Combination Vancomycin/Cefazolin (VAN/CFZ) for Methicillin-Resistant Staphylococcus aureus (MRSA) Bloodstream Infections (BSI)

BACKGROUND: VAN remains the standard for MRSA BSI but has been associated with treatment failures and resulted in prolonged BSI durations and recurrences. In vitro studies of VAN/CFZ against MRSA demonstrated synergy and prevention of VAN resistance. However, clinical use of VAN/CFZ has not been reported. The objective of this study was to compare patient outcomes treated with VAN/CFZ vs. VAN for MRSA BSI. METHODS: This was a retrospective, cohort, comparative-effectiveness study of hospitalized adults ≥18y with ≥1 MRSA blood culture and received VAN/CFZ combination for ≥24h or VAN alone initiated within 72h of index infection between 1/1/08 and 5/1/17. Patients who received >24h β-lactams other than CFZ, MRSA-active antibiotics other than VAN, with polymicrobial BSI, or had a second MRSA BSI episode during the study period were excluded. The primary composite failure outcome included: 30d mortality, MRSA BSI ≥7d, and 60d recurrence. Demographics were compared by Χ(2), Fisher’s exact, Student’s t, or Mann–Whitney U tests. Multivariable regression models compared outcomes between the two treatment groups. Covariates with p-values ≤0.2 in bivariate analyses were included in the model. RESULTS: A total of 101 patients were included (CFZ/VAN = 41, VAN = 60). Demographics were similar except VAN patients were older (mean (±SD) age 58 (±14) v. 51 (±18) y, P = 0.04), had higher median (IQR) Charlson Comorbidity Index (3 (2-5) v. 1 (0–4), P < 0.01), APACHE II scores (13 (8-18) v. 11 (8-18), P = 0.2), and more endocarditis BSI source (37% v. 20%, P = 0.06). After accounting for BSI source, VAN/CFZ (adjusted odds ratio [aOR], 95% confidence intervals [CI], 0.33, 0.13-0.83) and low APACHE II scores (aOR 1.07, 95% CI 1–1.15) were independently associated with fewer failures. Bivariate outcomes are in table below: CONCLUSION: In this cohort of MRSA BSI, patients treated with VAN/CFZ experienced fewer failures than with VAN alone, with shorter BSI durations. Additional studies are needed to confirm the role of VAN/CFZ combination treatment for MRSA BSI. DISCLOSURES: J. M. Pogue, Achaogen, Inc.: Consultant, Consulting fee. M. J. Rybak, Allergen: Scientific Advisor, Consulting fee.