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15 January 2007

Volume 44, Number 2
Clinical Infectious Diseases 2007;44:190–196
© 2006 by the Infectious Diseases Society of America. All rights reserved.
1058-4838/2007/4402-0004$15.00
DOI: 10.1086/510386
MAJOR ARTICLE

Use of Vancomycin or First‐Generation Cephalosporins for the Treatment of Hemodialysis‐Dependent Patients with Methicillin‐Susceptible Staphylococcus aureus Bacteremia

Martin E. Stryjewski,1,5

Lynda A. Szczech,1,3

Daniel K. Benjamin, Jr.,1

Jula K. Inrig,1,3

Zeina A. Kanafani,1,2

John J. Engemann,2

Vivian H. Chu,1,2

Maria J. Joyce,2,4

L. Barth Reller,2,4

G. Ralph Corey,1,2 and

Vance G. Fowler, Jr.1,2

1Duke Clinical Research Institute and Divisions of 2Infectious Diseases, 3Nephrology, and 4Clinical Microbiology Laboratory, Duke University Medical Center, Durham, North Carolina; and 5Department of Medicine, Centro de Educación Médica e Investigaciones Clínicas, Buenos Aires, Argentina

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 ( ) tended to be younger (51 vs. 57 years; ) and had a lower rates of metastatic complications at presentation (11.7% vs. 36.7%; ) than did those receiving cefazolin ( ). 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%; ). 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 β‐lactams), vancomycin should not be continued beyond empirical therapy for hemodialysis‐dependent patients with MSSA bacteremia.

Received 7 June 2006; accepted 11 September 2006; electronically published 8 December 2006.

Reprints or correspondence: Dr. Martin E. Stryjewski, Azcuenaga 1757, Apt. 1C, Capital Federal (C1128AAC), Buenos Aires, Argentina ().

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  • Presented in part: at 45th Annual Meeting of the Interscience Conference on Antimicrobial Agents and Chemotherapy, Washington, D.C., 16 December 2005 (slide session K‐424).

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