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Study IDs Risk Factors for Fatal MRSA (CME/CE)

By Charles Bankhead, , MedPage TodayPublished: June 13, 2012Reviewed by Robert Jasmer, MD; Associate Clinical Professor of Medicine, University of California, San Francisco

Severe bacteremia also predicted an increased mortality risk, but the MRSA strain was not predictive. Consultation with an infectious disease specialist was associated with a significantly lower mortality risk.

“The consequences of MRSA bacteremia are clear — many patients will die or experience a decline from their baseline clinical condition,” Mina Pastagia, MD, of Rockefeller University in New York City, and co-authors wrote of their findings. “The adjusted risk difference enables clinicians to use a targeted approach, directed toward patients with the highest risk of death …

“These patients should be treated carefully and should possibly receive a consult from an infectious diseases specialist. What remains unclear is whether patients with increased risk for death should be treated with antimicrobial drugs other than vancomycin.”

MRSA bacteremia has a high mortality of 30% to 35% in most studies. However, predictors of fatal MRSA bacteremia have not been clearly delineated, providing impetus for the investigation by Pastagia and colleagues.

Investigators analyzed medical records associated with 699 episodes of MRSA bacteremia involving 603 patients, including 65 patients who were hospitalized two or more times. Additional data came from hospital databases and frozen MRSA specimens.

Each new hospitalization represented a new episode of MRSA bacteremia, and the first positive blood culture defined infection. An episode ended with the first negative culture after hospitalization or patient death, and any subsequent episodes during the same hospitalization were not included.

Hospital-associated bacteremia was defined as onset more than 48 hours after admission in a patient with no risk factors.

Examination of clinical characteristics showed that length of stay averaged 33 days for all patients. A majority of the patients had renal insufficiency and cardiovascular disease. More than 40% of the patients had surgery within the previous 3 months. In 43% of cases, a central venous catheter was the source of infection.

The authors found that 47% of the patients had prior vancomycin exposure, and 60% of those patients had a history of MRSA infection. Overall, vancomycin was used to treat 566 (81%) of MRSA bacteremia episodes.

Multivariable regression analyses resulted in the following adjusted risk ratios for all-cause mortality:

Age — RR 1.34 (95% CI 1.12 to 1.65) Liver cirrhosis — RR 1.40 (95% CI 1.04 to 1.77) Renal insufficiency — RR 1.33 (95% CI 1.05 to 1.70) Nursing home residence — RR 1.62 (95% CI 1.31 to 2.06)

Consultation with an infectious disease specialist had the greatest risk-reducing effect on all-cause mortality (RR 0.69, 95% CI 0.57 to 0.93).

“Our findings can help clinicians estimate the risk that a patient with MRSA bacteremia will die,” the authors wrote in the discussion of their findings. “For example, an elderly patient with liver cirrhosis and MRSA bacteremia who lived in a nursing home before hospital admission would have an extremely poor prognosis.

“Conversely, an otherwise healthy patient with diabetes mellitus might have a better prognosis that could be improved even more by consultation with an infectious disease specialist.”

The study was supported in part by Cubist Pharmaceuticals.

Pastagia disclosed a financial relationship with Cubist.

Working from Houston, home to one of the world’s largest medical complexes, has more than 20 years of experience as a medical writer and editor. His career began as a science and medical writer at an academic medical center. He later spent nearly a decade as a writer and editor for Medical World News, one of the leading medical trade magazines of its era. His byline has appeared in medical publications that have included Cardio, Cosmetic Surgery Times, Dermatology Times, Diagnostic Imaging, Family Practice, Journal of the National Cancer Institute, Medscape, Oncology News International, Oncology Times, Ophthalmology Times, Patient Care, Renal and Urology News, The Medical Post, Urology Times, and the International Medical News Group newspapers. He has a BA in journalism and MA in mass communications, both from Texas Tech University.

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