Surgical Site Infection: New Solutions to a Continuing Problem

1
Surgical Site InfectionNew Solutions to a
Continuing Problem

• R. Lawrence Reed, II, MD, FACS, FCCM
• Professor of Surgery
• Loyola University Medical Center
• Director, SICU, Hines VA Medical Center
• Maywood, IL

2
Surgical Site Infections (SSI)

• Third most common nosocomial infection (1416)
• Most common nosocomial infection among surgical
  patients (38)
• 2/3 incisional
• 1/3 organs or spaces accessed during surgery
• 7.3 additional postoperative days at cost of
  3,152 in extra charges

Mangram AJ et al. Infect Control Hosp Epidemiol.
199920250-278.
3
Colonization vs Contamination Definitions

• Colonization
• Bacteria present in a wound with no signs or
  symptoms of systemic inflammation
• Usually less than 105 cfu/mL
• Contamination
• Transient exposure of a wound to bacteria
• Varying concentrations of bacteria possible
• Time of exposure suggested to be lt 6 hours
• SSI prophylaxis best strategy

4
SSI Definitions

• Infection
• Systemic and local signs of inflammation
• Bacterial counts 105 cfu/mL
• Purulent versus nonpurulent
• LOS effect
• Economic effect
• Surgical wound infection is SSI

LOSlength of stay.
5
Superficial Incisional SSI

• Infection occurs within 30 days after the
  operation and involves only skin or subcutaneous
  tissue of the incision

Mangram AJ et al. Infect Control Hosp Epidemiol.
199920250-278.
6
Deep Incisional SSI

• Infection occurs within 30 days after the
  operation if no implant is left in place or
  within 1 year if implant is in place and the
  infection appears to be related to the operation
  and the infection involves the deep soft tissue
  (e.g., fascia and muscle layers)

Superficial incisional SSI
Mangram AJ et al. Infect Control Hosp Epidemiol.
199920250-278.
7
Organ/Space SSI

• Infection occurs within 30 days after the
  operation if no implant is left in place or
  within 1 year if implant is in place and the
  infection appears to be related to the operation
  and the infection involves any part of the
  anatomy, other than the incision, which was
  opened or manipulated during the operation

Superficial incisional SSI
Deep incisional SSI
Mangram AJ et al. Infect Control Hosp Epidemiol.
199920250-278.
8
SSI Risk FactorsOperation Factors

• Foreign material at surgical site
• Surgical drains
• Surgical technique
• Poor hemostasis
• Failure to obliterate dead space
• Tissue trauma

• Duration of surgical scrub
• Maintain body temp
• Skin antisepsis
• Preoperative shaving
• Duration of operation
• Antimicrobial prophylaxis
• Operating room ventilation
• Inadequate sterilization of instruments

Mangram AJ et al. Infect Control Hosp Epidemiol.
199920250-278.
9
SSI Risk FactorsPatient Characteristics

• Age
• Diabetes
• HbA1C and SSI
• Glucose gt 200 mg/dL postoperative period (lt48
  hours)
• Nicotine use delays primary wound healing
• Steroid use controversial
• Malnutrition no epidemiological association
• Obesity 20 over ideal body weight

• Prolonged preoperative stay surrogate of the
  severity of illness and comorbid conditions
• Preoperative nares colonization with
  Staphylococcus aureus significant association
• Perioperative transfusion controversial
• Coexistent infections at a remote body site
• Altered immune response

Mangram AJ et al. Infect Control Hosp Epidemiol.
199920250-278.
10
Risk of Infection
Bacterial dose
Virulence
Impaired host resistance
11
(No Transcript)
12
Risk of Infection
Virulence
Impaired host resistance
13
SSI Wound Classification

• Class 1 Clean
• Class 2 Clean contaminated
• Class 3 Contaminated
• Class 4 Dirty infected

Mangram AJ et al. Infect Control Hosp Epidemiol.
199920250-278.
14
SSI Risk Stratification NNIS Project

• 3 independent variables associated with SSI risk
• Contaminated or dirty/infected woundclassificatio
  n
• ASA gt 2
• Length of operation gt 75th percentile of the
  specific operation being performed

NNISNational Nosocomial Infections Surveillance.
NNIS. CDC. Am J Infect Control. 200129404-421.
15
SSI Wound Class vs NNIS Class

• Wound Class All NNIS 0 NNIS 1 NNIS 2
  NNIS 3
• Clean 2.1 1.0
  2.3 5.4 N/A
• Clean contaminated 3.3 2.1
  4.0 9.5 N/A
• Contaminated 6.4 N/A 3.4
  6.8 13.2
• Dirty infected 7.1 N/A
  3.1 8.1 12.8
• All 2.8 1.5 2.9 6.8
  13.0

NNIS. CDC. Am J Infect Control. 200129404-421.
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Campaign to PreventAntimicrobial Resistance

• Centers for Disease Control and Prevention
• National Center for Infectious Diseases
• Division of Healthcare Quality Promotion

Clinicians hold the solution!

