Yonsei Med J.  2005 Aug;46(4):496-502. 10.3349/ymj.2005.46.4.496.

A Comparison of Clinical Features and Mortality among Methicillin-Resistant and Methicillin-Sensitive Strains of Staphylococcus aureus Endocarditis

• Yoon HJ
• Choi JY
• Kim CO
• Kim JM
• Song YG

• KMID: 1716519
• DOI: http://doi.org/10.3349/ymj.2005.46.4.496

Abstract

Our objective was to assess the clinical factors that would reliably distinguish methicillin-resistant S. aureus (MRSA) from methicillin-susceptible S. aureus (MSSA) endocarditis. A retrospective cohort study of clinical features and mortality in patients with MRSA and MSSA endocarditis between March 1986 and March 2004 was performed in a 750-bed, tertiary care teaching hospital. A total of 32 patients (10 MRSA [31.3%] vs 22 MSSA [68.7%]) were evaluated. Their mean age and sex ratio (male/female) were as follows: 30.8 +/- 16.0 vs 24.4 +/- 19.6 years old and 6/4 vs 13/9, for MRSA and MSSA infective endocarditis (IE), respectively. Univariate and multivariate analyses revealed that persistent bacteremia was significantly more prevalent in MRSA IE (OR, 10.0 [1.480- 67.552]; p, 0.018). There was a higher mortality trend for MRSA IE (50.0%) than for MSSA IE (9.1%) (p=0.019). However, persistent bacteremia was not associated with higher mortality (p > 0.05). These results indicate that if persistent bacteremia is documented, the likelihood of MRSA endocarditis should be viewed as high, and the patient's anti- staphylococcal therapy should be prolonged and/or changed to a more "potent" regimen.

Keyword

Staphylococcus aureus; bacteremia; endocarditis

MeSH Terms

Adult
Bacteremia/drug therapy/microbiology
Cohort Studies
Comparative Study
Endocarditis, Bacterial/drug therapy/*microbiology
Female
Humans
Male
*Methicillin Resistance
Middle Aged
Retrospective Studies
Staphylococcal Infections/drug therapy/*microbiology
Staphylococcus aureus/*drug effects

Reference

1. Nissen H, Nielsen PF, Frederiksen M, Helleberg C, Nielsen JS. Native valve infective endocarditis in the general population: a 10-year survey of the clinical picture during the 1980s. Eur Heart J. 1992; 13:872–877. PMID: 1644074.

2. Netzer ROM, Zollinger E, Seiler C, Cerny A. Infective endocarditis: Clinical spectrum, presentation and outcome: an analysis of 212 cases 1980-1995. Heart. 2000; 84:25–30. PMID: 10862581.

3. Sanabria TJ, Alpert JS, Goldberg R, Pape LA, Cheeseman SH. Increasing frequency of staphylococcal infective endocarditis: experience at a university hospital. Arch Intern Med. 1990; 150:1305–1309. PMID: 2353863.

4. Manford M, Matharu J, Farrington K. Infective endocarditis in a district general hospital. J R Soc Med. 1992; 85:262–266. PMID: 1433086.

5. Skehan JD, Murray M, Mills PG. Infective endocarditis: incidence and mortality in the north east Thames region. Br Heart J. 1988; 59:62–68. PMID: 3342151.

6. Cho BC, Lee JH, Park JW, Hong CS, Kim JM, Kang SM, et al. Subacute bacterial endocarditis associated with upper endoscopy. Yonsei Med J. 2004; 45:936–940. PMID: 15515208.

7. Chong Y, Lim HS, Lee SY, Cho SY. Lactobacillus casei subspecies casei endocarditis - a case report. Yonsei Med J. 1991; 32:69–73. PMID: 1908610.

8. Chong Y, Yoon KJ, Lee SY, Chung NS. Erysipelothrix rhusiopathiae endocarditis - a case report. Yonsei Med J. 1986; 27:239–243. PMID: 3798967.

9. Chong Y, Kim TS, Lee SY, Shim WH, Choo BK. Cardiobacterium hominis endocarditis - a case report. Yonsei Med J. 1985; 26:78–81. PMID: 4072271.

10. Chong Y, Lee KW, Lee SY, Cho SY. Isolation of Actinobacillus actinomycetemcomitans from the blood of a patient with subacute bacterial endocarditis. Yonsei Med J. 1983; 24:54–58. PMID: 6659555.

