Tsai Ching-Yen, Lee Chen-Hsiang, Chen I-Ling
Division of Infectious Diseases, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan,
College of Medicine, Chang Gung University College of Medicine, Kaohsiung, Taiwan,
Infect Drug Resist. 2018 Oct 26;11:2011-2020. doi: 10.2147/IDR.S184411. eCollection 2018.
Recent reports have described decreased effectiveness of teicoplanin in the treatment of bacteremia due to methicillin-resistant (MRSA) with teicoplanin minimal inhibitory concentration (MIC) ≥1.5 mg/L. Consensus guidelines recommend considering use of alternative agents for MRSA infections involving a higher teicoplanin MIC, despite of limited data to support this recommendation.
To compare the clinical outcome among patients with bacteremia due to MRSA with teicoplanin MIC ≥1.5 mg/L, we included patients who received high-dose daptomycin (≥8 mg/kg/day) and those who received standard-dose (6 mg/kg/day) or high-dose (6 mg/kg/12 hours) maintenance teicoplanin. The primary endpoint was a favorable outcome, defined as the resolution of clinical signs and symptoms and a negative culture report at the end of therapy. Adjusted analyses were performed by multivariate analysis and propensity score-based matching.
Of 142 patients eligible for inclusion, 28 (19.7%) were treated with high-dose daptomycin, 27 (19.0%) with high-dose teicoplanin, and 87 (61.3%) with standard-dose teicoplanin. In multivariate regression analysis, Pittsburgh bacteremia score ≥4 (OR, 5.3; 95%CI, 1.9-14.5) was independently associated with an unfavorable outcome. After propensity-score matching with age and Pittsburgh bacteremia score ≥4, patients on high-dose daptomycin were more likely to have favorable outcomes than those on standard-dose teicoplanin (74.1% vs 42.6%; =0.02). However, there was no significant difference in terms of favorable outcomes (=0.12) between patients receiving high-dose daptomycin and those receiving high-dose teicoplanin after the same propensity-score matching.
Treatment with high-dose daptomycin resulted in significantly better outcomes than with standard-dose teicoplanin in the treatment of MRSA bacteremia with teicoplanin MIC ≥1.5 mg/L. However, the clinical outcome of the patients receiving high-dose teicoplanin was similar to that of the patients receiving high-dose daptomycin.
最近的报告描述了替考拉宁治疗耐甲氧西林金黄色葡萄球菌（MRSA）所致菌血症时，当替考拉宁最低抑菌浓度（MIC）≥1.5mg/L时疗效降低。共识指南建议，对于替考拉宁MIC较高的MRSA感染，考虑使用替代药物，尽管支持该建议的数据有限。
为比较替考拉宁MIC≥1.5mg/L的MRSA所致菌血症患者的临床结局，我们纳入了接受高剂量达托霉素（≥8mg/kg/天）的患者以及接受标准剂量（6mg/kg/天）或高剂量（6mg/kg/12小时）维持剂量替考拉宁的患者。主要终点是良好结局，定义为治疗结束时临床体征和症状消失且培养报告为阴性。通过多变量分析和基于倾向评分的匹配进行校正分析。
在142例符合纳入标准的患者中，28例（19.7%）接受高剂量达托霉素治疗，27例（19.0%）接受高剂量替考拉宁治疗，87例（61.3%）接受标准剂量替考拉宁治疗。在多变量回归分析中，匹兹堡菌血症评分≥4（OR，5.3；95%CI，1.9 - 14.5）与不良结局独立相关。在按年龄和匹兹堡菌血症评分≥4进行倾向评分匹配后，接受高剂量达托霉素的患者比接受标准剂量替考拉宁的患者更有可能获得良好结局（74.1%对42.6%；P = 0.02）。然而，在相同的倾向评分匹配后，接受高剂量达托霉素的患者与接受高剂量替考拉宁的患者在良好结局方面无显著差异（P = 0.12）。
在治疗替考拉宁MIC≥1.5mg/L的MRSA菌血症时，高剂量达托霉素治疗的结局明显优于标准剂量替考拉宁。然而，接受高剂量替考拉宁的患者的临床结局与接受高剂量达托霉素的患者相似。
