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Editorial Comment

All Together Now

Clinicians, Microbiologists, Epidemiologists, Pharmacists, Antimicrobial Stewardship Programs, Infectious Diseases Specialists, and Staphylococcus aureus Bacteremia

Rodriguez-Noriega, Eduardo MD, PhD*; Morfin-Otero, Rayo MD, PhD

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Infectious Diseases in Clinical Practice: March 2020 - Volume 28 - Issue 2 - p 55-57
doi: 10.1097/IPC.0000000000000830
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Written as an editorial commentary regarding Lewis et al. Impact of Infectious Diseases Consultation on the Treatment of Staphylococcus aureus Bacteremia pages 67–70 of the Journal.

Rapid initiation of appropriate therapy for infectious diseases saves lives and decreases morbidity, hospital lengths of stays, and overall costs. The determination of the most appropriate empiric antibiotic treatment regimens and their impact on a variety of infectious diseases syndromes have been the subject of multiple studies. In 1980, Kreger et al1 reported that appropriate antibiotic treatment of gram-negative bacteremia reduced both mortality and the incidence of shock by approximately 50%; in 1997, Weinstein et al2 demonstrated that mortality was lowest in patients with bacteremia and fungemia who received appropriate antimicrobial therapy throughout the course of infection compared with those who received inadequate treatment either during empiric therapy or for their entire treatment course (mortality rates 10%, 13%, and 33%, respectively).

The optimization of antimicrobial therapy is crucial in critically ill patients in medical and surgical intensive care units. In a prospective cohort study of intensive care unit patients, Koleff et al3 found that inadequate antibiotic treatment was the most important independent determinate of mortality, with a 42% mortality rate among patients receiving inadequate therapy compared with 17.7% in patients receiving appropriate antibiotics.

The impact of infectious disease specialty consultations on the delivery of appropriate antibiotic therapy of bacteremia was evaluated in 428 episodes of bacteremia prospectively assessed over 1 year.4 Infectious diseases consultations resulted in higher rates of appropriate empiric treatment (78% vs 54% in cases without consultation) and directed therapy guided by blood culture results (97% vs 89%), more frequent transitions from parenteral to oral therapy, and decreased use of broad-spectrum antibiotics.4,5

Staphylococcus aureus bacteremia (SAB) is a common bloodstream infection associated with major complications including metastatic infections and endocarditis.6Staphylococcus aureus bacteremia frequently recurs, leading to readmissions with extended lengths of stay and high mortality rates.7 The clinician must be aware of clinical findings suggesting a complicated SAB; these include community acquisition, cutaneous lesions, persistent fever at 72 hours, and positive follow-up blood cultures at 48 to 96 hours.6 Diagnostic criteria are expanded in the 2011 clinical practice guidelines of the Infectious Diseases Society of America for the treatment of methicillin-resistant S. aureus infections.8 Uncomplicated bacteremia is defined by positive blood cultures and the exclusion of endocarditis, the absence of implanted prostheses, follow-up blood cultures performed on specimens obtained 2 to 4 days after the initial set that do not grow methicillin-resistant S. aureus, defervescence within 72 hours of initiating effective therapy, and no evidence of metastatic infection. Complicated SAB is defined by positive blood cultures in patients who do not meet the criteria for uncomplicated bacteremia.8 The exclusion of endocarditis requires echocardiography, with transesophageal imaging providing higher sensitivity than transthoracic studies.9 Minejima et al10 have highlighted that the duration of bacteremia is of the utmost importance; in their multicenter, prospective, observational study of hospitalized adults with SAB, short (1–2 days), intermediate (3–6 days), or prolonged (>7 days) durations had increasing 30-day mortality rates of 5%, 11%, and 22%, respectively. Every additional day of bacteremia increased the probability of death, with a significant risk at 3 days of continuous bacteremia.10 The optimal antibiotic regimens for both methicillin-sensitive and methicillin-resistant SAB are still being debated.

One approach to provide care to a patient with SAB that includes accurate diagnosis; thorough assessments of risk factors, clinical severity, comorbidities, and prognosis; anticipation of potential complications; and the design optimal therapy is to seek an expert opinion. In this issue of Infectious Diseases in Clinical Practice, Lewis et al11 report their evaluation of the impact of infectious diseases consultations on the treatment of SAB. Infectious diseases consultations resulted in a lower readmission rate (19% vs 46.4% in the group without infectious diseases consultation) and higher adherence to guideline-directed therapy. These findings reinforce those of other investigators that associate infectious diseases consultations with improved clinical outcomes including lower mortality,12–17 improved adherence to standards of care and quality measures,15–20 more frequent initiation of effective empiric therapy,17 earlier discharge,17 and fewer readmissions.20 These findings have led to a suggestion that routine bedside infectious diseases consultation should become the standard of care in adults with SAB.18 The impact of infectious diseases consultations has also been reviewed in 2 recent systematic reviews.21,22

In the quest to improve diagnosis and treatment of SAB, evidence-based care bundles have been developed. They reduce mortality and improve adherence to quality care indicators.23 Interventions include antimicrobial stewardship bundles to optimize antibiotic therapy,24,25 evidence-based care processes that integrate appropriate treatment; echocardiography and infectious diseases consultation,26 algorithm-based therapy,27 and an unsolicited prospective audit and feedback of using a standardized care bundle that includes infectious diseases consultation, appropriate empiric and definitive therapy, echocardiography, and other quality indicators.28

Advances in the clinical microbiology laboratory can accelerate the diagnosis of SAB and the initiation of targeted antimicrobial therapy. Rapid molecular methods for pathogen identification and antibiotic susceptibility testing29–31 and direct communication between laboratorians and clinicians32,33 have improved the clinical outcomes of patients with SAB.

By instituting evidence-based best practices similar to those recommended by the Centers for Disease Control and Prevention in the 12 Steps to Prevent Antimicrobial Resistance Campaign to Prevent Antimicrobial Resistance in Healthcare Settings,34 with multidisciplinary collaborations between clinical microbiologists,35 epidemiologists, clinical pharmacists, and infectious disease-trained physicians, we will move forward to provide optimal care for patients with SAB.

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