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.
(See fever Guideline http://uktraumaprotocol.blogspot.com/2014/02/fever-guideline.html). 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. Also
listed is a UK Healthcare 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 (see UK Optimal Care© Adult
Endocarditis Algorithm http://careweb/ICISdocs/CAREWEB_Endocarditis+Algorithm_Jan_2017.pdf)
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
for
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.
Updated 6/2017
