Comparable Effectiveness of First Week Treatment with Anti-Staphylococcal Penicillin versus Cephalosporin in Methicillin-Sensitive Staphylococcus aureus Bacteremia: A Propensity-Score Adjusted Retrospective Study

Abstract

The objective was to compare the prognostic impact of first week treatment with anti-staphylococcal penicillin (ASP) versus cephalosporin in methicillin-sensitive Staphylococcus aureus bacteremia (MS-SAB). Altogether 580 patients were retrospectively followed and categorized according to first week treatment; 84% (488) received ASP (cloxacillin) and 16% (92) cephalosporin (cefuroxime or ceftriaxone). SAB management was optimized with formal bedside infectious disease specialist consultation in 88%, deep infection foci diagnosed in 77% and adjunctive rifampicin therapy given to 61% of patients. The total case fatality in 580 patients was 12% at 28 days and 18% at 90 days. When comparing effectiveness of first week ASP versus cephalosporin treatment there were no significant differences in 28-days (11% vs. 12%, OR; 1.05, 95% CI, 0.53-2.09) or 90-days (17% vs. 21% OR; 1.25, 95% CI, 0.72-2.19) outcome. In univariate analysis no prognostic impact of either first week ASP or cephalosporin treatment was observed for 28-days (OR; 0.96, 95% CI, 0.48-1.90 and OR; 1.05, 95% CI, 0.53-2.09) or 90-days (OR; 0.80, 95% CI, 0.46-1.39 and OR; 1.25, 95% CI, 0.72-2.19) outcome. Propensity-score adjusted Cox proportional regression analysis for first week treatment with cephalosporin demonstrated no significant prognostic impact at 28-days (HR 1.54, 95% CI 0.72-3.23) or 90-days (HR 1.56, 95% CI 0.88-2.86).

In conclusion: There is a comparable effectiveness with respect to 28- and 90-days outcome for first week treatment with ASP versus cephalosporin in MS-SAB. The results indicate that the difference in prognostic impact between first week ASP and cephalosporin may be non-significant in patient cohorts with SAB management optimized by infectious disease specialist consultation.

Fig 1. Study profile.

Originally 617 patients with methicillin-sensitive Staphylococcus aureus bacteraemia (SAB) were identified. Patients with methicillin-resistant SAB were not included in the study. Patients were divided according to anti-staphylococcal penicillin (cloxacillin) or cephalosporin (cefuroxime or ceftriaxone) therapy during the 1^st week. ¹ Carbapenemes, Clindamycin, Vancomycin or Piperasillin-Tazobactam ² Cefuroxime or ceftriaxone ³ Cloxacillin

Fig 2. Kaplan-Meier interpretation of 90 days outcome in 580 methicillin-sensitive Staphylococcus aureus bacteremia patients receiving either anti-staphylococcal penicillin (ASP, cloxacillin) (n = 488) or cephalosporin (cefuroxime or ceftriaxone) (n = 92) as first week antibiotic treatment after positive blood cultures.

Log-rank non-significant.