Hugo Torres, MD, MPH

Background: Methicillin-resistant Staphylococcus aureus bloodstream infections carry a high risk of morbidity and relapse with most published guidelines recommending prolonged courses of IV antibiotics to ensure complete clearance of the infection. However, long-term IV antibiotic therapy may also be costly and is not without its own complications. An equally effective IV-to-oral antibiotic therapy would be welcome.

Study design: Retrospective cohort study.

Setting: A single academic center in the United States.

Synopsis: The investigators reviewed data from 492 adults with at least one positive blood culture for MRSA who had not yet completed their antibiotic course at the time of discharge during the index hospitalization but were sufficiently stable to complete outpatient antibiotic treatment. Of this cohort, 70 patients were switched to oral antibiotic therapy on discharge, while the rest received OPAT. The primary outcome was clinical failure, a 90-day composite measure of MRSA bloodstream infection recurrence, deep MRSA infection, or all-cause mortality. The most commonly used oral antibiotics were linezolid, trimethoprim/sulfamethoxazole, and clindamycin, all with high bioavailability. Endovascular infection was present in 21.5% of the study population. After propensity score adjustment for covariates, patients who received oral antibiotics had a nonsignificant reduction in the rate of clinical failure (hazard ratio, 0.379; 95% CI, 0.131-1.101).

Limitations of the study included its observational design with potential for significant residual confounding despite the propensity score–adjusted analysis, its ­single-center setting, the low frequency of endovascular infections, and the uncertainty in how the loss of patients to follow-up might have affected the results.

Bottom line: Selected patients with MRSA BSI may be successfully treated with sequential IV-to-oral antibiotic therapy.

Citation: Jorgensen SCJ et al. Sequential intravenous-to-oral outpatient antibiotic therapy for MRSA bacteraemia: One step closer. J Antimicrob Chemother. 2019 Feb;74(2):489-98.

Dr. Torres is a hospitalist at Massachusetts General Hospital.

Background: Methicillin-resistant Staphylococcus aureus bloodstream infections carry a high risk of morbidity and relapse with most published guidelines recommending prolonged courses of IV antibiotics to ensure complete clearance of the infection. However, long-term IV antibiotic therapy may also be costly and is not without its own complications. An equally effective IV-to-oral antibiotic therapy would be welcome.

Study design: Retrospective cohort study.

Setting: A single academic center in the United States.

Synopsis: The investigators reviewed data from 492 adults with at least one positive blood culture for MRSA who had not yet completed their antibiotic course at the time of discharge during the index hospitalization but were sufficiently stable to complete outpatient antibiotic treatment. Of this cohort, 70 patients were switched to oral antibiotic therapy on discharge, while the rest received OPAT. The primary outcome was clinical failure, a 90-day composite measure of MRSA bloodstream infection recurrence, deep MRSA infection, or all-cause mortality. The most commonly used oral antibiotics were linezolid, trimethoprim/sulfamethoxazole, and clindamycin, all with high bioavailability. Endovascular infection was present in 21.5% of the study population. After propensity score adjustment for covariates, patients who received oral antibiotics had a nonsignificant reduction in the rate of clinical failure (hazard ratio, 0.379; 95% CI, 0.131-1.101).

Limitations of the study included its observational design with potential for significant residual confounding despite the propensity score–adjusted analysis, its ­single-center setting, the low frequency of endovascular infections, and the uncertainty in how the loss of patients to follow-up might have affected the results.

Bottom line: Selected patients with MRSA BSI may be successfully treated with sequential IV-to-oral antibiotic therapy.

Citation: Jorgensen SCJ et al. Sequential intravenous-to-oral outpatient antibiotic therapy for MRSA bacteraemia: One step closer. J Antimicrob Chemother. 2019 Feb;74(2):489-98.

Dr. Torres is a hospitalist at Massachusetts General Hospital.

Background: Methicillin-resistant Staphylococcus aureus bloodstream infections carry a high risk of morbidity and relapse with most published guidelines recommending prolonged courses of IV antibiotics to ensure complete clearance of the infection. However, long-term IV antibiotic therapy may also be costly and is not without its own complications. An equally effective IV-to-oral antibiotic therapy would be welcome.

Study design: Retrospective cohort study.

Setting: A single academic center in the United States.

Synopsis: The investigators reviewed data from 492 adults with at least one positive blood culture for MRSA who had not yet completed their antibiotic course at the time of discharge during the index hospitalization but were sufficiently stable to complete outpatient antibiotic treatment. Of this cohort, 70 patients were switched to oral antibiotic therapy on discharge, while the rest received OPAT. The primary outcome was clinical failure, a 90-day composite measure of MRSA bloodstream infection recurrence, deep MRSA infection, or all-cause mortality. The most commonly used oral antibiotics were linezolid, trimethoprim/sulfamethoxazole, and clindamycin, all with high bioavailability. Endovascular infection was present in 21.5% of the study population. After propensity score adjustment for covariates, patients who received oral antibiotics had a nonsignificant reduction in the rate of clinical failure (hazard ratio, 0.379; 95% CI, 0.131-1.101).

Limitations of the study included its observational design with potential for significant residual confounding despite the propensity score–adjusted analysis, its ­single-center setting, the low frequency of endovascular infections, and the uncertainty in how the loss of patients to follow-up might have affected the results.

Bottom line: Selected patients with MRSA BSI may be successfully treated with sequential IV-to-oral antibiotic therapy.

