基本だね S. aureus bacteremia ．
合併症確認は必ず S. aureus bacteremia
De-escalationだね S. aureus bacteremia．
心エコーだね S. aureus bacteremia
治療期間の決定は血液培養陰性だね S. aureus bacteremia．
少量アミノグリコシドの併用はやめよう S. aureus bacteremia
The clinical approach to S. aureus bacteremia consists of careful history and physical examination, infectious disease consultation, and diagnostic evaluation including echocardiography and additional imaging as needed.
Patients should be questioned regarding potential portals of entry, presence of indwelling prosthetic devices, and symptoms that may reflect metastatic infection. These include bone or joint pain (particularly back pain, suggesting vertebral osteomyelitis, discitis, and/or epidural abscess) and protracted fever and/or sweats (suggestive of endocarditis).
The physical examination should include cardiac examination for signs of new murmurs or heart failure. A search should be undertaken for clinical stigmata of endocarditis, including evidence of small and large emboli. Serial bedside examinations are critical for detection of complications that may develop after initial evaluation and during the course of treatment.
We recommend bedside infectious disease consultation for management of patients with S. aureus bacteremia (Grade 1B); this is a critical component of management for patients with S. aureus bacteremia and is associated with better outcomes including fewer deaths, fewer relapses, and lower readmission rates.
In general, blood cultures positive for S. aureus should be respected as a clinically significant finding that should prompt clinical evaluation and initiation of empiric therapy. All patients with S. aureus bacteremia should undergo echocardiography to evaluate for presence of endocarditis. Additional diagnostic imaging should be tailored to findings on history and physical examination.
In the setting of blood cultures with gram-positive cocci prior to availability of culture and susceptibility data, we suggest administration of empiric antimicrobial therapy with activity against methicillin resistant S. aureus (MRSA; rather than empiric therapy with activity against both MRSA and methicillin-susceptible S. aureus [MSSA]) (Grade 2B). Empiric treatment consists of vancomycin; daptomycin is an acceptable alternative agent.
We recommend treating MSSA bacteremia with a beta-lactam antibiotic (in preference to vancomycin or daptomycin) (Grade 1B). Regimens include penicillin, nafcillin, oxacillin, or flucloxacillin. A first-generation cephalosporin such as cefazolin is an acceptable alternative.
Vancomycin is less effective for treatment of S. aureus bacteremia than beta-lactam agents and should not be administered as primary therapy for methicillin-sensitive strains unless the use of a beta-lactam agent is precluded by drug intolerance.
We recommend NOT combining low-dose aminoglycosides with antistaphylococcal penicillins or vancomycin for treatment of S. aureus bacteremia (Grade 1B).
The duration of therapy depends on the etiology of infection. In general, patients with bacteremia with a removable focus of infection may be treated with 14 days of intravenous therapy from the first negative blood culture.
DURATION OF THERAPY
The duration of therapy for S. aureus bacteremia depends on the etiology of infection . Determination of treatment duration requires differentiation of patients with uncomplicated S aureus bacteremia (who may be cured with 14 days of intravenous therapy from the first negative blood culture) from patients with complicated S. aureus bacteremia (who require longer duration of intravenous treatment).
In general, a patient may be presumed to have uncomplicated S. aureus bacteremia if all of the following criteria are met:
- Infective endocarditis has been excluded via echocardiography.
- No indwelling devices (such as prosthetic heart valves or vascular grafts) are present.
- Follow-up blood cultures drawn two to four days after initiating intravenous antistaphylococcal therapy and removing the presumed focus of infection (if present) are negative.
- The patient defervesced within 48 to 72 hours after initiating intravenous antistaphylococcal therapy and removal of the presumed focus of infection (such as debridement of soft tissue infection or intravascular catheter removal).
- There is no evidence of metastatic staphylococcal infection on physical examination.
Patients with S. aureus bacteremia and cardiac valvular abnormalities with no vegetation on transesophageal echocardiography (TEE) may be treated with 14 days of antimicrobial therapy. These patients should have negative surveillance blood cultures within 72 hours after initiation of appropriate antimicrobial therapy and no signs of systemic staphylococcal infection.
Patients with S. aureus bacteremia who do not meet all of the above criteria should be presumed to have a deep focus of infection, warranting intravenous treatment for longer than two weeks.