consolidation patterns (17.8% vs 10.8%, p=0.04), respiratory failure (59.3% vs 42.8%, p=0.001), ICU admission (17.8% vs 7%, p=0.001) and invasive mechanical ventilation (9.3% vs 2.8%, p=0.003). Risk factors for respiratory failure were chronic lung disease, age >65 years, positive blood cultures and viral infection. Influenza, virus but no other respiratory viruses, was associated with respiratory failure (OR, 3.72; 95% CI, 2.06-6.73).

CONCLUSIONS

Our study reinforces the idea that co-viral infection has an impact in the clinical presentation of CAP causing a more severe clinical picture. This impact seems to be mainly due to influenza virus infection.

Optimal drug therapy for Staphylococcus aureus bacteraemia in adults

PURPOSE OF REVIEW

Staphylococcus aureus is a significant human pathogen, causing a variety of infections, from skin and soft tissue infections to endocarditis, bone and joint infections and deep tissue abscesses. Mortality from S. aureus bacteraemia remains high, without major therapeutic advances in recent decades.

RECENT FINDINGS

In recent years, optimized dosing of antibiotics is increasingly being recognized as a cornerstone of management for severe infections including S. aureus bacteraemia. This comprehensive review details the pharmacokinetics/pharmacodynamics (PK/PD) targets for commonly used antistaphylococcal antibiotics and the doses predicted to achieve them in clinical practice. Recent advances in dosing of teicoplanin and use of cefazolin in CNS infections and findings from combination therapy studies are discussed. Drug exposure relationships related to toxicity are also detailed.

SUMMARY

This review details the different PK/PD targets for drugs used to treat S. aureus bacteraemia and how to apply them in various scenarios. The drug doses that achieve them, and the risks of toxicity are also provided.

Comparison of ceftriaxone and cefazolin as prophylactic antibiotics for surgical site infection in orthopedic upper extremity surgery: The nationwide shortage of cefazolin in March 2019

BACKGROUND

Due to the nationwide supply shortage of cefazolin in March 2019 in Japan, ceftriaxone was used as an alternative prophylaxis antibiotic agent. This retrospective study was designed to investigate the impact of cefazolin and ceftriaxone as a prophylactic antibiotic agent for surgical site infection (SSI) in orthopedic upper extremity surgery.

METHODS

We used cefazolin for antibiotic prophylaxis to prevent SSI before March 2019. Because of cefazolin shortage, ceftriaxone was used as an alternative agent in our hospital. From April 2014 to May 2021, 2493 upper extremity surgeries were reviewed. The exclusion criteria in this study were as follows: patients aged under 16 years, those with an open wound, those with infectious diseases, those who underwent trigger finger surgery, and those who underwent percutaneous pinning surgery. The incidence of deep SSI was evaluated according to the Centers for Disease Control and Prevention guidelines.

RESULTS

Among the 2493 eligible cases, 1674 were included in this study. In the cefazolin group, 1140 cases were included, whereas, in the ceftriaxone group, 534 cases were included. No significant differences in the demographic data of the patients were observed between the two groups. The incidence of deep SSI was 0.08% (1/1140 cases) in the cefazolin group and 1.1% (6/534 cases) in the ceftriaxone group, with a significant difference between the two groups (odds ratio, 12.9; p = 0.005).

CONCLUSIONS

This study indicated that the use of ceftriaxone instead of cefazolin after upper extremity surgery increases the risk of deep SSI.

