Staphylococcus aureus bacteremia: Difference between revisions
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Staphylococcus aureus bacteremia
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+ | ==Background== |
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− | == |
+ | ===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) |
− | ** |
+ | **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 |
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+ | ***[[Meningitis]] |
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+ | ***[[Cardiovascular implantable electronic device infection|Implantable cardiac device]] or [[prosthetic heart valve]] |
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+ | ***Prior [[infective endocarditis]] |
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+ | ***Native valve disease |
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+ | ***Injection drug use |
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+ | ***Persistent bacteremia beyond 72 hours |
||
− | == |
+ | ==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== |
{{DISPLAYTITLE:''Staphylococcus aureus'' bacteremia}} |
{{DISPLAYTITLE:''Staphylococcus aureus'' bacteremia}} |
Revision as of 15:43, 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)
- 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:
- Cerebral or peripheral emboli
- Meningitis
- Implantable cardiac device or prosthetic heart valve
- Prior infective endocarditis
- Native valve disease
- Injection drug use
- Persistent bacteremia beyond 72 hours
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
- ^ 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.
- ^ 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.
- ^ Thomas W van der Vaart, Jan M Prins, Robin Soetekouw, Gitte van Twillert, Jan Veenstra, Bjorn L Herpers, Wouter Rozemeijer, Rogier R Jansen, Marc J M Bonten, Jan T M van der Meer. Prediction Rules for Ruling Out Endocarditis in Patients With Staphylococcus aureus Bacteremia. Clinical Infectious Diseases. 2021;74(8):1442-1449. doi:10.1093/cid/ciab632.