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Review
. 2023 Nov 30;77(11):e57-e68.
doi: 10.1093/cid/ciad500.

Contemporary Management of Staphylococcus aureus Bacteremia-Controversies in Clinical Practice

Daniel J Minter  1 , Ayesha Appa  1   2 , Henry F Chambers  1   2 , Sarah B Doernberg  1
Affiliations
Review

Contemporary Management of Staphylococcus aureus Bacteremia-Controversies in Clinical Practice

Daniel J Minter et al. Clin Infect Dis. .

Abstract

Staphylococcus aureus bacteremia (SAB) carries a high risk for excess morbidity and mortality. Despite its prevalence, significant practice variation continues to permeate clinical management of this syndrome. Since the publication of the 2011 Infectious Diseases Society of America (IDSA) guidelines on management of methicillin-resistant Staphylococcus aureus infections, the field of SAB has evolved with the emergence of newer diagnostic strategies and therapeutic options. In this review, we seek to provide a comprehensive overview of the evaluation and management of SAB, with special focus on areas where the highest level of evidence is lacking to inform best practices.

Keywords: Staphylococcus aureus bacteremia.

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Conflict of interest statement

Potential conflicts of interest. D. J. M. reports payment from the Antimicrobial Resistance Leadership Group for participation in a systematic review and travel support from the University of California, San Francisco (UCSF), ID Division to attend IDWeek. H. F. C. reports an institutional grant from the National Institutes of Health/National Institute on Allergy and Infectious Diseases (NIH/NIAID) for the Antibacterial Resistance Leadership Group (UM1AI104681); royalties earned as editor for The Sanford Guide to Antimicrobial Therapy; payment for expert testimony in a patent dispute for Nexus Pharmaceuticals and a product liability case for Eli Lilly; support from Merck for participation in a Data and Safety Monitoring or Advisory Board; and stock in Moderna and Merck (spouse's IRA). S. B. D. reports funding for clinical research studies from Gilead, Pfizer, F2G, Regeneron, Chan Zuckerberg Biohub, and NIAID; personal consulting fees from Genentech and Janssen/J+J; travel support from IDSA to speak at IDWeek; a patent for Mif agonists and antagonist and therapeutic uses (US20100143379A1); roles on the IDSA Antibacterial Resistance Committee, CADPH HAI Advisory Committee, Antibacterial Resistance Leadership Group Innovations Group, Laboratory Center, Mentorship Committee, Gram Positive Committee, and Immunosuppressed Host Group; and compensation for clinical events committee participation from Shinogi, Basilea, and Duke Clinical Research Institute. A. A. reports no potential conflicts. All authors have submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Conflicts that the editors consider relevant to the content of the manuscript have been disclosed.

Figures

Figure 1.
Figure 1.
Proposed algorithm for the evaluation and management of SAB, modified with permission from Kouijzer et al [5]. All patients should undergo a standardized minimum evaluationa (thorough history and examination, repeat blood cultures, and TTE) that serves to stratify risk of metastatic foci. In those determined to have low-risk SAB (see below), additional workup can potentially be deferred. In those with indeterminant or high-risk SAB, additional evaluationb (guided by the patient's clinical features) is recommended. Classification of patients as having SAB with or without metastatic foci assists in guiding treatment decisions, which should include antibiotics, source control, and (when applicable) substance-use treatment. †Low-risk SAB: no predisposing host factors, negative TTE; blood cultures clear in <48 hours, bacteremia is hospital-acquired; no persistent fever, timely antibiotic start, and no clinical signs of metastatic infection. ‡High-risk SAB: risk factors and/or suspicion for IE; clinical signs of metastatic infection, implanted prostheses, history of IDU and/or IE; blood cultures are positive >48 hours of therapy, delayed start in antibiotics, persistent fever. ††Indeterminant-risk SAB: not meeting criteria for low- or high-risk SAB. Abbreviations: CIED, cardiac implantable electronic device; CT, computed tomography; MRI, magnetic resonance imaging; MRSA, methicillin-resistant Staphylococcus aureus; MSSA, methicillin-sensitive Staphylococcus aureus; OUD, opioid use disorder; PET/CT, positron emission tomography/computed tomography; SAB, Staphylococcus aureus bacteremia; SUD, substance-use disorder; TEE, transesophageal echocardiogram; TTE, transthoracic echocardiogram.
None
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References

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