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Published on: January 3, 2020
Association between vancomycin minimum inhibitory concentration and mortality among patients with Staphylococcus
Andre C Kalil1, Trevor C Van Schooneveld1, Paul D Fey2
1Department of Internal Medicine, Division of Infectious Disease, University of Nebraska Medical Center, Omaha.
Importance:
Staphylococcus aureus bacteremia (SAB) is a worldwide problem. It is unclear whether higher-vancomycin minimum inhibitory concentration (MIC) is associated with mortality. This potential association has direct consequences for patients and public health.
Data Sources:
PubMed, Embase, the Cochrane Library, Evidence-based Medicine BMJ, and the American College of Physicians Journal Club were searched from inception through April 2014.
Study Selection:
Studies reporting mortality and vancomycin MIC in patients with SAB were included.
Data Extraction And Synthesis:
Two authors performed the literature search and the study selection separately. Random-effects modeling was used for all analyses.
Main Outcomes And Measures:
All-cause mortality.
Findings:
Among 38 included studies that involved 8291 episodes of SAB, overall mortality was 26.1%. The estimated mortality was 26.8% among SAB episodes (n = 2740) in patients with high-vancomycin MIC (≥1.5 mg/L) compared with 25.8% mortality among SAB episodes (n = 5551) in patients with low-vancomycin MIC (<1.5 mg/L) (adjusted risk difference [RD], 1.6% [95% CI, -2.3% to 5.6%]; P = .43). For the highest-quality studies, the estimated mortality was 26.2% among SAB episodes (n = 2318) in patients with high-vancomycin MIC compared with 27.8% mortality among SAB episodes (n = 4168) in patients with low-vancomycin MIC (RD, 0.9% [95% CI, -2.9% to 4.6%]; P = .65). In studies that included only methicillin-resistant S aureus infections (n = 7232), the mortality among SAB episodes (n = 2384) in patients with high-vancomycin MIC was 27.6% compared with mortality of 27.4% among SAB episodes (n = 4848) in patients with low-vancomycin MIC (adjusted RD, 1.6% [95% CI, -2.3% to 5.5%]; P = .41). No significant differences in risk of death were observed in subgroups with high-vancomycin MIC vs low-vancomycin MIC values across different study designs, microbiological susceptibility assays, MIC cutoffs, clinical outcomes, duration of bacteremia, previous vancomycin exposure, and treatment with vancomycin.
Conclusions And Relevance:
In this meta-analysis of SAB episodes, there were no statistically significant differences in the risk of death when comparing patients with S aureus exhibiting high-vancomycin MIC (≥1.5 mg/L) to those with low-vancomycin MIC (<1.5 mg/L), although the findings cannot definitely exclude an increased mortality risk. These findings should be considered when interpreting vancomycin susceptibility and in determining whether alternative antistaphylococcal agents are necessary for patients with SAB with elevated but susceptible vancomycin MIC values.
Insights
Higher vancomycin minimum inhibitory concentration (MIC) in Staphylococcus aureus bacteremia (SAB) did not significantly increase mortality risk. This meta-analysis found no statistically significant difference in death rates between high and low vancomycin MIC groups.
Area of Science:
- Infectious Diseases
- Clinical Microbiology
- Pharmacology
Background:
- Staphylococcus aureus bacteremia (SAB) is a significant global health concern.
- The relationship between vancomycin minimum inhibitory concentration (MIC) and mortality in SAB is not well-established.
- Understanding this association is crucial for patient outcomes and public health strategies.
Purpose of the Study:
- To investigate the association between higher vancomycin MIC values and mortality in patients with SAB.
- To synthesize evidence from existing studies to determine the impact of vancomycin MIC on SAB outcomes.
- To inform clinical decision-making regarding vancomycin use in SAB treatment.
Main Methods:
- A comprehensive literature search was conducted across multiple databases (PubMed, Embase, Cochrane Library, etc.) up to April 2014.
- Studies reporting mortality and vancomycin MIC in SAB patients were included.
- Random-effects modeling was employed for meta-analysis of all-cause mortality.
Main Results:
- The meta-analysis included 38 studies with 8291 SAB episodes; overall mortality was 26.1%.
- No statistically significant difference in mortality was observed between patients with high vancomycin MIC (≥1.5 mg/L) and low vancomycin MIC (<1.5 mg/L).
- Subgroup analyses across various study designs and patient populations did not reveal significant differences in mortality risk.
Conclusions:
- This meta-analysis found no statistically significant association between high vancomycin MIC and increased mortality in SAB.
- While an increased risk cannot be definitively excluded, these findings suggest vancomycin may remain a viable option for SAB with elevated, susceptible MICs.
- Clinical interpretation of vancomycin susceptibility and consideration of alternative agents should be guided by these results.
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