Ceftaroline fosamil monotherapy for methicillin resistant Staphylococcus aureus bacteremia (MRSAB) A comparative clinical outcomes study Accepted Manuscript Title Ceftaroline fosamil monotherapy for m[.]
Accepted Manuscript Title: Ceftaroline fosamil monotherapy for methicillin-resistant Staphylococcus aureus bacteremia (MRSAB): A comparative clinical outcomes study Authors: Samia Arshad, Vanthida Huang, Pamela Hartman, Mary B Perri, Daniela Moreno, Marcus J Zervos PII: DOI: Reference: S1201-9712(17)30022-X http://dx.doi.org/doi:10.1016/j.ijid.2017.01.019 IJID 2844 To appear in: International Journal of Infectious Diseases Received date: Revised date: Accepted date: 19-10-2016 13-1-2017 18-1-2017 Please cite this article as: Arshad Samia, Huang Vanthida, Hartman Pamela, Perri Mary B, Moreno Daniela, Zervos Marcus J.Ceftaroline fosamil monotherapy for methicillin-resistant Staphylococcus aureus bacteremia (MRSAB): A comparative clinical outcomes study.International Journal of Infectious Diseases http://dx.doi.org/10.1016/j.ijid.2017.01.019 This is a PDF file of an unedited manuscript that has been accepted for publication As a service to our customers we are providing this early version of the manuscript The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain Ceftaroline fosamil monotherapy for methicillin-resistant Staphylococcus aureus bacteremia (MRSAB): A comparative clinical outcomes study Running Title: Ceftaroline for MRSA bloodstream infections Samia Arshad1, Vanthida Huang2, Pamela Hartman1, Mary B Perri1, Daniela Moreno1, Marcus J Zervos1,3 Division of Infectious Diseases, Henry Ford Hospital, Detroit, MI, USA; 2Midwestern University College of Pharmacy-Glendale, Glendale, AZ, USA; 3Wayne State University School of Medicine, Detroit, MI, USA Corresponding Authors: Samia Arshad Division of Infectious Diseases, Henry Ford Hospital 2799 West Grand Blvd, CFP 314 Detroit, MI 48202 Phone: 917-449-3734 Fax: 313-916-2993 Email: sarshad1@hfhs.org Abstract Objectives: Vancomycin is the treatment of choice for methicillin-resistant Staphylococcus aureus (MRSA) bacteremia; however, it has been scrutinized due to failure in severe infections Ceftaroline fosamil (CPT-F) is approved for MRSA acute bacterial skin and skin structure infection (ABSSSI) but not in bloodstream infections We evaluated clinical outcomes of treatment with CPT-F in patients with MRSA bacteremia (MRSAB) Methods: Patients diagnosed with MRSAB at Henry Ford Hospital in Detroit, MI due to isolates with vancomycin MIC ≥ 1.0 mg/L, and susceptible in vitro to CPT-F were systematically reviewed retrospectively CPT-F-treated patients were matched with vancomycin- and daptomycin-treated patients based on age (≥ 65 years), ICU status, and severity of illness Outcomes evaluated included duration of hospitalization, duration of therapy, adverse events, relapse, hospital readmission, and death Results: 30 consecutive cases of MRSAB treated with CPT-F were identified from May 2011 - June 2013, and matched to 56 vancomycin and 46 daptomycin MRSAB patients Primary sources of CPT-F-treated MRSAB cohort were endocarditis (n=7, 23%), skin/wound (n=9, 30%), and bone/joint (n=8, 27%) Origin of CPT-F-treated MRSAB was 43% community-acquired, 43% healthcare-associated, and 13% hospital- acquired Mean hospital length of stay for CPT-F pts was 22 days Overall 30-day mortality rate was observed in 13% (n=4) of CPT-F cases versus 24% (n=11) of daptomycin pts and 11% (n=6) in the vancomycin cohort (p=0.188) Conclusions: Ceftaroline fosamil demonstrated comparable clinical outcomes in MRSAB patients compared with the other agents, especially as salvage therapy Key Words: methicillin-resistant Staphylococcus aureus, bacteremia, bloodstream infection, ceftaroline fosamil Introduction Methicillin-resistant Staphylococcus aureus (MRSA) bloodstream infections (BSI) continue to have high mortality with rates of 20-30% in recent studies [1], with an attributable 94,360 invasive infections and 18,650 deaths annually in the USA according to the CDC [2] Due to the high rates of mortality, the key to improving outcomes