Post-treatment outcomes of ceftriaxone versus antistaphylococcal penicillins or cefazolin for definitive therapy of methicillin-susceptible Staphylococcus aureus bacteremia

Methicillin-susceptible Staphylococcus aureus (MSSA) bacteremia is associated with poor outcomes. Ceftriaxone offers logistical advantages over other standard therapies, though in vitro studies have questioned its efficacy and clinical studies of ceftriaxone in MSSA bacteremia are conflicting.We performed a multicenter, retrospective cohort study of adult patients who received ceftriaxone, cefazolin, or antistaphylococcal penicillins as definitive therapy for MSSA bacteremia from 2018 to 2019. Definitive therapy was defined as the antibiotic used in the outpatient setting. Patients were excluded if they received less than 7 days of outpatient therapy. Follow-up started on the date of definitive therapy completion. The primary outcome was 90-day treatment failure, defined as a composite of mortality and microbiologic recurrence. This was analyzed with multivariable Cox regression. A total of 223 patients were included, 37 (16.6%) of whom received ceftriaxone. The most common ceftriaxone dose was 2 g daily (83.8%). The most common primary site of infection was skin/soft tissue (37.2%), unknown (21.1%), and catheter-related (15.2%). Twenty-six (11.7%) developed infective endocarditis. Median total duration of treatment was 31.0 days, and median outpatient duration was 24.0 days. Twenty-six (11.7%) developed 90-day treatment failure. After adjusting for Charlson comorbidity index, duration of therapy, and use of transesophageal echocardiography, definitive treatment with ceftriaxone was associated with treatment failure (hazard ratio 2.66, 95% confidence interval 1.15-6.12; p=0.022). Among patients with MSSA bacteremia, definitive treatment with ceftriaxone was associated with a higher risk of treatment failure within 90 days as compared to cefazolin or antistaphylococcal penicillins.

Effect of Antimicrobial Exposure in Pregnancy on Adverse Pregnancy Outcomes and Admission Rate to the Neonatal Intensive Care Unit: A Multi-Center Cohort Study

Purpose

Antimicrobial agents are frequently prescribed during pregnancy. This study aims to explore the association between antimicrobial exposure and pregnancy outcomes.

Patients and Methods

A multi-center retrospective cohort study of pregnant patients (n=370) was conducted in 22 tertiary hospitals in China. Adverse pregnancy outcomes and admission of neonate to neonatal intensive care unit (NICU) were considered as outcomes. The effect of antimicrobial exposure on pregnancy outcomes was assessed using a multivariate logistic regression model.

Results

Use of first-generation cephalosporins during pregnancy was associated with a significantly higher risk of adverse pregnancy outcomes (odds ratio [OR]: 3.64 [95% confidence interval, CI: 1.43-9.24], P = 0.007) and admission of neonate to the NICU (OR: 3.41, 95% CI: 1.37-8.53, P=0.009) compared with use of third-generation cephalosporins, after adjusting for gestational age of exposure to antimicrobial agents, cesarean section, and antimicrobial dose. Similarly, a higher risk of adverse pregnancy outcomes (OR: 14.76, 95% CI: 4.43-49.11) and neonatal NICU admission (OR: 11.74, 95% CI: 3.59-38.35) were observed among women with first-generation cephalosporins use compared with mothers with no antimicrobial use.

Conclusion

Both first- and third-generation cephalosporins use was associated with an increased risk of adverse pregnancy and neonatal outcomes. In addition, first-generation cephalosporins were associated with an increased risk of those pregnant and neonatal outcomes, when compared with third-generation cephalosporins. We should require to determine the indications and contraindications for use of cephalosporins during pregnancy.

Outpatient management of moderate cellulitis in children using high-dose oral cephalexin

Objectives

To evaluate the effectiveness of a high-dose (HD) oral cephalexin treatment guideline for children with moderate cellulitis treated as outpatients.

Methods

In this retrospective cohort study, we included children who presented to the emergency department (ED) with moderate cellulitis and treated according to the institution’s HD oral cephalexin guideline over a 2-year period. All children had standardized follow-up at a medical day hospital (MDH). Treatment was considered effective in the absence of treatment failure, defined as admission, switch to IV treatment or ED visit within 2 weeks of discharge from the MDH. Safety was ascertained by recording adverse events and severe complications at follow-up.

