Lauren Olsen, Pharm.D 1 PGY1 Resident Objectives Identify - - PowerPoint PPT Presentation

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Methicillin-Resistant Staphylococcus aureus Infective Endocarditis What to do with Resistance? Lauren Olsen, Pharm.D 1 PGY1 Resident Objectives Identify limitations with current guideline recommended therapies for MRSA Infective

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SLIDE 1

Methicillin-Resistant Staphylococcus aureus Infective Endocarditis What to do with Resistance?

Lauren Olsen, Pharm.D PGY1 Resident 1

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SLIDE 2

Objectives

2

  • Identify limitations with current guideline recommended therapies for

MRSA Infective Endocarditis

  • Describe the seesaw effect of beta-lactam combination therapy for

MRSA Infective Endocarditis

  • Discuss appropriate indications for salvage therapy with β-lactams

based on literature evaluated

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SLIDE 3

Patient Case

Vitals

  • Blood Pressure:

152/78 mmHg

  • Temperature:

102.9 °F

  • Pulse:

115 bpm Labs

  • WBC

23

  • SCr

1.9

  • CrCl

45 Allergies: NKDA PMH: IV drug use, alcohol abuse Physical Examination:

  • (+) Splinter hemorrhages
  • (+) Janeway lesions

3

AL is a 55-year-old male has been recently admitted for continued fever and generalized fatigue over the past 7 days

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SLIDE 4

Patient Case

  • Day 1
  • Patient is then admitted and started on Vancomycin and

Piperacillin/Tazobactam empirically

  • Day 2
  • Blood cultures (+) S. aureus pending susceptibilities
  • TTE: vegetation measuring 0.8cm x 1.4cm in the mitral valve with

severe regurgitation

4

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SLIDE 5

Patient Case

  • Day 3
  • Susceptibilities return  MRSA

(Vancomycin MIC =1)

  • Piperacillin/Tazobactam discontinued and

repeat blood culture drawn

  • Kidney function continue to decline
  • Day 5: Patient continues to clinically

deteriorate, repeat culture returns

5

Repeat Blood Culture Day 5 Staphylococcus aureus Antibiotic SYS MIC

Vancomycin 2 S Gentamicin <4 S Oxacilllin >2 R Clindamycin >4 R Amp/Sub <8/4 R Trimeth/Sulfa <2/38 S

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SLIDE 6

Patient Case

  • Day 3
  • Susceptibilities return  MRSA

(Vancomycin MIC =1)

  • Piperacillin/Tazobactam discontinued and

repeat blood culture drawn

  • Kidney function continue to decline
  • Day 5: Patient continues to clinically

deteriorate, repeat culture returns

6

Repeat Blood Culture Day 5 Staphylococcus aureus Antibiotic SYS MIC

Vancomycin 2 S Gentamicin <4 S Oxacilllin >2 R Clindamycin >4 R Amp/Sub <8/4 R Trimeth/Sulfa <2/38 S Daptomycin >2 R

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SLIDE 7

Why the Concern for S. aureus IE?

  • Compared with IE* caused by other pathogens, S. aureus IE has

shown to have higher correlation

  • Clinical debilitation
  • Severe sepsis
  • Major neurological events
  • Multiple organ failure
  • Mortality

7

Nadji G, et al. Heart. 2005;91(7):932-937. *IE= Infective Endocarditis

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SLIDE 8

AHA/IDSA Guidelines

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Initial Treatment Therapy for MRSA Regimen Dose and Route Duration, wk Strength of Recommendation Oxacillin-resistant strain 1st Line Vancomycin 30 mg/kg /24 hr IV in 2 equally divided doses 6 CI 2nd Line Daptomycin >6 mg/kg/dose 6 BII

Baddour et al. Circulation. 2015;132:1435-1486

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SLIDE 9

When to Consider Salvage Therapy?

9

  • MRSA IDSA Guidelines
  • For isolates with a vancomycin MIC ≤ 2 µg/mL, the patient’s

clinical response should determine continued use of vancomycin, independent of the MIC

  • Persistent bacteremia ~7 days
  • Earlier if clinical deterioration is present

OK HS, et al. Korean J Intern Med. 2013 Nov; 28(6): 678–686. Liu, et al. Clin InfectDis. 2011;52:e18–e55.