includes better safety and efficacy of treatment, reduction of infection rates and better prevention measures to decrease readmission rates and hospitalization costs The initial treatment of choice for serious MRSA infections is vancomycin [3, 4] However, there have been increasing reports of vancomycin failures and failures attributed to elevated vancomycin MIC’s [5] Consensus guidelines recommend consideration of the use of alternative agents in this setting [3,6], thus optimal therapeutic options for serious MRSA infections remains to be determined [3] Ceftaroline fosamil (CPT-F) is a novel cephalosporin approved by the FDA for the treatment of acute bacterial skin and skin structure infections caused by MRSA and community-acquired bacterial pneumonia [7] Ceftaroline, which is the active metabolite of the pro-drug ceftaroline fosamil has been used for the treatment of serious infections and reported as case observations [8, 9, 10, 11] There is no data which has evaluated comparative outcomes with this approach, and minimal evidence for the use of ceftaroline therapy for strains with vancomycin heteroresistance, reduced in vitro susceptibility within the susceptible range, or in patients that have failed or are intolerant of vancomycin Currently, the role of ceftaroline has not been evaluated in the treatment of severe MRSA infections Therefore, we sought to evaluate ceftaroline fosamil as monotherapy versus daptomycin and vancomycin in the treatment of MRSAB with strains having vancomycin MICs of ≥ 1.0 mg/L Methods This was a retrospective matched cohort study conducted at Henry Ford Hospital in Detroit, MI, USA, which was approved by the hospital Institutional Review Board We identified patients ≥ 18 years of age who were diagnosed with MRSAB with vancomycin MIC ≥ 1.0 mg/L and susceptible to CPT-F from November 2009 to December 2013 The selection of antibiotics were at the discretion of the ID physicians caring for the patient Ceftaroline fosamil-treated patients were matched with two vancomycin and two daptomycin-treated control patients based on age (≥ 65 years), intensive care unit (ICU) status during MRSAB related admission, and severity of illness Severity was defined by source of BSI classified into of categories: low-risk sources (related mortality rate, 20%) which included endovascular, lower respiratory tract, abdominal, and central nervous system foci sources as previously described [12, 13] Demographic information and outcome measures collected included duration of hospitalization and therapy, adverse events, 42-day relapse, 30-day hospital readmission, and 30-day mortality from onset of infection The initial identification of isolates and susceptibility testing via Vitek® (BioMérieux, Inc., Durham, NC) was performed by the clinical microbiology laboratory The MICs for CPT-F, daptomycin, and vancomycin were performed on all isolates utilizing Epsilometer tests (Etest; BioMérieux, Durham, NC) according to the manufacturer instructions The MICs for vancomycin were also performed on all isolates using broth microdilution according to CLSI guidelines [14] Isolates were screened for heteroresistance to vancomycin using the macrodilution method E-test (AB-Biodisk, Solna, Sweden) [15] We estimated a sample size collection of charts on a total of 150 patients who were hospitalized with MRSA bacteremia during the study period, with approximately 30 patients (20%) treated with ceftaroline and 120 patients (80%) treated with other therapeutic agents; patients treated with ceftaroline versus vancomycin or daptomycin were matched 1:4 to yield a sufficient sample size for comparative analysis, using 2sided significance level for α of 0.05 and 80% power Patient demographics were evaluated using descriptive statistics; categorical variables were compared using a χ2 test or Fisher exact test where sample sizes are small Continuous variables were compared using the 2-sample t test Conditional logistic regression modeling was used throughout to account for the case-control matching P < 0.05 was considered statistically significant All data were analyzed