11. Chong Y, Song KS, Lee SY. Neisseria subflava infections-bacteriological aspects of two cases. Yonsei Med J. 1975; 16:44–49. PMID: 1224640.

12. Chung Y, Lee SY. Vibrio fetus human infection-isolation from a subacute bacterial endocar-ditis case. Yonsei Med J. 1970; 11:126–130. PMID: 5526468.

13. Weinstein MP, Towns ML, Quartey SM, Mirrett S, Reimer LG, Parmigiani G, et al. The clinical significance of positive blood cultures in the 1990s: a prospective comprehensive evaluation of the microbiology, epidemiology, and outcome of bacteremia and fungemia in adults. Clin Infect Dis. 1997; 24:584–602. PMID: 9145732.

14. Mylotte JM, McDermott C, Spooner JA. Prospective study of 114 consecutive episodes of Staphylococcus aureus bacteremia. Rev Infect Dis. 1987; 9:891–907. PMID: 3317734.

15. Soriano A, Martinez JA, Mensa J, Marco F, Almela M, Moreno-Martinez A, et al. Pathogenic significance of methicillin resistance for patients with Staphylococcus aureus bacteremia. Clin Infect Dis. 2000; 30:368–373. PMID: 10671343.

16. Steinberg JP, Clark CC, Hackman BO. Nosocomial and community-acquired Staphylococcus aureus bacteremias from 1980 to 1993: impact of intravascular devices and methicillin resistance. Clin Infect Dis. 1996; 23:255–259. PMID: 8842259.

17. Darouiche RO, Musher DM. Editorial response: increasing rates of Staphylococcus aureus bacteremia - a medical device is a merit in disguise and methicillin resistance is merely a vice. Clin Infect Dis. 1996; 23:260–261. PMID: 8842260.

18. Romero-Vivas J, Rubio M, Fernandez C, Picazo JJ. Mortality associated with nosocomial bacteremia due to methicillin-resistant Staphylococcus aureus. Clin Infect Dis. 1995; 21:1417–1423. PMID: 8749626.

19. Li JS, Sexton DJ, Mick N, Nettles R, Fowler VG, Ryan T, et al. Proposed modifications to the Duke criteria for the diagnosis of infective endocarditis. Clin Infect Dis. 2000; 30:633–638. PMID: 10770721.

20. National Committee for Clinical Laboratory Standards (NCCLS). NCCLS document M100-S12:22:1. Performance standards for antimicrobial susceptibility testing: 12th international supplement. 2002. Wayne PA: NCCLS.

21. Benn M, Hagelskjaer LH, Tvede M. Infective endocarditis, 1984 through 1993: a clinical and microbiological survey. J Intern Med. 1997; 242:15–22. PMID: 9260562.

22. Espersen F, Frimodt-Moller N. Staphylococcus aureus endocarditis. A review of 119 cases. Arch Intern Med. 1986; 146:1118–1121. PMID: 3718098.

23. Hecht SR, Berger M. Right-sided endocarditis in intravenous drug users: prognostic features in 102 episodes. Ann Intern Med. 1992; 117:560–566. PMID: 1524330.

24. Manolis AS, Melita H. Echocardiographic and clinical correlates in drug addicts with infective endocarditis. Implications in vegetation size. Arch Intern Med. 1988; 148:2461–2465. PMID: 3190378.

25. Watanakunakorn C. Staphylococcus aureus endocarditis at a community teaching hospital, 1980 to 1991. An analysis of 106 cases. Arch Intern Med. 1994; 154:2330–2335. PMID: 7944855.

26. Watanakunakorn C, Burkert T. Infective endocarditis at a large community teaching hospital, 1980-1990. A review of 210 episodes. Medicine. 1993; 72:90–102. PMID: 8479327.

27. Cabell CH, Jollis JG, Peterson GE, Corey GR, Anderson DJ, Sexton DJ, et al. Changing patient characteristics and the effect on mortality in endocarditis. Arch Intern Med. 2002; 162:90–94. PMID: 11784225.

28. Nakatani S, Mitsutake K, Hozumi T, Yoshikawa J, Akiyama M, Yoshida K, et al. Current characteristics of infective endocarditis in Japan: an analysis of 848 cases in 2000 and 2001. Circ J. 2003; 67:901–905. PMID: 14578594.

