Bacteremia

 

VBMC TRAUMA CARE SERVICES GUIDELINE

Bacteremia (Antimicrobial Duration and Follow-Up Cultures)

Vascular catheters cause most bacteremia in hospitalized patients. Patients with and without vascular catheters may also develop bacteremia from remote infections-pneumonia, UTI, intra-abdominal infection, necrotizing soft tissue infection, burn wound infection, etc. Blood cultures should be obtained selectively in patients who exhibit signs and symptoms of severe infection.

Positive blood cultures may represent contamination during collection or processing. Cultures that become ‘positive’ quickly (12-24 hours) or that are positive in multiple bottles are likely to be true positives. Procalcitonin can also be used to adjudicate a contaminant versus a true positive. Listed below is a guideline for duration of antimicrobial therapy and interval of follow-up cultures.

Guideline for management of the most common type of bacteremia—that caused by Staphylococcus aureus.  

Antimicrobial Duration Guidelines for the Treatment of Adults with Bacteremia

 


Guidelines for the Treatment of Adults with Bacteremia due to Staphylococcus aureus

 

I.  Source control

a.     Remove infected catheters and drain infected abscesses as soon as patient is clinically stable

                                               i.     Patients with CVCs as the source of infection are more likely to have persistent bacteremia

                                             ii.     Foci of infection that are not eradicated are associated with higher rates of mortality & relapse

b.     Evaluate for metastatic disease (e.g., endocarditis, osteomyelitis)

                                               i.     Determine risk for IE based on Duke’s criteria

                                             ii.     Obtain echocardiography to evaluate to IE if suspected

1.   TTE is highly sensitive and should be obtained within 12 hours of initial evaluation

2.   If TTE negative but high suspicion of IE (e.g., persistent bacteremia, prosthetic heart valve, pacemaker), TEE should be obtained. 

                                            iii.     Consult cardiology

1.   IE with prosthetic valve

2.   TTE positive

                                            iv.     ID should be consulted for endocarditis

II.             Document clearance – repeat blood cultures every 48 hours until bacteremia cleared

III.           Targeted antimicrobial therapy

a.     MSSA

                                               i.     Cefazolin 2g q8h or nafcillin 12g q24h (cont. infusion)

                                             ii.     If considering using other beta-lactam antibiotics, consider ID consult

b.     MRSA

                                               i.     Vancomycin dosed to obtain trough level 15-20mcg/mL (may consider 10-15mcg/mL based on source and response)

                                             ii.     For persistent bacteremia or lack of clinical improvement

1.   Ensure adequate source control

2.   Consider ID consult

3.   Daptomycin 6-10mg/kg q24h (ABW if BMI < 30, DBW if BMI ≥ 30) 

4.   Ceftaroline 600mg q8-12h

IV.           Duration of therapy

a.     Uncomplicated bacteremia can be treated for 2 weeks from negative culture

                                               i.     No IE or osteomyelitis

                                             ii.     No implanted prostheses

                                            iii.     Documented clearance of bacteremia within 96 hours of first culture

                                            iv.     Defervescence within 72 hours of appropriate therapy

b.     Longer duration of treatment 

                                               i.     Osteomyelitis (inc. prosthetic joint infections) or IE – 6-8 weeks

                                             ii.     Persistent bacteremia/fever – 4 weeks

 

 

References

Fowler VG, et al. Am J Coll Cardiol 1997; 30: 1072-8.

Hawkins C, et al. Arch Intern Med 2007; 167; 1861-7.

Joseph JP, et al. J Antimocrob Chemother 2013; 68: 444-9.

Kaasch AJ, et al. Clin Infect Dis 2011; 51: 1-9.

Kullar R, et al. Clin Infect Dis 2011; 52: 975-81.

Liu C, et al. Clin Infect Dis 2011; 52: 1-38.

Lopez-Cortes LE, et al. Clin Infect Dis 2013; 57: 1225-33.

Murray KP, et al. Clin Infect Dis 2013; 56: 1562-9.

Sakoulas G, et al. Clin Ther 2014; 36: 1317-33.

Schweizer ML, et al. BMC Infect Dis 2011; 11: 279.

Welsh KJ, et al. J Clin Microbiol 2011; 49: 3669-72.