using both SPSS software version 20 and SAS software version 9.2 (SAS Institute Inc, Cary, NC) The primary outcome was composite failure defined as the presence of any of the main efficacy endpoints including mortality within 30 days from onset of infection, infection relapse within 42 days or readmission within 30 days after end of treatment Results Overall, of 132 total patients, 30 consecutive cases of MRSAB treated with CPT-F were identified from May 2011 to December 2013 The matched control group consisted of 102 MRSAB patients, 46 daptomycin-treated, and 56 vancomycin-treated patients identified from November 2009 to May 2013 Baseline demographic information between all three treatment groups are shown in Table Baseline demographics were similar in all treatment groups; however, CPT-F-treated patients had a longer duration of bacteremia (p=0.075) than the other two cohorts, which may be attributable to more than half of ceftaroline patients (n=17, 57%) initially failing standard treatment and consequently being switched to CPT-F due to documented poor clinical response per consulting ID physician The origin of MRSAB for CPT-F-treated versus standard of care treatment groups were 43% vs 61% community-acquired, 43% vs 34% healthcare-associated, and 13% vs 6% hospital-acquired, respectively Overall, 30-day mortality from onset of infection was observed in 13.3% of CPT-F-treated patients, 24% of daptomycin-treated patients, and 11% of vancomycin treated patients (p=0.188) In the CPT-F-treated group, of patients who died were endocarditis bacteremia patients and were left-sided with APACHE II score of 15-20 points The results from tables and indicate that the CPT-F treated patients were not significantly associated (either univariably or multivariably) with composite failure (mortality/relapse/readmission) Data indicates that the composite failure outcome was seen in of 30 CPT-F patients (23.3%) and 22 of 102 non-ceftaroline patients (21.6%), this difference was not statistically significant (p=0.837) Patient-related factors associated with composite failure were African American race (p=0.026, OR: 7.1) and COPD (p=0.038, OR: 6.4) (Table 3) The duration of intravenous therapy for all patients was to weeks All but one of CPT-F-treated cases had microbiological cure at the end of treatment (97%) The susceptibility testing in the CPT-F-treated group was as follows: vancomycin MIC90 was 1.7 mg/L by Etest; mean vancomycin MIC was 1.13 mg/L by automation (Vitek® [BioMérieux, Inc., Durham, NC]); mean daptomycin MIC was 0.52 mg/L and CPT-F MIC was 0.65 mg/L by E-test For the control group, vancomycin MIC90 was 1.6 mg/L by Etest, and 1.06 mg/L by Vitek The mean MICs for CPT-F and daptomycin were 0.62 mg/L and 0.52 mg/L, respectively, with one isolate which was intermediate-susceptible to CPT-F with a MIC of 1.5 mg/L None of the isolates in either treatment group demonstrated heteroresistance to vancomycin All susceptibilities were performed on all isolates with vancomycin utilizing Etest, Vitek® 2, and manual broth microdilution methods while CPT-F and daptomycin MICs were performed using only Etest Discussion The treatment of choice for MRSAB was vancomycin for over decades from its discovery In the last few decades; however, there has been increasing reports of vancomycin failure in patients with serious MRSA infections, such as bacteremia and infective endocarditis [12, 13] Furthermore, reports of increasing vancomycin MICs poses challenges for clinicians to maximize vancomycin pharmacodynamic parameters to achieve the appropriate treatment dose for these infections [12, 13, 3, 4] The optimal management of MRSAB is uncertain The current IDSA recommendations for vancomycin are serum trough levels of 15-20 mg/L for serious infections [3] These serum trough levels; however, have not been shown to be safe with an associated risk of nephrotoxicity in recent studies [16, 17] Nephrotoxicity, recurrence of infection, microbiologic failure, and mortality must be considered in the selection and overall clinical success of therapy Therefore, recommendations have