Background Vancomycin dosing strategies targeting trough concentrations of 15–20 mg/L are no longer supported due to lack of efficacy evidence and increased risk of nephrotoxicity. Area-under-the-curve (AUC24) nomograms have demonstrated adequate attainment of AUC24 goals ≥ 400 mg h/L with more conservative troughs (10–15 mg/L). Objective The purpose of this study is to clinically validate a vancomycin AUC24 dosing nomogram compared to conventional dosing methods with regards to therapeutic failure and rates of acute kidney injury. Setting This study was conducted at a tertiary, community, teaching hospital in the United States. Method This retrospective, cohort study compared the rates of therapeutic failures between AUC24-extrapolated dosing and conventional dosing methods. Main outcome measure Primary outcome was treatment failure, defined as all-cause mortality within 30 days, persistent positive methicillin-resistant Staphylococcus aureus blood culture, or clinical failure. Rates of acute kidney injury in non-dialysis patients was a secondary endpoint. Results There were 96 participants in the extrapolated-AUC24 cohort and 60 participants in the conventional cohort. Baseline characteristics were similar between cohorts. Failure rates were 11.5% (11/96) in the extrapolated-AUC24 group compared to 18.3% (11/60) in the conventional group (p = 0.245). Reasons for failure were 6 deaths and 5 clinical failures in the extrapolated-AUC24 cohort and 10 deaths and 1 clinical failure in the conventional group. Acute kidney injury rates were 2.7% (2/73) and 16.4% (9/55) in the extrapolated-AUC24 and conventional cohorts, respectively (p = 0.009). Conclusion Extrapolated-AUC24 dosing was associated with less nephrotoxicity without an increase in treatment failures for bloodstream infections compared to conventional dosing. Further investigation is warranted to determine the relationship between extrapolated-AUC24 dosing and clinical failures.

Since 1999, Methicillin-resistant Staphylococcus aureus (MRSA) outbreaks have occurred in many correctional facilities. Even after the Federal Bureau of Prisons developed clinical practice guidelines on the management of MRSA within correctional facilities, the prevalence of MRSA decreased only insignificantly. Other researchers suggested infection control compliance was equally as important as developing clinical practice guidelines in reducing the incidence of MRSA. Several studies identified the healthcare professionals' nonadherence and inconsistencies to clinical practice guidelines as contributors to MRSA transmission. Accordingly, this project was designed to develop evidence-based recommendations for improving nurse professionals' adherence to MRSA practice guidelines in correctional settings. Using the health belief model as the theoretical framework, this project examined the nurse professionals' perceptions as well as their level of knowledge regarding MRSA by using an original instrument, Knowledge and Health Beliefs Regarding MRSA Questionnaire. The study employed a quantitative design with a purposeful sample of 36 participants using social media. Through descriptive statistical analysis, it was determined that MRSA training and education were the greatest barriers among the nurse professionals in taking MRSA preventive action (64%, n = 23). Based on the findings, assessing the educational needs of the nurse professionals must become the priority when designing infection control programs. This study contributes to social change by recognizing the potential health impact of MRSA and cautions that if public health officials do not control MRSA within correctional settings, such behavior can affect the transmission of MRSA both nationally and globally.