• Link to Campaign to Prevent Antimicrobial
  Resistance Online
• Link to Federal Action Plan to Combat
  Antimicrobial Resistance

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12 Steps to Prevent Antimicrobial Resistance
AmongSurgical Patients

• Step 1 Prevent SSIs
• Monitor and maintain normal glycemia
• Maintain normothermia
• Perform proper skin preparation using appropriate
  antiseptic agent and, when necessary, hair
  removal techniques
• Think outside the wound to stop surgical site
  infections

CDC. Available at http//www.cdc.gov/drugresistanc
e/healthcare/surgery/12steps_surgery.htm.
Accessed July 16, 2004.
18
Opportunity to Prevent SSI

• An estimated 4060 of SSIs are preventable
• Overuse, underuse, improper timing, and misuse of
  antibiotics occurs in 2550 of operations

Mangram AJ et al. Infect Control Hosp Epidemiol.
199920250-278.
19
Principles of Antibiotic Prophylaxis
Mangram AJ et al. Infect Control Hosp Epidemiol.
199920250-278.
20
Surgical Site Infection (SSI)
Mangram AJ et al. Infect Control Hosp Epidemiol.
199920250-278.
21
Surgical Infection Prevention ProjectMedicare
Quality Improvement Community
Clinical Infectious Diseases 2004 June 38170615
22
National Data Collection

• State-level baseline description from random
  sample of 788 cases per state
• Data collected from records by two professional
  clinical data abstraction centers
• Abstraction tool for hospitals is available.Is
  JCAHO compatible

23
Surgical Infection PreventionPreliminary Results
24
Discontinuation of Antibiotics
Patients were excluded from the denominator of
this performance measure if there was any
documentation of an infection during surgery or
in the first 48 hours after surgery.
25
Most Common Pathogens Associated With Nosocomial
Infections (NNIS 19891998) Medical Surgical
Combined
Relative Percentage by Site of Infection
Pathogen All Sites BSI
Pneumonia SSI n235,758 n50,091 n64,056 n
22,043 Coag-neg Staph 14.3 39.3
2.5 13.5 S aureus 11.4 10.7
16.8 12.6 Enterococci spp. 8.1
10.3 1.9
14.5 P aeruginosa 9.9 3.0
16.1 9.2 Enterobacter spp. 7.3
4.2 10.7 8.8 E coli
7.0 2.9 4.4 7.1 C
albicans 6.6 4.9 4.0
4.8 K pneumoniae 4.7 2.9
6.5 3.5 Others 30.7 21.8
37.1 26.0
BSIbloodstream infection SSIsurgical site
infection. Fridkin SK et al. Clin Chest Med.
199920303-316.
26
Predominance of S aureus in Skin and Skin
Structure Infections (SSSIs)SENTRY US and
Canada 2000
N1,404 isolates
Rennie RP et al. Diagn Microbiol Infect Dis.
200345287-293.
27
Progression of Methicillin Resistant S aureus
United States
13?
CDC. MMWR. 199746624-628, 635. (1975 data)
Lowy FD. N Engl J Med. 1998339520-532.
(1987-1997 data) CDC. NNIS System Report,
JanuaryNovember 1998. (1998 data) CDC. NNIS
System Report, January 1990May 1999, issued June
1999. Am J Infect Control. 199927520-532. (1999
data) CDC. NNIS System Report, January 1992June
2001. Am J Infect Control. 200129404-421. (2000
data) NNIS. CDC. Am J Infect Control.
200331481-498.
28
Impact of MRSA on SSI

• N479 patients
• MRSA greater 90-d mortality vs MSSA (adjusted
  odds ratio, 3.4 95 CI 1.57.2)
• MRSA longer LOS after infection (median
  additional days5 Plt0.001)
• MRSA associated with greater hospital charges
  (1.19-fold increase in hospital charges, P0.03)

