Management of S. aureus Bacteremia

Infectious diseases consultation for Staphylococcus aureus bacteremia (SAB) has been associated with significant improvement in patient outcomes and mortality.[J Infect 2016; OFID 2016; Clin Infect Dis 2015; J Infect 2009] However, as evidenced by several recent EIN posts, there exists substantial variation in provider practice with respect to certain aspects of this condition, particularly in areas where there are limited data to guide management.

The main purpose of this survey is to assess provider opinion and practice habits regarding areas in the management of SAB where data are inconclusive and clinical management is most likely to vary between providers.
Our hope is that the responses can help to identify areas of consensus in practice, guide future directions in SAB research, as well as inform development of future IDSA guidelines on the management of SAB.

Name:                                                                    EIN ID: If you do not manage patients with S. aureus bacteremia, check here:    [Stop here & submit] A 63 y/o man presents with fever x 2 days, WBC 12, and a 7x5 cm leg skin abscess. After I&D, IV vancomycin is started, and 2 of 2 blood cultures grow MRSA susceptible to TMP/SMX, clindamycin, and doxycycline. He rapidly defervesces, repeat blood cultures and TTE are negative, and there is no evidence of metastatic infection. What is your treatment choice?         [Select one answer]       5-7 days   14 days  Transition to oral antibiotics and treat for:           IV vancomycin for: An alternative management strategy, specify: A 70 y/o woman with CHF presents with shortness of breath x 4 days. She is afebrile, WBC is normal, CXR shows pulmonary edema, and 1 of 2 blood cultures grow MSSA. She is started on IV abx and diuresis with clinical improvement. Repeat blood cultures and TEE are negative and there is no evidence of metastatic infection. What is your treatment strategy? Stop antibiotics as initial cultures likely a contaminant Transition to oral antibiotics to complete:   [select one duration] 7 or 14 days Continue IV antibiotics to complete:           [select one duration] 7 or 14 days I would choose an alternative management strategy: In a patient with MSSA bacteremia, what is your preferred choice of valve imaging? I only perform a TTE or TEE if repeat blood cultures are positive or patient doesn’t improve I perform a TTE on every patient, and if it is negative perform a TEE on every patient I perform a TTE on every patient, but if negative I only perform a TEE if:   [Select all that apply]             Repeat blood cultures are positive             Patient does not demonstrate clinical improvement             Community-onset bacteremia             Other clinical factors, specify: How would you treat MRSA bacteremia (MIC: vancomycin 2, daptomycin 0.5, linezolid 0.5, ceftaroline 1, TMP-SMX 1, telavancin 0.25) in a clinically stable patient? Treat with vancomycin as long as patient demonstrates clinical and microbiologic response Treat with the following antibiotic, specify: In a patient with MRSA endocarditis (MIC: vancomycin 0.5, daptomycin 0.5, linezolid 0.5, ceftaroline 1, TMP-SMX 1, telavancin 0.25) on day 6 of vancomycin (trough 18) with persistently positive blood cultures, what is your antibiotic treatment strategy? Continue vancomycin alone Change to the following antibiotic, specify: Continue vancomycin and ADD another MRSA active agent, specify: Change to daptomycin and ADD another MRSA active agent, specify: Other, specify: For a 35 y/o previously healthy man with left-sided MSSA endocarditis but no meningitis or CNS disease, what antibiotic would you use for the treatment course? Cefazolin, because: [insert rationale] Nafcillin, because: [insert rationale] Cefazolin or nafcillin (they are equivalent) Other, specify: What diagnostic work-up do you routinely perform when evaluating a patient with SAB?   Rarely     Sometimes     Usually    Almost always  Repeat blood cultures q24-48hrs until negative TTE and/or TEE Spine MRI Abdominal/pelvis CT Dilated eye exam Other, specify: In MRSA bacteremia, which of the following would increase your treatment duration from 2 weeks to 4-6 weeks assuming that a TTE and/or TEE are negative?     [Select all that apply]  Repeat blood cultures positive at 48-96hrs                    None of the above  Persistent fevers at 72hrs  Diabetes  Immunosuppressing condition(s)  Presence of a prosthetic device implant (prosthetic joint, spinal hardware)  Community-onset bacteremia  Other, specify:  If daptomycin is used for the treatment of MRSA bacteremia (daptomycin MIC 0.5), what dose would you use? 6 mg/kg IV Q24hrs 8 mg/kg IV Q24hrs 10 mg/kg IV Q24hrs 12 mg/kg IV Q24hrs Other, specify:  In a patient with MSSA bacteremia and a deep vein thrombus at the site of a recent PICC line now removed, what is your management strategy and decision regarding anticoagulation?    Anticoagulation Antibiotic/Intervention Yes     No     [Select a single choice below] Two weeks of effective IV antibiotics Yes    No Four weeks of effective IV antibiotics Yes    No Six weeks of effective IV antibiotics Yes    No Other strategy:         Yes    No What topics would you like guidelines on S. aureus bacteremia to address?