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645: RISK FACTORS FOR CLINICAL FAILURE WITH VANCOMYCIN THERAPY IN MRSA BLOODSTREAM INFECTIONS

Learning Objectives: Vancomycin remains first-line therapy for methicillin-resistant Staphylococcus aureus (MRSA) bloodstream infections (BSI); however, clinical failure with this agent still occurs in practice. Clinicians currently lack a method to identify patients at increased risk of clinical failure who may benefit from alternative strategies of care. The purpose of this retrospective cohort study was to identify risk factors for clinical failure with vancomycin therapy in patients with MRSA bloodstream infections. Methods: Hospitalized patients age 18 years and older with monomicrobial MRSA BSI treated with vancomycin from January 1, 2015 to July 31, 2017 were identified. Data collected included chronic comorbidities, source of infection, acute severity of illness, and management of infection. Univariable and multivariable logistic regression models were performed to identify risk factors associated with the primary outcome of clinical failure (defined as 30-day mortality, persistent bacteremia, or 60-day recurrence). A subgroup analysis compared various vancomycin combination therapies versus monotherapy among patients with clinical failure. Results: Among 116 patients with MRSA BSI, 37 (32%) had clinical failure. Independent risk factors for clinical failure in the multivariable model were ICU admission (aOR 4.54, 95% CI 1.3–15.8) and lack of early source control (aOR 9.62, 95% CI 2.5–37.0). Patients with clinical failure were also more likely to have received vancomycin monotherapy or combination therapy with a nonMRSA beta-lactam compared to combination therapy with an additional MRSA agent (15/37 [41%] vs. 22/37 [60%] vs. 0/37 [0%]) respectively, p=0.046). Conclusions: Patients admitted to the ICU and/or lacking early source control are at increased risk for clinical failure with MRSA BSI while on vancomycin. Such high-risk patients may warrant alternative or augmented therapy. Further research is warranted to define optimal MRSA management in this patient population.