Engemann JJ et al. Clin Infect Dis.
200336592-598.
29
Vascular SSI

• Retrospective review (19932000)
• Leicester Royal Infirmary, United Kingdom
• 172 patients MRSA-positive (4.4 of total)
• 75 infected, 97 colonized
• Proportion of wound/graft infections caused by
  MRSA has increased
• 4 in 1994, increased to 63 in 2000
• All patients with aortic graft infection died
• All patients with infected prosthetic
  infrainguinal bypass required amputations

Nasim A et al. Eur J Vasc Endovasc Surg.
200122211-214.
30
MRSA in Orthopedic SSI

• Prospective study, London, United Kingdom
• 12-month study, January through December 2000
• Total of 1,879 patients admitted, 121 screened
• 1.6 of total with MRSA infection/colonization
• Higher risk for MRSA infection
• Hip surgery
• Emergency surgery for femoral neck fracture
• Presence of wound
• MRSA infection increased hospital LOS (88 vs 11
  days)
• 41 of positive patients still carried MRSA on
  discharge

Tai CC et al. Int Orthop. 20042832-35.
31
MRSA in Cardiac Surgery

• 3,443 CABG patients, all received antimicrobial
  prophylaxis
• June 1997 through December 2000
• Sternal SSI developed in 122 (3.5)
• 71 (58.2) were superficial SSI
• 51 (41.8) were deep SSI
• Gram-positive cocci were most frequently
  recovered (81)
• S aureus was the most frequently isolated
  pathogen (49)
• S aureus bacteremia occurred in 18 and was
  significantly associated with deep SSI (P0.002)

CABGcoronary artery bypass grafting. Sharma M et
al. Infect Control Hosp Epidemiol.
200425468-471.
32
Impact of MRSA in Cardiac Surgery

• Retrospective review (41 patients)
• Poststernotomy S aureus mediastinitis
• MRSA 15 patients
• MSSA 26 patients
• Logistic regression analysis MRSA was the only
  independent risk factor for increased mortality,
  P0.04

Mekontso-Dessap A et al. Clin Infect Dis.
200132877-883.
33
Nasal Mupirocin and SSI

• 4,030 patients enrolled, 3,864 ITT patients
• PRDBPCT, intranasal mupirocin
• 891 patients (23.1) had S aureus in anterior
  nares
• 444 mupirocin,
• 447 placebo
• S aureus SSI
• 2.3 mupirocin
• 2.4 placebo

ITTintent-to-treat PRDBPCTprospective,
randomized, double-blind placebo-controlled
trial. Perl TM et al. N Engl J Med.
20023461871-1877.
34
Surgical Wound ManagementSSI Prophylaxis in
MRSA-Colonized Patient

• Must use same principles
• Drug choice difference
• MRSA drugs
• Vancomycin
• Quinupristin/dalfopristin
• Linezolid
• Daptomycin

Not FDA approved for MRSA.
35
Vancomycin

• Bactericidal glycopeptide
• Discovered in 1956
• Produced by Streptococcus orientalis, an
  actinomycete isolated from soil samples from
  Indonesia India
• Introduced clinically in 1958
• Quickly overshadowed by less toxic
  anti-staphylococcal penicillins and
  cephalosporins
• Re-emergence as an important antibiotic in 1980s
  1990s

36
Historical Yearly Usage of Vancomycin
2001 1.8 million courses of vancomycin annually
in U.S. 30 million doses of vancomycin estimated
Kirst HA et al. Antimicrob Agents Chemother.
1998421303-1304 NNIS. Am J Infect Control.
200129404-421.
37
12 Steps to Prevent Antimicrobial Resistance
AmongSurgical Patients

• Step 9. Know when to say no to vanco
• Vanco should be used to treat known infections,
  not for routine prophylaxis
• Treat staphylococcal infection, not contaminants
  or colonization
• Consider other antimicrobials in treating MRSA

CDC. Available at http//www.cdc.gov/drugresistanc
e/healthcare/surgery/12steps_surgery.htm.
Accessed July 16, 2004.
38
Vancomycin Tissue Penetration

• 33 open-heart surgery patients, mean vancomycin
  concentrations after 15 mg/kg IV dose
• Below the mean MICs for many strains of
  staphylococci

