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Bacteremia secondary to methicillin-resistant Staphylococcus aureus (MRSA) is a dreaded medical condition that is not only associated with a significant medical cost but also carries high morbidity and mortality. The poor clinical outcomes seen in MRSA patients and the nephrotoxic effects of high-doses of vancomycin are challenging its current status as the first-line treatment for MRSA. Fortunately, vancomycin-intermediate-staphylococcus aureus (VISA) and vancomycin-resistant-staphylococcus aureus (VRSA) are not common in the United States. However, MRSA still presents different treatment challenges. Elevated vancomycin minimum inhibitory concentrations (MICs) commonly result in decreased efficacy and an increased probability of treatment failure, prompting the use of alternative agents. Although daptomycin is an alternative, adverse effects (i.e., elevations in serum creatine phosphokinase (CPK), drug-induced myopathy, peripheral neuropathy, and eosinophilic pneumonia) may limit its use in some patients. In the search for a suitable replacement for vancomycin, great promise has been shown by anti-MRSA cephalosporins. We present a case of MRSA bacteremia and endocarditis requiring a different approach to treatment as compared to traditional treatment with vancomycin alone. This case report describes the successful treatment of MRSA bacteremia with ceftaroline fosamil in a patient who responded poorly to conventional therapy, specifically vancomycin, due to an elevated MIC (2 µg/mL).
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INTRODUCTION: Atrial fibrillation (AF) has been shown to be associated with activation of the renin-angiotensin-aldosterone system, endothelial dysfunction, and increased sympathetic activity, all of which could lead to hypertension (HTN). While the effects of HTN on AF incidence and arrhythmogenesis have been reported, the long-term effects of AF on blood pressure (BP) remain unknown. We hypothesized that a rate control strategy is associated with an increase in BP and/or antihypertensive drug therapy when compared with a rhythm control strategy in patients with a history of AF and HTN. METHODS AND RESULTS: Using the intention to treat method, BP readings and the number of antihypertensive medication categories were analyzed over the first year of follow-up in patients with AF and HTN enrolled in the AFFIRM trial. No clinically significant changes in BP occurred. Medication data were available in 2,876 patients. In the rate control group, 27.8% of patients required a net increase in the number of antihypertensive medications when compared to 18.3% in the rhythm control group (P < 0.001). Furthermore, 27.1% of patients in the rate control group had a net decrease in the number of antihypertensive medications when compared with 41.7% in the rhythm control group (P < 0.001). CONCLUSIONS: Our findings suggest that AF could be contributing to BP elevation in patients with a history of HTN and that a rhythm control strategy might result in a decrease in BP in these patients. This hypothesis however, requires future testing.
