title: Cloxacillin versus vancomycin for presumed late-onset sepsis in the Neonatal Intensive Care Unit and the impact upon outcome of coagulase negative staphylococcal bacteremia: a retrospective cohort study.
abstract: BACKGROUND
  Coagulase negative staphylococcus (CONS) is the main cause of late-onset sepsis in Neonatal Intensive Care Units (NICU). Although CONS rarely causes fulminant sepsis, vancomycin is frequently used as empiric therapy. Indiscriminate use of vancomycin has been linked to the emergence of vancomycin resistant organisms. The objective of this study was to compare duration of CONS sepsis and mortality before and after implementation of a policy of selective vancomycin use and compare use of vancomycin between the 2 time periods.
  
  
  METHODS
  A retrospective study was conducted of infants > or =4 days old, experiencing signs of sepsis with a first positive blood culture for CONS, during two 12-month periods. Late-onset sepsis was treated empirically with vancomycin and gentamicin during period 1, and cloxacillin and gentamicin during period 2. The confidence interval method was used to assess non-inferiority of the outcomes between the two study groups.
  
  
  RESULTS
  There were 45 episodes of CONS sepsis during period 1 and 37 during period 2. Duration of sepsis was similar between periods (hazard ratio of 1.00, 95%CI: 0.64, 1.57). One death during period 2 was possibly related to CONS sepsis versus none in period 1. Vancomycin was used in 97.8% of episodes in period 1 versus 81.1% of episodes in period 2.
  
  
  CONCLUSIONS
  Although we failed to show non-inferiority of duration of sepsis in the cloxacillin and gentamicin group compared to the vancomycin and gentamicin group, duration of sepsis was clinically similar. Restricting vancomycin for confirmed cases of CONS sepsis resistant to oxacillin appears effective and safe, and significantly reduces vancomycin use in the NICU.
authors.affiliation: Department of Obstetrics, Gynecology and Newborn Care, The Ottawa Hospital, Ottawa, Ontario, Canada. sllawrence@cheo.on.ca
authors.forename: Sarah L
authors.initials: SL
authors.lastname: Lawrence
authors.forename: Virginia
authors.initials: V
authors.lastname: Roth
authors.forename: Robert
authors.initials: R
authors.lastname: Slinger
authors.forename: Baldwin
authors.initials: B
authors.lastname: Toye
authors.forename: Isabelle
authors.initials: I
authors.lastname: Gaboury
authors.forename: Brigitte
authors.initials: B
authors.lastname: Lemyre
mesh_terms: D000900:Anti-Bacterial Agents / Q000627:therapeutic use*; D016470:Bacteremia / Q000188:drug therapy* / Q000401:mortality / Q000503:physiopathology; D003023:Cloxacillin / Q000627:therapeutic use*; D003030:Coagulase; D015331:Cohort Studies; D005839:Gentamicins / Q000627:therapeutic use; D006801:Humans; D007231:Infant, Newborn; D007363:Intensive Care Units, Neonatal; D017063:Outcome Assessment, Health Care; D016016:Proportional Hazards Models; D012189:Retrospective Studies; D013203:Staphylococcal Infections / Q000188:drug therapy* / Q000401:mortality / Q000503:physiopathology; D014640:Vancomycin / Q000627:therapeutic use*; D020713:Vancomycin Resistance
chemical_list: D000900:Anti-Bacterial Agents; D003030:Coagulase; D005839:Gentamicins; D014640:Vancomycin; D003023:Cloxacillin