MICminimum inhibitory concentration. Daschner FD
et al. J Antimicrob Chemother. 198719359-362.
39
Sternal Bone157Heart Valve4 12
Vancomycin Penetration
1. Massias L et al. Antimicrob Agents
Chemother. 1992362539-2541 2. Cruciani M et
al. J Antimicrob Chemother. 199638865-869. 3.
Lamer C et al. Antimicrob Agents Chemother.
199337281-286 4. Daschner FD et al. J
Antimicrob Chemother. 198719359-362 5.
Graziani AL et al. Antimicrob Agents
Chemother. 1988321320-1322.
40
Quinupristin/Dalfopristin (Synercid)

• Streptogramin class related to macrolide-lincosami
  des
• Quinupristin is a Group B streptogramin
• Dalfopristin is a Group A streptogramin
• Activity against
• MSSA potently bactericidal
• Streptococcus pneumoniae (including PRSP)
  potently bactericidal
• MRSA moderately active
• E faecium moderately active against most E
  faecium strains
• NO activity against E faecalis

PRSPpenicillin-resistant Streptococcus
pneumoniae. Synercid IV (quinupristin/dalfopristi
n for injection) package insert. Bristol, Tenn
Monarch Pharmaceuticals, Inc 2002.
41
Quinupristin/Dalfopristin (Synercid)

• Central line access used to decrease incidence of
  infusion-related venous irritation
• 330 incidence of severe myalgias and
  arthralgias
• Resistance has already been reported
• Bacteriostatic
• Does not have indication for pneumonia
• Did not perform as well as vancomycin

Synercid IV (quinupristin/dalfopristin for
injection) package insert. Bristol, Tenn
Monarch Pharmaceuticals, Inc 2002.
42
Daptomycin (Cubicin)

• Lipopeptide natural product
• Activity in Gram-positive organisms
• Distinct mechanism of action
• Rapidly bactericidal in vitro and in vivo
• No mechanisms of resistance identified
• No cross-resistance with other antibiotics
• Safety profile similar to comparators
• Once-daily IV dosing

Cubicin (daptomycin for injection) prescribing
information. Lexington, MA Cubist
Pharmaceuticals September 2003.
43
Linezolid (ZYVOX)

• An oxazolidinone a novel antimicrobial class
• 100 oral bioavailability
• Equivalent dosing oral/IV
• No dose adjustment in renal failure
• Bacteriostatic
• No cross-resistance with other antibiotics
• Reversible thrombocytopenia with prolonged use
• Binds selectively to the 50S ribosomal subunit
• Inhibits the formation of a functional initiation
  complex

ZYVOX (linezolid injection, tablets, and oral
suspension) package insert. Kalamazoo, Mich
Pharmacia Upjohn, a Pfizer Company revised
June 2004.
44
Average Steady-State Plasma Linezolid
Concentrations After Oral Administration of 400
or 600 mg Twice Daily
600 mg BID 400 mg BID MIC-90 Staph MIC-90
Entero MIC-90 Strep
Linezolid concentration (µg/mL)
Time After Last Dose (hours)
Linezolid Research Update. Denver, Colo
Infectious Diseases Society of America November
13, 1998.
45
Linezolid Penetration
1. Cottagnound et al. J Antimicrob Chemother.
200046981-985 2. ZYVOX (linezolid injection,
tablets, and oral suspension) package insert.
Kalamazoo, Mich Pharmacia Upjohn, a Pfizer
Company revised 2003 3. Lovering AM et al. J
Antimicrob Chemother. 2002, 5073-77 4. Conte JE
et al. Antimicrob Agents Chemother.
2002461475-1480 5. Gee T. Antimicrob Agents
Chemother. 2001451843-1846.
46
Comparison of Tissue Concentrations (
Tissue/Serum)
Tissue Vancomycin Linezolid
Bone 7131 608
Cerebral Spinal Fluid 0182,3 709
Epithelial Lining Fluid (Lung) 11174,5 4509
Inflammatory Blister Fluid ---- 10410
Muscle 306 948
Peritoneal dialysis fluid 207 6111
1. Graziani AL et al. Antimicrob Agents
Chemother. 1988321320-1322 2. Matzke et al.
Clin Pharmacokinet. 198611257-282 3. Albanese
J et al. Antimicrob Agents Chemother.
2000441356-1358 4. Georges H et al. Eur J Clin
Microbiol Infect Dis. 199716385-388 5. Lamer C
et al. Antimicrob Agents Chemother.
199337281-286 6. Daschner FD et al. J
Antimicrob Chemother. 198720776-782 7. Blevins
RD et al. Antimicrob Agents Chemother.
198425603-606 8. Lovering AM et al. J
Antimicrob Chemother. 20025073-77 9. Conte JE
et al. Antimicrob Agents Chemother.
2002461475-1480 10. Gee T et al. Antimicrob
Agents Chemother. 2001451843-1846 11. Gendjar
SR et al. 2001 ASN/ISN World Congress of
Nephrology 2001 San Francisco, Calif. Abstract
550865.
47
Complicated Skin and Soft Tissue Infection
(cSSTI) Treatment

