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Implementation of an Antimicrobial Stewardship Pathway with Daptomycin for Optimal Treatment of Methicillin‐Resistant S taphylococcus aureus Bacteremia
Author(s) -
Kullar Ravina,
Davis Susan L.,
Kaye Keith S.,
Levine Donald P.,
Pogue Jason M.,
Rybak Michael J.
Publication year - 2013
Publication title -
pharmacotherapy: the journal of human pharmacology and drug therapy
Language(s) - English
Resource type - Journals
SCImago Journal Rank - 1.227
H-Index - 109
eISSN - 1875-9114
pISSN - 0277-0008
DOI - 10.1002/phar.1220
Subject(s) - daptomycin , vancomycin , bacteremia , medicine , staphylococcus aureus , methicillin resistant staphylococcus aureus , antibiotics , surgery , microbiology and biotechnology , biology , bacteria , genetics
Study Objective To evaluate a clinical pathway using daptomycin in patients with bacteremia caused by methicillin‐resistant S taphylococcus aureus ( MRSA ) isolates exhibiting vancomycin minimum inhibitory concentrations (MICs) greater than 1 mg/L. Design Two‐phase quasi‐experimental study. Setting Level I trauma center in D etroit, M ichigan. Patients The study population consisted of a total of 170 patients with MRSA bacteremia susceptible to vancomycin: 70 patients who had initial blood MRSA isolates exhibiting a vancomycin MIC > 1 mg/L and were treated with vancomycin were included in phase I (retrospective baseline period [2005–2007]) and 100 patients who were switched to daptomycin after initial vancomycin therapy according to the institutional MRSA bacteremia treatment pathway were included in phase II (the period after implementation of the treatment pathway [2008–2010]). Intervention The MRSA bacteremia treatment pathway was as follows: vancomycin therapy was initiated, optimizing target trough concentrations to 15–20 mg/L; for isolates demonstrating vancomycin MIC s greater than 1 mg/L, therapy was switched to daptomycin, initiated at dosages of 6 mg/kg/day or higher. Measurements and Main Results Infection characteristics, patient outcomes, and costs were evaluated. Patient characteristics were similar between the phase I and phase II groups. Phase II patients were more likely to achieve clinical success than were phase I patients (75.0% vs 41.4%, p<0.001). Phase II patients demonstrated a shorter total hospital length of stay and shorter durations of inpatient therapy, fever, and bacteremia. Treatment during phase I was independently associated with failure. Nine patients during phase I experienced nephrotoxicity, and two patients during phase II experienced increases in creatine kinase level. Costs were similar between phases I and II ($18,385 vs $19,755, p>0.05), although the hospital readmission rate was higher in phase I (33% vs 21%, p=0.08). Conclusion Among the patients with bacteremia who had MRSA isolates that exhibited elevated vancomycin MIC s, the switch to daptomycin improved clinical success without increasing treatment cost.