Nafcillin safe alternative to vancomycin for late-onset sepsis in premature infants: Study
USA: A recent study has supported a change in treatment guidelines that recommend reducing vancomycin use in the neonatal intensive care unit (NICU) for late-onset sepsis (LOS) and using nafcillin over vancomycin. Reducing vancomycin use was shown to be safe and sustained, and resulted in similar mortality outcomes.
The study, published in the journal Pediatrics found nafcillin to be a safe alternative to vancomycin for empirical therapy of LOS among NICU infants not having a history of methicillin-resistant S aureus infection or colonization.
The Neonatal Antimicrobial Stewardship Program in 2014 at Nationwide Children's Hospital had recommended nafcillin over vancomycin for empirical therapy of possible late-onset sepsis in infants without a history of methicillin-resistant Staphylococcus aureus colonization or infection. Jacqueline Magers, Department of Pharmacy, Nationwide Children's Hospital, Columbus, OH, and colleagues report their experience with this guideline and assess its safety.
For this purpose, the researchers retrospectively reviewed all infants who received nafcillin or vancomycin for empirical treatment of possible LOS at 3 NICUs before (January 2013–May 2014) and after (January 2017–March 2019) implementation of a vancomycin reduction guideline. Safety measures included recurrence of infection with the same previously identified pathogen in the 14 days after discontinuation of antibiotic therapy, duration of blood culture positivity, and mortality.
The research led to the following findings:
- Among 366 infants who received a first antibiotic course for possible LOS, 84% (95 of 113) and 25% (62 of 253) received empirical therapy with vancomycin before and after the guideline implementation, respectively, representing a 70% reduction. Nafcillin use increased by 368%.
- Duration of blood culture positivity did not differ before and after the guidance. In 2 infants, antibiotic therapy was restarted within 14 days of discontinuation of the initial therapy for recurrence of the same infection; both had received empirical vancomycin.
- Overall in-hospital mortality was 10%, and there was no difference before (9%) and after (10%) implementation of the vancomycin reduction guidance (odds ratio, 0.97).
To conclude, the researchers wrote, "nafcillin can be a safe alternative to vancomycin for empirical therapy of LOS among NICU infants who do not have a history of methicillin-resistant S aureus infection or colonization."
Jacqueline Magers, Pavel Prusakov, Sunday Speaks, Sara Conroy, Pablo J. Sánchez; Safety and Efficacy of Nafcillin for Empiric Therapy of Late-Onset Sepsis in the NICU. Pediatrics 2022; e2021052360. 10.1542/peds.2021-052360
KEYWORDS: Pediatrics journal, vancomycin, nafcillin, sepsis, neonatal ICU, NICU, late-onset sepsis, antibiotic, therapy, methicillin-resistant S aureus infection, Jacqueline Magers, infants, neonates, newborn, premature infants