• Staph most common cause
• Staph resistance continues to increase
• 57.1 in 2002
• Treatment for MRSA cSSTI prior to 2000
• Vancomycin
• Quinupristin/dalfopristin
• New alternatives for treatment of MRSA cSSTI
• Linezolid
• Daptomycin

Not FDA approved for MRSA.
NNIS. CDC. Am J Infect Control. 200331481-498.
48
Quinupristin/Dalfopristin (Q/D) Efficacy

• Design 2 randomized, open-label, controlled
  clinical trials in cSSSI
• Study 1 Q/D (7.5 mg/kg q12h IV) vs oxacillin (2
  g q6h IV)
• Study 2 Q/D (7.5 mg/kg q12h IV) vs cefazolin (1
  g q8h IV)

Q/D (n450) Comparator (n443)
Study 1 (US) 49.5 51.9
Study 2 (International) 66.4 64.2
Postoperative infections 14/38 (36.8) 24/42 (57.1)
Traumatic wound infections 33/55 (60.0) 33/55 (60.0)
Efficacy in the Clinically Evaluable Population
Vancomycin 1 g q12h IV could be substituted if
the pathogen was suspected or confirmed
methicillin-resistant Staphylococcus or the
patient was allergic to penicillin,
cephalosporins, or carbapenems. Patients cured
or improved. Results are combined from the 2
clinical trials. Statistical conclusions could
not be reached due to the small number of
patients in the subsets.
Not FDA approved for MRSA.
Synercid IV (quinupristin/dalfopristin for
injection) package insert. Bristol, Tenn
Monarch Pharmaceuticals, Inc 2002.
49
Quinupristin/Dalfopristin (Q/D) Efficacy

• Design 2 randomized, open-label, controlled
  clinical trials in cSSSI
• Summary of Clinical and Microbiologic Results

Q/D (n450) Comparator (n443)
Clinical efficacy 68.2 70.7
Microbiologic eradication 66.6 77.7
MSSA 64.3 76.6
MRSA 77.8 50.0
Gram-positive cocci only 56.3 69.7
Results are combined from the 2 clinical trials.
Patients cured or improved in the clinically
evaluable population. Overall and by-pathogen
bacteriologic eradication rates in the
microbiologically evaluable population. cSSSIscom
plicated skin and skin structure
infections. Nichols RL et al. J Antimicrob
Chemother. 199944263-273.
Not FDA approved for MRSA.
50
Linezolid vs Vancomycin for cSSTI Presumed or
Known to Be Caused by MRSA

• Study design Open-label, randomized,
  comparator-controlled, multicenter, multinational
  clinical study
• Population 1,200 hospitalized adult patients
  with cSSTI
• Treatment arms

