MRSA Bacteremia

Helmi Sulaiman
MRSA
• Gram positive cocci

• Arranged in grape like clusters

• Catalase +

• Beta lactams attack an enzyme

that build the walls

• called PBP (penicillin

binding protein)

• MRSA produces PBP 2A

instead- lower affinity to beta
lactams
MRSA
• Gram positive cocci

• Arranged in grape like clusters

• Catalase +

• Beta lactams attack an enzyme

that build the walls

• called PBP (penicillin

binding protein)

• MRSA produces PBP 2A

instead- lower affinity to beta
lactams
Lets discuss the
common
understandings

do we understand the
common things?
Case 1

• A 65 year old obese gentleman was admitted for a simple

hernial operation which was delayed due to no OT time

• On day 3 of admission he developed fever with chills and

rigours and the blood pressure was 70/50 mmHg and Spo2
of 100 % at room air and there was no CBD in situ

• On thorough examination there was no focal localising signs

and he has a neck line (inserted at day 0)

• The neck line exit site was clean and not erythematous

• What will you do?

Additional points

• The CXR is clear

• The urine FEME shows nitrate of 3+, leucocytes of 3+

and leukocyte esterase of 2+

• The sputum grew ESBL klebsiella

• Where is the infection?

The patient has:

• A - Line related sepsis

• B- UTI

• C- Hospital acquired pneumonia

• D- I do not know
What can we agree upon?

• This is a possible hospital acquired infection

• We need to look at the LLU- lungs/ line/ urine

• Patient is unlikely to have HAP

• The patient is unlikely to have line related sepsis

• The patient is unlikely to have UTI

What happens next…

• Patient was commenced on pip tazobactam

• The fever did not abate

• Patient continued to be dependent on inotropes

• Patient chills and rigours become more often

• The blood culture grew MRSA from both the lines and
the peripheral cultures

• What is your final diagnosis and management?

 skin

Blood
vessels
Agenda for today

• Understanding MRSA infections

• Length of treatment

• Vancomycin dosing strategy

Treatment scheme for staph aureus bacteremia

Start Where is the infection?

treatment !
Where has it seeded?
!
Has it caused IE?
!
!
Length of treatment
 Bacteremia
Simple Complicated

• “Simpleness” is defined by:

• No implantable prosthesis

• No endocarditis

• Repeat blood culture at day 2-4 is negative after appropriate Rx

• Defervesce within 72 hours

• No evidence of metastatic infections

IDSA Jan 2011

Case 2 (moderate level)

• 56 year old hypertensive and diabetic gentleman was admitted

for severe sepsis with no obvious localising signs and symptoms

• His blood culture then grew MRSA in both the bottles

• An appropriate anti MRSA treatment was commenced and the

patient fever abated at day 2

• However the repeat blood culture at day 3 was still +

• TOE and CT scans were non indicative of deep seeded infections

• What is your plan?

 Bacteremia (classification 2.0)
Primary Secondary

• Primary: when the source is unknown

• Secondary: when the source is known

Stratifications of infections
• Low risk

• catheter related infection/ UTI

• Intermediate risk

• OM/ septic arthritis/ soft tissue

• Primary

• High risk infection

• pneumonia/ CNS/Intra-abdominal infections/ Endovascular

Duration of therapy

• Thus this patient has an intermediate risk of infection

• Most probably better with 4 weeks treatment duration of

anti staph agent
You were called to see
the patient at day 18
of admission

Patient: “Doctor, I want to go

back. is this possible?”

!
Houseman: “doctor, the MRSA
is sensitive to both the rifampin/
fusidic acid/ ciprofloxacin”
I will…

• A- discharge the patient home with tab rifampin and

Fusidate

• B- use PO linezolid and discharge him

• C- cont IV vancomycin
 Can this patient be discharged with oral
antibiotics?

• There are limited data on the use of oral ciprofloxacin in

combination with oral rifampin primarily in patients with
MSSA right-sided endocarditis

• In the absence of additional studies among patients with

MRSA, transition from parenteral to oral therapy should
be done cautiously and only in those with un-
complicated bacteremia. (IDSA MRSA 2012)

• I vote for non oral, strictly IV course of antibiotic

Case 3 (Dewa level)

• A hypotensive IVDU was admitted into ICU and was started

with imipenem and vancomycin.

• There was no respiratory symptoms

• His blood culture taken was positive for both MSSA and
MRSA

• MRSA x 2 bottles

• MSSA x 1 out of 2 bottles

• What will you do?

What is your options?

• A- Stop Imipenem and continue vancomycin

• B- Start daptomycin

• C- Start vancomycin and cloxacillin 2gm QID

• D- All wrong
Vancomycin use in MSSA bacteremia

• Treatment of MSSA with vancomycin is associated with

poorer outcome

• When compared to beta lactams

• Shown in many studies

• Case control study, AAC 2008, 52, no. 1, 192-197

• Might be related to vanco large molecules

• Slowly bactericidal compared to B lactams

The right answer

• None of the above

• This patient should be treated with vancomycin plus

high dose cloxa 2 mg 4 hourly as this patient may have
infective endocarditis as he is an IVDU

• As such an echo (preferably TOE) must be done

Vancomycin
Not exactly the magic bullet

!
Its not a wine… it does not get
better with age

Vancomycin

• Has a narrow therapeutic index

• TDM needs to be done to achieve optimal level

• Aim: the trough (lowest) level of at least of 15-20 ug/mL

• This supposedly correlates with AUC/MIC- 400

CONCENTRATION

MIC= 2

MIC= 1

TIME

The target for the vanco level would be AUC/MIC > 400
for clinical cure
!
But this is easier with MIC at 1 and below
• The argument will be, not all centres have MIC results
available

• Clinicians in general do not know how to interpret MIC

to vancomycin?

• Source control is the “best antibiotic” in treating staph

aureus invasive infections (i.e. knifamycin)
Summary

• In MRSA (inc MSSA) bacteremia, one should decide

upfront whether it is simple or complicated

• Follow up culture is a must after appropriate anti-staph

treatment (2-3day)

• Vancomycin has a narrow therapeutic index and as such

a target level should be decided (in relation to MIC, if
available)

• In MSSA bacteremia, beta lactams are superior to

vancomycin