Clinical approach to Staphylococcus aureus bacteremia in adults
- Vance G Fowler, Jr, MD
Vance G Fowler, Jr, MD
- Professor of Medicine
- Duke University Medical Center
- Daniel J Sexton, MD
Daniel J Sexton, MD
- Editor-in-Chief — Infectious Diseases
- Section Editor — Bacterial Infections
- Professor of Medicine
- Duke University Medical Center
Staphylococcus aureus is a leading cause of community-acquired and hospital-acquired bacteremia. Patients with S. aureus bacteremia can develop a broad array of complications that may be difficult to recognize initially and can increase morbidity. Mortality rates of 20 to 40 percent have been described [1,2]. Mortality appears to be higher with methicillin-resistant (MRSA) compared with methicillin-sensitive S. aureus (MSSA) bacteremia [1,2].
Treatment failure (ie, death within 30 days following treatment, persistent bacteremia >10 days after initiation of appropriate therapy, or recurrence of bacteremia within 60 days of discontinuing therapy) is fairly common in patients with S. aureus bacteremia, particularly in the setting of infection due to MRSA .
Issues related to the clinical approach to S. aureus bacteremia in adults will be reviewed here. Issues related to clinical manifestations of S. aureus infection are discussed separately. The epidemiology, risk factors, and complications of S. aureus bacteremia and treatment of methicillin-resistant or vancomycin-resistant S. aureus infections are discussed separately. (See "Clinical manifestations of Staphylococcus aureus infection in adults".)
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.
History and physical examination — A careful history and physical examination is essential. For circumstances in which the source of bacteremia is uncertain, patients should be questioned carefully regarding potential portals of entry including recent skin or soft tissue infection and presence of indwelling prosthetic devices (including intravascular catheters, orthopedic hardware, and cardiac devices).
- Mylotte JM, McDermott C, Spooner JA. Prospective study of 114 consecutive episodes of Staphylococcus aureus bacteremia. Rev Infect Dis 1987; 9:891.
- Shurland S, Zhan M, Bradham DD, Roghmann MC. Comparison of mortality risk associated with bacteremia due to methicillin-resistant and methicillin-susceptible Staphylococcus aureus. Infect Control Hosp Epidemiol 2007; 28:273.
- Lodise TP, Graves J, Evans A, et al. Relationship between vancomycin MIC and failure among patients with methicillin-resistant Staphylococcus aureus bacteremia treated with vancomycin. Antimicrob Agents Chemother 2008; 52:3315.
- Ing MB, Baddour LM, Bayer AS. Bacteremia and infective endocarditis: Pathogenesis, diagnosis, and complications. In: The Staphylococci in Human Disease, Crossley KB, Archer GL (Eds), Churchill Livingstone, New York 1997. p.331.
- Jensen AG, Espersen F, Skinhøj P, Frimodt-Møller N. Bacteremic Staphylococcus aureus spondylitis. Arch Intern Med 1998; 158:509.
- Danner RL, Hartman BJ. Update on spinal epidural abscess: 35 cases and review of the literature. Rev Infect Dis 1987; 9:265.
- Darouiche RO, Hamill RJ, Greenberg SB, et al. Bacterial spinal epidural abscess. Review of 43 cases and literature survey. Medicine (Baltimore) 1992; 71:369.
- Jernigan JA, Farr BM. Short-course therapy of catheter-related Staphylococcus aureus bacteremia: a meta-analysis. Ann Intern Med 1993; 119:304.
- Jenkins TC, Price CS, Sabel AL, et al. Impact of routine infectious diseases service consultation on the evaluation, management, and outcomes of Staphylococcus aureus bacteremia. Clin Infect Dis 2008; 46:1000.
- Honda H, Krauss MJ, Jones JC, et al. The value of infectious diseases consultation in Staphylococcus aureus bacteremia. Am J Med 2010; 123:631.
- Lahey T, Shah R, Gittzus J, et al. Infectious diseases consultation lowers mortality from Staphylococcus aureus bacteremia. Medicine (Baltimore) 2009; 88:263.
- Rieg S, Peyerl-Hoffmann G, de With K, et al. Mortality of S. aureus bacteremia and infectious diseases specialist consultation--a study of 521 patients in Germany. J Infect 2009; 59:232.