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SLIDE 10

Limitations of Standard Therapy

  • Poor outcomes among isolates with higher MICs, within the

susceptible range (> 1mg/L)

10 5 10 15 20 25 30 35

Dapt Vanc Dapt Vanc Dapt Vanc

Clinical Success Clinical Failure

Murray KP, et al. CID 2013; 56(11):1562-9.

Endocarditis Bone/Joint Unknown # of patients

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SLIDE 11
  • In MRSA, hVISA* strains demonstrate

thicker cell walls with binding sites that sequester the drug

  • May decrease ability of

Daptomycin to reach binding sites

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Vancomycin and Daptomycin Correlation

Moise, P.A et al. Lancet Infect Dis. 2009; 9: 617–624

*hVISA= Heterogeneous Vancomycin intermediate S. aureus

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SLIDE 12

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Now what if there is resistance to both Vancomycin and Daptomycin?

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SLIDE 13

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See-Saw Effect

β-lactam Glycopeptides Lipopeptides

  • Staph. aureus

susceptibility for -peptides

  • Staph. aureus

susceptibility for β-lactam Barber KE, et al. Infect Dis Ther. 2014 Jun; 3(1): 35–43.

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SLIDE 14

14

Yang SJ, et al.

  • Antimicrob. Agents Chemother. 54

54:3161–3169.

  • Antimicrob. Agents Chemother. 54

54:3161–3169.

  • Antimicrob. Agents Chemother. 54

54:3161–3169.

Yang SJ, et al. Antimicrob. Agents Chemother. 2010. 54:3161–3169.

Objective Evaluate whether combination therapy regimens of Daptomycin-Oxacillin (DAP-OX) would enhance the in vitro efficacy over Daptomycin resistant strains of MRSA Methods n=6

  • Population analysis of the strain sets
  • In vitro time-kill curves

Results Combination of DAP and OX was found to increase the early in vitro bactericidal activity relative to that of DAP or OX alone in DAPr strains Conclusion Suggests that combination therapy regimens of DAP and OX has enhanced in vitro efficacy relative to DAP monotherapy in DAPr strains which exhibit the DAP-OX seesaw phenomenon in vitro

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SLIDE 15

15

Werth BJ, et al.

  • Antimicrob. Agents Chemother. 54

54:3161–3169.

  • Antimicrob. Agents Chemother. 54

54:3161–3169.

  • Antimicrob. Agents Chemother. 54

54:3161–3169.

Werth BJ, et al. Antimicrob Agents Chemother. 2013 May; 57(5): 2376–2379.

Objective Evaluated possible synergy activity of antibiotics against mecA- positive hVISA and VISA isolates using beta-lactams, and vancomycin Methods n=154

  • (n=61) VISA; (n=93) hVISA
  • Susceptibility testing; Time-kill synergy assays

Results Vancomycin + Ceftaroline

  • Synergy against 5/5 VISA and 4/5 hVISA strains

Vancomycin + Oxacillin

  • Synergy against 3/5 VISA isolates and 1/5 hVISA strains

Conclusion Ceftaroline may be more consistently synergistic than traditional antistaphylococcal beta-lactams with vancomycin

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SLIDE 16

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Vancomycin + β-lactam

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SLIDE 17

Dilworth TJ, et al.

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Objective Examine the impact of combination therapy with Vancomycin and a β-lactam on the microbiological eradication of MRSA bacteremia compared to Vancomycin alone Methods Retrospective cohort study, n=80

  • n=50 combination group vs n=30 Vancomycin alone
  • β-lactam choice varied
  • Had to have at least one positive blood culture for MRSA with

a Vancomycin MIC of 2mg/L

Dilworth TK, et al. Antimicrob Agents Chemother. 2014;58(1):102-9

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SLIDE 18

Dilworth TJ, et al.

18

MIC of MRSA Isolates for Endocarditis patients Combination (11/50) Vancomycin alone (11/30) P value Median Vancomycin MIC (mg/L) 2 (1.5-2) 1.5 (1.5-2) 0.066

Dilworth TK, et al. Antimicrob Agents Chemother. 2014;58(1):102-9

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SLIDE 19

Dilworth TJ, et al.

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Results Microbiological eradication

  • 48(96%) Combination therapy vs 24(80%) in the

Vancomycin alone (P=0.021)

  • Infective endocarditis (n=22), 11/11 (100%) combination vs.