29. Chang FY, MacDonald BB, Peacock JE Jr, Musher DM, Triplett P, Mylotte JM, et al. A prospective multicenter study of Staphylococcus aureus bacteremia: incidence of endocarditis, risk factors for mortality, and clinical impact of methicillin resistance. Medicine. 2003; 82:322–332. PMID: 14530781.

30. Chang FY. Staphylococcus aureus bacteremia and endocarditis. J Microbiol Immunol Infect. 2000; 33:63–68. PMID: 10917874.

31. Peacock JE, Moorman D, Wenzel RP, Mandell GL. Methicillin-resistant Staphylococcus aureus: microbiological virulence of an epidemiologic strain. J Infect Dis. 1981; 144:575–582. PMID: 6977003.

32. Cutler RR. Relationship between antibiotic resistance, the production of "virulence factors" and virulence for experimental animals in Staphylococcus aureus. J Med Microbial. 1979; 12:55–62.

33. French GL, Cheng AF, Ling JM, Mo P, Donnan S. Hong Kong strains of methicillin-resistant and methicillin-sensitive Staphylococcus aureus have similar virulence. J Hosp Infect. 1990; 15:117–125. PMID: 1969433.

34. Rello J, Torres A, Ricart M, Valles J, Gonzalez J, Artigas A, et al. Ventilator-associated pneumonia by Staphylococcus aureus: comparison of methicillin-resistant and methicillin-sensitive episodes. Am J Respir Crit Care Med. 1994; 150:1545–1549. PMID: 7952612.

35. Mekontso-Dessap A, Kirsch M, Brun-Buisson C, Loisance D. Poststernotomy mediastinitis due to Staphylococcus aureus: comparison of methicillin-resistant and methicillin-susceptible cases. Clin Infect Dis. 2001; 32:877–883. PMID: 11247711.

36. Blot SI, Vandewoude KH, Hoste EA, Colardyn FA. Outcome and attributable mortality in critically ill patients with bacteremia involving methicillin-susceptible and methicillin-resistant Staphylococcus aureus. Arch Intern Med. 2002; 162:2229–2235. PMID: 12390067.

37. Talon D, Woronoff-Lemsi MC, Limat S, Bertrand X, Chatillon M, Gil H, et al. The impact of resistance to methicillin in Staphylococcus aureus bacteremia on mortality. Eur J Intern Med. 2002; 13:31–36. PMID: 11836080.

38. Conterno LO, Wey SB, Castelo A. Risk factors for mortality in Staphylococcus aureus bacteremia. Infect Control Hosp Epidemiol. 1998; 19:32–37. PMID: 9475347.

39. Ibelings MM, Bruining HA. Methicillin-resistant Staphylococcus aureus: acquisition and risk of death in patients in the intensive care unit. Eur J Surg. 1998; 164:411–418. PMID: 9696441.

40. Engemann JJ, Carmeli Y, Cosgrove SE, Fowler VG, Bronstein MZ, Trivette SL, et al. Adverse clinical and economic outcomes attributable to methicillin resistance among patients with Staphylococcus aureus surgical site infection. Clin Infect Dis. 2003; 36:592–598. PMID: 12594640.

41. Cheng AF, French GL. Methicillin-resistant Staphylococcus aureus bacteremia in Hong Kong. J Hosp Infect. 1988; 12:91–101. PMID: 2905726.

42. Topeli A, Unal S, Akalin HE. Risk factors influencing clinical outcome in Staphylococcus aureus bacteremia in a Tukish University Hospital. Int J Antimicrob Agents. 2000; 14:57–63. PMID: 10717502.

43. Cosgrove SE, Sakoulas G, Perencevich EN, Schwaber MJ, Karchmer AW, Carmeli Y. Comparison of mortality associated with methicillin-resistant and methicillin-susceptible Staphylococcus aureus bacteremia: a metaanalysis. Clin Infect Dis. 2003; 36:53–59. PMID: 12491202.

44. Harbarth S, Rutschmann O, Sudre P, Pittet D. Impact of methicillin resistance on the outcome of patients with bacteremia caused by Staphylococcus aureus. Arch Intern Med. 1998; 158:182–189. PMID: 9448557.

