Staphylococcus aureus bacteremia: Difference between revisions

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Staphylococcus aureus bacteremia
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==Background==
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== Classification ==
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===Classification===
   
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* '''Community-onset:''' positive blood culture obtained within 48 hours of presentation
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*'''Community-onset:''' positive blood culture obtained within 48 hours of presentation
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* '''Nosocomial:''' positive blood culture obtained after 48 hours of presentation
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*'''Nosocomial:''' positive blood culture obtained after 48 hours of presentation
   
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== Etiology ==
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===Etiology===
   
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* IVDU
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*IVDU
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* Poor dentition
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*Poor dentition
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* Dental work
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*Dental work
   
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== Clinical Manifestations ==
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==Clinical Manifestations==
   
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* Often non-specific fevers and chills, diagnosed on blood cultures
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*Often non-specific fevers and chills, diagnosed on blood cultures
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* May have back pain unrelated to spinal osteomyelitis
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*May have back pain unrelated to spinal osteomyelitis
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* May present with focus of metastatic disease
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*May present with focus of metastatic disease
   
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== Investigations ==
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==Investigations==
   
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* Repeat blood cultures every 24 to 48 hours until negative
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*Repeat blood cultures every 24 to 48 hours until negative
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* Transthoracic echo (TTE) or transesophageal echo (TEE)
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*Transthoracic echo (TTE) or transesophageal echo (TEE)
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** A modern TTE that is good-quality and shows normal valves is quite good, though TEE is still better
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**A modern TTE that is good-quality and shows normal valves is quite good, though TEE is still better
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**TEE is strongly suggested in certain cases:
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***[[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
   
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== Management ==
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==Management==
   
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* Infectious diseases consultation
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*Infectious diseases consultation
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* Must rule out endocarditis! TTE, followed by TEE if suspicion remains high
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*Must rule out endocarditis! TTE, followed by TEE if suspicion remains high
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* Low risk for endocarditis (no TEE) if all of the following:
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*Low risk for endocarditis (no TEE) if all of the following:
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** No intracardiac device
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**No intracardiac device
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** Sterile follow-up blood cultures within 4 days from the initial set
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**Sterile follow-up blood cultures within 4 days from the initial set
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** No hemodialysis
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**No hemodialysis
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** Nosocomial acquisition of [[S. aureus]]
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**Nosocomial acquisition of [[S. aureus]]
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** Absence of secondary foci
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**Absence of secondary foci
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** No clinical signs of endocarditis
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**No clinical signs of endocarditis
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* Uncomplicated if
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*Uncomplicated if
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** Endocarditis is excluded
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**Endocarditis is excluded
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** No implanted prostheses
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**No implanted prostheses
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** Blood cultures clear by 2-4 days
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**Blood cultures clear by 2-4 days
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** Defervesces within 72 hours
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**Defervesces within 72 hours
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** No evidence of metastases
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**No evidence of metastases
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** +/- identified source has been removed
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**+/- identified source has been removed
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* Two-week course acceptable if uncomplicated, otherwise 4-6 weeks
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*Two-week course acceptable if uncomplicated, otherwise 4-6 weeks
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* MSSA: [[cloxacillin]] 2g IV q4h for 2 weeks ([[cefazolin]] as an alternative)
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*MSSA: [[cloxacillin]] 2g IV q4h for 2 weeks ([[cefazolin]] as an alternative)
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* MRSA: [[vancomycin]] 1g IV q12h for 2 weeks
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*MRSA: [[vancomycin]] 1g IV q12h for 2 weeks
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** Adjust based on serum trough before every fourth dose
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**Adjust based on serum trough before every fourth dose
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** Target trough 15-20
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**Target trough 15-20
   
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== Prognosis ==
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==Prognosis==
   
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* Mortality 20-50% at 30 days, 60% at 1 year
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*Mortality 20-50% at 30 days, 60% at 1 year
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* Mortality halved by ID consult
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*Mortality halved by ID consult
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* Prognosis worse with
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*Prognosis worse with
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** Increased age
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**Increased age
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** Female sex
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**Female sex
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** Pneumonia or source unknown
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**Pneumonia or source unknown
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** Dementia
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**Dementia
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** Increasing comorbidities
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**Increasing comorbidities
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** Shock at time of presentation
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**Shock at time of presentation
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** Institutionalized patient
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**Institutionalized patient
   
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== Further Reading ==
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==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)

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. ^  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.
  3. ^  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.

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