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Nasal methicillin-resistant Staphylococcus aureus screening in patients with pneumonia: A powerful antimicrobial stewardship tool

Published:August 22, 2017DOI:https://doi.org/10.1016/j.ajic.2017.06.032
      The Infectious Diseases Society of America (IDSA) and American Thoracic Society (ATS) treatment guidelines for patients with hospital-acquired pneumonia (HAP) and ventilator-associated pneumonia (VAP) were recently updated.
      • Kalil A.C.
      • Metersky M.L.
      • Klompas M.
      • Muscedere J.
      • Sweeney D.A.
      • Palmer L.B.
      • et al.
      Management of adults with hospital-acquired and ventilator-associated pneumonia: 2016 Clinical Practice Guidelines by the Infectious Diseases Society of America and the American Thoracic Society.
      Notably, the revised guidelines, citing a lack of evidence, do not endorse the use of nasal surveillance swabs for methicillin-resistant Staphylococcus aureus (MRSA) to guide de-escalation of empirical antimicrobials in patients with HAP and VAP. As antimicrobial stewardship and infectious diseases clinicians, one of the most challenging aspects we face in caring for such patients is de-escalation of empirical antimicrobial therapy in the absence of definitive culture data, particularly in the patient with marked clinical improvement. Although there has been widespread acceptance of shorter durations of antimicrobial therapy for HAP and VAP, the risks and benefits of continuing empirical broad-spectrum antimicrobials, including coverage for MRSA, for the entire course of therapy have not been fully evaluated.
      • Kalil A.C.
      • Metersky M.L.
      • Klompas M.
      • Muscedere J.
      • Sweeney D.A.
      • Palmer L.B.
      • et al.
      Management of adults with hospital-acquired and ventilator-associated pneumonia: 2016 Clinical Practice Guidelines by the Infectious Diseases Society of America and the American Thoracic Society.
      • Chastre J.
      • Wolff M.
      • Fagon J.
      • Chevret S.
      • Thomas F.
      • Wermert D.
      • et al.
      Comparison of 8 vs 15 days of antibiotic therapy for ventilator-associated pneumonia in adults.
      The report by Sarikonda et al that is referenced within the IDSA and ATS guideline suggests nasal MRSA colonization is a poor predictor of MRSA lower respiratory tract infections (LRTIs); however, it is important to note the prevalence of MRSA LRTI was high (16%) in this population, likely contributing to the relatively low 84.6% negative predictive value (NPV).
      • Sarikonda K.V.
      • Micek S.T.
      • Doherty J.A.
      • Reichley R.M.
      • Warren D.
      • Kollef M.H.
      Methicillin-resistant Staphylococcus aureus nasal colonization is a poor predictor of intensive care unit-acquired, methicillin-resistant Staphylococcus aureus infections requiring antibiotic treatment.
      Compared with this report, more contemporary data have consistently demonstrated substantially higher NPVs for nares MRSA screening in the detection of MRSA pneumonia.
      • Chan J.D.
      • Dellit T.H.
      • Choudhuri J.A.
      • McNamara E.
      • Melius E.J.
      • Evans H.L.
      • et al.
      Active surveillance cultures of methicillin-resistant Staphylococcus aureus as a tool to predict methicillin-resistant S. aureus ventilator-associated pneumonia.
      • Boyce J.M.
      • Pop O.
      • Abreu-Lanfranco O.
      • Hung W.Y.
      • Fisher A.
      • Karjoo A.
      • et al.
      A trial of discontinuation of empiric vancomycin therapy in patients with suspected methicillin-resistant Staphylococcus aureus health care-associated pneumonia.
      • Tilahun B.
      • Faust A.C.
      • McCorstin P.
      • Ortegon A.
      Nasal colonization and lower respiratory tract infections with methicillin-resistant Staphylococcus aureus.
      • Dangerfield B.
      • Chung A.
      • Webb B.
      • Seville M.T.
      Predictive value of methicillin-resistant Staphylococcus aureus (MRSA) nasal swab PCR assay for MRSA pneumonia.
      • Hiett J.
      • Patel R.K.
      • Tate V.
      • Smulian G.
      • Kelly A.
      Using active methicillin-resistant Staphylococcus aureus surveillance nasal swabs to predict clinical respiratory culture results.
      • Johnson J.A.
      • Wright M.E.
      • Sheperd L.A.
      • Musher D.M.
      • Dang B.N.
      Nasal methicillin-resistant Staphylococcus aureus polymerase chain reaction: a potential use in guiding antibiotic therapy for pneumonia.
      • Langsjoen J.
      • Brady C.
      • Obenauf E.
      • Kellie S.
      Nasal screening is useful in excluding methicillin-resistant Staphylococcus aureus in ventilator-associated pneumonia.
      • Giancola S.E.
      • Nguyen A.T.
      • Le B.
      • Ahmed O.
      • Higgins C.
      • Sizemore J.A.
      • et al.
      Clinical utility of a nasal swab methicillin-resistant Staphylococcus aureus polymerase chain reaction test in intensive and intermediate care unit patients with pneumonia.
      • Trevino S.E.
      • Pence M.A.
      • Marschall J.
      • Kollef M.H.
      • Babcock H.M.
      • Burnham C.D.
      Rapid MRSA PCR on respiratory specimens from ventilated patients with suspected pneumonia: a tool to facilitate antimicrobial stewardship.
      • Baby N.
      • Faust A.C.
      • Smith T.
      • Sheperd L.A.
      • Knoll L.
      • Goodman E.L.
      Nasal methicillin-resistant Staphylococcus aureus (MRSA) PCR testing reduces the duration of MRSA-targeted therapy in patients with suspected MRSA pneumonia.
      • Smith M.N.
      • Erdman M.J.
      • Ferreira J.A.
      • Aldridge P.
      • Jankowski C.A.
      Clinical utility of methicillin-resistant Staphylococcus aureus nasal polymerase chain reaction assay in critically ill patients with nosocomial pneumonia.
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