Results

A total of 123 children were treated as outlined in the guideline, including 117 treated with HD oral cephalexin. The success rate was 89.7% (105/117). Among 12 (10.3%) children who had treatment failure, 10 (8.5%) required admission, 1 (0.9%) received IV antibiotics at the MDH and 1 (0.9%) had a return visit to the ED without admission. No severe complications were reported; four abscesses required drainage and one patient had a rash. The mean number of visits per child at the MDH was 1.6 (SD 1.0).

Conclusions

With a success rate of 89.7%, HD oral cephalexin seems effective and safe for the treatment of children with moderate cellulitis. Its use potentially reduces hospitalization rates for this condition and decreases the need for IV insertion.

Ceftriaxone and methicillin-susceptible staphylococcus aureus: a perspective from pharmacokinetics/pharmacodynamics studies

INTRODUCTION

: Usage of ceftriaxone-based therapy to treat Methicillin-Susceptible Staphylococcus aureus (MSSA) infections is a controversial issue, from in vitro to clinical studies.

AREA COVERED

: We conducted a literature review using PubMed of articles with ceftriaxone pharmacokinetics parameters and built a probability of target attainment (PTA) based on PK values from stable conditions (non-critically-ill patients) with goals of fT>55%, fT>75%, and fT>100%. Ceftriaxone's minimal inhibitory concentration from 31 MSSA strains (0.25-64mg/L) was used to build the cumulative fraction response (CFR). The isolates were clinically relevant from blood, bronchoalveolar lavage, and soft tissue biopsy.

EXPERT OPINION

The results from controversies about using ceftriaxone for MSSA infections have been commonly addressed in the literature. However, variables such as (i) pharmacokinetic profile, (ii) pharmacodynamic target, (iii) site of infection, and (iv) MIC distributions may influence divergences. From this pharmacokinetics-pharmacodynamics perspective, ceftriaxone may be a reasonable option for MSSA infections when the MIC50 and MIC90 were 4mg/L and 8mg/L. CFR analysis demonstrated that ceftriaxone 1g q24h could be used if bacteriostasis is the aim (fT>55%), while 1g q12h should be used for bactericidal effects (fT>75% or fT>100%). Since there is a lack of data from clinical trials, the findings should be interpreted cautiously.

Clinical cure with ceftriaxone versus ceftaroline or ceftobiprole in the treatment of staphylococcal pneumonia: a systematic review and meta-analysis

Ceftriaxone is an empirical antibiotic commonly used to treat pneumonia. However, its use to treat infections caused by methicillin-susceptible Staphylococcus aureus (MSSA) is controversial given limited evidence of its clinical efficacy. The objective of this study was to compare the clinical efficacy of ceftriaxone with either ceftaroline or ceftobiprole in the treatment of pneumonia caused by MSSA. A systematic review and meta-analysis of randomised controlled trials (RCTs) comparing clinical cure in patients with pneumonia who received ceftriaxone versus those who received either ceftaroline or ceftobiprole was conducted. Patients who received ceftriaxone plus vancomycin were excluded. The PubMed, Embase and Cochrane Library databases as well as clinical trial registries were searched up to 8 June 2018. Risk differences (RDs) with 95% confidence intervals (CIs) were estimated using a random-effects model and assessing for heterogeneity (I2). A total of five RCTs met the inclusion criteria; four used ceftaroline and one used ceftobiprole. Four studies included adults and one included paediatric patients. The adult studies included non-intensive care unit patients with mild-to-moderate community-acquired pneumonia. Clinical cure was statistically lower with ceftriaxone (RD, -28.5%, 95% CI -53.5% to -3.4%; P = 0.026; I2 = 16.321%) than with ceftaroline or ceftobiprole. In conclusion, ceftriaxone use was associated with higher clinical failure of MSSA pneumonia compared with ceftaroline or ceftobiprole. This supports the notion that ceftriaxone is not an ideal agent for the treatment of MSSA infections and adds new evidence against its use for MSSA pneumonia.