Risk Factors for Community-Onset Methicillin-Resistant Staphylococcus aureus Bacteremia Public
Jacob, Jesse Thomas (2011)
Abstract
The characteristics and risk factors for bacteremia with
methicillin-resistant
Staphylococcus aureus (MRSA) at the time of admission to an
acute care hospital have
not been well characterized after the recent changes in MRSA
epidemiology. All charts
for adults with S. aureus in blood cultures obtained within
48 hours of admission
(community-onset, CO) were reviewed over a five year period, with
only the first episode
of S. aureus bacteremia per patient included in the
analysis. Patients with MRSA
bacteremia were classified as cases, and those with
methicillin-sensitive S. aureus
(MSSA) were used as the comparison group. Patients with CO MRSA
bacteremia had a
median age of 59.4 (range: 37.1-87.2) and were 94.8% male and 48.8%
black. The most
common co-morbidity was diabetes mellitus (54.4%). Patients with CO
MSSA
bacteremia had similar demographic and clinical characteristics.
Among the 84 cases and
58 comparators, there were similar rates for prior culture
positivity with MSSA (6.0% vs.
5.2%), but only cases had prior positive culture with MRSA (14.3%
vs. 0%, p<0.01).
Frequency of hospitalization was higher among cases (53.6% vs.
31.0%, p=0.01). In
univariate analysis, the major definable predictors of CO MRSA
bacteremia were receipt
of oral (OR 3.19, p<0.01) and intravenous (OR 2.78, p<0.01)
antibiotics as well as prior
hospitalization (OR 3.19, p<0.01). For patients who were
previously hospitalized, the
OR for was 7.42 if they had received IV antibiotics, compared to
0.85 if they had not
received IV antibiotics (p=0.01). In multivariate analysis, the
single greatest predictor of
CO MRSA bacteremia was hospitalization in the last 90 days among
patients receiving
antibiotics (OR 6.12, p=0.01). Among those who did not receive
antibiotics, no single
variable predicted outcome. Post-hospitalization surveillance
interventions may be
important considerations in developing prevention strategies.
Antimicrobial stewardship
may also pray a crucial role in decreasing the burden of MRSA
bacteremia on the
healthcare system.
Table of Contents
INTRODUCTION
............................................................................................................................1
BACKGROUND
.............................................................................................................................2
METHODS
...................................................................................................................................5
Setting
.......................................................................................................................................5
Case and Comparisons Selection
.................................................................................................
5
Chart Review
.............................................................................................................................
6
Statistical Analysis
......................................................................................................................7
RESULTS
.....................................................................................................................................8
Description of Cases
....................................................................................................................8
Cases and Comparators
...............................................................................................................9
Univariate and Multivariate Analysis
.............................................................................................10
DISCUSSION
...............................................................................................................................12
REFERENCES
...............................................................................................................................17
TABLES and FIGURES
...................................................................................................................19
Table 1: Selected Characteristics of Patients with Community-Onset Methicillin-resistant
S. aureus (MRSA) Bacteremia
...........................................................................................19
Figure 1: Source of Methicillin-resistant S. aureus (MRSA)
Bacteremia at Admission................. 20
Figure 2: Frequency of Community Onset-Methicillin Resistant S.
aureus Bacteremia
by Quarter, 2005-2008
...................................................................................................
21
Table 2: Frequency of Selected Characteristics of Patients with
Community-Onset
S. aureus Bacteremia within 90 days
...............................................................................
22
Figure 3: Number of Community-Onset S. aureus Bacteremias by
Months
Since Last Hospitalization
................................................................................................23
Table 3: Association of Selected Characteristics of Patients with
Community-Onset
Methicillin-resistant S. aureus (MRSA)
Bacteremia.................................................................24
Table 4: Assessment of Interaction of Hospitalization with Other
Covariates........................... 25
Table 5: Multivariate Analysis of Risk Factors for
Methicillin-resistant S. aureus (MRSA)
Compared to Methicillin-sensitive S. aureus
Bacteremia: Basic Model....................................
26
Tables 6A and 6B: Multivariate Analysis of Risk Factors for
Methicillin-resistant S. aureus
(MRSA) Compared to Methicillin-sensitive S. aureus Bacteremia:
Basic Model Stratified by IV Antibiotics
............................................................................27
Tables 7A and 7B: Multivariate Analysis of Risk Factors for
Methicillin-resistant S. aureus
(MRSA) Compared to Methicillin-sensitive S. aureus Bacteremia:
Extended Model Stratified by IV Antibiotics
......................................................................28
Table 8A and 8B: Final Model of Multivariate Analysis of Risk
Factors for Methicillin-resistant
S. aureus (MRSA) Compared to Methicillin-sensitive S. aureus Bacteremia,
Stratified by IV
Antibiotics...............................................................................................29
Table 9A and 9B: Sensitivity analysis excluding patients with prior
Methicillin-resistant
S. aureus (MRSA) of the Final Model of Multivariate Analysis of Risk Factors for MRSA
Compared to Methicillin-sensitive S. aureus
Bacteremia, Stratified by IV Antibiotics ........... 30
Table 10A and 10B: Sensitivity analysis excluding patients with
infections in 2008 of the
Final Model of Multivariate Analysis of Risk Factors for Methicillin-resistant S. aureus (MRSA)
Compared to Methicillin-sensitive S. aureus Bacteremia, Stratified by IV Antibiotics............. 31
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