Evidence-Based Medicine Online First, published on April 20, 2015 as 10.1136/ebmed-2014-110122
Staphylococcus aureus bacteraemia management: where do we stand and where are we going? 10.1136/ebmed-2014-110122 Pamela A Moise,1 George Sakoulas2 1
Department of Medical Affairs, Cubist Pharmaceuticals, Lexington, Massachusetts, USA; 2University of California San Diego, La Jolla, California, USA Correspondence to: Dr Pamela A Moise, Department of Medical Affairs, Cubist Pharmaceuticals, 65 Hayden Avenue, Lexington, MA 02421, USA; [email protected]
bacteremia; (2) duration of therapy should default to 4–6 weeks unless the patient fulﬁls criteria for uncomplicated bacteraemia (endocarditis excluded; no implanted prostheses; negative blood cultures in 2–4 days; afebrile within 3 days of therapy; no evidence of metastatic infection). The authors also provide an evaluation of trimethoprim/sulfamethoxazole, linezolid and combination therapy.
Commentary Probably the most important reminder offered in this paper is the fact that while science and technology continues to move forward in so many facets of our daily lives, management of SaB has not changed in decades other than the addition of daptomycin and linezolid to the therapeutic armamentarium, the former receiving Food and Drug Administration (FDA) and clinical endorsement. While in-depth clinical evaluations are needed, science has yet to be effectively translated into clinical practice. Our lack of progress in this ﬁeld requires us a re-evaluation of our position and what our next steps should be.
Implications for practice Commentary on: Holland TL, Arnold C, Fowler VG Jr. Clinical management of Staphylococcus aureus bacteraemia: a review. JAMA 2014;312:1330–41.
Context Staphylococcus aureus is a common cause of bacteraemia from hospitalised patients in the USA. It is also a very prevalent bacterial pathogen among clinical isolates from outpatients. Despite our technological innovations within and outside of the practice of science and medicine in the past two decades, mortality due to S. aureus bacteremia (SaB) has not changed during this time, remaining at about 20%. The goals of this review were to determine which patients with SaB need transesophageal echocardiography (TEE) and to determine the optimal antibiotic regimen.
Methods This largely narrative review by Holland and colleagues provides a thorough literature review on the clinical data on which therapeutic and diagnostic standards in the management of this disease are based. PubMed, EMBASE and the Cochrane Trials Register were searched through May 2014. References of included studies were also reviewed. Studies were restricted to English language and adult population. No meta-analysis was performed.
Findings The ﬁrst strategy reviewed in detail in this paper is the utility of TEE in patients with SaB. In this assessment, the authors agreed with the current standard of care that all patients with SaB have an echocardiogram, with the option to forego a TEE if: (1) patients had negative blood cultures within 4 days; (2) no haemodialysis dependence; (3) no secondary foci of infection; (4) no clinical signs of endocarditis. Subsequently, the majority of the paper focused on the evaluation of the optimal antibiotic therapy for methicillin-resistant S. aureus (MRSA) bacteremia. This was done based on careful scrutiny of 24 papers that fulﬁlled exclusionary criteria and quality review. The authors conclude that: (1) vancomycin or daptomycin are ﬁrst-line therapies for MRSA
SaB represents such a heterogeneous group of patients that perhaps we should start viewing SaB as a symptom rather than a disease state. S. aureus is such a complex pathogen that our goal moving forward should be on deﬁning diagnostics and therapeutics based on the characteristic host-pathogen relationship deﬁned by the speciﬁc diseases. Examining the role of TEE in different patient populations likely may yield different results. From a therapeutic standpoint, our understanding of the see-saw effect with daptomycin and vancomycin on one side and β-lactams on the other offers a very promising avenue in daptomycin plus β-lactam therapy that may stand out above other antibiotic combinations. The 2014 Sanford Guide1 endorses daptomycin plus β-lactams in treatment of persistent MRSA bacteraemia due to vancomycin-intermediately susceptible strains. Much work remains to be done on which patients and at what time point to pull the trigger on this more potent yet cumbersome regimen. As pointed out in this review, some studies suggest infectious disease consultation offers a signiﬁcant clinical beneﬁt in the treatment of SaB. The data suggest that there is an element of clinician experience and expertise that goes beyond diagnostic tests and antibiotics that may be critical towards improving patient outcome in SaB. Contributors PAM and GS were involved in the drafting and editing the commentary, and have approved the ﬁnal submitted version. Funding GS has received research grant support to his institution from Forrest and speaking honoraria from Cubist and Forest. Competing interests PM is an employer and shareholder of Cubist Pharmaceuticals. Provenance and peer review Commissioned; internally peer reviewed. Reference 1. Gilbert DN, Chambers HF, Eliopoulos GM, et al. The Sanford Guide to Antimicrobial Therapy 2014. 44th edn, Sperryville, VA: Antimicrobial Therapy Inc.
Evid Based Med Month 2015 | volume 0 | number 0 |
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