1073. Predictors of Vancomycin Switch or Escalation in Patients With Methicillin-Resistant Staphylococcus aureus Bloodstream Infection

BACKGROUND: Vancomycin (VAN) is the primary agent for the treatment methicillin-resistant Staphylococcus aureus (MRSA) bloodstream infections (BSI). VAN is frequently combined with or switched to a second anti-MRSA agent for the treatment of serious BSI because VAN monotherapy has been linked to treatment failures. We aimed to determine the potential risk factors for patients with MRSA BSI who switched or had therapy escalated. METHODS: This was a multicenter, retrospective cohort study of adults (≥18 years) initially treated with VAN (>24 hours) for MRSA BSI between 2006 and 2018. Patients with a respiratory source were excluded. Baseline clinical and infection characteristics were compared between patients who received VAN as the sole anti-MRSA agent and continued on VAN until discharge and patients who switched or had a second anti-MRSA agent added during their admission (switch/escalate group). Multivariable logistic regression was performed to identify independent predictors of therapy switch or escalation. RESULTS: A total of 195 patients were included (66 VAN and 129 switch/escalate). The mean (SD) age of the study population was 56 (15.5) years, 68.2% were male, and 81.0% were African-American. Most (80%) of patient had community-onset BSI. The median (IQR) Charlson Comorbidity index and Acute Physiology and Chronic Health Evaluation (APACHE) II scores were 3 (1–5) and 14 (8–20), respectively. The major sources of BSI were skin/soft tissue (24.6%), infective endocarditis (24.1%), and bone/joint (23.1%). Median (IQR) time to switch/escalation was 67 (44–97) hours. In multivariable logistic regression analysis, infective endocarditis (aOR 6.2, 95% CI 2.2–16), hospitalization in the past 90 days (aOR 2.0, 95% CI 1.0–4.0), and APACHE II (aOR 1.07, 95% CI 1.01–1.12) were independently associated with switch/escalation. CONCLUSION: We have identified a number of baseline clinical and infection characteristics that should be taken into account for clinicians to predict the likelihood of switch or escalation in vancomycin treated patients with MRSA BSI. Further studies evaluating the impact of up front alternative therapies in these higher risk patients are needed. DISCLOSURES: S. L. Davis, Achaogen: Scientific Advisor, Consulting fee. Allergan: Scientific Advisor, Consulting fee. Melinta: Scientific Advisor, Consulting fee. Nabriva: Scientific Advisor, Consulting fee. Zavante: Scientific Advisor, Consulting fee. M. J. Rybak, Allergan: Consultant, Grant Investigator and Speaker’s Bureau, Research grant and Research support. Achaogen: Consultant, Grant Investigator and Speaker’s Bureau, Consulting fee, Research grant and Research support. Bayer: Consultant, Grant Investigator and Speaker’s Bureau, Consulting fee, Research grant and Research support. Melinta: Consultant, Grant Investigator and Speaker’s Bureau, Consulting fee, Research grant and Research support. Merck: Consultant, Grant Investigator and Speaker’s Bureau, Consulting fee, Research grant and Research support. Theravance: Consultant, Grant Investigator and Speaker’s Bureau, Consulting fee, Research grant and Research support. Sunovian: Consultant, Grant Investigator and Speaker’s Bureau, Consulting fee, Research grant and Research support. Zavante: Consultant, Grant Investigator and Speaker’s Bureau, Consulting fee, Research grant and Research support. NIAID: Consultant, Grant Investigator and Speaker’s Bureau, Consulting fee, Research grant and Research support.