Early use of Daptomycin Compared to Vancomycin for MRSA Bacteremia

Watkins, Richard R.
July 2013
Infectious Disease Alert;Jul2013, Vol. 32 Issue 10, p112
Methicillin-resistant Staphylococcus aureus bacteremia (MRSAB) is a frequently-encountered infection that can lead to a number of serious complications, such as infective endocarditis, septic arthritis, and vertebral osteomyelitis. This has led to the increased use of vancomycin, followed by a corresponding increase in MRSA strains with vancomycin minimum inhibitory concentrations (MICs) > 1 µg/mL. Data suggest MRSA isolates with higher vancomycin MICs are associated with worse clinical outcomes, although current clinical guidelines from the Infectious Diseases Society of America do not recommend the early use of alternative therapy. A recent case-control study showed a mortality benefit in patients switched to daptomycin after failing vancomycin. Murray and colleagues sought to compare clinical outcomes in patients with MRSAB and vancomycin MICs > 1 µg/mL who were switched to daptomycin within 72 hours after starting vancomycin therapy. The investigators conducted a retrospective, matched cohort study on patients with MRSAB treated with vancomycin or daptomycin at four hospitals within the Detroit Medical Center between January 2005 and March 2012. Starting in February 2008, one of the centers implemented a treatment guideline that required the use of daptomycin if the vancomycin MIC was between l/µg/mL and 2 µg/mL. Included patients were adults with an MRSA bloodstream isolate with an initial vancomycin MIC > 1 µg/mL who received vancomycin or daptomycin for at least 72 hours. Exclusion criteria were if pneumonia or an intravenous catheter was the source of bacteremia, dialysis for acute or chronic renal failure, or if an alternative MRSA therapy was used for ≥72 hours prior to starting daptomycin or vancomycin. Among 1863 consecutive cases of MRSAB with a vancomycin MIC > µg/mL, 85 daptomycin-treated patients were matched to 85 vancomycin-treated patients. There was no significant difference in median length of ICU stay (7 days in the daptomycin group vs. 5 days in the vancomycin group; P = .824). The median duration of vancomycin therapy prior to daptomycin was 1.7 days and the median daptomycin dose was 8.4 mg/kg. In the crude analysis, treatment with daptomycin was associated with significantly less clinical failure at 30 days than vancomycin (20.0% vs. 48.2%; P < .001). In multivariate logistic regression analysis, r vancomycin was associated with significantly higher risk of clinical failure at 30 days (adjusted odds ratio, 4.5). Furthermore, patients in the daptomycin group had lower mortality compared to those who received vancomycin (3.5% vs 12.9%; P = .047), less persistent bacteremia (18.8% vs. 42.4%; P = .001), and shorter in. duration of bacteremia (3 days vs. 5 days; P = .003). Length of stay and duration of therapy was not significantly different between the two groups. Average hospital charges were higher in the daptomycin group ($95,244 vs. $86,504; P = .643). In the vancomycin group, 25.9% of patients experienced nephrotoxicity, with the median vancomycin trough 18.1 µg/mL. However, many of them were also receiving an aminoglycoside. One patient in the daptomycin group had a significant elevation in serum CPK concentration but it was not associated with any symptoms and promptly returned to normal after the daptomycin was switched to vancomycin.


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