45. Tumbarello M, De Gaetano Donati K, Tacconelli E, Citton R, Spanu T, Leone F, et al. Risk factors and predictors of mortality of methicillin-resistant Staphylococcus aureus (MRSA) bacteraemia in HIV-infected patients. J Antimicrob Chemother. 2002; 50:375–382. PMID: 12205062.

46. Roghmann MC. Predicting methicillin resistance and the effect of inadequate empiric therapy on survival in patients with Staphylococcus aureus bacteremia. Arch Intern Med. 2000; 160:1001–1004. PMID: 10761966.

47. Mylotte JM, Tayara A. Staphylococcus aureus bacteremia: predictors of 30-day mortality in a large cohort. Clin Infect Dis. 2000; 31:1170–1174. PMID: 11073748.

48. Lewis E, Saravolatz LD. Comparison of methicillin-resistant and methicillin-sensitive Staphylococcus aureus bacteremia. Am J Infect Control. 1985; 13:109–114. PMID: 3849269.

49. Hershow RC, Khayr WF, Smith NL. A comparison of clinical virulence of nosocomially acquired methicillin-resistant and methicillin-sensitive Staphylococcus aureus infections in a university hospital. Infect Control Hosp Epidemiol. 1992; 13:587–593. PMID: 1469267.

50. Mylotte JM, Aeschlimann JR, Rotella DL. Staphylococcus aureus bacteremia: factors predicting hospital mortality. Infect Control Hosp Epidemiol. 1996; 17:165–168. PMID: 8708354.

51. Marty L, Flahault A, Suarez B, Caillon J, Hill C, Andremont A. Resistance to methicillin and virulence of Staphylococcus aureus strains in bacteremic cancer patients. Intensive Care Med. 1993; 19:285–289. PMID: 8408938.

52. Selvey LA, Whitby M, Johnson B. Nosocomial methicillin-resistant Staphylococcus aureus bacteremia: is it any worse than nosocomial methicillin-sensitive Staphylococcus aureus bacteremia? Infect Control Hosp Epidemiol. 2000; 21:645–648. PMID: 11083180.

53. Markowitz N, Quinn EL, Saravolatz LD. Trimethoprim-sulfamethoxazole compared with vancomycin for the treatment of Staphylococcus aureus infection. Ann Intern Med. 1992; 117:390–398. PMID: 1503330.

54. Mizushima Y, Kawasaki A, Hirata H, Daimon Y, Oosaki R, Morinaga S, et al. An analysis of bacteremia in a university hospital in Japan over a 10-year period. J Hosp Infect. 1994; 28:285–298. PMID: 7963471.

55. Pujol M, Pena C, Pallares R, Ayats J, Ariza J, Gudiol F. Risk factors for nosocomial bacteremia due to methicillin-resistant Staphylococcus aureus. Eur J Clin Microbiol Infect Dis. 1994; 13:96–102. PMID: 8168571.

56. Garner JS, Jarvis WR, Emori TG, Horan TC, Hughes JM. CDC definitions for nosocomial infections. Am J Infect Control. 1988; 16:128–140. PMID: 2841893.

57. Lesens O, Hansmann Y, Brannigan E, Remy V, Hopkins S, Martinot M, et al. Positive surveillance blood culture is a predictive factor for secondary metastatic infection in patients with Staphylococcus aureus bacteraemia. J Infect. 2004; 48:245–252. PMID: 15001303.

58. Levine DP, Fromm BS, Reddy BR. Slow response to vancomycin or vancomycin plus rifampin in methicillin-resistant Staphylococcus aureus endocarditis. Ann Intern Med. 1991; 115:674–680. PMID: 1929035.

59. Dworkin RJ, Lee BL, Sande MA, Chambers HF. Treatment of right-sided Staphylococcus aureus endocarditis in intravenous drug users with ciprofloxacin and rifampicin. Lancet. 1989; 2:1071–1073. PMID: 2572799.

60. Chang FY, Turnidge J. Yu VL, Merigan TC, Barriere S, editors. Staphylococcus aureus. Antimicrobial chemotherapy and vaccines. 1999. 1st ed. Baltimore: Williams & Wilkins;p. 389–404.

61. Mortara LA, Bayer AS. Staphylococcus aureus bacteremia and endocarditis. Infect Dis Clin North Am. 1993; 7:53–68. PMID: 8463653.