Surveillance and management of all types of Staphylococcus aureus bacteraemia
BMJ 2006; 333 doi: https://doi.org/10.1136/bmj.333.7562.269 (Published 03 August 2006) Cite this as: BMJ 2006;333:269
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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
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
Competing interests: No competing interests
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
Competing interests: No competing interests