9/11 (81.8%) treated with Vancomycin alone (P=0.20)

  • Mean duration of bacteremia
  • 3 days standard therapy vs 1.94 days combination group

Author’s Conclusion Combination therapy with Vancomycin and β-lactam is more likely to achieve microbiological eradication among patients with MRSA bacteremia than treatment with Vancomycin

Dilworth TK, et al. Antimicrob Agents Chemother. 2014;58(1):102-9

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SLIDE 20

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Gritsenko D, et al.

Objective Review cases of refractory MRSA bacteremia treated with the combination of Vancomycin and Ceftaroline

  • Persistent bacteremia or deterioration of patient clinical status on

Vancomycin alone Methods Case series, n=5

  • Vancomycin MIC’s within range (<1 mcg/mL)
  • Dosing for Ceftaroline 600mg q8hr
  • 2 cases = endocarditis
  • 2 cases= epidural abscess
  • 1 case = psoas abscess

Gritsenko, D et al Clinical Therapeutics , Volume 39, Issue 1 , 212 - 218

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SLIDE 21

Gritsenko D, et al.

21

Gritsenko D, et al.

Results 4/5 microbiologic cure, 1 transitioned to palliative care

  • Successful endocarditis patient

Author’s Conclusion Combination may be considered when Vancomycin monotherapy does not lead to microbiological and/or clinical improvement inpatients with metastatic MRSA bacteremia.

Gritsenko, D et al Clinical Therapeutics , Volume 39, Issue 1 , 212 - 218

Duration of Bacteremia (days) Vancomycin MIC (mcg/L) Daptomycin MIC (mcg/L) Ceftaroline MIC (mcg/L) Previous Therapy Ceftaroline Dose and Duration Duration of combination therapy with Ceftaroline 4 1 N/A 0.38 Vancomyci n 15mg.kg IV q12 Ceftaroline 400mg IV q12h (CrCl between 30-50mL/ min) for 14 days; 6

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SLIDE 22

How to Increase Vancomycin Efficacy?

22

Gritsenko D, et al.

  • Ensure therapeutic levels
  • Target trough 15-20 mg/L
  • Vancomycin Combinations
  • Greater bactericidal activity
  • See-Saw Effect
  • Concern for MIC creep
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SLIDE 23

23

Daptomycin + β-lactam

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SLIDE 24

Dhand, et al.

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Objective Determine whether the addition of an ASBL* to Daptomycin would increase activity in eradicating MRSA bacteremia Methods

  • Case series (n=7)
  • Nafcillin or Oxacillin 2g IV q4hr to Daptomycin 8–10

mg/kg/day

  • Time Kill curves
  • Daptomycin (10mg/L) +/- Oxacillin (20 mg/L)

Dhand, et al. Clin Infect Dis 2011. *ASBL= anti-staphylococcal B-lactam

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SLIDE 25

Time Kill Curve

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Dhand, et al. Clin Infect Dis 2011. Daptomycin Susceptible Strains

Daptomycin Resistant Strains

DAP= Daptomycin OXA= Oxacillin

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SLIDE 26

Dhand, et al.

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Results 7/7 cases showed addition of high-dose ASBLs resulted in rapid bacteremia clearance

  • 2/7 experienced relapsed

Author’s Conclusion

  • Rapid clearance of bacteremia within 24-48 hours
  • Restoration of DAP susceptibility
  • Increases in DAP membrane binding
  • Reduction in membrane surface charge by ASBLs that

was more pronounced in the DAP-R strain

Dhand, et al. Clin Infect Dis 2011. *ASBL= anti-staphylococcal B-lactam

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SLIDE 27

Sakoulas G, et al.

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Sakoulas et al, Clin Therap. 2014 Oct 1;36(10):1317-33

Objective Evaluate the use of Daptomycin and Ceftaroline as a salvage antimicrobial regimen in the treatment of refractory staphylococcal bacteremia Methods

  • Case study, n=26
  • Endocarditis 54% (14/26)
  • MRSA 20/26
  • Daptomycin 8mg/kg/day + Ceftaroline 600mg q24hr
  • In vitro (synergy studies, binding assays, cathelicidin LL-

37 killing assays)

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SLIDE 28

Time Kill Curve

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Sakoulas et al, Clin Therap. 2014 Oct 1;36(10):1317-33

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SLIDE 29

Sakoulas, et al.

