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IDSA Emerging Infections Network

Report for ‘S. aureus and Community-Acquired Pneumonia’ Urgent Query

Overall response rate: 509/1086 (46.9%) physicians responded from 3/26/07 to 5/7/07.

• Six of these responses could not be linked with our member database but are included in the analyses below.

Not all respondents answered all questions, so totals for individual questions vary.

Responders as percent of overall members in each category:

Geographical division (state) of practice:

New England (CT, ME, MA, RI, VT): 50 (53% of 94 members)

Mid Atlantic (NJ, NY, PA): 80 (41% of 197 members)

ENC (IN, IL, MI, OH, WI): 64 (44% of 146 members)

WNC (IA, KS, MN, MO): 39 (53% of 74 members)

S Atlantic (DC, FL, GA, MD, NC, SC, VA, WV): 97 (45% of 217 members)

E S Central (AL, KY, MS, TN): 23 (47% of 49 members)

W S Central (LA, OK, TX): 35 (47% of 74 members)

Mountain (AZ, CO, NM, MT, UT, NV, WY): 25 (46% of 54 members)

Pacific (CA, OR, WA): 80 (50% of 160 members)

U.S. Territories 2 (29% of 7 members)

Canada (NS, ON) 8 (62% of 13 members)

Practice type: Academic institution 222 (55% of 403 members)

Private practice 151 (55% of 276 members)

Practice: Adult only 362 (46% of 793 members)

Pediatric only 110 (51% of 216 members)

Question 1. Cared for patients hospitalized with S. aureus CAP?

No 355 (70%)

Yes 154 (30%)

Number with SA CAP who: Mean (Std Dev), Range

a. were adults 3.1 (5.8), 0-40

b. were children 0.9 (1.7), 0-10

c. required mechanical ventilation 1.8 (3.0), 0-25

d. died 0.4 (1.2), 0-5

e. had suspected influenza 1.0 (2.9), 0-32

f. had lab-confirmed influenza 0.4 (1.1), 0-11

g. had S. aureus isolated from sputum 2.8 (4.3), 0-40

h. had S. aureus isolated from blood 1.6 (2.9), 0-20

i. had a methicillin-resistant isolate 2.5 (4.6), 0-37

j. (of i.) received empiric MRSA coverage 2.5 (5.0), 0-40

Permission was given by 113 individuals for CDC contact.

Cases of SA CAP were reported in every U.S. geographical division:

|Division |% of members reporting cases |Mean adult cases |Mean peds cases |

|New England |22.0 |1.7 |0 |

|Mid Atlantic |22.5 |2.4 |0.7 |

|ENC |21.9 |4.8 |1.3 |

|WNC |25.6 |1.4 |0.8 |

|S Atlantic |33.0 |2.0 |1.0 |

|E S Central |26.1 |1.2 |1.2 |

|W S Central |55.9 |4.6 |0.7 |

|Mountain |40.0 |2.4 |0.9 |

|Pacific |33.8 |3.4 |1.0 |

Question 2: Most common organism causing bacterial pneumonia in patients with influenza (answered by 379 individuals):

S. pneumoniae/presumed pneumococcus 194 (51%)

Haven’t seen any/much influenza and/or bacterial

pneumonia so can’t assess 78 (20%)

Unknown 59 (16%)

S. aureus / MRSA 32 (8%)

Other organisms (e.g., Klebsiella, group A strep) 8 (2%)

H. influenzae 3 (1%)

The organism above accounted for what proportion of cases?

165 members provided numeric responses:

Mean 52% (std deviation 25), range 1-100

135 members provided text responses:

Unknown or not sure 83 (61%)

Too few cases this year to say 20 (15%)

None, low or few 21 (15%)

About half 3 (2%) [2 pneumococcus, 1 MRSA]

Most or majority 4 (3%) [all pneumococcus]

All 5 (4%) [3 pneumococcus, 2 unknown]

Empiric MRSA coverage was provided for what proportion of cases?

150 members provided numeric responses:

Mean 54% (std deviation 33), range 0-100

162 members provided text responses:

Unknown (don’t track, didn’t see enough cases) 50 (31%)

None 49 (30%)

Few 23 (14%)

Most or majority 8 (5%)

All (some wrote ‘if severe’ or ‘if in ICU’) 32 (20%)

Question 3: Cared for patients hospitalized with ILI without bacterial pneumonia?

