Empiric Treatment - Unstable, Severe Infection or Complicating Factors

Preferred Regimen (Until Susceptibilities Known):

  • Dose adjustment required in renal impairment.

PLUS

  • Target trough of 10-15 mg/L.

  • Dose adjustment required in renal impairment.

If Cannot Take Vancomycin (And Pulmonary Source NOT Suspected):

  • Dose adjustment required in renal impairment.

If evidence of toxic shock syndrome (very rare occurrence), then consider adding:

  • Staphylococcal toxic shock syndrome is characterized by rapid onset fever, rash, hypotension and multiorgan system involvement (see CDC case definition for more detail)

Clinical Considerations

  • An allergy to ceFAZolin

    OR

  • Severe non-IgE mediated reaction to a β-lactam

    • i.e. Stevens Johnson Syndrome, toxic epidermal necrolysis, drug rash with eosinophilia and systemic symptoms, serum sickness, etc.

Duration of Therapy

Duration of therapy depends on whether the S. aureus bacteremia is uncomplicated or complicated (i.e. presumed metastatic or deep focus of infection requiring a longer duration)

Uncomplicated bacteremia (all factors must be met):

  • Sterile follow-up blood cultures within 4 days;

  • No permanent intracardiac device or implanted prosthesis;

  • No hemodialysis dependence;

  • No clinical signs of endocarditis or metastatic foci of infection;

  • Removable focus of infection removed promptly, if present;

  • Defervescence within 72 hours of antimicrobial therapy;

  • No evidence of endocarditis on a good quality echo.

Complicating factors include (only 1 required):

  • Evidence or clinical suspicion of endocarditis;

  • Failure to defervesce by 72 hours of antimicrobial therapy;

  • Failure to clear blood cultures within 2 to 4 days of initiation of antimicrobial therapy;

  • Evidence of a metastatic infection or deep source;

  • Indwelling prosthetic device;

  • Intravascular catheter source not removed.