Outbreaks of Staphylococcus aureus infections during treatment of late onset pneumonia with ciprofloxacin in a prospective, randomized study

Abstract

We carried out a prospective, randomized four-center study in nosocomial pneumonia to evaluate the clinical and microbiological efficacy and safety of different treatment regimens in adult intensive care patients. During the randomized treatment of 18 patients with late onset pneumonia, ciprofloxacin (CIP) was compared to ceftazidim plus gentamicin (CAZ/GM), outbreaks of Staphylococcus aureus infections occurred in center 1. This article reports the unexpected findings. In the CIP group six out of ten patients were superinfected or reinfected with ciprofloxacin-resistant pathogens at the follow-up on day 5 after treatment. Four out of these six patients were superinfected with methicillin-susceptible or methicillin-resistant S. aureus (MRSA). Four superinfected patients died with pneumonia during treatment or before the follow-up. In the CAZ/GM group one out of eight patients was superinfected with MRSA. One patient died with pneumonia during treatment. There was no problem with multiresistant S. aureus or MRSA before the study period in center 1. In conclusion, we observed outbreaks of S. aureus infections during the treatment of late onset pneumonia with ciprofloxacin, which were associated with a high mortality. These superinfections occurred in mechanically ventilated, postoperative cardiac surgical patients after 13 days in the intensive care unit (ICU). We recommend combining ciprofloxacin with an antibiotic agent active against gram-positive bacteria in ventilator-associated pneumonia after a prolonged ICU stay. Selective pressure of ciprofloxacin could have played a role in these superinfections.

Pseudomonas aeruginosaVentilator‐Associated Pneumonia: Comparison of Episodes Due to Piperacillin‐Resistant versus Piperacillin‐Susceptible Organisms

“…These findings are in accordance with the results of Harris et al [8], who found multidrug and lengthy antipseudomonal antibiotic exposures to be factors that predispose for the development of an infection with multidrugresistant P. aeruginosa. One pertinent finding is that recent exposure to a fluoroquinolone was also found to be an independent risk factor for carriage of and persistent colonization with methicillin-resistant Staphylococcus aureus [27][28][29]. This information could provide an extremely simple way to identify subgroups of patients from whom PRPA are likely to be isolated.…”

Induction of Fibronectin-Binding Proteins and Increased Adhesion of Quinolone-ResistantStaphylococcus aureusby Subinhibitory Levels of Ciprofloxacin

“…Interestingly, one recent study evaluating the relationship between the incidence of MRSA and the use of different classes of antimicrobials in Belgian hospitals found a correlation with increasing use of quinolones in a multivariate analysis (7). In another prospective randomized study, outbreaks of MRSA superinfections causing late-onset pneumonia were clearly associated with ciprofloxacin use in intensive care units (23).…”

Antimicrobial therapy for patients with severe sepsis and septic shock: An evidence-based review

“…One study showed that monotherapy with ciprofloxacin was as effective as therapy with a ␤-lactam and/or an aminoglycoside for the treatment of patients with documented Gramnegative sepsis (80). However, given that first-generation fluoroquinolones exhibit suboptimal activities against Grampositive bacteria, this class of antibiotics should not be used as empirical singleagent therapy in patients with severe sepsis.…”