been made for consideration of alternative agents However; most of the alternative agents not have FDA indications for these serious infections which proven to be challenging for clinicians Daptomycin is recommended as an alternative per IDSA guidelines for the treatment of MRSAB In 2012, Moore et al demonstrated daptomycin was associated with better outcomes than vancomycin in the treatment of MRSAB with higher vancomycin MICs (defined as MIC > mg/L) [18] A year later, Murray et al demonstrated that an early switch to daptomycin compared to vancomycin for the treatment of MRSAB with vancomycin MIC > mg/L significantly improved outcomes [19] In addition, they have shown a decrease in 30-day mortality with daptomycin (20.0% vs 48.2%; P14 days) [27] The future of ceftaroline is warranted in the utilization of serious infections as monotherapy versus combination therapy in a randomized trial in the optimization of its role as a therapeutic option Funding: This study was funded by Forest Research Institute 10 References Kullar R, Davis SL, Levine DP, Rybak MJ 2011 Impact of vancomycin exposure on outcomes in patients with methicillin-resistant Staphylococcus aureus bacteremia: support for consensus guidelines suggested targets Clin Infect Dis 52:975-981 Klevens RM, Morrison MA, Nadle J, Petit S, Gershman K, Ray S, Harrison LH, Lynfield R, Dumyati G, Townes JM, Craig AS, Zell ER, Fosheim GE, McDougal LK, Carey RB, Fridkin SK 2007 Invasive methicillin-resistant Staphylococcus aureus infections in the United States Jama 298:1763-1771 Liu C, 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Wayne, Pennsylvania 19087-1898 USA, 2012 15 Wootton M, MacGowan AP, Walsh TR, Howe RA 2007 A Multicenter Study Evaluating the Current Strategies for Isolating Staphylococcus aureus Strains with Reduced Susceptibility to Glycopeptides J Clin Microbiol 45:329-332 16 van Hal SJ, Paterson DL, Lodise TP 2013 Systematic review and meta-analysis of vancomycin-induced nephrotoxicity associated with dosing schedules that maintain troughs between 15 and 20 milligrams per liter Antimicrob Agents Chemother 57:734-744 17 Mergenhagen KA, Borton AR 2014 Vancomycin nephrotoxicity: a review J Pharm Pract 27:545-553 18 Moore CL, Osaki-Kiyan P, Haque NZ, Perri MB, Donabedian S, Zervos MJ 2012 Daptomycin versus vancomycin for bloodstream infections due to methicillinresistant Staphylococcus aureus with a high vancomycin minimum inhibitory concentration: a case-control study Clin Infect Dis 54:51-58 19 Murray KP, Zhao JJ, Davis SL, Kullar R, Kaye KS, Lephart P, Rybak MJ 2013 Early use of daptomycin versus vancomycin for methicillin-resistant Staphylococcus aureus bacteremia with vancomycin minimum inhibitory concentration >1 mg/L: a matched cohort study Clin Infect Dis 56:1562-1569 20 van Hal SJ, Paterson DL, Gosbell IB 2011 Emergence of daptomycin resistance following vancomycin-unresponsive Staphylococcus aureus bacteraemia in a daptomycin-naive patient a review of the literature Eur J Clin Microbiol Infect Dis 30:603-610 13 21 Kullar R, McKinnell JA, Sakoulas G 2014 Avoiding the perfect storm: the biologic and clinical case for reevaluating the 7-day expectation for methicillin-resistant Staphylococcus aureus bacteremia before switching therapy Clin Infect Dis 59:1455-1461 22 Rose WE, Schulz LT, Andes D, Striker R, Berti AD, Hutson PR, Shukla SK 2012 Addition of ceftaroline to daptomycin after emergence of daptomycin-nonsusceptible Staphylococcus aureus during therapy improves antibacterial activity Antimicrob Agents Chemother 56:5296-5302 23 Cunha BA, Pherez FM 2009 Daptomycin resistance and treatment failure following vancomycin for methicillin-resistant Staphylococcus aureus (MRSA) mitral valve acute bacterial endocarditis (ABE) Eur J Clin Microbiol Infect Dis 28:831-833 24 Kalimuddin S, Phillips R, Gandhi M, de Souza NN, Low JG, Archuleta S, Lye D, Tan TT 2014 Vancomycin versus daptomycin for the treatment of methicillinresistant Staphylococcus aureus bacteremia due to isolates with high vancomycin minimum inhibitory concentrations: study protocol for a phase IIB randomized controlled