Internal Medicine

0521779407-19 CUNY1086/Karliner 0 521 77940 7 June 6, 2007 17:50

1374 Staphylococcal Infections

management

What to Do First

■In serious infections (e.g.: sepsis, endocarditis, neurosurgical shunt

infection), empiric antibiotics are important before definitive micro-

biological diagnosis

■Septic joints need immediate drainage

➣In suspected intravenous catheter infection, early removal of the

line is important (particularly in S. aureus infections)

General Measures

■General supportive care

specific therapy

Treatment Options

■The first-line drugs are the anti-staphylococcal penicillins (nafcillin

IV, dicloxicillin po). The first-generation cephalosporins (cefazolin

IV cephalexin po) also have excellent staphylococcal activity. Fluo-

roquinolones such as levofloxacin also have very good activity. The

beta-lactam/beta-lactamase inhibitor combinations (ampicillin-

sulbactam, piperacillin-tazobactam, ticarcillin-clavulanate) are out-

standing. Vancomycin is an important agent for methicillin resis-

tantS. aureus. Trimethoprim-sulfamethoxazole, clindamycin, or

minocycline can be tried if the patient cannot tolerate Vancomycin.

Quinupristin/dalfopristin (Synercid), linezolid, tigecycline, and dap-

tomycin have activity against methicillin-resistantS. aureusbut at

present these agents should be reserved for vancomycin-resistant

enterococcus (VRE). For vancomycin intermediate (VISA) and resis-

tant S. aureus (VRSA), obtain infectious disease consultation, and

isolates should be sent to CDC for susceptibility testing. Isolates

reported to date have been susceptible to other drugs.

■ForS. aureusbacteremia, would treat for 2 weeks if no evidence

of endocarditis. If evidence of metastatic disease, may need longer

therapy (4 weeks). For endocarditis and osteomyelitis, the duration

of therapy is 4–6 weeks. For uncomplicated right-sided endocarditis,

can treat for 2 weeks if synergistic doses of gentamicin or tobramycin

are concomitantly administered with nafcillin. Rifampin is added to

regimen for prosthetic valve endocarditis.

■For line-infections, use vancomycin empirically, if etiology isS.

aureus, need to remove catheter, treat for at least 2 weeks. If eti-

ology isS. epidermidis, can try to “save” catheter (>80% cure rate if

infection limited to exit site).