Download Guidance on management of proven or suspected Staphylococcus

Guidance on management of proven or suspected Staphylococcus aureus bacteraemia in adults(SAB)
Staphylococcus aureus bacteraemia suspected or identified in the laboratory. Consider rapid identification test if available.
INITIAL MANAGEMENT – ATTENDING CLINICIAN
CLINICAL MANAGEMENT – MICROBIOLOGY/INFECTIOUS DISEASES
•Check for signs of sepsis and assess severity. Initiate fluid resuscitation if required.
•Ensure prompt administration of empirical antibiotic therapy following local policy.
•Look for potential source of infection: skin (cellulitis, ulcer, site of current or recent indwelling medical device,
drug use by injection, surgical site infection), septic DVT, bone or joint inflammation (specifically paravertebral
tenderness), prosthesis, urinary catheter, endocarditis (ausculate heart, examine for heart murmur or stroke in
the context of sepsis and cutaneous stigmata of endocarditis), pneumonia (chest X ray).
•Consider recent medical history – hospitalisation, vascular device, drug use by injection or previous SAB.
•Consider need for further microbiology samples if evidence of infection e.g. swab from ulcer or IV device site,
MSSU/CSU, sputum sample
•Discuss with senior clinician in all cases.
•Repeat blood cultures (BC) in 48-96 hours and if ongoing fever despite antibiotic therapy
•Communicate result to attending clinical team by phone and agree provisional management plan.
•Contact Infection Prevention and Control Team to provide advice to ward staff and initiate SAB
investigation.
•Discuss case with patient’s consultant or specialist registrar as soon as possible, make arrangements within
24-48 hours for a consultation and ensure clinical management plan is documented in notes.
•Daily review by attending clinical team and review by infectious diseases (ID) physician or clinical
microbiologist at least once during course of therapy.
•Identify and document primary source of infection and remove or drain infected foci.
Septic arthritis or
Osteomyelitis
SSTI/ SSI/
Infected Ulcer
Consider and
discuss:
•Orthopaedic review
•Imaging - MRI/ CT/
nuclear medicine
•Intervention aspiration/washout/
device removal
Poor response
to treatment?
Minimum 2 weeks IV
therapy or as advised
by ID physician or
clinical microbiologist
Septic arthritis:
further 2 weeks
IV/oral or as advised.
Osteomyelitis: at
least 4 further weeks
IV/oral or as advised.
January 2015
Yes
Indwelling
IV device
Remove
device if
possible
No
Repeat BC
negative
and no
ongoing
symptoms
Source
unknown
TTE
negative,
repeat BC
negative
and
no ongoing
symptoms
No ongoing
concern
regarding
cardiac,
bone, joint,
prosthetic
or other
deep source
2 weeks IV treatment or as
advised by ID physician or
clinical microbiologist
Review date: January 2017
Infective
endocarditis
Treat as per
local/British
Society for
Antimicrobial
Chemotherapy
guidelines
Other potential
primary sources
include:
•Pneumonia
•Urinary tract
•Haemodialysis
-related
•Drug use by
injection
Discuss treatment
with ID physician or
clinical
microbiologist
ECHOCARDIOGRAPHY
•Discuss the need for a transthoracic echocardiogram (TTE) with a cardiologist for all patients with SAB
while the patient is receiving IV anti-staphylococcal therapy.
•Consider transoesophageal echocardiogram (TOE) in patients at high risk of endocarditis ; persistent
bacteraemia > 4 days, permanent intra-cardiac device, TTE negative AND repeat BC Positive, source
unknown.
EMPIRICAL ANTIBIOTIC THERAPY
•Assess clinical risk to determine likelihood of MRSA considering previous MRSA, admission from residential
care , wound or indwelling vascular device, community or healthcare acquired infection.
•Risk assessment negative, treat as MSSA - IV flucloxacillin 2g 4-6 hourly (assuming normal renal function).
•Risk assessment positive, treat as MRSA - local vancomycin protocol.
•Penicillin allergy – use vancomycin first line for MSSA and MRSA.
•In patients with intolerance, vancomycin allergy, treatment failure or if clinical concern regarding response
discuss alternative therapy with ID physician or clinical microbiologist.
VANCOMYCIN THERAPY
• Intermittent (pulsed) infusions: Aim for trough of 15-20 mg/L and consider increasing the dose/ dose
frequency to achieve this level.
• Continuous infusion: Aim for steady state concentration of 20-25 mg/L.
• In patients on concomitant nephrotoxic drugs or with impaired renal function monitor levels closely and
seek specialist advice on tailoring dosage.
• If poor clinical response to vancomycin switch to an alternative agent rather than increasing the
dose/dose frequency. Vancomycin MIC testing by E-test recommended. If MIC > 1.0 mg/L by E-test and
patient not responding switch to alternative antibiotic and continue search for underlying focus.
Guidance developed by the Scottish Antimicrobial Prescribing Group in
collaboration with the Scottish Microbiology and Virology Network.