Staphylococcal

bacteremia

Shannon Galvin, M.D.

August 2006

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

Wisplinghoff et al. Clin Infect Dis. 2004 Aug; 39(3)

Coag neg Staph

Consider as a pathogen when
2 or more positive cultures from different
sites
Clinical findings of infection especially in
immunocompromised patient
Similar genotype from different time points
Isolated from a sterile sitejoint, CSF
especially if prosthetic device present
(shunt, artificial joint)

Staph aureus bacteremia

Serious life threatening infection
30% mortality
20% severe metastatic complications
Any positive culture for Staph aureus from a
sterile site must be treated

5147

Staphylococcus aureus

MRSA
UNC antibiogram 2004
Staph aureus-57% oxacillin susceptible

Nationwide approx 53% ICU, 46% inpatient

31% outpatient isolates were MRSA

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

MRSA independent poor prognostic factor in

Staph endocarditis
Differences in host populations

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)

Clinical examination underestimates the

frequency of complications

Complications
Endocarditis
Vertebral osteomyelitis/discitis
Septic arthritis
Splenic abscess
Mycotic aneurysms
Meningitis
Tissue abscess

Risk of endocarditis with Staph

bacteremia
Series of patients with S. aureus
bacteremia
25% had endocarditis by TEE
7% by TTE

Definite infective endocarditis

Pathological criteria
Microorganisms demonstrated by culture or histological examination of a
vegetation, a vegetation that has embolized, or an intracardiac abscess specimen; or
Pathological lesions; vegetation or intracardiac abscess confirmed by histological
examination showing active endocarditis
Clinical criteria
2 major criteria; or
1 major criterion and 3 minor criteria; or
5 minor criteria
Possible IE
1 major criterion and 1 minor criterion; or
3 minor criteria
Rejected
Firm alternative diagnosis explaining evidence of IE; or
Resolution of IE syndrome with antibiotic therapy for <4 days; or
No pathological evidence of IE at surgery or autopsy, with antibiotic therapy for <4
days; or
Does not meet criteria for possible IE as above

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

Chang FY, MacDonald BB, Peacock JE Jr, Musher DM, Triplett P,

Mylotte JM, O'Donnell A, Wagener MM, Yu VL.
A prospective multicenter study of Staphylococcus aureus bacteremia:
incidence of endocarditis, risk factors for mortality, and clinical impact
of methicillin resistance.
Medicine (Baltimore). 2003 Sep;82(5):322-32
Observational study of 505 pts with Staph bacteremia
13% had found to have endocarditis
21% of community acquired bacteremias, 5% hospital acquired, 12% of
dialysis acquired

MRSA pts had more persistent bactermia, MRSA an independent

predictor of death from endocarditis
Positive blood cultures at day 3, valvular heart disease, IVDU,
community acquired source, or unknown source risks for having
endocarditis
31% 30 day mortality for endocarditis, 21% others

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.

Retrospective study of 125/800 pts at a single

center who had both TTE and TEE.
Negative likelihood ratio 0.33 for endocarditis
with normal TTE
Endocarditis by TEE was found in less than 2%
of patients without embolic phenomena with
normal (no valvular lesions, and no or trivial
regurgitation) echo

Management of catheter-related Staphylococcus aureus bacteremia:

when may sonographic study be unnecessary?
Pigrau C, Rodriguez D, Planes AM, Almirante B, Larrosa N, Ribera E,
Gavalda J, Pahissa A. Eur J Clin Microbiol Infect Dis. 2003
Dec;22(12):713-9.
213 episodes of bacteremia were registered and 167 (78.4%) were
nosocomial. Among these, 87 (52.1%) were catheter-related
Staphylococcus aureus bacteremia and 20 were primary
nosocomial bacteremia. Endocarditis was diagnosed during the
acute episode in 7/107 of these patients (2 by persistent fever after
catheter removal and 5 by metastatic foci; 3 of them also had
cardiac risk factors) and confirmed with transesophageal
echocardiography. Among the 84/87 catheter-related
Staphylococcus aureus bacteremia and 16/20 primary nosocomial
bacteremia patients who did not develop endocarditis, 31 patients
died during the acute episode (16 due to sepsis despite initiation of
antibiotic treatment and 15 due to the underlying disease) and five
had osteoarticular foci. 64 episodes were considered to be
uncomplicated bacteremia (no cardiac risk factors, persistent fever,
metastatic foci, or clinical signs of endocarditis) and were treated
with 10-14 days of high-dose antistaphylococcal antibiotics.
Echocardiography was not mandatory in these patients. Of the 64
uncomplicated episodes, 62 were followed for at least 3 months and
none relapsed or developed endocarditis

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

Shorr AF, Kunkel MJ, Kollef M.

Linezolid versus vancomycin for Staphylococcus aureus bacteraemia:
pooled analysis of randomized studies.
J Antimicrob Chemother. 2005 Nov;56(5):923-9.

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