The Real-World Boards: Question #6
Considering treatment courses for bacteremia with an assertive pharmacist
These are the Real-World Boards. As in the real world, there is often no “right” answer, and you are only competing against yourself. Upgrade to the Lifelong Learner level for full access to all the questions and unlimited CME credits with an included Learner+ account.
Your hospital has recently launched a new antibiotic stewardship initiative. During interdisciplinary rounds for bed 16, the pharmacist inquires whether antibiotics should be limited to 7 days rather than the traditional 14, as recent randomized trial results and a meta-analysis have suggested this is safe.
You note the patient had penicillin-sensitive Staphylococcus aureus bacteremia; she has received vancomycin and then cefazolin for a total of 8 days, with repeat blood cultures drawn 3 days ago showing no growth to date, a normal white blood cell count, and without fever for 6 days. All the infectious diseases physicians are currently out on mental health leave.
Bacteremia has traditionally been treated for 14 days of I.V. antibiotics. Randomized trials have tested shorter antibiotic courses and generally found 7-day courses to result in equivalent survival and cure rates. However, these trials have important limitations to consider. For example, patients with Staphylococcus aureus bacteremia were excluded from the major trials testing shorter antibiotic courses.
S. aureus bacteremia (including penicillin-sensitive species) is particularly dangerous and should generally be treated for a minimum of 14 days of antibiotics. Some patients are eligible for switching to oral antibiotics after a period of parenteral therapy, but this should be considered under consultation with an infectious diseases specialist.
Staphylococcus aureus bacteremia management (Review)
Staphylococcus aureus is a particularly virulent gram-positive bacteria that lives harmlessly on the skin or mucous membranes of about one-third of people. When S. aureus gains access to the bloodstream, it can become life-threatening within a short period.
Your caravan of Computers-On-Wheels rolls onward. “When it rains, it pours,” jokes the charge nurse. “Mr. Davis in bed 17 also has bacteremia.”
He was admitted with sepsis without shock and found to have pan-sensitive E. coli bacteremia likely from a urinary tract infection associated with prostate hyperplasia. He steadily improved on ceftriaxone, and on hospital and antibiotic day 4, his white blood cell count is 13,000, and he has been afebrile for 48 hours. He appears ready for transfer to the medical ward. During your handoff, the hospitalist asks how long you recommend antibiotics be continued. The pharmacist suggests 7 days, as the patient fits the profile of those enrolled in the relevant randomized trials. Everyone is looking at you.
