Vancomycin monotherapy may be insufficient to treat methicillin-resistant staphylococcus aureus coinfection in children with influenza-related critical illness

Adrienne G. Randolph, Ruifei Xu, Tanya Novak, Margaret M. Newhams, Juliane Bubeck Wardenburg, Scott L. Weiss, Ronald C. Sanders, Neal J. Thomas, Mark W. Hall, Keiko M. Tarquinio, Natalie Cvijanovich, Rainer G. Gedeit, Edward J Truemper, Barry Markovitz, Mary E. Hartman, Kate G. Ackerman, John S. Giuliano, Steven L. Shein, Kristin L. Moffitt

Research output: Contribution to journalArticle

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Abstract

Background. Coinfection with influenza virus and methicillin-resistant Staphylococcus aureus (MRSA) causes life-threatening necrotizing pneumonia in children. Sporadic incidence precludes evaluation of antimicrobial efficacy. We assessed the clinical characteristics and outcomes of critically ill children with influenza-MRSA pneumonia and evaluated antibiotic use. Methods. We enrolled children (<18 years) with influenza infection and respiratory failure across 34 pediatric intensive care units 11/2008-5/2016. We compared baseline characteristics, clinical courses, and therapies in children with MRSA coinfection, non-MRSA bacterial coinfection, and no bacterial coinfection. Results. We enrolled 170 children (127 influenza A, 43 influenza B). Children with influenza-MRSA pneumonia (N = 30, 87% previously healthy) were older than those with non-MRSA (N = 61) or no (N = 79) bacterial coinfections. Influenza-MRSA was associated with increased leukopenia, acute lung injury, vasopressor use, extracorporeal life support, and mortality than either group (P ≤ .0001). Influenza-related mortality was 40% with MRSA compared to 4.3% without (relative risk [RR], 9.3; 95% confidence interval [CI], 3.8-22.9). Of 29/30 children with MRSA who received vancomycin within the first 24 hours of hospitalization, mortality was 12.5% (N = 2/16) if treatment also included a second anti-MRSA antibiotic compared to 69.2% (N = 9/13) with vancomycin monotherapy (RR, 5.5; 95% CI, 1.4, 21.3; P = .003). Vancomycin dosing did not influence initial trough levels; 78% were <10 μg/mL. Conclusions. Influenza-MRSA coinfection is associated with high fatality in critically ill children. These data support early addition of a second anti-MRSA antibiotic to vancomycin in suspected severe cases.

Original languageEnglish (US)
Pages (from-to)365-372
Number of pages8
JournalClinical Infectious Diseases
Volume68
Issue number3
DOIs
StatePublished - Jan 1 2019

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Vancomycin
Methicillin-Resistant Staphylococcus aureus
Coinfection
Critical Illness
Human Influenza
Staphylococcal Pneumonia
Anti-Bacterial Agents
Staphylococcus aureus
Mortality
Confidence Intervals
Pediatric Intensive Care Units
Extracorporeal Membrane Oxygenation
Acute Lung Injury
Leukopenia
Orthomyxoviridae
Respiratory Insufficiency
Hospitalization
Incidence

Keywords

  • children
  • influenza
  • methicillin-resistant Staphylococcus aureus
  • mortality.
  • vancomycin

ASJC Scopus subject areas

  • Microbiology (medical)
  • Infectious Diseases

Cite this

Vancomycin monotherapy may be insufficient to treat methicillin-resistant staphylococcus aureus coinfection in children with influenza-related critical illness. / Randolph, Adrienne G.; Xu, Ruifei; Novak, Tanya; Newhams, Margaret M.; Wardenburg, Juliane Bubeck; Weiss, Scott L.; Sanders, Ronald C.; Thomas, Neal J.; Hall, Mark W.; Tarquinio, Keiko M.; Cvijanovich, Natalie; Gedeit, Rainer G.; Truemper, Edward J; Markovitz, Barry; Hartman, Mary E.; Ackerman, Kate G.; Giuliano, John S.; Shein, Steven L.; Moffitt, Kristin L.