No 213 (50%)

Yes 214 (50%)

Number with SA CAP who: Mean (Std Dev), Range

a. were adults 4.0 (4.9), 0-40

b. were children 2.8 (6.9), 0-50

c. required mechanical ventilation 0.8 (1.4), 0-11

d. died 0.2 (0.5), 0-2

e. had lab-confirmed influenza 4.3 (9.2), 0-90

Question 4. Drug of choice for empiric therapy of MRSA CAP?

Vancomycin 311 (73%)

Linezolid 95 (22%)

Other 20 (5%)

Clindamycin 15

Doxycycline + vancomycin 1

Trimethoprim-sulfamethoxazole + rifampin 1

Doxycycline + vancomycin 1

Doxycycline or clindamycin 1

Comments about drug choice:

•16 members who specified vancomycin as their drug of choice also indicated ‘Other’: Clindamycin (5), minocycline or doxycycline (3), linezolid (3), clindamycin, trimethoprim-sulfamethoxazole (2), ceftriaxone + azithromycin (1), daptomycin (1), levofloxacin (1).

•3 members provided an algorithm: clindamycin - although if terribly ill, use vanco too (1), clindamycin unless critical, then vanco (1), if severe – vancomycin; if not severe – Septra (1).

Comments [Pediatric comments provided in blue]:

Choice of antimicrobial therapy

• When dosing linezolid for confirmed MRSA pneumonia, dose 600 IV q8h

• If not responding, then switch to linezolid; if very sick, then start with linezolid.

• We do not use linezolid for empiric Rx

• Could use either vanco or linezolid depending on host factors, prior therapy, etc.

• Evidence supports linezolid for pneumonia and if MRSA documented usually switch from vanco for efficacy as well as convenience (oral dosing)

• Given the capability of linezolid to reduce toxin production, this has been a reassuring aspect of using linezolid, particularly in cases where improvement has been slow on vancomycin

• High dose vanco has been useful in those intolerant of linezolid. I keep trough levels 20-25.

• I have been reluctant to start linezolid as empiric therapy but very often had to use it with impressive results and I am having second thoughts that it may be my first choice in MRSA suspected pulmonary infections as well as in pneumococci infections.

• Most CAP therapy is empiric. Vancomycin seems to be added more based on severity of illness than on any specific risk factors. Vancomycin is the empiric drug that we typically use for ?MRSA at any site. If the sputum gram stain or culture suggests SA in a patient with proven pneumonia, I would normally switch to linezolid, while acknowledging that there is no solid evidence favoring LZD over vanco in this specific setting.

• I switch to linezolid with confirmed MRSA pneumonia (by 5 members)

• Preference for linezolid when confirmed MRSA pneumonia unless reason to suspect endocarditis

• If MRSA and pt does not respond to vanco will change to linezolid - some in our group will start with linezolid but not all

• Linezolid may be used first depending on severity, still typically are starting with vanco

• Initially use vancomycin then switch to PO linezolid

• Use vanco or linezolid depending on potential Rx’s toxicities (renal, thrombocytopenia)

• Still use vancomycin as 1st line but convert to linezolid if slow to respond. Also move to CT to eval for necrosis/abscess if slow to respond.

• We have had linezolid resistance in 1-2 cases.

• We use "high dose" vancomycin as empiric coverage in patients at risk for S. aureus pneumonia and change to linezolid if MRSA is confirmed from the sputum and/or blood in a patient with clinical pneumonia.

• Our use of vanco or linezolid is attending [staff] dependent.

• We are still using vanco as our first line MRSA rx - I am wary of the side effects of linezolid, among other skepticisms.

• When I use vanco, I am always looking for trough levels that are > 20. I rarely see any significant non reversible renal impairment.

• Remains very uncommon in the Northeast. Nevertheless, I empirically add vanco in all severe CAPs.

• We prove the etiology of very few of our bacterial pneumonias in children. We therefore reserve therapy with vancomycin to the sicker kids, otherwise we are stuck with a lengthy parenteral therapy for children who may not need it.

• I would consider adding clindamycin for severe cases, due to concern regarding PVL-positive strains and the role of this toxin in CA-MRSA necrotizing pneumonia.