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Sakoulas et al, Clin Therap. 2014 Oct 1;36(10):1317-33

Results

  • Bacteremia persisted for a median of 10 day on previous therapy
  • After Daptomycin + Ceftaroline was started
  • Median time to bacteremia clearance was 2 days
  • In vitro studies
  • Ceftaroline synergy against MRSA and enhanced MRSA killing

by cathelicid in LL-37and neutrophils

  • Induced Daptomycin binding in MSSA and MRSA to a

comparable degree as Nafcillin Author’s Conclusion Ceftaroline + Daptomycin may be an option to hasten clearance of refractory staphylococcal bacteremia.

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SLIDE 30

How to Increase Daptomycin Efficacy?

  • High Dose Daptomycin
  • Difficult to treat infections and high bacterial burden
  • Pharmacokinetics – concentration dependent killing
  • Guideline recommendation >6mg/kg/day
  • Consider 8-10 mg/kg/day
  • High Dose Daptomycin Combination with β-lactam
  • Greater bactericidal activity
  • Avoid development of resistance
  • See-Saw Effect

30

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SLIDE 31

What makes Ceftaroline the better β-lactam

  • ption?

31

  • Possesses anti-MRSA activity
  • Penicillin Binding Protein 2
  • In-vitro evidence regarding superiority over other β-lactams in

combination with Vancomycin

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SLIDE 32

What’s to Come

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Combination Antibiotic Therapy for Methicillin Resistant Staphylococcus Aureus Infection CAMERA-2 Primary Outcome: Complication-free 90 day survival

  • Composite outcome at 90 days of:
  • All-cause mortality
  • Persistent bacteraemia at day 5 or beyond
  • Microbiological relapse
  • Microbiological treatment failure

Standard of Therapy

  • Daptomycin 6-10 mg/kg IVPB daily
  • Vancomycin 15-20 mg/kg IVPB

adjusted dose per site protocol Experimental Arm

  • Standard Therapy +
  • IV Flucloxacillin 2g q6hrs OR
  • IV Cloxacillin 2g q6hrs

Tong SY, et al. Trials. 2016 Mar 31;17:170

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SLIDE 33

Patient Case

  • Day 3
  • Susceptibilities return  MRSA

(Vancomycin MIC =1)

  • Piperacillin/Tazobactam discontinued and

repeat blood culture drawn

  • Kidney function continue to decline
  • Day 5: Patient continues to clinically

deteriorate, repeat culture returns

33

Repeat Blood Culture Day 5 Staphylococcus aureus Antibiotic SYS MIC

Vancomycin 2 S Gentamicin <4 S Oxacilllin >2 R Clindamycin >4 R Amp/Sub <8/4 R Trimeth/Sulfa <2/38 S Daptomycin >2 R

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SLIDE 34

Patient Case

34

At this point in the patient case, what modification to therapy would you consider making?

  • A. Continue Vancomycin because patient has not had enough

time on therapeutic therapy

  • B. Discontinue Vancomycin and start Bactrim + Gentamicin
  • C. Continue Vancomycin and add on Ceftaroline
  • D. Discontinue Vancomycin and switch to Daptomycin+ Nafcillin
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SLIDE 35

Patient Follow-Up

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  • Day 6: CrCl 28 - Vancomycin is discontinued, Daptomycin at 10mg/kg

q48hrs + Ceftaroline 300mg q12hrs is started, repeat blood cultures drawn

  • Day 9: MRSA bacteremia continues, repeat blood cultures
  • Day 13: Patient WBC downtrending, afebrile, blood cultures are no

growth to date

  • Day 17: Latest blood cultures finalized – clear of bacteremia
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SLIDE 36

Key Takeaways

36

  • Consider escalation to salvage therapy when
  • 7 days of therapeutic antibiotics
  • Persistent bacteremia
  • MIC >2 for Vancomycin
  • Resistance to Daptomycin
  • Consider sooner if clinical deterioration
  • For salvage therapy consider Daptomycin or Vancomycin with

Ceftaroline

  • Other β-lactams shown in-vitro success as well
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SLIDE 37

Methicillin-Resistant Staphylococcus aureus Infective Endocarditis What to do with Resistance?

Lauren Olsen, Pharm.D PGY1 Resident 37