trial Trials 15:233 25 Holland TL, Arnold C, Fowler VG, Jr 2014 Clinical management of Staphylococcus aureus bacteremia: a review Jama 312:1330-1341 26 Casapao AM, Davis SL, Barr VO, Klinker KP, Goff DA, Barber KE, Kaye KS, Mynatt RP, Molloy LM, Pogue JM, Rybak MJ 2014 Large retrospective evaluation of the effectiveness and safety of ceftaroline fosamil therapy Antimicrob Agents Chemother 58:2541-2546 27 Yam FK, Kwan BK 2014 A case of profound neutropenia and agranulocytosis associated with off-label use of ceftaroline Am J Health Syst Pharm 71:1457-1461 14 Table Baseline demographics characteristics of patients with MRSA bacteremia stratified by treatment group Ceftaroline Variable Age Gender Race Vancomycin Daptomycin Overall p (N=30) (N=46) /(N=56) value N 30 46 56 0.721 Mean (SD) 55.9 (12.7) 53.5 (15.4) 54.9 (16.7) Female 13 (43%) 23 (50%) 24 (43%) Male 17 (57%) 23 (50%) 32 (57%) African 16 (57%) 30 (68%) 35 (69%) 0.745 0.439 American Caucasian (32%) 13 (30%) 15 (29%) Other (11%) ( 2%) (2%) N 30 46 56 Mean (SD) 11.8 (4.7) 12.2 (5.7) 11.8 (5.3) 15 (50%) 28 (61%) 28 (50%) 0.491 (30%) 10 (22%) (14%) 0.219 APACHE II Score Previous 0.978 hospitalization 90-days from onset of infection S aureus infection year prior to admission Source of Bacteremia Endocarditis (23%) 19 (41%) 13 (23%) 0.096 Bone_joint (27%) 10 (22%) (16%) 0.492 Skin_wound (30%) 10 (22%) 15 (27%) 0.704 12 (40%) 27 (59%) 20 (36%) 0.057 ICU_ ever during admission 15 Cancer (7%) (11%) (11%) 0.867 HIV (7%) (4%) (7%) 0.810 Diabetes mellitus 16 (53%) 16 (35%) 19 (34%) 0.170 Liver Disease (23%) 12 (26%) 13 (23%) 0.937 IV Drug User (23%) 16 (35%) 12 (21%) 0.285 Acute Renal (27%) 11 (24%) (13%) 0.195 Congestive Heart (17%) 11 (24%) (11%) 0.205 Vascular Disease (10%) (9%) (16%) 0.483 COPD (13%) (11%) (13%) 0.943 Clinical Failure Failure Outcomes 30 day mortality (14%) 11 (24%) (11%) 0.188 42 day relapse (7%) (2%) (2%) 0.443 (7%) (7%) (5%) 1.000 rate of infection 30 day Readmission 16 Table Univariable Logistic Regression Results for Composite Failure outcome (30day Mortality/42day Relapse/30day Readmission) Variable Odds 95% Odds Ratio P-value Ratio Confidence Limits Ceftaroline Treatment 0.623 1.295 0.463 3.621 Age 0.118 1.041 0.990 1.094 Male Gender 0.615 0.772 0.282 2.116 AA Race 0.156 2.485 0.707 8.738 APACHE II 0.919 0.995 0.903 1.097 Previous hospitalization 0.680 0.818 0.315 2.124 0.143 0.356 0.089 1.419 90-days from onset of infection S aureus infection year prior to admission Source of bacteremia Endocarditis 0.580 0.584 0.087 3.914 Bone/Joint 0.178 0.367 0.086 1.575 Skin/Wound 0.201 2.519 0.611 10.376 Cancer 0.754 0.794 0.187 3.366 HIV 0.485 2.062 0.270 15.749 Diabetes 0.548 0.733 0.266 2.021 Liver Disease 0.495 1.538 0.446 5.306 IV Drug User 0.768 0.823 0.226 2.998 Acute Renal Failure 0.202 2.182 0.658 7.241 Congestive Heart Failure 0.729 1.218 0.398 3.726 Vascular disease 0.732 1.338 0.252 7.100 COPD 0.056 3.652 0.970 13.753 17 Table Multivariable Logistic Regression Results for Composite failure outcome (30d Mortality/42d Relapse/30d Readmission) Variable Odds 95% Odds Ratio P-value Ratio Confidence Limits Ceftaroline Treatment 0.633 1.390 0.360 5.368 Age 0.124 1.062 0.984 1.146 African American Race 0.026* 7.118 1.269 39.918 SA Infection Previous 0.071 0.170 0.025 1.160 0.206 0.265 0.034 2.077 0.038* 6.388 1.112 36.707 Year Bone/Joint infection source COPD Note: Variables with univariable p-values < 0.20 have been included, along with ceftaroline treatment *Statistically Significant, P < 0.05 18 .. .Ceftaroline fosamil monotherapy for methicillin- resistant Staphylococcus aureus bacteremia (MRSAB): A comparative clinical outcomes study Running Title: Ceftaroline for MRSA bloodstream... agents, especially as salvage therapy Key Words: methicillin- resistant Staphylococcus aureus, bacteremia, bloodstream infection, ceftaroline fosamil Introduction Methicillin- resistant Staphylococcus. .. Kullar R, McKinnell JA, Sakoulas G 2014 Avoiding the perfect storm: the biologic and clinical case for reevaluating the 7-day expectation for methicillin- resistant Staphylococcus aureus bacteremia