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EDITORIALS: John Paul Surveillance and management of all types of Staphylococcus aureus bacteraemia BMJ 2006; 333: 269-270 [Full text]

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Optimising treatment of Staphylococcus aureus bacteraemia

William J Olver, Charis Marwick   (9 August 2006)

Should antibiotic courses be much shorter?

CK Connolly   (24 August 2006)

Optimising treatment of Staphylococcus aureus bacteraemia 9 August 2006
William J Olver, Consultant microbiologist Department of Microbiology, Ninewells Hospital, Dundee DD1 9SY, Charis Marwick Send response to journal: Re: Optimising treatment of Staphylococcus aureus bacteraemia	EDITOR- Paul’s editorial on S.aureus bacteraemia addresses important issues on the prevention of this infection.1 However his statement that ‘some doubt remains about the optimal duration of antibiotic treatment for S.aureus bacteraemia’ deserves comment. A prospective study of 278 cases of S.aureus bacteraemia (mainly methicillin-sensitive strains) looked at potential risk factors and outcome, using multiple regression analysis.2 Factors related to death were duration of treatment less than 14 days, an uneradicated focus, septic shock, total daily dose of flucloxacillin <4g and age 60 years or more. Anecdotally, treatment of S.aureus is often stopped before 14 days, as the patient appears to have recovered, and the requirement for this minimum length of treatment is not widely appreciated. We think that close liaison between infection specialists (microbiologists/ infectious disease physicians) and clinicians also needs to be emphasised. In a study of 244 patients with S.aureus bacteraemia, clinical outcome was improved (better eradication of S.aureus and less relapses of infection) when advice from an infectious disease physician was taken, compared when it was not.3 However it has been shown that telephoned blood culture advice is recorded in medical records in less than two-thirds of cases,4 so verbal advice may be forgotten. In our hospital an infectious disease physician reviews at the bedside every case of S.aureus bacteraemia on the medical and surgical wards. In this way, advice is given and documented on antibiotic choice, route of administration and duration, the removal of the infective focus where possible (e.g intravascular lines) and the need for further investigations such as echocardiography. Charis Marwick SpR Infectious Diseases William J Olver Consultant Microbiologist Ninewells Hospital and Medical School, Dundee DD1 9SY william.olver@nhs.net 1. Paul J. Surveillance and management of all types of Staphylococcus aureus bacteraemia. BMJ 2006;333:269-70 2. Jensen AG, Wachmann CH, Espersen F et al. Treatment and outcome of Staphylococcus aureus bacteraemia: a prospective study of 278 cases. Arch Intern Med 2002;162:25-32 3. Fowler VG Jr, Sanders LL, Sexton DJ et al. Outcome of Staphylococcus aureus bacteremia according to compliance with recommendations of infectious diseases specialists: experience with 244 patients. Clin Infect Dis 1998;27:478-86 4. Greig JR. Accuracy and completeness of the documentation of blood culture results. J Clin Path 2003;56:558 Competing interests: None declared
Should antibiotic courses be much shorter? 24 August 2006
CK Connolly, Retired Physician Aldbrough St John Richmond DL1 7 TP Send response to journal: Re: Should antibiotic courses be much shorter?	Dr Paul is to be congratulated on his article and his emphasis on antibiotic stewardship. This must entail a substantial reduction in the total exposure of the population to antibiotics. This might require a radical rethink of the length of courses and dose reduction, particularly in acute infections in the otherwise fit. On the one hand the time scale of bacteriological propogation suggests that one dose might be sufficient in many cases, but on the other hand, dose reduction seems inappropriate. If subsequent doses are needed, they may well be directed at partially resistant or relatively inaccessible organisms. There is an urgent need to investigate very short high dose antibiotics in the management of infections .This should not be overshadowed by fear of increased numbers of relapses which may be a necessary but relatively small price to pay. If relapse is entirely due to too short a course, it will occur with sensitive organisms, so if antibiotic is reintroduced immediately the patient should respond satisfactorily. It is the prolonged and intermittent use of antibiotics that leads to the development of antibiotic resistance both in organisms responsible for the treated infection and present in the local environment. Competing interests: None declared