title: No survival benefit with empirical vancomycin therapy for coagulase-negative staphylococcal bloodstream infections in infants.
abstract: BACKGROUND
  Coagulase-negative Staphylococcus (CoNS) is the most common cause of bloodstream infections (BSI) in hospitalized infants. CoNS BSI is most reliably treated with vancomycin; however, concerns about side effects and promoting resistance often delay empirical vancomycin therapy until culture results become available.
  
  
  METHODS
  All infants with CoNS BSI discharged from 348 neonatal intensive care units managed by the Pediatrix Medical Group from 1997 to 2012 were identified. Empirical vancomycin therapy was defined as vancomycin exposure on the day of the first positive blood culture. Delayed vancomycin therapy was defined as vancomycin exposure 1-3 days after the first positive blood culture. We used multivariable logistic regression with random effects for site to evaluate the association between the use of empirical vancomycin therapy versus delayed vancomycin therapy and 30-day mortality, controlling for gestational age, small-for-gestational age status, postnatal age on the day of the first positive culture, oxygen requirement, ventilator support and inotropic support on the day the first positive culture was obtained.
  
  
  RESULTS
  A total of 4364 infants with CoNS BSI were identified; 2848 (65%) were treated with empirical vancomycin. The median postnatal age at first positive culture was 14 days (interquartile range: 9, 21). Unadjusted 30-day mortality was similar for infants treated with empirical vancomycin and infants treated with delayed vancomycin therapy [166/2848 (6%) vs. 69/1516 (4%); P = 0.08]. There was no significant difference in 30-day mortality on multivariable analysis [odds ratio: 1.14 (0.84, 1.56)]. The median duration of bacteremia was 1 day longer for infants with delayed vancomycin therapy [4 days (interquartile range: 2, 6) vs. 3 days (2, 5); P < 0.0001].
  
  
  CONCLUSIONS
  The median duration of bacteremia was 1 day longer in infants with CoNS BSI who received delayed vancomycin therapy. Despite this finding, empirical vancomycin therapy for CoNS BSI was not associated with improved mortality.
authors.affiliation: From the *Department of Pediatrics, Duke University; †Duke Clinical Research Institute, Duke University; ‡Department of Medicine, Duke University, Durham, NC; and §Pediatrix-Obstetrix Center for Research and Education, Sunrise, FL.
authors.forename: Jessica E
authors.initials: JE
authors.lastname: Ericson
authors.forename: Joshua
authors.initials: J
authors.lastname: Thaden
authors.forename: Heather R
authors.initials: HR
authors.lastname: Cross
authors.forename: Reese H
authors.initials: RH
authors.lastname: Clark
authors.forename: Vance G
authors.initials: VG
authors.lastname: Fowler
authors.forename: Daniel K
authors.initials: DK
authors.lastname: Benjamin
authors.forename: Michael
authors.initials: M
authors.lastname: Cohen-Wolkowiez
authors.forename: Christoph P
authors.initials: CP
authors.lastname: Hornik
authors.forename: P Brian
authors.initials: PB
authors.lastname: Smith
mesh_terms: D000900:Anti-Bacterial Agents / Q000627:therapeutic use*; D016470:Bacteremia / Q000188:drug therapy* / Q000382:microbiology / Q000401:mortality*; D003030:Coagulase / Q000032:analysis; D005260:Female; D006801:Humans; D007223:Infant; D007231:Infant, Newborn; D007363:Intensive Care Units, Neonatal; D008297:Male; D055502:Secondary Prevention; D013203:Staphylococcal Infections / Q000188:drug therapy* / Q000382:microbiology / Q000401:mortality*; D013210:Staphylococcus / Q000187:drug effects / Q000201:enzymology / Q000302:isolation & purification*; D016019:Survival Analysis; D013997:Time Factors; D016896:Treatment Outcome; D014640:Vancomycin / Q000008:administration & dosage*
chemical_list: D000900:Anti-Bacterial Agents; D003030:Coagulase; D014640:Vancomycin