Vancomycin (IV only) 1 g every 12 hours
Linezolid (oral or IV) 600 mg every 12 hours
OR
Weigelt JA et al. Infectious Diseases Society of
America, 2003, poster 314. San Diego, CA.
51
Linezolid vs Vancomycin for cSSTI Clinical Cure
Rates in Clinically Evaluable Subset
P0.023
Weigelt JA et al. Infectious Diseases Society of
America, 2003, poster 314. San Diego, CA.
52
Linezolid vs Vancomycin for cSSTIClinical Cure
Rates in MRSA Subgroup
P0.011
126/134
112/134
Weigelt JA et al. Infectious Diseases Society of
America, 2003, poster 314. San Diego, CA.
53
Linezolid Reduces LOS vs Vancomycinin cSSTI due
to MRSA
Mean LOS (days)
Study Sample (linezolid/vancomycin) Linezolid Vancomycin P Value
ITT (592/588) 7.4 9.8 lt0.0001
CE (491/472) 7.4 9.9 lt0.0001
ME (349/334) 7.6 9.8 lt0.0001
MRSA (143/146) 8.1 10.7 0.0026
CEclinically evaluable ITTintent-to-treat
LOSlength of stay MEmicrobiologically
evaluable. Weigelt JA et al. Infectious Diseases
Society of America 2003, poster 315. San Diego,
CA.
54
Linezolid vs Vancomycin for cSSTI IV Antibiotic
Treatment Days
Duration of IV treatment (days)
CEclinically evaluable ITTintent-to-treat
MEmicrobiologically evaluable MITTmodified
intent-to-treat.
Weigelt JA et al. Infectious Diseases Society of
America, 2003, poster 315. San Diego, CA.
55
Cost Effectiveness of Linezolid vs Vancomycin in
cSSTI
5,187 CI (4,6915,714)
4,143 CI (3,7504,576)
C O S T ()
Linezolid
Vancomycin
2003 Per diem hospital cost, administration of IV
therapy, wholesale acquisition cost
Fleming T, ed. Red Book. 2004 edition. Montvale
NJ Thompson PDR2004.
56
Linezolid vs Vancomycin for Surgical Site
Infection (SSI )
Total Patients With cSSTI 1,200
-Weigelt J et al. Am J Surg 2004188760-766.
57
Linezolid vs Vancomycin in SSIStudy Population
Study Population Linezolid (n, ) Vancomycin (n, )
All patients 66 (100) 69 (100)
MRSA 34 (52) 31 (45)
Baseline demographics No significant
difference Baseline comorbidities/MRSA risk
factors No significant difference
-Weigelt J et al. Am J Surg 2004188760-766.
58
Linezolid vs Vancomycin in SSIClinical Cure
Rates at TOC
P0.06
-Weigelt J et al. Am J Surg 2004188760-766.
59
Linezolid vs Vancomycin in SSI Microbiological
Cure Rates at TOC
P0.007
-Weigelt J et al. Am J Surg 2004188760-766.
60
Linezolid vs Vancomycin in SSIMicrobiological
Cure Rates at TOC in MRSA Pts.
P0.002
-Weigelt J et al. Am J Surg 2004188760-766.
61
Daptomycin for cSSSIs

• Phase III 2 international, multicenter,
  randomized, double-blind (evaluator blinded)
  studies (Studies 9801 9901)
• Daptomycin (4 mg/kg IV qd) vs 1 of 2 comparators
• Vancomycin (1 g q12h)
• Synthetic penicillin (412 g/d in 4 daily doses)
• Primary endpoint was safety and efficacy
• Both studies demonstrated equivalence of
  daptomycin to the comparator

Arbeit RD et al. Clin Infect Dis.
2004381673-1681.
62
Daptomycin Efficacy

• Design 2 randomized, multinational, multicenter
  investigator-blinded studies
• Daptomycin 4 mg/kg IV q24h or vancomycin 1 g IV
  q12h or a semisynthetic penicillin (nafcillin,
  oxacillin, cloxacillin, flucloxacillin)

Clinical Success Rate CE Population

Type of Infection Daptomycin No. of Pts (Success rate ) Comparator No. of Pts (Success rate )
Wound infection 169 (84) 180 (87)
Major abscess 102 (92) 92 (88)
Ulcer infection 47 (66) 56 (70)
Other infection 47 (79) 58 (83)
Comparator was vancomycin or a semisynthetic
penicillin. Other infections included
complicated cellulitis, major abscess, or
traumatic wound infection.
Arbeit RD et al. Clin Infect Dis.
2004381673-1681.
63
Comparison of MRSA Antimicrobials
Daptomycin
Linezolid
Quinupristin/ Dalfopristin
cSSSI
cSSSI and pneumonia
cSSSI (not MRSA)
Parenteral
Parenteral, oral
Parenteral (central?)
QD
BID
q8-12h
Faster cure (rapidly cidal)
Gets patients home
Works when vancomycin wont
Unfamiliarity and cost, reversible hematologic
abnormalities, resistance (ie, VRE with
prolonged use)
Limited indications, acquisition cost, myalgia,
not effective for pneumonia
Infusion site inflammation, myalgias,
arthralgias, and resistance
Potential for less resistance
Oral dosing?removal of catheters, early
discharge, evidence of superiority to vancomycin
in cSSTI
Alternative to vancomycin
64
Summary

• SSI is a preventable morbidity
• Gram-positive organisms are the primary pathogens
• MRSA increasing
• Treatment alternatives in MRSA SSIs and cSSTIs
• Vancomycin
• Linezolid
• Daptomycin
• Quinupristin/dalfopristin

Not FDA approved for MRSA.