Staphylococcus aureus bacteremia: Difference between revisions

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Staphylococcus aureus bacteremia
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==Background==
== Classification ==
===Classification===


* '''Community-onset:''' positive blood culture obtained within 48 hours of presentation
*'''Community-onset:''' positive blood culture obtained within 48 hours of presentation
* '''Nosocomial:''' positive blood culture obtained after 48 hours of presentation
*'''Nosocomial:''' positive blood culture obtained after 48 hours of presentation


== Etiology ==
===Etiology===


* IVDU
*IVDU
* Poor dentition
*Poor dentition
* Dental work
*Dental work


== Clinical Manifestations ==
==Clinical Manifestations==


* Often non-specific fevers and chills, diagnosed on blood cultures
*Often non-specific fevers and chills, diagnosed on blood cultures
* May have back pain unrelated to spinal osteomyelitis
*May have back pain unrelated to spinal osteomyelitis
* May present with focus of metastatic disease
*May present with focus of metastatic disease


== Investigations ==
==Investigations==


* Repeat blood cultures every 24 to 48 hours until negative
*Repeat blood cultures every 24 to 48 hours until negative
* Transthoracic echo (TTE) or transesophageal echo (TEE)
*Transthoracic echo (TTE) or transesophageal echo (TEE)
** A modern TTE that is good-quality and shows normal valves is quite good, though TEE is still better
**A modern TTE that is good-quality and shows normal valves is quite good, though TEE is still better
**TEE is strongly suggested in certain cases:
***[[Embolic stroke|Cerebral]] or peripheral emboli
***[[Meningitis]]
***[[Cardiovascular implantable electronic device infection|Implantable cardiac device]] or [[prosthetic heart valve]]
***Prior [[infective endocarditis]]
***Native valve disease
***Injection drug use
***Persistent bacteremia beyond 72 hours


== Management ==
==Management==


* Infectious diseases consultation
*Infectious diseases consultation
* Must rule out endocarditis! TTE, followed by TEE if suspicion remains high
*Must rule out endocarditis! TTE, followed by TEE if suspicion remains high
* Low risk for endocarditis (no TEE) if all of the following:
*Low risk for endocarditis (no TEE) if all of the following:
** No intracardiac device
**No intracardiac device
** Sterile follow-up blood cultures within 4 days from the initial set
**Sterile follow-up blood cultures within 4 days from the initial set
** No hemodialysis
**No hemodialysis
** Nosocomial acquisition of [[S. aureus]]
**Nosocomial acquisition of [[S. aureus]]
** Absence of secondary foci
**Absence of secondary foci
** No clinical signs of endocarditis
**No clinical signs of endocarditis
* Uncomplicated if
*Uncomplicated if
** Endocarditis is excluded
**Endocarditis is excluded
** No implanted prostheses
**No implanted prostheses
** Blood cultures clear by 2-4 days
**Blood cultures clear by 2-4 days
** Defervesces within 72 hours
**Defervesces within 72 hours
** No evidence of metastases
**No evidence of metastases
** +/- identified source has been removed
**+/- identified source has been removed
* Two-week course acceptable if uncomplicated, otherwise 4-6 weeks
*Two-week course acceptable if uncomplicated, otherwise 4-6 weeks
* MSSA: [[cloxacillin]] 2g IV q4h for 2 weeks ([[cefazolin]] as an alternative)
*MSSA: [[cloxacillin]] 2g IV q4h for 2 weeks ([[cefazolin]] as an alternative)
* MRSA: [[vancomycin]] 1g IV q12h for 2 weeks
*MRSA: [[vancomycin]] 1g IV q12h for 2 weeks
** Adjust based on serum trough before every fourth dose
**Adjust based on serum trough before every fourth dose
** Target trough 15-20
**Target trough 15-20


== Prognosis ==
==Prognosis==


* Mortality 20-50% at 30 days, 60% at 1 year
*Mortality 20-50% at 30 days, 60% at 1 year
* Mortality halved by ID consult
*Mortality halved by ID consult
* Prognosis worse with
*Prognosis worse with
** Increased age
**Increased age
** Female sex
**Female sex
** Pneumonia or source unknown
**Pneumonia or source unknown
** Dementia
**Dementia
** Increasing comorbidities
**Increasing comorbidities
** Shock at time of presentation
**Shock at time of presentation
** Institutionalized patient
**Institutionalized patient


