akinohanayuki ブログ

学位を持っても、センスのない、感染制御専門薬剤師のブログ.  I have Ph.D. but less sense ID pharmacist.

MSSA菌血症治療を復習する

最近、有名雑誌から報告の多い
トレンディーMSSA菌血症

実習生とMSSAについてディスカッションしました。こんな機会だからこそ、復習します。

もちろん、ペニシリンが使えれば、主治医に推奨してます。

1.UpToDate より

We recommend treating methicillin-sensitive S. aureus (MSSA) bacteremia with a beta-lactam antibiotic (in preference to vancomycin or daptomycin) (Grade 1B). Regimens include penicillin, nafcillin, oxacillin, or flucloxacillin. A first-generation cephalosporin such as cefazolin is an acceptable alternative in patients with hypersensitivity to the preceding agents. 

Vancomycin is less effective for treatment of S. aureus bacteremia than beta-lactam agents and should not be administered as primary therapy for methicillin-sensitive strains unless the use of a beta-lactam agent is precluded by drug intolerance.

We recommend NOT combining low-dose aminoglycosides with antistaphylococcal penicillins or vancomycin for treatment of S. aureus bacteremia (Grade 1B). 

The duration of therapy depends on the etiology of infection. In general, patients with bacteremia with a removable focus of infection may be treated with 14 days of intravenous therapy from the first negative blood culture. 

2.論文あれこれ

Clin Infect Dis. 2007;44(2):190.
  • SAB (MSSA)
  • Hemodialysis-dependent patients 
  • Treatment failure
  • ◎Cefazolin > ✖️vancomycin
  • prospectively
Antimicrob Agents Chemother. 2008;52(1):192.
http://www.ncbi.nlm.nih.gov/m/pubmed/17984229/
  • SAB (MSSA)
  • SAB-related mortality
  • ◎beta-lactam treatment > ✖️vancomycin
  •  a retrospective cohort study ,  a matched case-control study. 
Antimicrob Agents Chemother. 2011 Nov;55(11):5122-6. 
  • SAB (MSSA)
  • treatment failure rates (4 or 12 weeks)
  • Cefazolin ≒ nafcillin
  • 10% [4/41]versus 10% [4/41]at 4 weeks [P>0.99]and 15% [6/41]versus 15% [6/41]at 12 weeks [P>0.99]
  • retrospective propensity-score-matched case-control study
J Antimicrob Chemother. 2013 Aug;68(8):1894-900. 
  • SAB (MSSA)
  • 30 mortality 
  • penicillin > ✖️cefuroxime
  • adjusted HR 2.54, 95% CI 1.49-4.32
  • retrospective, propensity-score-adjusted case-control and cohort analysis.
Antimicrob Agents Chemother. 2013 Mar;57(3):1150-6. 
  • uncomplicated SAB (MRSA 47.7%)
  • treatment failure rates : short-course  (<14 days) ≒ intermediate-course (≥14 days) 
  • crude mortality : short-course ≒ intermediate-course
  • relapse: intermediate-course > short-course
  • prospective observational cohort study
Clin Infect Dis. 2013;56(4):527.
  • 342 patients with S. aureus bacteremia
  • mortality
  • ◎bedside consultation > ✖️telephone consultation 
  • 7 days (OR0.09; 95% CI, .02-.49; P = .001)
  • 28 days (OR0.27; 95% CI, .11-.65; P = .002)
  • 90 days (OR0.25; 95% CI, .13-.51; P<.0001)
  • retrospective study 
Clin Infect Dis. 2014;59(3):369.
  • SAB (MSSA)
  • premature antimicrobial discontinuation (PAD) 
  • ◎nafcillin > ✖️cefazolin 
  • HR2.81 ; 95% CI 1.26-3.68
  • outpatient setting
  • retrospective cohort
J Antimicrob Chemother. 2015;70(5):1539.
  • SAB (MSSA)
  • Ninety-day mortality
  • cefazolin ≒ cloxacillin
  • HR 0.58 (95% CI 0.31-1.08, P = 0.0846)
  • retrospective cohort
Clin Infect Dis. 2015;61(3):361.
  • SAB (MSSA)
  • 122 hospitals
  • mortality
  • Empiric therapy : beta-lactam ≒ VCM
  • definitive therapy : ◎beta-lactam >✖️ VCM
  • retrospective cohort study
Clin Infect Dis. 2015 Sep;61(5):741-9. 
  • Patients with MSSA bacteremia and a reported PCN allergy should have the allergy addressed for optimal treatment. Full allergy evaluation with skin testing seems to be preferred, although more data are needed