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Updated: May 25, 2025
Biosensor for Detection of Antibiotic Resistant Staphylococcus Bacteria
Published on: May 8, 2013
Methicillin-resistant Staphylococcus aureus and Vancomycin Prescribing in the Emergency Department: A Single-center
Joshua D Niforatos1, Jeremiah S Hinson1, Richard E Rothman1
1Department of Emergency Medicine, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.
Objectives:
Given the support for methicillin-resistant Staphylococcus aureus (MRSA) antimicrobial stewardship in the 2021 Surviving Sepsis Campaign Guidelines, we sought to measure the use of vancomycin in the emergency department (ED) in the years preceding these recommendations.
Methods:
A retrospective cohort study was conducted of all patients aged ≥ 18 years presenting to 5 emergency departments within a university-based health system who were given intravenous (IV) vancomycin during their ED index visit. The primary outcome assessed the proportion of patients with MRSA-positive blood cultures who received IV vancomycin in the ED. We also measured associations between clinical attributes associated with any MRSA infection.
Results:
Of the 20,212 unique ED visits for patients who received IV vancomycin, 63% (n = 12,755) had at least 1 MRSA risk factor. Only 2.4% (n = 494) and 14.1% (n = 2850) of patients receiving IV vancomycin in the ED were found to have MRSA bacteremia or any MRSA-positive culture, respectively. A total of 3160 patients met Sepsis-3 criteria and received IV vancomycin, though 65% (n = 2064) had no MRSA risk factors. For any patient with culture-proven MRSA, 63.8% (n = 315) and 43.4% (n = 1236) received an MRSA antimicrobial in the ED. MRSA risk factors were not associated with MRSA bacteremia (≥1 MRSA risk factor: odds ratio, 1.3, 95% CI, 0.9-1.8) or an MRSA-positive culture of any type (odds ratio, 0.9, 95% CI, 0.7-1.1).
Conclusion:
Within our hospital system, MRSA was an infrequent cause of bacteremia for patients presenting to the ED with sepsis or septic shock. Although vancomycin is frequently used in the ED, many patients with culture-proven MRSA did not receive MRSA antimicrobials. Notably, one-third of patients with culture-proven MRSA had no MRSA risk factors. MRSA risk factors were not predictive of culture-proven MRSA, thus highlighting the complexity of antimicrobial stewardship in the ED without validated clinical decision rules.
Insights
Vancomycin use in the emergency department (ED) is common, but MRSA bacteremia is infrequent. Many patients with MRSA did not receive appropriate antimicrobials, and MRSA risk factors were not predictive.
Area of Science:
- Infectious Diseases
- Antimicrobial Stewardship
- Emergency Medicine
Background:
- The 2021 Surviving Sepsis Campaign Guidelines support methicillin-resistant Staphylococcus aureus (MRSA) antimicrobial stewardship.
- Vancomycin is frequently administered in the emergency department (ED).
Purpose of the Study:
- To assess vancomycin utilization in the ED prior to the 2021 guidelines.
- To evaluate the proportion of patients with MRSA-positive cultures receiving vancomycin.
- To identify clinical factors associated with MRSA infection.
Main Methods:
- Retrospective cohort study of adult patients receiving IV vancomycin in 5 EDs.
- Assessed MRSA-positive blood cultures and MRSA risk factors.
- Analyzed associations between clinical attributes and MRSA infection.
Main Results:
- Of 20,212 ED visits with vancomycin, 63% had MRSA risk factors.
- Only 2.4% had MRSA bacteremia and 14.1% had any MRSA-positive culture.
- Many patients with culture-proven MRSA (63.8% bacteremia, 43.4% any culture) did not receive MRSA-specific antimicrobials in the ED.
- MRSA risk factors were not associated with MRSA bacteremia or positive cultures.
Conclusions:
- MRSA is an infrequent cause of bacteremia in ED sepsis/septic shock patients.
- Vancomycin is overused in the ED, and appropriate MRSA antimicrobials are underutilized.
- Lack of predictive value for MRSA risk factors complicates ED antimicrobial stewardship.
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