December 31, 2018

Nebulized Vancomycin for Eradication of Persistent MRSA in Patients with Cystic Fibrosis

An aggressive strategy falls short

18-PUL-5868_CQD_650x450_Base-File

By Elliott C. Dasenbrook, MD, MHS

Advertisement

Cleveland Clinic is a non-profit academic medical center. Advertising on our site helps support our mission. We do not endorse non-Cleveland Clinic products or services. Policy

Methicillin-resistant Staphylococcus aureus (MRSA) increases the risk of death for people with cystic fibrosis (CF). Studies reveal a dramatic increase in the number of individuals with CF living with MRSA infection, now comprising 25 percent of the CF population in the United States. Cleveland Clinic is leading research on MRSA in CF patients. Results of our recent study, the Persistent MRSA Eradication Protocol (PMEP), emphasize the difficulty of eradicating persistent MRSA infection, even with multimodal antibiotics.

This double-blind, randomized, placebo-controlled trial tested the use of nebulized vancomycin for treating CF patients with persistent MRSA. The results were published in the Journal of Cystic Fibrosis and showed that while inhaled vancomycin did suppress MRSA infection, chronic MRSA infection cannot be eradicated despite a comprehensive treatment protocol. This underscores the importance of infection prevention and control to prevent patients from acquiring MRSA infection in the first place.

Recruitment challenges and adverse events

We randomized 29 patients with persistent MRSA infection (two positive MRSA respiratory cultures in the past two years at least six months apart as well as two positive cultures during the screening period). Participants received either nebulized placebo or vancomycin (250 mg in 5 cc sterile water) twice per day, and all patients received oral trimethoprim/sulfamethoxazole or doxycycline, rifampin, mupirocin and Hibiclens liquid skin cleanser, as well as environmental decontamination.

Four patients from the intervention arm withdrew from the study due to bronchospasm. Though we hoped to recruit 40 patients to power the study adequately, we analyzed 25 participants due to challenges with recruitment and enrollment as well as withdrawals.

Advertisement

The primary endpoint was rate of infection at a one-month follow-up visit, at which time 20 percent of subjects in each group had a sputum culture negative for MRSA. At the three-month follow-up visit, the intervention group was unchanged, whereas only 13 percent of the placebo group was MRSA negative. We also did not observe a statistically significant difference in forced expiratory volume in one second (FEV1) between the groups at any time.

Our findings contrast with previous studies that suggest inhaled vancomycin may warrant inclusion in an aggressive eradication strategy. Our study was small, but our inclusion criteria were stringent as we did not want patients with intermittent MRSA to dilute the results. This study did not address the question of whether inhaled vancomyin may be beneficial as a suppressive treatment for chronic MRSA infection. This is also an important question as CF patients chronically infected with respiratory tract Pseudomonas aeruginosa benefit from repeated courses of inhaled antibiotics.

Our findings underscore the challenging nature of MRSA in CF established by our large registry study that tracked nearly 20,000 patients with CF in the U.S. Cystic Fibrosis Patient Registry and found no easily modifiable patient-level risk factors.

Advances in infection control and treatment at Cleveland Clinic

Persistent MRSA in patients with CF is not easy to prevent or treat, but stringent infection control practices can reduce transmission and optimize outcomes. When patients with CF present to Cleveland Clinic for ambulatory visits, we utilize robust infection control practices, including immediately placing the patient in a clinic room where vital signs and spirometry are obtained and the entire visit is conducted. When patients with CF present to our emergency department, radiology department or other hospital sites, an alert in the electronic medical record notifies the provider that special infection control precautions must be implemented.

Advertisement

Our expertise in treatment and infection control protocols for MRSA infections in CF patients continues to grow and evolve as we seek to address this dangerous risk.

Dr. Dasenbrook directs Cleveland Clinic’s Adult Cystic Fibrosis Program which is accredited by the U.S. Cystic Fibrosis Foundation.

Related Articles

Image of lungs
February 28, 2024
New Cleveland Clinic-Led Research Highlights Novel Disease Monitoring Technique in Heart Failure

Volatile organic compounds have potential in heart failure diagnostics

24-PUL-4507382-CQD-Portopulmonary-Hypertension-Hero-967×544
January 26, 2024
Portopulmonary Hypertension: A Focused Review for the Internist

Insights for diagnosing, assessing and treating

opioids
December 6, 2023
Can Kappa and Alpha-2 Agonist Agents Treat Opioid-Induced Ventilatory Depression Risk While Preserving Analgesic Effects?

Two NIH grants are looking at developing new antidotes against fentanyl overdose

Lab research
November 22, 2023
Unravelling the Mysteries of Sepsis and Septic Shock

Exploring the responses to medications and other supportive therapies

spirometry
August 7, 2023
A Tool to Help in Transition to “Race-Neutral” PFT Interpretation

A set of graphs helps quantify the expected changes in forced expiratory volume at one second (FEV1), forced vital capacity (FVC) and FEV1/FVC ratio with the new race-neutral equation

Dyspnea
June 2, 2023
Persistent Dyspnea after COVID-19 Infection: Evaluation and Management

Because of the associated symptoms, a multidisciplinary approach to care is essential

Imaging of ribcage
March 8, 2023
COPD and Skeletal Muscle Mass: Discovering New Possibilities

Patients with COPD are often affected by sarcopenia, but the underlying mechanisms for the development are poorly understood. New research looks into the causes and potential therapies

Lungs
January 19, 2023
Looking at the Impact of the New Lung Transplant Allocation System

Research explores how incorporating long-term benefits will impact the new U.S. lung transplant allocation system

Ad