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Staphylococcus aureus bacteremia
Rembert Mertens
UZ Brussel
Advanced Education Program of theBelgian Society of Internal Medicine
February 6th, 2015
Case
l Male, 82 y
l Admission ER (by ambulance)g 3 days diarrhea, N+V+
g 3 ‘shocks’ from ICD
g ECG AF, V respons rate 150/min
g At ER spontaneous resinusalisation (onlytreatment at ER was 1L ‘Plasmalyte’ IV)
l transfer cardiology ward, monitoringg D: gastro-enteritis, hypovolemia, with
secondary rapid AF
g VT vs inappropiate shock on AF
Medical history
l AHT, Hypercholesterolemia
l Hypothyroidism (post-op)
l 2004: VF, cardiogenic shockg MI (infero-lateral), PTCA RCA (LvEF 50%)
g Post-ACS syncope: inducible VT/VF: ICD implantation
l 2007 prox RCA dissectiong BMS
Medical history (continued)
l Appendectomy
l Nephrolithiasis (ESWL)
l THP ’96 (L)
l Partial thyroidectomy ‘98 (polynodular, euthyroid, goitre/ ‘nodules’)g follicular adenoma
l Shoulder prosthesis ’06 (L)
l Cataract (L&R) ‘13
During the admission
l 38,5°C at admission cardiology wardg Blood cultures neg.
g Feces culture : Campylobacter sp.
l Clinical improvement without AB
l Stop IV rehydration after 24h
l D5 again feverg Cubital redness, pain, swelling
g Generalised urticarial rash
Staphylococcal septicemia
l Blood culture staphylococcus sp.
l Echo: thrombophlebitis (precubitalveins)
l Flucloxacilline 3x 2g IV
l Dermatologistg Urticarial rash in the setting of the infection
g Local treatment with potassiumpermangenate
Staphylococcus Aureus !
l D7: again fever
l Bloodcultures staph. aureus (MSSA)
l 1st ID consultation (by telephone)g 4x 1g flucloxacillin
g Control bloodcultures, TEE
l 2nd blood cultures + staph. aureus (at 48h h under IV flucloxacillin…)
l TEE – (at D10)
l D8: pain left shoulder
l D9: again inappropriate shock, again AF
l 2nd consult IDg TEE !
g 6x 2g (+HC under 4x 1g), minimally 2 weeks
l Pain shoulder: g Rx prosthesis OK
g Echo synovial thickening
g CT : hypodensity >2mm (cement ~ bone(glenoid)
l Echo at D 22 synovial thickening, minimal fluid intra-articular
l Consult ortho: g Maybe loosening, no need for immediate
action or punction
g ambulant follow-up in 2 weeks
l Treated with IV flucloxacilline in total 14 days
2 weeks later Consultation orthopedics
l More and more pain
l No fever
l Punction: g Clear fluid
g Culture + Staph. Aureus (MSSA)
g Bone scintigraphy
Bacterial Basics
l Gram stain: + clusters = staphylococci (no differentiation) g DD ‘non-pathogens’ : Micrococcus, Stomatococcus, Peptostreptococcus,
Pediococcus, and Aerococcus species
l Coagulase test differentiates between Staph.aureus & other staphylococcig Coagulase – staphylococci
g Coagulase + staphylococci SA
l MSSA
l MRSA- Health-care associated MRSA
Hospital onset
Community onset
- Community associated MRSA
Epidemiology
l Mortality rates 20-40%
l MRSA > MSSA g Hazard ratio 1,8
l Treatment failure is commong Death 30d, persistance of bacteremia after
10d vancomycine, recurrence within 60 days
g MRSA >MSSA
g MIC > 1,5 mg/LComparison of mortality risk associated with bacteremia due to methicillin-resistant and methicillin-susceptibleStaphylococcus aureus. Shurland S, Zhan M, Bradham DD, Roghmann MC Infect Control Hosp Epidemiol. 2007;28(3):273.
Relationship between vancomycin MIC and failure among patients with methicillin-resistant Staphylococcus aureus bacteremia treated with vancomycin. Lodise TP, Graves J, Evans A, Graffunder E, Helmecke M, Lomaestro BM, StellrechtK Antimicrob Agents Chemother. 2008;52(9):3315.
Clinical approach: history
l Portal of entry ?g Recent SSTI
g Indwellling prosthetic devicesl IV catheters, orthopedic hardware, cardiac
devices
l Metatstatic infection ? g Bone/joint pain
g Protracted fever
g Abdominal pain (left upper quadrant, spleen)
g Costo-vertebral angle (renal infarction)
g headache
Clinical approach: clinical exam
l Cardiac murmur
l Emboli skin, digits, conjunctivae, fundi
l Focal neurological deficit
l Serial bedside examination ..
l ID consultation !