- Fowler VG Jr, Sanders LL, Sexton DJ, et al. Outcome of Staphylococcus aureus bacteremia according to compliance with recommendations of infectious diseases specialists: experience with 244 patients. Clin Infect Dis 1998; 27:478.
- Forsblom E, Ruotsalainen E, Ollgren J, Järvinen A. Telephone consultation cannot replace bedside infectious disease consultation in the management of Staphylococcus aureus Bacteremia. Clin Infect Dis 2013; 56:527.
- Bai AD, Showler A, Burry L, et al. Impact of Infectious Disease Consultation on Quality of Care, Mortality, and Length of Stay in Staphylococcus aureus Bacteremia: Results From a Large Multicenter Cohort Study. Clin Infect Dis 2015; 60:1451.
- Vogel M, Schmitz RP, Hagel S, et al. Infectious disease consultation for Staphylococcus aureus bacteremia - A systematic review and meta-analysis. J Infect 2016; 72:19.
- Holland TL, Arnold C, Fowler VG Jr. Clinical management of Staphylococcus aureus bacteremia: a review. JAMA 2014; 312:1330.
- Liu C, Bayer A, Cosgrove SE, et al. Clinical practice guidelines by the infectious diseases society of america for the treatment of methicillin-resistant Staphylococcus aureus infections in adults and children. Clin Infect Dis 2011; 52:e18.
- Kaasch AJ, Fowler VG Jr, Rieg S, et al. Use of a simple criteria set for guiding echocardiography in nosocomial Staphylococcus aureus bacteremia. Clin Infect Dis 2011; 53:1.
- Rasmussen RV, Høst U, Arpi M, et al. Prevalence of infective endocarditis in patients with Staphylococcus aureus bacteraemia: the value of screening with echocardiography. Eur J Echocardiogr 2011; 12:414.
- Fowler VG Jr, Li J, Corey GR, et al. Role of echocardiography in evaluation of patients with Staphylococcus aureus bacteremia: experience in 103 patients. J Am Coll Cardiol 1997; 30:1072.
- Abraham J, Mansour C, Veledar E, et al. Staphylococcus aureus bacteremia and endocarditis: the Grady Memorial Hospital experience with methicillin-sensitive S aureus and methicillin-resistant S aureus bacteremia. Am Heart J 2004; 147:536.
- Sullenberger AL, Avedissian LS, Kent SM. Importance of transesophageal echocardiography in the evaluation of Staphylococcus aureus bacteremia. J Heart Valve Dis 2005; 14:23.
- Incani A, Hair C, Purnell P, et al. Staphylococcus aureus bacteraemia: evaluation of the role of transoesophageal echocardiography in identifying clinically unsuspected endocarditis. Eur J Clin Microbiol Infect Dis 2013; 32:1003.
- Rosen AB, Fowler VG Jr, Corey GR, et al. Cost-effectiveness of transesophageal echocardiography to determine the duration of therapy for intravascular catheter-associated Staphylococcus aureus bacteremia. Ann Intern Med 1999; 130:810.
- Sochowski RA, Chan KL. Implication of negative results on a monoplane transesophageal echocardiographic study in patients with suspected infective endocarditis. J Am Coll Cardiol 1993; 21:216.
- Khandheria BK, Seward JB, Tajik AJ. Transesophageal echocardiography. Mayo Clin Proc 1994; 69:856.
- Showler A, Burry L, Bai AD, et al. Use of Transthoracic Echocardiography in the Management of Low-Risk Staphylococcus aureus Bacteremia: Results From a Retrospective Multicenter Cohort Study. JACC Cardiovasc Imaging 2015; 8:924.
- Khatib R, Sharma M. Echocardiography is dispensable in uncomplicated Staphylococcus aureus bacteremia. Medicine (Baltimore) 2013; 92:182.
- Palraj BR, Baddour LM, Hess EP, et al. Predicting Risk of Endocarditis Using a Clinical Tool (PREDICT): Scoring System to Guide Use of Echocardiography in the Management of Staphylococcus aureus Bacteremia. Clin Infect Dis 2015; 61:18.