Methicillin-resistenta Staphylococcus aureus (MRSA) har blivit en allt vanligare patogen inom sjukvården och i samhället. MRSA orsakar infektioner som inte kan behandlas med β-laktamantibiotika. För att förhindra spridning genomgår patienter och sjukvårdspersonal screening-tester. I dessa screening-tester ingår PCR-analys av mecA, nuc och/eller Sa442. MecA är lokaliserad på Staphylococcal Cromosomal Cassette mec (SCCmec) och används som en markör för MRSA medan nuc och Sa442 anger S. aureus. PCR-positiva isolat odlas ut på agarplattor efter anrikning i en selektiv buljong. Kolonier av S. aureus resistensbestäms mot cefoxitin som MRSA är resistent mot. Idag används dock PCR-analys av mecA som en referensmetod för diagnostisering av MRSA. Under det senaste årtiondet har även rapporterats fynd av stammar som enligt resistensmönster är MRSA men som har utfallit negativt för mecA i PCR. Under 2011 rapporterades en ny variant av SCCmec och en ny variant av mecA, mecALGA251. I denna studie har en realtids-PCR tagits fram för att identifiera den nya varianten, mecALGA251. Denna PCR användes för att undersöka 43 kliniska isolat, fyra cefoxitin-känsliga S. aureus från rutinen och tre referensstammar. De kliniska isolaten hade samlats in under perioden 2004 – 2011 och hade uppvisat cefoxitin-resistens men gett negativt resultat i mecA-PCR. Totalt 40 av de 43 cefoxitin-resistenta kliniska isolaten visades bära mecALGA251. Resistensbestämningar med diskdiffusion och E-test mot cefoxitin, oxacillin, cefuroxim och cefotaxim visade att denna typ av MRSA inte kan skiljas från klassisk MRSA. Resultaten visar att cefoxitin-resistenta S. aureus isolat som bär mecALGA251 finns bland skånska patienter. De visar också att det finns cefoxitin-resistent S. aureus som saknar både klassiska mecA och mecALGA251. Dessa stammar har inte studerats vidare i denna studie. / Methicillin-resistant Staphylococcus aure s (MRSA) has become a more frequent pathogen within health care facilities and the community. MRSA causes infections that can’t be treated with β-lactamantibiotics. To prevent the spread of MRSA, patients and medical personnel undergo screening-tests. In the screening-tests PCR-analysis of mecA, nuc and/or Sa442 is included. MecA is located at Staphylococcal Chromosomal Cassette mec (SCCmec) and is a marker for MRSA, whereas nuc and Sa442 state regular S. Aureus infections. PCR-positive isolates are grown on agar plates after enrichment in selective broth. Colonies of S. aureus are tested for cefoxitin susceptibility to which MRSA is resistant. PCR-analysis of mecA is the reference method that is being used today when MRSA is being diagnosed. During the last decade cefoxitin-resistant strains that lack mecA in the PCR has been reported. In 2011 a new variant of SCCmec and a new variant of mecA, mecALGA251 was reported. In this study a new real-time-PCR has been developed in order to identify mecALGA251. The new PCR protocol was being used to examine 43 clinical isolates, four cefoxitin-susceptible S. aureus from the routine and three reference strains were examined. The clinical isolates had been collected during the period 2004-2011 and were cefoxitin-resistant but lacked mecA. In total of 40 of the 43 cefoxitin-resistant was PCR positive for mecALGA251. Susceptibility testing with disk diffusion and E-test for cefoxitin, oxacillin, cefuroxime and cefotaxime showed that this type of MRSA can’t be distinguished from regular MRSA. The results showed that cefoxitin-resistantS. aureus isolates carrying mecALGA251 exist among patients in Skåne County. One cefoxitin-resistant S. aureus isolate lacked both classic mecA and mecALGA251, which indicates that other mechanisms may exist, however these results has not been further analysed in this study.

Background Vancomycin dosing strategies targeting trough concentrations of 15–20 mg/L are no longer supported due to lack of efficacy evidence and increased risk of nephrotoxicity. Area-under-the-curve (AUC24) nomograms have demonstrated adequate attainment of AUC24 goals ≥ 400 mg h/L with more conservative troughs (10–15 mg/L). Objective The purpose of this study is to clinically validate a vancomycin AUC24 dosing nomogram compared to conventional dosing methods with regards to therapeutic failure and rates of acute kidney injury. Setting This study was conducted at a tertiary, community, teaching hospital in the United States. Method This retrospective, cohort study compared the rates of therapeutic failures between AUC24-extrapolated dosing and conventional dosing methods. Main outcome measure Primary outcome was treatment failure, defined as all-cause mortality within 30 days, persistent positive methicillin-resistant Staphylococcus aureus blood culture, or clinical failure. Rates of acute kidney injury in non-dialysis patients was a secondary endpoint. Results There were 96 participants in the extrapolated-AUC24 cohort and 60 participants in the conventional cohort. Baseline characteristics were similar between cohorts. Failure rates were 11.5% (11/96) in the extrapolated-AUC24 group compared to 18.3% (11/60) in the conventional group (p = 0.245). Reasons for failure were 6 deaths and 5 clinical failures in the extrapolated-AUC24 cohort and 10 deaths and 1 clinical failure in the conventional group. Acute kidney injury rates were 2.7% (2/73) and 16.4% (9/55) in the extrapolated-AUC24 and conventional cohorts, respectively (p = 0.009). Conclusion Extrapolated-AUC24 dosing was associated with less nephrotoxicity without an increase in treatment failures for bloodstream infections compared to conventional dosing. Further investigation is warranted to determine the relationship between extrapolated-AUC24 dosing and clinical failures.

