Patients with Staphylococcus aureus bacteremia require a mandatory Infectious Diseases consult. Unless there are significant issues with IV access, do not place central venous access or PICC lines until blood cultures are sterile.
S. aureus should NEVER be treated as a contaminant.
Clinical assessment to identify the source as well as the presence and extent of septic complications of the infection.
Elimination and/or debridement of sites of infection (e.g. removal of intravenous and intra-arterial catheters that were in place while the patient was bacteremic).
Follow-up blood cultures every 48 hours after start of treatment until clearance of S. aureus from blood.
Echocardiography (TTE initially +/- TEE).
PICC line for prolonged antibiotic treatment should only be placed once sterilization of blood cultures has been documented.
Empiric: vancomycin 20mg/kg IV x 1 load dose then 15mg/kg IV q12h (adjusted for renal function; refer to vancomycin dosing guidelines)
Targeted:
Methicillin-sensitive S. aureus (MSSA): cloxacillin 2g IV q4h or ceFAZolin 2g IV q8h
Methicillin-resistant S. aureus (MRSA): continue vancomycin IV
Trough level prior to dose 4 dose to target level 13-20.
Consider pharmacy consultation for vancomycin IV monitoring and dosing.
Intravenous therapy is recommended for the entire duration of treatment.
2 weeks from last positive blood cultures with negative follow-up blood cultures after 48-96 hours of appropriate treatment, absence of endocarditis by TEE, no indwelling devices, patient defervesced within 72 hours after initiation of appropriate treatment, and no signs/symptoms of complications/metastatic focus.
Minimum 4-6 weeks if these criteria are not met.
Liu C, Bayer A, Cosgrove SE, Daum RS, Fridkin SK, Gorwitz RJ, Kaplan SL, Karchmer AW, Levine DP, Murray BE, J Rybak M, Talan DA, Chambers HF. Clinical practice guidelines by the Infectious Diseases Society of America for the treatment of methicillin-resistant Staphylococcus aureus infections in adults and children. Clin Infect Dis. 2011;52(3):e18.
Lowy FD. Staphylococcus aureus infections. NEJM. 1998;339(8):520.