title: Use of vancomycin or first-generation cephalosporins for the treatment of hemodialysis-dependent patients with methicillin-susceptible Staphylococcus aureus bacteremia.
abstract: BACKGROUND
  Because of its ease of dosing, vancomycin is commonly used to treat methicillin-susceptible Staphylococcus aureus (MSSA) bacteremia in patients undergoing long-term hemodialysis. Clinical outcomes resulting from such a therapeutic strategy have not been well defined.
  
  
  METHODS
  We prospectively identified patients undergoing long-term hemodialysis who received a diagnosis of MSSA bacteremia. Clinical outcomes were grouped according to the predominant antibiotic received during their therapy (vancomycin or a first-generation cephalosporin [cefazolin]). Treatment failure (defined as death or recurrent infection) was determined at 12 weeks after the initial positive blood culture results. A multivariable analysis was used to adjust for confounders.
  
  
  RESULTS
  During an 84-month period, 123 hemodialysis-dependent patients with MSSA bacteremia were identified. Patients receiving vancomycin (n=77) tended to be younger (51 vs. 57 years; P=.06) and had a lower rates of metastatic complications at presentation (11.7% vs. 36.7%; P=.001) than did those receiving cefazolin (n=46). The 2 groups were similar with regard to Acute Physiology and Chronic Health Evaluation II scores, comorbidities, source of infection, type of hemodialysis access, and access removal rates. Treatment failure was more common among patients receiving vancomycin (31.2% vs. 13%; P=.02). In the multivariable analysis, factors independently associated with treatment failure included vancomycin use (odds ratio, 3.53; 95% confidence interval, 1.15-13.45) and retention of the hemodialysis access (odds ratio, 4.99; 95% confidence interval, 1.89-13.76).
  
  
  CONCLUSIONS
  Hemodialysis-dependent patients with MSSA bacteremia treated with vancomycin are at a higher risk of experiencing treatment failure than are those receiving cefazolin. In the absence of patient specific circumstances (e.g., allergy to beta-lactams), vancomycin should not be continued beyond empirical therapy for hemodialysis-dependent patients with MSSA bacteremia.
authors.affiliation: Duke Clinical Research Institute, Durham, North Carolina, USA. stryj001@mc.duke.edu
authors.forename: Martin E
authors.initials: ME
authors.lastname: Stryjewski
authors.forename: Lynda A
authors.initials: LA
authors.lastname: Szczech
authors.forename: Daniel K
authors.initials: DK
authors.lastname: Benjamin
authors.forename: Jula K
authors.initials: JK
authors.lastname: Inrig
authors.forename: Zeina A
authors.initials: ZA
authors.lastname: Kanafani
authors.forename: John J
authors.initials: JJ
authors.lastname: Engemann
authors.forename: Vivian H
authors.initials: VH
authors.lastname: Chu
authors.forename: Maria J
authors.initials: MJ
authors.lastname: Joyce
authors.forename: L Barth
authors.initials: LB
authors.lastname: Reller
authors.forename: G Ralph
authors.initials: GR
authors.lastname: Corey
authors.forename: Vance G
authors.initials: VG
authors.lastname: Fowler
mesh_terms: D000328:Adult; D000368:Aged; D016470:Bacteremia / Q000188:drug therapy* / Q000382:microbiology*; D002437:Cefazolin / Q000627:therapeutic use*; D005260:Female; D006801:Humans; D008297:Male; D016106:Methicillin Resistance; D008826:Microbial Sensitivity Tests; D008875:Middle Aged; D016017:Odds Ratio; D006435:Renal Dialysis; D012307:Risk Factors; D013203:Staphylococcal Infections / Q000188:drug therapy* / Q000382:microbiology*; D013211:Staphylococcus aureus / Q000187:drug effects; D017211:Treatment Failure; D014640:Vancomycin / Q000627:therapeutic use*
chemical_list: D014640:Vancomycin; D002437:Cefazolin