BACKGROUND: Evidence supporting beta-lactam plus vancomycin synergy for methicillin-resistant (MRSA) continues to grow. Current evidence demonstrates that combination therapy is associated with shorter time to blood sterilization than vancomycin monotherapy. However, this combination has not been reported as salvage therapy for persistent MRSA bacteremia. CASE REPORT: We report a case of an 81-year-old male who was successfully treated with vancomycin plus nafcillin after failing vancomycin monotherapy, daptomycin monotherapy, and daptomycin plus gentamicin combination therapy. The patient originally presented with sepsis from a suspected urinary tract infection. Blood cultures drawn on days 1, 3, 5, 15, 19, 23, and 28 remained positive for MRSA despite multiple antimicrobial therapy changes. On day 29, therapy was changed to vancomycin plus nafcillin. Blood cultures drawn on day 32 remained negative. After 11 days, nafcillin was changed to piperacillin-tazobactam due to an infected decubitus ulcer. The combination was continued for 42 days after achieving blood sterility, 71 days after the patient originally presented. Evidence regarding salvage therapy for persistent bacteremia is sparse and is limited to case reports and case series. CONCLUSION: This case report supports that vancomycin plus an anti-staphylococcal beta-lactam combination should be further studied as salvage therapy for persistent MRSA bacteremia.

Methicillin Resistant Staphylococcus Aureus (MRSA) has been receiving significant attention, highlighting an increased risk of infectious transmission associated with athletic participation. As MRSA infections are becoming increasing virulent, athletic trainers are presented with immediate prevention challenges. While recommendations have been offered by the Centers for Disease Control and Prevention outlining basic prevention procedures, adherence to proposed guidelines and actual perception of the threat still pose the greatest hurdles to eradication of MRSA. Success in control and prevention of transmission of MRSA in athletic environments can be furthered by first investigating the perceptions of the problem in one of the first line of defense for athletes—their athletic trainers. Of particular importance are the perceptions of trainers' adherence to guidelines, perceptions of protocol standards, and relative threat of MRSA in the athletic environment. This study attempts to determine these perceptions and predict how athletic trainers will receive and adhere to standardized guidelines through written policy for MRSA prevention. Results reflect an increase in the awareness of MRSA as a threat to athletics since 2004. Overall positive perception of the development of guidelines and protocols specifically targeted to prevention of MRSA transmission in the athletic environment were also defined through this study. Athletic trainers surveyed expressed strong desire for additional training in procedures specific to reducing transmission of MRSA to prevent outbreaks. / Ph. D.

Methicillin-resistant Staphylococcus aureus (MRSA) is a serious public health problem nationwide, threatening to develop into an epidemic. Many of these patients are presenting to their primary care clinics with skin and soft tissue infections (SSTIs). The CDC has reported that in 2005, MRSA was responsible for an estimated 94,000 life-threatening infections and 16,650 deaths. The purpose of this study is to estimate the incidence of CA-MRSA within a specific family practice in Florida and to identify epidemiologic factors, classify antibiotic susceptibility patterns, and evaluate patient education in regard to disease management and prevention. This study was a descriptive, epidemiologic, three-year retrospective medical record review of all wound cultured skin and soft tissue infections that presented to a family practice between January 2007 and December 2009. Sixty-two medical records met the inclusion and exclusion criteria for the study. Of these 62 SSTIs, 44 cultures grew one or more bacterial organisms. The incidence of CA-MRSA was 66% (n=29). The mean age of those with CA-MRSA was 40 years old, with a range from 7 to 90 years old. Sixty-two percent (n=18) were male and 38% (n=11) were female; additionally 69% (n=20) lived within a 10 mile radius from the family practice, while 31% (n=9) lived in a surrounding suburb. The most frequent race was Caucasian 83% (n=24), with African American at 10% (n=3) and Hispanics 7% (n=2). Risk factors associated with CA-MRSA was obesity 41% (n=10), diabetes mellitus 24% (n=7), and a previous history of MRSA infection 24% (n=7). Skin and soft tissue infections were diagnosed as either an abscess 62% (n=18), boil 24% (n=7), pustule 10% (n=3), or cellulitis 4% (n=1). CA-MRSA isolates were susceptible to trimethoprim-sulfamethoxazole 100% (n=29), doxycycline 93% (n=27), and rifampin 100% (n=14). Clindamycin susceptibility was 65% (n=15) with resistance at 30% (n=7) and 5% (n=1) intermediate. Both cephalexin and erythromycin were 100% resistant. Documentation in the medical record on wound care was found in 45% (n=13) of the records. The incidence of CA-MRSA SSTI was 66%, which identifies this suburban community at high risk for this bacterial infection. Risk factors associated with CA-MRSA included obesity (BMI > 30), history of previous MRSA infection, and diabetes mellitus. There were no clinical characteristics that helped distinguish MRSA infection from other bacterial SSTIs. Most SSTI were treated with incision and drainage and a susceptible antibiotic. Judicious use of antibiotics not only provides appropriate treatment, but is also critical in prevention of antibiotic resistance. Lastly, patient education in adequate hygiene is essential in preventing the spread of CA-MRSA

No description available.

