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2014 ; 312
(13
): 1330-41
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Clinical management of Staphylococcus aureus bacteremia: a review
#MMPMID25268440
Holland TL
; Arnold C
; Fowler VG Jr
JAMA
2014[Oct]; 312
(13
): 1330-41
PMID25268440
show ga
IMPORTANCE: Several management strategies may improve outcomes in patients with
Staphylococcus aureus bacteremia. OBJECTIVES: To review evidence of management
strategies for S. aureus bacteremia to determine whether transesophageal
echocardiography is necessary in all adult cases and what is the optimal
antibiotic therapy for methicillin-resistant S. aureus (MRSA) bacteremia.
EVIDENCE REVIEW: A PubMed search from inception through May 2014 was performed to
identify studies addressing the role of transesophageal echocardiography in S.
aureus bacteremia. A second search of PubMed, EMBASE, and the Cochrane Library
from January 1990 through May 2014 was performed to find studies addressing
antibiotic treatment for MRSA bacteremia. Studies reporting outcomes from
antibiotic therapy for MRSA bacteremia were included. All searches, which were
limited to English and focused on adults, were augmented by review of
bibliographic references from included studies. The quality of evidence was
assessed using the Grades of Recommendation, Assessment, Development and
Evaluation system with consensus of independent evaluations by at least 2 of the
authors. FINDINGS: In 9 studies with a total of 4050 patients, use of
transesophageal echocardiography was associated with higher rates of a diagnosis
of endocarditis (14%-28%) compared with transthoracic echocardiography (2%-15%).
In 4 studies, clinical or transthoracic echocardiography findings did not predict
subsequent transesophageal echocardiography findings of endocarditis. Five
studies identified clinical or transthoracic echocardiography characteristics
associated with low risk of endocarditis (negative predictive values from 93% to
100%). Characteristics associated with a low risk of endocarditis include absence
of a permanent intracardiac device, sterile follow-up blood cultures within 4
days after the initial set, no hemodialysis dependence, nosocomial acquisition of
S. aureus bacteremia, absence of secondary foci of infection, and no clinical
signs of infective endocarditis. Of 81 studies of antibiotic therapy for MRSA
bacteremia, only 1 high-quality trial was identified. In that study of 246
patients with S. aureus bacteremia, daptomycin was not inferior to vancomycin or
an antistaphylococcal penicillin, each in combination with low-dose, short-course
gentamicin (clinical success rate, 44.2% [53/120] vs 41.7% [48/115]; absolute
difference, 2.4% [95% CI, -10.2% to 15.1%]). CONCLUSIONS AND RELEVANCE: All adult
patients with S. aureus bacteremia should undergo echocardiography.
Characteristics of low-risk patients with S. aureus bacteremia for whom
transesophageal echocardiography can be safely avoided have been identified.
Vancomycin and daptomycin are the first-line antibiotic choices for MRSA
bacteremia. Well-designed studies to address the management of S. aureus
bacteremia are needed.
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