Bacteremic Staphylococcus aureus spondylitis. Jensen AG, Espersen F, Skinhøj P, Frimodt-Møller N Arch Intern Med. 1998;158(5):509.
Telephone consultation cannot replace bedside infectious disease consultation in the management of Staphylococcus aureus bacteremia.Forsblom E, Ruotsalainen E, Ollgren J, Järvinen A Clin Infect Dis. 2013;56(4):527.
Diagnostic evaluation
l Infective endocarditis 25-32%g Higher rate with MSSA than MRSA
l All patients should undergoechocardiography
l TTE vs TEE ?g Most sensitive 5-7 days after onset of
bacteremia
Staphylococcus aureus bacteremia and endocarditis: the Grady Memorial Hospital experience with methicillin-sensitive S aureus and methicillin-resistant S aureus bacteremia. Abraham J, Mansour C, Veledar E, Khan B, Lerakis S Am Heart J. 2004;147(3):536.
Always!?
l Persistent blood culture despite AB
l Unknown duration
l CV material
l Predisposing valve abnormality
l Absence of removable source
l Hemodialysis
l Spinal infection
l Peripheral stigmata IE
Use of a simple criteria set for guiding echocardiography in nosocomial Staphylococcus aureus bacteremia. Kaasch AJ, Fowler VG Jr, Rieg S, Peyerl-Hoffmann G, Birkholz H, Hellmich M, Kern WV, Seifert HClin Infect Dis. 2011;53(1):1.
Never say never (and never say always)
l Nosocomial acquisition of bacteremia
l Sterile follow-up blood cultures withinfour days after the initial positive culture
l No permanent intracardiac device
l No hemodialysis dependence
l No clinical signs of endocarditis or secondary foci of infection
Imaging ?
l Depending on clinical suspicion
l CT scan thorax or abdomeng Renal, splenic infarction
g Psoas abces
l MRI brain (headache or IE)
Treatment
l Source control !g Removal of catheter
g Abces? surgical drainage
l Empirical coverage of MRSAg Vancomycine 30 mg/kg/d
g (daptomycine alternative)
l Deescalate to beta-lactam if MSSA
l Role for combination AB ?
The empirical combination of vancomycin and a β-lactam for Staphylococcal bacteremia.McConeghyKW, Bleasdale SC, Rodvold KA Clin Infect Dis. 2013;57(12):1760.
Methicilline susceptible SA
l Penicilline ? (4 milj. q4h)
l Flucloxacilline 2g q6h
l Alternative cefazoline 2g q8h
l NO Vancomycine
l Synergism with aminoglycoside? g in vitro (and experimental models of
endocarditis)
g evidence for clinically significant benefit is minimal
Initial low-dose gentamicin for Staphylococcus aureus bacteremia and endocarditis is nephrotoxic. Cosgrove SE, Vigliani GA, Fowler VG Jr, Abrutyn E, Corey GR, Levine DP, Rupp ME, Chambers HF, KarchmerAW, Boucher HW Clin Infect Dis. 2009;48(6):713.
Methicilline resistant SA
l Vancomycine 30 mg/kg/d
l Check MIC (E-test)g £ 1,5 mg/L OK
g ≥ 2,0 mg/L not OK
l ‘salvage’ linezolid ?
l No evidence for combination(aminoglycoside or rifampicine) whenabsence of prosthetic device
Clinical practice guidelines by the infectious diseases society of america for the treatment of methicillin-resistant Staphylococcus aureus infections in adults and children. Liu C, Bayer A, CosgroveSE, Daum RS, Fridkin SK, Gorwitz RJ, Kaplan SL, Karchmer AW, Levine DP, Murray BE, J Rybak M, TalanDA, Chambers HF, Infectious Diseases Society of America Clin Infect Dis. 2011;52(3):e18.
Follow-up cultures
l Repeat untill documented clearance
l Failure to clear within 48h ?g Appropriate AB and dosing?
g Susceptibility data
g Clinical evaluation (occult focus?)
Duration
l Removable sourceg 14d (from the first – bloodculture)
g Afebrile within 48 h
g Controle culture neg. (2 to 4 days afterinitiation of AB)
g No localizing complaints attributable tometastatic staphylococcal infection.
g No valvular abnormalities predisposing toendocarditis.
g No indwelling devices (prosthetic heart valvesor vascular grafts)
Duration : deep foci
l Infective endocarditis: 42d
l Cardiac device infectiong Limited to pocket or SC tissue: 14 d
g 50% have associated endocarditis
l Osteomyelitis ≥ 42 d
l Prosthetic joint infection ?
l Septic arthritis 14d IV + ≥14d PO?
l Meningitis 14d
l Pneumonia 14d (21d?)
What about our patient?
l Revision in 2 stages
l 2x more than 1 month hospitalised
l After second stage lost to follow-up..
l Contacted by telephone: OK
