Staphylococcus aureus Bacteremia

Background

  • Associated with improved patient outcomes and decreased mortality.
  • Never consider S. aureus bacteremia to be secondary to contamination (even if only 1 positive blood culture).

  • Staphylococcus aureus bacteremia is associated with significant patient morbidity and mortality (mortality rate 10 – 30%).

  • Staphylococcus aureus can spread from the blood and cause metastatic foci of infection in nearly any organ system including the brain, eye, bone/joint, lung, intraabdominal cavity, liver, spleen, artery/endothelium, endocarditis etc.

  • Staphylococcus aureus bacteriuria may be an indicator of a S. aureus bacteremia – recommend obtaining blood cultures and clinically evaluate for a systemic Staphylococcal infection.

Most Common Organisms

  • History of MRSA infection or colonization

  • Household contact with a MRSA colonized individual

  • IV drug use

  • Homelessness

  • Incarcerated persons

  • Recent travel to or residing in an MRSA endemic region or community

Management & Work-Up

  • Thorough physical examination and careful history required to determine the potential source of infection and possible metastatic foci.

  • Diagnostic imaging should be tailored to the findings from history and physical examination (ex: acute onset lumbar spine pain should prompt an MRI lumbar spine).

  • Indwelling prosthetic devices (e.g. cardiac device, orthopedic hardware, central lines, etc.) should be identified and carefully evaluated for infection.

  • Transthoracic echocardiogram recommended in all patients with Staphylococcus aureus bacteremia to rule out endocarditis.

    • Transesophageal echocardiogram preferred in those at high risk: embolic events, pacemaker, prosthetic valve, previous infective endocarditis, or intravenous drug use.
    • Consult infectious diseases for recommendations.

  • Remove the focus of infection if possible (e.g. catheter-associated bacteremia; drainable abscess, etc.).

    • New central lines should NOT be inserted, unless necessary for IV access, until there is documented clearance of the bacteremia.
  • Repeat blood cultures every 48 hours after until negative to document sterilization and determine duration of therapy.

  • Persistent bacteremia after initiation of appropriate antimicrobial therapy warrants careful reassessment and suggests inadequate source control or presence of an endovascular infection.

Empiric Treatment

More Information

Content derived from: NB Provincial Health Authorities Anti-Infective Stewardship Committee. Management of Staphylococcus aureus Bacteremia. 2021-02.

  1. Holland TL, Arnold C, Fowler VG Jr. Clinical management of Staphylococcus aureus bacteremia: a review. JAMA 2014; 312:1330.
  2. van Hal SJ, Jensen SO, Vaska VL, et al. Predictors of mortality in Staphylococcus aureus Bacteremia. Clin Microbiol Rev 2012; 25:362.
  3. Anantha RV, Jegatheswaran J, Pepe DL, et al. Risk factors for mortality among patients with Staphylococcus aureus bacteremia: a single-centre retrospective cohort study. CMAJ Open 2014; 2:E352.
  4. Holland, T.L. and Fowler V.G. (2019). Epidemiology of Staphylococcus aureus bacteremia in adults. UpToDate. Retrieved August 7, 2020 from https://www.uptodate.com/contents/epidemiology-of-staphylococcus-aureus-bacteremia-in-adults
  5. 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.
  6. 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.
  7. 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.
  8. Fowler, G.F. and Holland T.L. (2020). Clinical approach to Staphylococcus aureus bacteremia in adults. UpToDate. Retrieved August 7, 2020 from https://www.uptodate.com/contents/clinical-approach-to-staphylococcus-aureus-bacteremia-in-adults
  9. 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.
  10. Wong D, Wong T, Romney M, and Leung V. Comparison of outcomes in patients with methicillin-susceptible Staphylococcus aureus (MSSA) bacteremia who are treated with β-lactam vs vancomycin empiric therapy: a retrospective cohort study. BMC Infect Dis. 2016; 16: 224. Published online 2016 May 23. doi: 10.1186/s12879-016-1564-5
  11. Holland TH, Arnold C and Fowler VG. Clinical management of Staphylococcus aureus bacteremia: a review. JAMA. 2014 Oct 1;312(13):1330-41. doi: 10.1001/jama.2014.9743.
  12. Jung N and Rieg S. Essentials in the management of S. aureus bloodstream infection. Infection. 2018 Aug;46(4):441-442. doi: 10.1007/s15010-018-1130-8. Epub 2018 Mar 6.
  13. Shi C, Xiao Y, Zhang Q, Li Q,Wang F, Wu J, and Lin N. Efficacy and safety of cefazolin versus antistaphylococcal penicillins for the treatment of methicillin-susceptible Staphylococcus aureus bacteremia: a systematic review and meta-analysis. BMC Infect Dis. 2018; 18: 508.
  14. Schweizer ML, Furuno JP, Harris AD, Johnson JK, Shardell MD, McGregor JC, Thom KA, Cosgrove SE, Sakoulas G, and Perencevich EN. Comparative effectiveness of nafcillin or cefazolin versus vancomycin in methicillin-susceptible Staphylococcus aureus bacteremia. BMC Infect Dis. 2011 Oct 19;11:279. doi: 10.1186/1471-2334-11-279.
  15. Bidell MR, Patel N, and O'Donnell JN. Optimal treatment of MSSA bacteraemias: a meta-analysis of cefazolin versus antistaphylococcal penicillins. J Antimicrob Chemother. 2018 Oct 1;73(10):2643-2651. doi: 10.1093/jac/dky259.
  16. Weis S, Kesselmeier M, Davis JS, Morris AM, Lee S, Scherag A, Hagel S , and Pletz MW. Cefazolin versus anti-staphylococcal penicillins for the treatment of patients with Staphylococcus aureus bacteraemia. Clin Microbiol Infect. 2019 Jul;25(7):818-827. doi: 10.1016/j.cmi.2019.03.010.
  17. Horino T and Hori S. Metastatic infection during Staphylococcus aureus bacteremia. J Infect Chemother. 2020 Feb;26(2):162-169. doi: 10.1016/j.jiac.2019.10.003.
  18. Bai AD , Agarwal A , Steinberg M , Showler A , Burry L , Tomlinson GA , Bell CM and Morris AM. Clinical predictors and clinical prediction rules to estimate initial patient risk for infective endocarditis in Staphylococcus aureus bacteraemia: a systematic review and meta-analysis. Clin Microbiol Infect. 2017 Dec;23(12):900-906. doi: 10.1016/j.cmi.2017.04.025.