- Barton T, Moir S, Rehmani H, et al. Low rates of endocarditis in healthcare-associated Staphylococcus aureus bacteremia suggest that echocardiography might not always be required. Eur J Clin Microbiol Infect Dis 2015.
- Mermel LA, Allon M, Bouza E, et al. Clinical practice guidelines for the diagnosis and management of intravascular catheter-related infection: 2009 Update by the Infectious Diseases Society of America. Clin Infect Dis 2009; 49:1.
- López-Cortés LE, Del Toro MD, Gálvez-Acebal J, et al. Impact of an evidence-based bundle intervention in the quality-of-care management and outcome of Staphylococcus aureus bacteremia. Clin Infect Dis 2013; 57:1225.
- McConeghy KW, Bleasdale SC, Rodvold KA. The empirical combination of vancomycin and a β-lactam for Staphylococcal bacteremia. Clin Infect Dis 2013; 57:1760.
- Kim SH, Kim KH, Kim HB, et al. Outcome of vancomycin treatment in patients with methicillin-susceptible Staphylococcus aureus bacteremia. Antimicrob Agents Chemother 2008; 52:192.
- Davis JS, Sud A, O'Sullivan MV, et al. Combination of Vancomycin and β-Lactam Therapy for Methicillin-Resistant Staphylococcus aureus Bacteremia: A Pilot Multicenter Randomized Controlled Trial. Clin Infect Dis 2016; 62:173.
- Khatib R, Saeed S, Sharma M, et al. Impact of initial antibiotic choice and delayed appropriate treatment on the outcome of Staphylococcus aureus bacteremia. Eur J Clin Microbiol Infect Dis 2006; 25:181.
- Lodise TP Jr, McKinnon PS, Levine DP, Rybak MJ. Impact of empirical-therapy selection on outcomes of intravenous drug users with infective endocarditis caused by methicillin-susceptible Staphylococcus aureus. Antimicrob Agents Chemother 2007; 51:3731.
- Stryjewski ME, Szczech LA, Benjamin DK Jr, et al. Use of vancomycin or first-generation cephalosporins for the treatment of hemodialysis-dependent patients with methicillin-susceptible Staphylococcus aureus bacteremia. Clin Infect Dis 2007; 44:190.
- McDanel JS, Perencevich EN, Diekema DJ, et al. Comparative effectiveness of beta-lactams versus vancomycin for treatment of methicillin-susceptible Staphylococcus aureus bloodstream infections among 122 hospitals. Clin Infect Dis 2015; 61:361.
- Nissen JL, Skov R, Knudsen JD, et al. Effectiveness of penicillin, dicloxacillin and cefuroxime for penicillin-susceptible Staphylococcus aureus bacteraemia: a retrospective, propensity-score-adjusted case-control and cohort analysis. J Antimicrob Chemother 2013; 68:1894.
- Lowy FD. Staphylococcus aureus infections. N Engl J Med 1998; 339:520.
- Sutherland R, Croydon EA, Rolinson GN. Flucloxacillin, a new isoxazolyl penicillin, compared with oxacillin, cloxacillin, and dicloxacillin. Br Med J 1970; 4:455.
- Youngster I, Shenoy ES, Hooper DC, Nelson SB. Comparative evaluation of the tolerability of cefazolin and nafcillin for treatment of methicillin-susceptible Staphylococcus aureus infections in the outpatient setting. Clin Infect Dis 2014; 59:369.
- Li J, Echevarria KL, Hughes DW, et al. Comparison of cefazolin versus oxacillin for treatment of complicated bacteremia caused by methicillin-susceptible Staphylococcus aureus. Antimicrob Agents Chemother 2014; 58:5117.
- Bai AD, Showler A, Burry L, et al. Comparative effectiveness of cefazolin versus cloxacillin as definitive antibiotic therapy for MSSA bacteraemia: results from a large multicentre cohort study. J Antimicrob Chemother 2015; 70:1539.
- Lee S, Choe PG, Song KH, et al. Is cefazolin inferior to nafcillin for treatment of methicillin-susceptible Staphylococcus aureus bacteremia? Antimicrob Agents Chemother 2011; 55:5122.
- Hartstein AI, Mulligan ME, Morthland VH, Kwok RY. Recurrent Staphylococcus aureus bacteremia. J Clin Microbiol 1992; 30:670.
