Burnham Jason P, Burnham C A, Warren David K, Kollef Marin H
Division of Infectious Diseases, Washington University School of Medicine, St. Louis, Missouri, USA
Department of Pathology & Immunology, Washington University School of Medicine, St. Louis, Missouri, USA.
Antimicrob Agents Chemother. 2016 Aug 22;60(9):5546-53. doi: 10.1128/AAC.00925-16. Print 2016 Sep.
Despite the increasing incidence of vancomycin-intermediate Staphylococcus aureus (VISA) infections, few studies have examined the impact of delay in receipt of appropriate antimicrobial therapy on outcomes in VISA patients. We examined the effects of timing of appropriate antimicrobial therapy in a cohort of patients with sterile-site methicillin-resistant S. aureus (MRSA) and VISA infections. In this single-center, retrospective cohort study, we identified all patients with MRSA or VISA sterile-site infections from June 2009 to February 2015. Clinical outcomes were compared according to MRSA/VISA classification, demographics, comorbidities, and antimicrobial treatment. Thirty-day all-cause mortality was modeled with Kaplan-Meier curves. Multivariate logistic regression analysis (MVLRA) was used to determine odds ratios for mortality. We identified 354 patients with MRSA (n = 267) or VISA (n = 87) sterile-site infection. Fifty-five patients (15.5%) were nonsurvivors. Factors associated with mortality in MVLRA included pneumonia, unknown source of infection, acute physiology and chronic health evaluation (APACHE) II score, solid-organ malignancy, and admission from skilled care facilities. Time to appropriate antimicrobial therapy was not significantly associated with outcome. Presence of a VISA infection compared to that of a non-VISA S. aureus infection did not result in excess mortality. Linezolid use was a risk for mortality in patients with APACHE II scores of ≥14. Our results suggest that empirical vancomycin use in patients with VISA infections does not result in excess mortality. Future studies should (i) include larger numbers of patients with VISA infections to confirm the findings presented here and (ii) determine the optimal antibiotic therapy for critically ill patients with MRSA and VISA infections.
尽管万古霉素中介金黄色葡萄球菌（VISA）感染的发病率不断上升，但很少有研究探讨延迟接受适当抗菌治疗对VISA患者预后的影响。我们研究了在一组无菌部位耐甲氧西林金黄色葡萄球菌（MRSA）和VISA感染患者中，适当抗菌治疗时机的影响。在这项单中心回顾性队列研究中，我们确定了2009年6月至2015年2月期间所有患有MRSA或VISA无菌部位感染的患者。根据MRSA/VISA分类、人口统计学、合并症和抗菌治疗情况比较临床结局。用Kaplan-Meier曲线对30天全因死亡率进行建模。采用多因素逻辑回归分析（MVLRA）确定死亡率的比值比。我们确定了354例患有MRSA（n = 267）或VISA（n = 87）无菌部位感染的患者。55例患者（15.5%）死亡。MVLRA中与死亡率相关的因素包括肺炎、感染源不明、急性生理与慢性健康状况评估（APACHE）II评分、实体器官恶性肿瘤以及从专业护理机构入院。开始适当抗菌治疗的时间与结局无显著相关性。与非VISA金黄色葡萄球菌感染相比，VISA感染的存在并未导致额外的死亡率。对于APACHE II评分≥14的患者，使用利奈唑胺有死亡风险。我们的结果表明，对VISA感染患者经验性使用万古霉素不会导致额外的死亡率。未来的研究应（i）纳入更多VISA感染患者以证实此处呈现的结果，以及（ii）确定针对重症MRSA和VISA感染患者的最佳抗生素治疗方案。
