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Community hospitals often fail to treat MRSA adequately
In almost half of the hospitals, health care providers did not administer an antimicrobial agent within seven days of infection.
About 40% of patients with bloodstream infection or a deep surgical site infection due to methicillin-resistant Staphylococcus aureus who were treated at community hospitals in Virginia and North Carolina did not receive appropriate antimicrobial treatment, according to researchers from Duke University.
The researchers conducted a cohort study at one tertiary care hospital and eight community hospitals in Virginia and North Carolina from 1994 to 2003. Included were 129 patients with surgical site infection and 564 with bloodstream infection. The average age of patients in the cohort was 63.1 years. Patients were eligible if they had one or more MRSA cultures positively identified.
Treatments
Health care providers administered vancomycin to 44.2% of the patients with surgical site infection on the date of diagnosis. Other treatments administered included ciprofloxacin, linezolid, aminoglycoside, macrolide, sulfamethoxazole and carbapenem. By day seven following diagnosis, 73.6% patients with surgical site infection had received an agent active against MRSA. Within 90 days of surgery, 95 patients with surgical site infection were readmitted to the hospital. There was a 22% mortality rate within one year after infection in the surgical site infection cohort.
Most patients in the surgical site infection cohort had undergone coronary artery bypass grafting, open-reduction internal fixation of fractures and hip prosthesis insertion prior to infection.
About 38% of patients with bloodstream infection received vancomycin on the day of infection. Seven days after diagnosis, health care providers had administered vancomycin to 66.1% of patients with bloodstream infection. There were 374 patients who survived to hospital discharge; 44.7% were receiving vancomycin. However, 36.4% of them were readmitted to the hospital within 90 days of diagnosis. Twelve patients were still receiving vancomycin six weeks after infection. There were 189 patients with bloodstream infection who died during their initial hospitalization.
The primary infection was bloodstream infection in 377 patients. There was secondary bloodstream infection in patients with pulmonary, surgical site and urinary tract infections.
Outcomes
Treatment regimens in the community hospitals were less effective than those in the tertiary care hospital for both surgical site infections and bloodstream infections. But the researchers noted that treatment at the tertiary care hospital was only slightly better than the community hospitals.
Nineteen percent of patients with surgical site infections at community hospitals received appropriate antimicrobial treatment upon diagnosis, compared with 64% of patients at the tertiary care hospital. Seven days after infection, health care providers at community hospitals administered appropriate antimicrobial therapy to 59% of patients, compared with 84% at the tertiary care hospital.
Outcomes for patients with surgical site infections were similar in community hospitals and the tertiary care hospital despite the different treatment regimens.
On the day of bloodstream infection diagnosis in community hospitals, 31.7% of patients received effective antimicrobial therapy; 43.4% of patients in the tertiary care hospital received effective antimicrobial therapy. At the seven-day mark, 58.9% of patients in community hospitals and 74.8% of patients in the tertiary care hospital were receiving appropriate treatment.
Health care providers at community hospitals discharged fewer patients with bloodstream infections than at the tertiary care hospital. Patients at community hospitals also had higher one-year mortality rates.
The researchers suggested that the high rate of administration of inappropriate therapy was cause for concern and that early and prolonged treatment methods need to be addressed in community hospital settings. – by Rob Volansky
For more information:
- Kaye K, Anderson D, Choi Y, et al. The deadly toll of invasive methicillin-resistant Staphylococcus aureus infection in community hospitals. Clin Infect Dis.2008;46:1568-1577.