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Holland TL, Boucher HW, Raad I, Anderson DJ, Cosgrove SE, Aycock S, Baddley JW, Chow SC, Chu VH, Cook PP, Corey GR, Daly JS, Hachem RY, Chaftari AM, Horton JM, Jenkins TC, Gu J, Levine DP, Miro JM, Riska P, Rubin ZA, Rupp ME, Schrank J, Sims M, Wray D, Zervos MJ, Fowler V. Doing the Same with Less: A Randomized, Multinational, Open-Label, Adjudicator-Blinded Trial of an Algorithm vs. Standard of Care to Determine Treatment Duration for Staphylococcal Bacteremia. Open Forum Infect Dis 2017. [PMCID: PMC5632232 DOI: 10.1093/ofid/ofx162.072] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Background
The appropriate duration of antibiotics for staphylococcal bloodstream infection (BSI) is unknown. An algorithm to identify patients with staphylococcal BSI who can be safely treated with shorter courses of therapy would improve care and reduce total antibiotic use.
Methods
Adult patients with staphylococcal BSI were randomized to treatment based on algorithm-based therapy (ABT) or to standard of care (SOC). Co-primary outcomes were clinical success, as determined by a blinded Adjudication Committee, and serious adverse event (SAE) rates. The prespecified secondary outcome measure was antibiotic days by treatment group, among patients without complicated BSI. Prespecified durations of therapy in ABT were: S. aureus BSI (SAB): uncomplicated: 14 days; complicated: 4–6 weeks. Coagulase-negative staphylococci BSI (CoNSB): simple (1 positive blood culture) (0–3 days), uncomplicated (>1 positive blood culture) (5 days), complicated (7–28 days). Outcomes were compared using intention-to-treat principles. The target sample size was 500 patients, to ensure 90% power for establishing noninferiority within a margin of 15%.
Results
Between April 2011 and March 2017, 509 adults with suspected staphylococcal BSI at 16 sites in the US and Spain were randomized to ABT (N = 255) or SOC (N = 254). There were 116 patients with SAB (23%) and 385 (76%) with CoNSB (Figure 1). Overall success rate in the ABT group was 82.0% vs. 81.5% in the SOC group, difference 0.5%, 95% CI −5.2% to 6.1%. SAEs were reported in 32.9% of ABT vs. 28.3% of SOC patients (OR 1.2, 95% CI 0.9 to 1.8). Among evaluable patients without complicated BSI, mean duration of therapy was 4.4 days in the ABT group vs. 6.4 days in the SOC group (difference −2.0 days, 95% CI −3.3 to −-0.7, P = 0.003). Among patients with uncomplicated SAB, treatment durations were similar (15.3 days in ABT vs. 16.3 days in SOC, difference −1 day, 95% CI −3.89 to 1.91, P = 0.497), whereas for uncomplicated CoNSB, duration was shorter in the ABT group (5.3 days in ABT vs. 8.4 days in SOC, difference −3 days, 95% CI −4.87 to −1.34, P < 0.001).
Conclusion
The use of a treatment algorithm for staphylococcal BSI was associated with significant reductions in duration of antibiotic therapy in patients without complicated BSI, without significant differences in overall success or SAEs.
Disclosures
V. Fowler Jr., NIH: Investigator, Contract HHSN272200900023C
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Affiliation(s)
| | | | - Issam Raad
- Department of Infectious Diseases, Infection Control and Employee Health, The University of Texas M.D. Anderson Cancer Center, Houston, Texas
| | - Deverick J Anderson
- Division of Infectious Diseases, Duke University Medical Center, Durham, North Carolina
| | | | - Suzanne Aycock
- Duke Clinical Research Institute, Durham, North Carolina
| | - John W Baddley
- University of Alabama at Birmingham, Birmingham, Alabama
| | | | - Vivian H Chu
- Duke University Medical Center, Durham, North Carolina
| | - Paul P Cook
- Infectious Diseases, Brody School of Medicine at East Carolina University, Greenville, North Carolina
| | - G Ralph Corey
- Duke University Medical Center, Durham, North Carolina
| | - Jennifer S Daly
- University of Massachusetts Medical School, Worcester, Massachusetts
| | - Ray Y Hachem
- University of Texas MD Anderson Cancer Center, Houston, Texas
| | | | | | | | - Jiezhun Gu
- Duke Clinical Research Institute, Durham, North Carolina
| | | | - Jose M Miro
- Hospital Clinic-IDIBAPS, Barcelona, Spain
- Hospital Clínic-IDIBAPS. University of Barcelona, Barcelona, Spain
| | - Paul Riska
- Albert Einstein College of Medicine, Bronx, New York
| | - Zachary A Rubin
- David Geffen School of Medicine/University of California, Los Angeles, Los Angeles, California
| | - Mark E Rupp
- Internal Medicine, Division of Infectious Diseases, University of Nebraska Medical Center, Omaha, Nebraska
| | - John Schrank
- Greenville Health System, Greenville, South Carolina
| | | | - Dannah Wray
- Medical University of South Carolina, Charleston, South Carolina
| | | | - Vance Fowler
- Duke University Medical Center, Durham, North Carolina
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