In: Clinical Infectious Diseases, Vol. 68, No. 3, 01.01.2019, p. 365-372.

Research output: Contribution to journalArticle

Randolph, AG, Xu, R, Novak, T, Newhams, MM, Wardenburg, JB, Weiss, SL, Sanders, RC, Thomas, NJ, Hall, MW, Tarquinio, KM, Cvijanovich, N, Gedeit, RG, Truemper, EJ, Markovitz, B, Hartman, ME, Ackerman, KG, Giuliano, JS, Shein, SL & Moffitt, KL 2019, 'Vancomycin monotherapy may be insufficient to treat methicillin-resistant staphylococcus aureus coinfection in children with influenza-related critical illness', Clinical Infectious Diseases, vol. 68, no. 3, pp. 365-372. https://doi.org/10.1093/cid/ciy495
Randolph, Adrienne G. ; Xu, Ruifei ; Novak, Tanya ; Newhams, Margaret M. ; Wardenburg, Juliane Bubeck ; Weiss, Scott L. ; Sanders, Ronald C. ; Thomas, Neal J. ; Hall, Mark W. ; Tarquinio, Keiko M. ; Cvijanovich, Natalie ; Gedeit, Rainer G. ; Truemper, Edward J ; Markovitz, Barry ; Hartman, Mary E. ; Ackerman, Kate G. ; Giuliano, John S. ; Shein, Steven L. ; Moffitt, Kristin L. / Vancomycin monotherapy may be insufficient to treat methicillin-resistant staphylococcus aureus coinfection in children with influenza-related critical illness. In: Clinical Infectious Diseases. 2019 ; Vol. 68, No. 3. pp. 365-372.
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abstract = "Background. Coinfection with influenza virus and methicillin-resistant Staphylococcus aureus (MRSA) causes life-threatening necrotizing pneumonia in children. Sporadic incidence precludes evaluation of antimicrobial efficacy. We assessed the clinical characteristics and outcomes of critically ill children with influenza-MRSA pneumonia and evaluated antibiotic use. Methods. We enrolled children (<18 years) with influenza infection and respiratory failure across 34 pediatric intensive care units 11/2008-5/2016. We compared baseline characteristics, clinical courses, and therapies in children with MRSA coinfection, non-MRSA bacterial coinfection, and no bacterial coinfection. Results. We enrolled 170 children (127 influenza A, 43 influenza B). Children with influenza-MRSA pneumonia (N = 30, 87{\%} previously healthy) were older than those with non-MRSA (N = 61) or no (N = 79) bacterial coinfections. Influenza-MRSA was associated with increased leukopenia, acute lung injury, vasopressor use, extracorporeal life support, and mortality than either group (P ≤ .0001). Influenza-related mortality was 40{\%} with MRSA compared to 4.3{\%} without (relative risk [RR], 9.3; 95{\%} confidence interval [CI], 3.8-22.9). Of 29/30 children with MRSA who received vancomycin within the first 24 hours of hospitalization, mortality was 12.5{\%} (N = 2/16) if treatment also included a second anti-MRSA antibiotic compared to 69.2{\%} (N = 9/13) with vancomycin monotherapy (RR, 5.5; 95{\%} CI, 1.4, 21.3; P = .003). Vancomycin dosing did not influence initial trough levels; 78{\%} were <10 μg/mL. Conclusions. Influenza-MRSA coinfection is associated with high fatality in critically ill children. These data support early addition of a second anti-MRSA antibiotic to vancomycin in suspected severe cases.",
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T1 - Vancomycin monotherapy may be insufficient to treat methicillin-resistant staphylococcus aureus coinfection in children with influenza-related critical illness

AU - Randolph, Adrienne G.

AU - Xu, Ruifei

AU - Novak, Tanya

AU - Newhams, Margaret M.

AU - Wardenburg, Juliane Bubeck

AU - Weiss, Scott L.

AU - Sanders, Ronald C.

AU - Thomas, Neal J.

AU - Hall, Mark W.

AU - Tarquinio, Keiko M.

