Management of Staphylococcus aureus bloodstream infections Established concepts and new developments

Staphylococcus aureus bloodstream infections (SAB) represent a distinct clinical entity. Due to the frequency and the associated high morbidity and mortality, special requirements apply to the clinical management. Thus, in contrast to coagulase-negative staphylococci, even the detection of S. aureus in a single blood culture bottle is considered to be an infection requiring treatment. A classification into complicated versus uncomplicated bloodstream infections is carried out, with implications for the recommended duration of treatment (2 vs. 4-6 weeks). The use of transesophageal echocardiography to exclude endocarditis is indicated in the vast majority of cases. Because of frequent clinically silent septic metastases, positron emission tomography with computed tomography (PET-CT) is a useful tool for detection of nidi. For methicillin-sensitive S. aureus (MSSA), flucloxacillin and cefazolin are applied as basic treatment and for methicillin-resistant S. aureus (MRSA), vancomycin or daptomycin are used depending on the focus and comorbidity. If foreign material is present, a combination of basic treatment with rifampicin or fosfomycin should be considered. Source control by abscess drainage or removal of infected intravascular catheters, intracardiac devices or if necessary artificial joints is important. Studies show that infectious disease consultations improve the quality of care and mortality in SAB. Current open questions address the identification of subpopulations that benefit from combination treatment, the effectiveness and timing of stepdown oral antibiotic treatment, and a possible reduction in the overall duration of treatment. This review article summarizes the current standards for diagnostics and treatment of patients with SAB and presents recent relevant studies on this condition.