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bacteremia
Staph bacteremia
Overview
Clinical syndromes
How to treat
Complications
GPC in blood
Other positive cultures
Bacteremia
Nosocomial
Most common pathogenStaph epi
2nd Staph aureus20% of nosocomial bacteremias
Risk factorsIV catheters, severe pneumonia,
surgical wound, foreign body, dialysis
Community acquired
More likely to have IVDU, epidural abscess
Australia 2005 49% of staph bacteremias
community onset, 12% of these MRSA
5147
Staphylococcus aureus
MRSA
UNC antibiogram 2004
Staph aureus-57% oxacillin susceptible
MRSA
Is MRSA more virulent than MSSA?
Unclear, but patients with MRSA bacteremia tend
to have higher morbidity and mortality
Efficacy of therapy-vanc inferior to
nafcillin/oxacillin
MSSA relapse 19% vanc vs 0% nafcillin Chang
Medicine 2003
Community MRSA
Defined as seen in patients with no health care contact
in past year and positive cultures within 48 hours of
admission or in outpatient setting
Seems especially prevalent in military personnel
Presents as soft tissue abscess- bug bite that can be
progressive and associated with bacteremia
Always check sensitivities
Initially can use trimethoprim-sulfamethoxazole or
Clindamycin- however resistance to this is inducible,
make sure a D-test is performed
Vancomycin for serious infections
Linezolid also an option
7824
D- test Blunting of the clindamycin susceptibility zone adjacent to the erythromycin zone
Clinical syndromes
Catheter associated infections
Endocarditis versus Bacteremia
Suppurative complications
Vertebral osteomyelitis and discitis
Septic arthritis
Splenic abscess
Meningitis
Deep tissue abscess
Complications
Patients at highest risk for complications
Absence of identifiable focus
> 3days of positive cultures (OR 5.58)
Complications
Endocarditis
Vertebral osteomyelitis/discitis
Septic arthritis
Splenic abscess
Mycotic aneurysms
Meningitis
Tissue abscess
Major criteria
Blood culture positive for IE
Typical microorganisms consistent with IE from 2 separate blood cultures: Viridans
streptococci, Streptococcus bovis, HACEK group, Staphylococcus aureus; or
community-acquired enterococci in the absence of a primary focus; or
Microorganisms consistent with IE from persistently positive blood cultures defined
as follows: At least 2 positive cultures of blood samples drawn >12 h apart; or all of 3 or
a majority of 4 separate cultures of blood (with first and last sample drawn at least 1 h
apart)
Single positive blood culture for Coxiella burnetii or antiphase 1 IgG
antibody titer >1:800
Evidence of endocardial involvement
Echocardiogram positive for IE (TEE recommended for patients with prosthetic
valves, rated at least "possible IE" by clinical criteria, or complicated IE
[paravalvular abscess]; TTE as first test in other patients) defined as follows:
oscillating intracardiac mass on valve or supporting structures, in the path of regurgitant
jets, or on implanted material in the absence of an alternative anatomic explanation; or
abscess; or new partial dehiscence of prosthetic valve; new valvular regurgitation
(worsening or changing or preexisting murmur not sufficient)
Minor criteria
Predisposition, predisposing heart condition, or IDU
Fever, temperature >38C
Vascular phenomena, major arterial emboli, septic pulmonary infarcts, mycotic
aneurysm, intracranial hemorrhage, conjunctival hemorrhages, and Janeways lesions
Immunologic phenomena: glomerulonephritis, Oslers nodes, Roths spots, and
rheumatoid factor
Microbiological evidence: positive blood culture but does not meet a major criterion as
noted above* or serological evidence of active infection with organism consistent with IE
Echocardiographic minor criteria eliminated
TTE vs TEE
Catheter associated Staph bacteremiaestimated probability of endocarditis 3-4%
here TTE is cost effective
Unexplained bacteremia-estimated risk of
endocarditis 4-50% but for Staph probably
exceeds 25% here TEE is cost effective
Heidenreich PA et al. Echocardiography in patients with suspected
endocarditis: a cost effective analyis
Van Hal SJ, Mathur G, Kelly J, Aronis C, Cranney GB, Jones PD. The role of
transthoracic echocardiography in excluding left sided infective endocarditis in
Staphylococcus aureus bacteraemia. J Infect. 2005 Oct;51(3):218-21.
Complications
Endocarditis
Vertebral osteomyelitis/discitis
Septic arthritis
Splenic abscess
Mycotic aneurysms
Meningitis
Tissue abscess
Principles of treatment
Remove focus-<18% treatment success if focus
remains
Drain fluid collections
Replace/remove prosthetic device if possible
High risk of endocarditis-need echo
TTE for line infections with no embolic
stigmata???, TEE for all others vs TEE for all
Vertebral osteo/deep soft tissue abscess often
overlooked-may require imaging
Treatment
Simple bacteremiafocus removed, neg echo,
normal heart valves, repeat cultures at 3 days
negative14 days
Complicated-positive blood cultures at 3 days,
continued fevers-consider imaging for osteo/soft
tissue focustreat for 3-4 weeks
Endocarditis-treat for 4-6 weeks
Osteo/abscess-drain focus treat for 4-8 weeks
Daptomycin
Daptomycin 6mg/kg daily n=124 vs antiStaph PCN/Vanc
plus gent (n=122)
At 42 days successful outcome 44% dapto vs 41%
showing noninferiority
Failure to reach successful outcome included death,
clinical or microbiologic failure, or discontinuation of
study drug due to adverse event or failure
Higher rate of microbiologic failure in daptomycin
More adverse renal events in standard therapy
Reduced susceptibility noted in daptomycin and vanc not
in oxacillin treated subjects
CK elevations in 6% of daptomycin treated subjects
Meta-analysis
Clinical cure 14 (56%) of 25 linezolid
recipients and 13 (46%) of 28 vancomycin
recipients (OR, 1.47; 95% CI, 0.50-4.34).
Microbiological success occurred in 41
(69%) of 59 linezolid recipients and 41
(73%) of 56 vancomycin recipients (OR,
0.83; 95% CI, 0.37-1.87
Numerous case reports of Staph aureus
developing linezolid resistance on therapy
Always treat
Any Staph aureusblood, CSF, urine,
most body fluids
Any fungus in blood, CSF
GNR in blood