• If the patient is not particularly ill, we use clindamycin. If they are ill, bacteremic, require mechanical ventilation, we use vancomycin.

• If the patient is not exceptionally ill (and not bacteremic) and I know the isolate is clindamycin susceptible, I use it without vanc.

• Try to get 'D' test as soon as possible completed. 70+% of our MRSA with R erythromycin but S to clindamycin are 'D' test negative (no induced resistance). Much prefer using clindamycin for MRSA if possible.

• We may use clindamycin plus ceftriaxone for many pneumonias. We see a lot of CA-MRSA and some MSSA pleural empyema, cutaneous disease, etc.

• Commonly have septic pictures and we have used clinda or linezolid to inhibit protein synthetase

• The lack of support for doxycycline in the current IDSA CAP guidelines needs to be reexamined. In view of the toxicity and expense of linezolid, we need some more balanced research on the efficacy of second-line but non-proprietary drugs in MRSA pneumonia such as doxycycline and clindamycin. Unfortunately, there is no drug company to fund these. The emergence of CA-MRSA CAP is another reason we should be doing MRSA screening on all hospitalized patients

• We are using tigecycline offlabel at times when it is suspected. If supported by clinical studies, this will potentially allow for some consolidation of therapy.

• Clindamycin and TMP/SMX are very active against our USA 300 Staph, and both get high lung levels. Doxycycline also. Our standard CAP order sheet recommends ceftriaxone PLUS doxy (oral).

• Bactrim would be an alternative drug

• I always add Bactrim DS for proven MRSA pneumonia. I will not use linezolid until there is a prospective comparison with TMP-SMZ.

Clinical presentation

• All children had empyema and rapidly progressing pneumonia. This is a terrible disease.

• One pt had c/s confirmed primary influenza A pneumonia and expired. One child had CA-MRSA bacteremia with pneumonia & septic shock and died - reports were widely publicized.

• I have seen 2 cases this winter of severe pneumonia with parapneumonic effusions that I suspected group A strep

• I saw an adolescent with a personal and household member history of CA-MRSA furunculosis and rapidly progressive multilobar pneumonia. We suspected CA-MRSA and treated empirically with vancomycin but his blood cultures grew Strep pneumo.

• Most of our positive isolates are from empyemas, not sputum (kids don't cough it up) or blood. Surprising this year is that two of the empyemas were in big strapping healthy teenagers.

• We have had problems with long-term care patients with trachs, more so than immunocompetent children.

• We had 1 previously healthy adolescent girl who had influenza B diagnosed by rapid testing and viral culture. She had terrible pneumonia, neutropenia on presentation and Staph aureus in sputum, and died within a few days. She was empirically treated with vancomycin and tamiflu, among other agents. It is hard to say what role the S aureus played in her death. We had a second death from flu A in a girl who had encephalitis, liver insufficiency and pneumonia.

• We had a case of necrotizing pneumonia due to S. pneumoniae which was complicated by ventilator associated lung abscess with Klebsiella pneumoniae and MRSA recovered from pleural fluid (abscess ruptured into pleural space creating pyopneumothorax).

• We have had 2 documented MRSA CAP in adolescent patients within the previous 2-1/2 years. Both died despite early recognition of pathogen and treatment. Neither had antecedent ILI.

• Pts with CA-MRSA had much more aggressive disease, both clinically and intraoperatively

• Rapid deterioration (or rapid clinical onset) with pneumatocele or empyema, by 2 members

• Both required empyema drainage

• Both cases presented with cavitary pneumonia

• More likely to present with respiratory failure

• We have seen 3 cases of CA-MRSA pneumonia in the last couple years, all with cavitation, none associated with influenza and none as clinically severe as reported in literature.

• Especially severe, especially slow to respond to antibiotics

• Pneumatoceles, necrotizing, PVL+

• MRSA pneumonias (CAP) severe x2 with necrotizing dz in one.

• Should note that case above was IVDU with endocarditis with likely hematogenous pneumonia

• He came in with 3-4 days of fever and cough and proceeded to "crash" in short order. We were consulted after the sputum culture was back

• Impressed by one MRSA case who died after having been sent home on vanco. Came back in with bilateral severe pneumonia and died. MIC was ................
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