== Further Reading ==
==Further Reading==


{{DISPLAYTITLE:''Staphylococcus aureus'' bacteremia}}
{{DISPLAYTITLE:''Staphylococcus aureus'' bacteremia}}

Revision as of 19:43, 20 August 2020

Background

Classification

  • Community-onset: positive blood culture obtained within 48 hours of presentation
  • Nosocomial: positive blood culture obtained after 48 hours of presentation

Etiology

  • IVDU
  • Poor dentition
  • Dental work

Clinical Manifestations

  • Often non-specific fevers and chills, diagnosed on blood cultures
  • May have back pain unrelated to spinal osteomyelitis
  • May present with focus of metastatic disease

Investigations

  • Repeat blood cultures every 24 to 48 hours until negative
  • Transthoracic echo (TTE) or transesophageal echo (TEE)

Management

  • Infectious diseases consultation
  • Must rule out endocarditis! TTE, followed by TEE if suspicion remains high
  • Low risk for endocarditis (no TEE) if all of the following:
    • No intracardiac device
    • Sterile follow-up blood cultures within 4 days from the initial set
    • No hemodialysis
    • Nosocomial acquisition of S. aureus
    • Absence of secondary foci
    • No clinical signs of endocarditis
  • Uncomplicated if
    • Endocarditis is excluded
    • No implanted prostheses
    • Blood cultures clear by 2-4 days
    • Defervesces within 72 hours
    • No evidence of metastases
    • +/- identified source has been removed
  • Two-week course acceptable if uncomplicated, otherwise 4-6 weeks
  • MSSA: cloxacillin 2g IV q4h for 2 weeks (cefazolin as an alternative)
  • MRSA: vancomycin 1g IV q12h for 2 weeks
    • Adjust based on serum trough before every fourth dose
    • Target trough 15-20

Prognosis

  • Mortality 20-50% at 30 days, 60% at 1 year
  • Mortality halved by ID consult
  • Prognosis worse with
    • Increased age
    • Female sex
    • Pneumonia or source unknown
    • Dementia
    • Increasing comorbidities
    • Shock at time of presentation
    • Institutionalized patient

Further Reading

References

  1. ^  Anthony D. Bai, Carson KL. Lo, Adam S. Komorowski, Mallika Suresh, Kevin Guo, Akhil Garg, Pranav Tandon, Julien Senecal, Olivier Del Corpo, Isabella Stefanova, Clare Fogarty, Guillaume Butler-Laporte, Emily G. McDonald, Matthew P. Cheng, Andrew M. Morris, Mark Loeb, Todd C. Lee. Staphylococcus aureus bacteremia mortality: A systematic review and meta-analysis. Clinical Microbiology and Infection. 2022. doi:10.1016/j.cmi.2022.03.015.
  2. ^  Bharath Raj Palraj, Larry M. Baddour, Erik P. Hess, James M. Steckelberg, Walter R. Wilson, Brian D. Lahr, M. Rizwan Sohail. Predicting Risk of Endocarditis Using a Clinical Tool (PREDICT): Scoring System to Guide Use of Echocardiography in the Management of Staphylococcus aureus Bacteremia. Clinical Infectious Diseases. 2015;61(1):18-28. doi:10.1093/cid/civ235.
  3. ^  Sarah Tubiana, Xavier Duval, François Alla, Christine Selton-Suty, Pierre Tattevin, François Delahaye, Lionel Piroth, Catherine Chirouze, Jean-Philippe Lavigne, Marie-Line Erpelding, Bruno Hoen, François Vandenesch, Bernard Iung, Vincent Le Moing. The VIRSTA score, a prediction score to estimate risk of infective endocarditis and determine priority for echocardiography in patients with Staphylococcus aureus bacteremia. Journal of Infection. 2016;72(5):544-553. doi:10.1016/j.jinf.2016.02.003.

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