Citation: Jorgensen SCJ et al. Sequential intravenous-to-oral outpatient antibiotic therapy for MRSA bacteraemia: One step closer. J Antimicrob Chemother. 2019 Feb;74(2):489-98.

Dr. Torres is a hospitalist at Massachusetts General Hospital.

Background: If left untreated, UTIs may lead to severe complications. Although campaigns aimed at decreasing unnecessary prescriptions have reduced the number of antibiotic prescriptions for UTI, a concurrent rise in the rates of gram-negative bloodstream infections (BSIs) has also been observed.

Study design: Retrospective, population-based cohort study with data compiled from primary care records from 2007 to 2015 linked to hospital episode statistics and death records.

Setting: General practices in England.

Synopsis: The investigators analyzed 312,896 UTI episodes among 157,264 unique patients (65 years of age or older) during the study period. Exclusion criteria included asymptomatic bacteriuria and complicated UTI. Of 271,070 patients who received antibiotics on the day of presentation with symptoms, 0.2% developed BSI within 60 days versus 2.2% of patients in whom antibiotics were delayed and 2.9% among patients not prescribed antibiotics. After adjustment for comorbidities, sex, and socioeconomic status, patients in whom antibiotics were deferred had a 7.12-fold greater odds of BSI, compared with the immediate-antibiotic group. BSIs were more common among men and older patients. All-cause mortality, a secondary outcome, was 1.16-fold higher with deferred antibiotics and 2.18 times higher with no antibiotics.

While the cohort studied was very large, a causal relationship cannot be firmly established in this observational study. Also, researchers were unable to include laboratory data, such as urinalysis and culture, in their analysis.

Bottom line: Delayed prescription of antibiotics for elderly patients presenting with UTI in primary care settings was associated with higher rates of BSI and death.

Citation: Gharbi M et al. Antibiotic management of urinary tract infection in elderly patients in primary care and its association with bloodstream infections and all-cause mortality: Population-based cohort study. BMJ. 2019 Feb;364:1525.

Dr. Torres is a hospitalist at Massachusetts General Hospital.

Background: If left untreated, UTIs may lead to severe complications. Although campaigns aimed at decreasing unnecessary prescriptions have reduced the number of antibiotic prescriptions for UTI, a concurrent rise in the rates of gram-negative bloodstream infections (BSIs) has also been observed.

Study design: Retrospective, population-based cohort study with data compiled from primary care records from 2007 to 2015 linked to hospital episode statistics and death records.

Setting: General practices in England.

Synopsis: The investigators analyzed 312,896 UTI episodes among 157,264 unique patients (65 years of age or older) during the study period. Exclusion criteria included asymptomatic bacteriuria and complicated UTI. Of 271,070 patients who received antibiotics on the day of presentation with symptoms, 0.2% developed BSI within 60 days versus 2.2% of patients in whom antibiotics were delayed and 2.9% among patients not prescribed antibiotics. After adjustment for comorbidities, sex, and socioeconomic status, patients in whom antibiotics were deferred had a 7.12-fold greater odds of BSI, compared with the immediate-antibiotic group. BSIs were more common among men and older patients. All-cause mortality, a secondary outcome, was 1.16-fold higher with deferred antibiotics and 2.18 times higher with no antibiotics.

While the cohort studied was very large, a causal relationship cannot be firmly established in this observational study. Also, researchers were unable to include laboratory data, such as urinalysis and culture, in their analysis.

Bottom line: Delayed prescription of antibiotics for elderly patients presenting with UTI in primary care settings was associated with higher rates of BSI and death.

Citation: Gharbi M et al. Antibiotic management of urinary tract infection in elderly patients in primary care and its association with bloodstream infections and all-cause mortality: Population-based cohort study. BMJ. 2019 Feb;364:1525.

Dr. Torres is a hospitalist at Massachusetts General Hospital.

Background: If left untreated, UTIs may lead to severe complications. Although campaigns aimed at decreasing unnecessary prescriptions have reduced the number of antibiotic prescriptions for UTI, a concurrent rise in the rates of gram-negative bloodstream infections (BSIs) has also been observed.

Study design: Retrospective, population-based cohort study with data compiled from primary care records from 2007 to 2015 linked to hospital episode statistics and death records.

Setting: General practices in England.

Synopsis: The investigators analyzed 312,896 UTI episodes among 157,264 unique patients (65 years of age or older) during the study period. Exclusion criteria included asymptomatic bacteriuria and complicated UTI. Of 271,070 patients who received antibiotics on the day of presentation with symptoms, 0.2% developed BSI within 60 days versus 2.2% of patients in whom antibiotics were delayed and 2.9% among patients not prescribed antibiotics. After adjustment for comorbidities, sex, and socioeconomic status, patients in whom antibiotics were deferred had a 7.12-fold greater odds of BSI, compared with the immediate-antibiotic group. BSIs were more common among men and older patients. All-cause mortality, a secondary outcome, was 1.16-fold higher with deferred antibiotics and 2.18 times higher with no antibiotics.

While the cohort studied was very large, a causal relationship cannot be firmly established in this observational study. Also, researchers were unable to include laboratory data, such as urinalysis and culture, in their analysis.

Bottom line: Delayed prescription of antibiotics for elderly patients presenting with UTI in primary care settings was associated with higher rates of BSI and death.

Citation: Gharbi M et al. Antibiotic management of urinary tract infection in elderly patients in primary care and its association with bloodstream infections and all-cause mortality: Population-based cohort study. BMJ. 2019 Feb;364:1525.

Dr. Torres is a hospitalist at Massachusetts General Hospital.