Approach to managing Staphylococcus aureus bacteraemia
Staphylococcus aureus bacteraemia is associated with significant morbidity and mortality; seek expert advice from an infectious diseases physician because this improves outcomes.
Always assume patients with gram-positive cocci in clusters in the blood have S. aureus bacteraemia, even if the patient appears well.
The approach to managing S. aureus bacteraemia in adults is summarised in Approach to managing adults with Staphylococcus aureus bacteraemia. Children with S. aureus bacteraemia are managed differently to adults; the recommendations in this topic can be used initially while seeking expert advice.
S. aureus bacteraemia is frequently complicated by metastatic infection. When treating patients with S. aureus bacteraemia and infection at another site, consider both the recommendations in this topic and those for the other site of infection. Infections associated with S. aureus bacteraemia include:
- osteomyelitis
- septic arthritis
- Staphylococcus aureus (staphylococcal) pneumonia
- lung abscess
- staphylococcal endocarditis
- cardiac implantable electronic device infections.
For management of staphylococcal toxic shock syndrome, see Staphylococcal toxic shock syndrome.
To manage an adult with S. aureus bacteraemia:
- Consult an infectious diseases physician.
- Immediately start empirical therapy with intravenous cefazolin or flucloxacillin plus vancomycin, provided the patient is not hypersensitive to penicillins. Adjust therapy as soon as the results of susceptibility tests are known.
- If possible, remove the source of infection (eg replace an intravenous catheter, drain an abscess, remove an intravascular device).
- Exclude cardiac implantable electronic device (CIED) infection in patients with a device in situ.
- Evaluate the patient for evidence of complicated S. aureus bacteraemia using the criteria in Duration of therapy for Staphylococcus aureus bacteraemia.
- Take blood samples for repeat culture 48 to 72 hours after starting antibiotics. Repeat every 2 days until the first negative culture result.
- For patients who have positive blood culture results on day 5 or later after starting treatment, management may need to be modified, see Persistent S. aureus bacteraemia.
- Monitor clinical response and blood tests (full blood count, C-reactive protein, serum electrolytes and liver enzymes) for the duration of treatment.
- Arrange for a transthoracic echocardiogram (TTE) to be performed. A transoesophageal echocardiogram (TOE) is recommended for some patients – see Assessing and monitoring patients with Staphylococcus aureus bacteraemia.
- Continue antibiotics for a minimum of 2 weeks; some patients require 4 to 6 weeks of treatment – see Duration of therapy for Staphylococcus aureus bacteraemia.
- For patients who require prolonged intravenous therapy, arrange insertion of a long-term vascular access device (eg a peripherally inserted central catheter [PICC]).
- Provide verbal and written advice to the patient and their family about the symptoms of relapse and the need for early review if these symptoms occur.