Quaternary ammonium compounds (QACs) have long served as lead disinfectants in residential, industrial, and hospital settings. Their simple yet effective amphiphilic nature makes them an ideal class of compounds through which to explore antibacterial activity. We have developed novel multiQAC scaffolds through simple and cost-efficient syntheses, yielding hundreds of diverse compounds strategically designed to examine various aspects of antibacterial and anti-biofilm activity, as well as toxicity. Many of these bis-, tris-, and tetraQACs display antibacterial activity 10 to 100 times greater than conventional monoQACs, and are among the most potent biofilm eradicators to date. Through analyzing their activity against several strains, we have uncovered and provided further evidence for key tenets of amphiphilic QAC bioactivity: a balance of hydrophobic side chains with cationic head groups generates optimal antibacterial activity, though toxicity to eukaryotic cells needs to be mitigated. Given their ubiquitous nature and chemical robustness, the overuse of QACs has led to the development of QAC resistance genes that are spreading throughout the microbial world at an alarming rate. These resistant strains, when found in bacterial biofilms, are able to persist in the presence of lead commercial QAC disinfectants, warranting the development of next-generation biocides. Several of our scaffolds were designed with QAC resistance machinery in mind; thus, we utilized these compounds not only as antibacterial agents but also as chemical probes to better understand and characterize QAC-resistance in methicillin-resistant Staphylococcus aureus (MRSA). Our findings support previous postulations that triscationic QACs would retain potency against QAC-resistant strains. Furthermore, we have identified monocationic and aromatic moieties, as well as conformational rigidity, as being more prone to recognition by the resistance machinery. Using our chemical toolbox comprised of QACs of various charge state and scaffold, we explored both the mechanism and scope of QAC-resistance by examining their structure-resistance relationship. Our holistic findings have allowed us to better understand the dynamics of this system towards the design and development of next-generation QACs that will: (1) allow us to better probe the resistance machinery, and (2) remain efficacious against a variety of microbial pathogens. / Chemistry

ABSTRACT Few antibiotics are left that are effective against methicillin-resistant Staphylococcus aureus (MRSA) and even strains resistant to these agents have been isolated. Previous studies have identified five distinct MRSA clonotypes, which are present globally. No comprehensive national study has previously been undertaken to investigate the MRSA types in South Africa, and this study was aimed at elucidating the genotypic population structure of South African MRSA isolates. SmaI digested genomic DNA, separated by pulsed-field gel electrophoresis, was used to characterise 349 S. aureus isolates, obtained from various state and private diagnostic laboratories. PFGE results were complemented with those of spa typing and staphylococcal cassette chromosome mec (SCCmec) typing results. Two-hundred-and-five different PFGE patterns were identified, which were grouped into twenty-four clusters. Three were major lineages, containing more than 20% of the isolates with a similarity cut-off of 70%. Only thirty-seven spa types were identified (fourteen novel spa types), which clustered into six spa-Clonal Complexes after BURP analysis. SCCmec types I-IV were identified, including variants of each type. Data suggest that the Archaic clone (RSA05), oldest of the epidemic clones, represents one of the major clones in South Africa. Strains that were part of this complex (n=98 (28.2%); t064; SCCmec type I-pls) clustered together with strain E2125/ATCC BAA-38 (t051; SCCmec type I). Another major complex, RSA16 (n=90 (25.7%); t012; SCCmec type II/IIB) possessed a single-locus variant (SLV) spa type and the same or a SLV SCCmec types as EMRSA-16 (t018; SCCmec type II). The third major complex, RSA03 (n=74 (21.2%); t037; SCCmec type III/IIIE), had similar spa and SCCmec types to control strainANS46 (t037; SCCmec type III). One MRSA and twelve MSSA isolates were also identified as carrying genes for the toxin Panton-Valentine leukocidin, which was confirmed by DNA nucleotide sequencing.