AU - Cvijanovich, Natalie

AU - Gedeit, Rainer G.

AU - Truemper, Edward J

AU - Markovitz, Barry

AU - Hartman, Mary E.

AU - Ackerman, Kate G.

AU - Giuliano, John S.

AU - Shein, Steven L.

AU - Moffitt, Kristin L.

PY - 2019/1/1

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N2 - Background. Coinfection with influenza virus and methicillin-resistant Staphylococcus aureus (MRSA) causes life-threatening necrotizing pneumonia in children. Sporadic incidence precludes evaluation of antimicrobial efficacy. We assessed the clinical characteristics and outcomes of critically ill children with influenza-MRSA pneumonia and evaluated antibiotic use. Methods. We enrolled children (<18 years) with influenza infection and respiratory failure across 34 pediatric intensive care units 11/2008-5/2016. We compared baseline characteristics, clinical courses, and therapies in children with MRSA coinfection, non-MRSA bacterial coinfection, and no bacterial coinfection. Results. We enrolled 170 children (127 influenza A, 43 influenza B). Children with influenza-MRSA pneumonia (N = 30, 87% previously healthy) were older than those with non-MRSA (N = 61) or no (N = 79) bacterial coinfections. Influenza-MRSA was associated with increased leukopenia, acute lung injury, vasopressor use, extracorporeal life support, and mortality than either group (P ≤ .0001). Influenza-related mortality was 40% with MRSA compared to 4.3% without (relative risk [RR], 9.3; 95% confidence interval [CI], 3.8-22.9). Of 29/30 children with MRSA who received vancomycin within the first 24 hours of hospitalization, mortality was 12.5% (N = 2/16) if treatment also included a second anti-MRSA antibiotic compared to 69.2% (N = 9/13) with vancomycin monotherapy (RR, 5.5; 95% CI, 1.4, 21.3; P = .003). Vancomycin dosing did not influence initial trough levels; 78% were <10 μg/mL. Conclusions. Influenza-MRSA coinfection is associated with high fatality in critically ill children. These data support early addition of a second anti-MRSA antibiotic to vancomycin in suspected severe cases.

AB - Background. Coinfection with influenza virus and methicillin-resistant Staphylococcus aureus (MRSA) causes life-threatening necrotizing pneumonia in children. Sporadic incidence precludes evaluation of antimicrobial efficacy. We assessed the clinical characteristics and outcomes of critically ill children with influenza-MRSA pneumonia and evaluated antibiotic use. Methods. We enrolled children (<18 years) with influenza infection and respiratory failure across 34 pediatric intensive care units 11/2008-5/2016. We compared baseline characteristics, clinical courses, and therapies in children with MRSA coinfection, non-MRSA bacterial coinfection, and no bacterial coinfection. Results. We enrolled 170 children (127 influenza A, 43 influenza B). Children with influenza-MRSA pneumonia (N = 30, 87% previously healthy) were older than those with non-MRSA (N = 61) or no (N = 79) bacterial coinfections. Influenza-MRSA was associated with increased leukopenia, acute lung injury, vasopressor use, extracorporeal life support, and mortality than either group (P ≤ .0001). Influenza-related mortality was 40% with MRSA compared to 4.3% without (relative risk [RR], 9.3; 95% confidence interval [CI], 3.8-22.9). Of 29/30 children with MRSA who received vancomycin within the first 24 hours of hospitalization, mortality was 12.5% (N = 2/16) if treatment also included a second anti-MRSA antibiotic compared to 69.2% (N = 9/13) with vancomycin monotherapy (RR, 5.5; 95% CI, 1.4, 21.3; P = .003). Vancomycin dosing did not influence initial trough levels; 78% were <10 μg/mL. Conclusions. Influenza-MRSA coinfection is associated with high fatality in critically ill children. These data support early addition of a second anti-MRSA antibiotic to vancomycin in suspected severe cases.

KW - children

KW - influenza

KW - methicillin-resistant Staphylococcus aureus

KW - mortality.

KW - vancomycin

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