- Fowler VG Jr, Kong LK, Corey GR, et al. Recurrent Staphylococcus aureus bacteremia: pulsed-field gel electrophoresis findings in 29 patients. J Infect Dis 1999; 179:1157.
- Karchmer AW. Staphylococcus aureus and vancomycin: the sequel. Ann Intern Med 1991; 115:739.
- Levine DP, Fromm BS, Reddy BR. Slow response to vancomycin or vancomycin plus rifampin in methicillin-resistant Staphylococcus aureus endocarditis. Ann Intern Med 1991; 115:674.
- Mortara LA, Bayer AS. Staphylococcus aureus bacteremia and endocarditis. New diagnostic and therapeutic concepts. Infect Dis Clin North Am 1993; 7:53.
- Small PM, Chambers HF. Vancomycin for Staphylococcus aureus endocarditis in intravenous drug users. Antimicrob Agents Chemother 1990; 34:1227.
- Chang FY, Peacock JE Jr, Musher DM, et al. Staphylococcus aureus bacteremia: recurrence and the impact of antibiotic treatment in a prospective multicenter study. Medicine (Baltimore) 2003; 82:333.
- Stevens DL. The role of vancomycin in the treatment paradigm. Clin Infect Dis 2006; 42 Suppl 1:S51.
- González C, Rubio M, Romero-Vivas J, et al. Bacteremic pneumonia due to Staphylococcus aureus: A comparison of disease caused by methicillin-resistant and methicillin-susceptible organisms. Clin Infect Dis 1999; 29:1171.
- Gentry CA, Rodvold KA, Novak RM, et al. Retrospective evaluation of therapies for Staphylococcus aureus endocarditis. Pharmacotherapy 1997; 17:990.
- Blumenthal KG, Parker RA, Shenoy ES, Walensky RP. Improving Clinical Outcomes in Patients With Methicillin-Sensitive Staphylococcus aureus Bacteremia and Reported Penicillin Allergy. Clin Infect Dis 2015; 61:741.
- Korzeniowski O, Sande MA. Combination antimicrobial therapy for Staphylococcus aureus endocarditis in patients addicted to parenteral drugs and in nonaddicts: A prospective study. Ann Intern Med 1982; 97:496.
- Fowler VG Jr, Boucher HW, Corey GR, et al. Daptomycin versus standard therapy for bacteremia and endocarditis caused by Staphylococcus aureus. N Engl J Med 2006; 355:653.
- Cosgrove SE, Vigliani GA, Fowler VG Jr, et al. Initial low-dose gentamicin for Staphylococcus aureus bacteremia and endocarditis is nephrotoxic. Clin Infect Dis 2009; 48:713.
- Chong YP, Moon SM, Bang KM, et al. Treatment duration for uncomplicated Staphylococcus aureus bacteremia to prevent relapse: analysis of a prospective observational cohort study. Antimicrob Agents Chemother 2013; 57:1150.
- Wyllie DH, Crook DW, Peto TE. Mortality after Staphylococcus aureus bacteraemia in two hospitals in Oxfordshire, 1997-2003: cohort study. BMJ 2006; 333:281.
- Gopal AK, Fowler VG Jr, Shah M, et al. Prospective analysis of Staphylococcus aureus bacteremia in nonneutropenic adults with malignancy. J Clin Oncol 2000; 18:1110.
- Lesens O, Methlin C, Hansmann Y, et al. Role of comorbidity in mortality related to Staphylococcus aureus bacteremia: a prospective study using the Charlson weighted index of comorbidity. Infect Control Hosp Epidemiol 2003; 24:890.
- Marra AR, Edmond MB, Forbes BA, et al. Time to blood culture positivity as a predictor of clinical outcome of Staphylococcus aureus bloodstream infection. J Clin Microbiol 2006; 44:1342.
- CLINICAL APPROACH
- History and physical examination
- Infectious disease consultation
- Diagnostic evaluation
- - Echocardiography
- - Imaging
- Empiric treatment
- Methicillin-susceptible S. aureus (MSSA)
- - Synergistic aminoglycosides
- Methicillin-resistant S. aureus (MRSA)
- Follow-up cultures
- DURATION OF THERAPY
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS