STAPHYLOCOCCUS AUREUS, THE GOLDEN CHILDNeil Goodloe, MD Cox Health ID

INTRODUCTIONS

! Staphylococcus is a gram positive organism ! Distinguished from Streptococcal species by

clusters versus chains on Gram stain ! 2 different catagories of Staphylococcal

organisms ! S. aureus ! Coag Negative Staph, can cause certain invasive

infections

INTRODUCTIONS INTRODUCTIONS

INTRODUCTIONS INTRODUCTIONS

! Mannitol-salt agar, is chemically-configured to turn yellow when S. aureus ferments the mannitol,changing the color of the phenol red indicator dye.

INTRODUCTIONS

! This is example of an antibiotic sensitivity test. The size of the “inhibition zones" depends on the sensitivity of the bacteria.

INTRODUCTIONS

WHAT AND WHY OF STAPHYLOCOCCUS AUREUS.

! It is now #1 for Native and prosthetic valve bacterial endocarditis.

! The types of infections are very broad ! Blood stream infections ! Skin and soft tissue infections

! Device infections

! Toxin mediated illnesses ! Community outbreaks

ANTI-STAPH ANTIBIOTICS

! Anti –staph penicillins ! Nafcillin, oxacillin, dicloxacillin

! Not active for anaerobes, enterococcus, Gram negatives or listeria

ANTI-STAPH ANTIBIOTICS

! Aminopenicillins ! Ampicillin and Amoxicillin

! Strep. pneumo, Prot mirabilis, many gonococci & meningococci & Clostid

! Amoxicillin – clavanutate (Augmentin)

! As for amoxicillin & also Staph. ! H influenzae, B fragilis & other anaerobes, E

coli, salmonella & shigella ! Among gram-positive bacteria, staphylococci are

the major pathogens that produce β-lactamase

ANTI-STAPH ANTIBIOTICS

Ceph Gen 1st 2nd 3rd 4th 5th S. aureus +++ ++ + + + MRSA - - - - + ! Of Course Vancomycin, Daptomycin,

Dalbavancin, Oritivancin, Linezolid, Tedezolid all also cover MRSA infections as well.

! Sulfa, Lincomycins, Tetracyclines are dependent on susceptibilities

! Ceftaroline is 5th gen cephalosporin

STAPHYLOCOCCUS AUREUS BACTEREMIA.

! Blood stream infections ! Complicated or uncomplicated? ! Additional blood culture

! NEVER consider a contaminate

! As apposed to Coag Negative Staphylococcus

! With an exclusion later ! Echo is recommended for all adult patients

UNCOMPLICATED BACTEREMIA.

! Positive blood culture results and the following: ! exclusion of endocarditis ! no implanted prostheses ! follow-up blood cultures performed 2–4 days

after the initial set that do not grow ! Defervescence within 72 h of initiating

effective therapy ! No evidence of metastatic sites of infection

! 2weeks of treatment

COMPLICATED BACTEREMIA STAPHYLOCOCCUS AUREUS

! Patients with positive blood culture results who do not meet criteria for uncomplicated bacteremia

! Increased risk ! Community acquired ! Fever >72 hours ! Repeat blood culture positive ! Any device

! 4-6 weeks of treatment ! Think about the source too!

COMPLICATED BACTEREMIA STAPHYLOCOCCUS AUREUS

! Risk ! 12% for Native valves ! 40% for Prosthetic valves ! Can not rule out BE by exam with

Staphylococcus aureus ! TEE is preferred method

! Staphylococcus lugdunensis, be aware and beware of this one

ILLUSTRATIVE CASE

! 48yo male ! Hypotensive SBP< 90 ! HR>120 ! Confusion, Lethargy ! Fever 103 ! Rhonchi bilaterally ! Murmur along LLSB

ILLUSTRATIVE CASE

ILLUSTRATIVE CASE ILLUSTRATIVE CASE

ILLUSTRATIVE CASE

! Uncomplicated versus Complicated? ! What do you want to do? ! What else do you want to know? ! What antibiotics do you want to give?

! Think of why, what you want to cover.

ILLUSTRATIVE CASE

! WBC 30,000 ! HGB 12 ! Platelet 130,000 ! NA 132 ! CRT 1.2 ! Blood culture GPC in clusters

! Does this change your plan?

ILLUSTRATIVE CASE

! TTE Large 1.0 MV lesion ! Blood cultures finally negative on day 3 ! Fever on going for 7 days ! CXR with septic pulmonary emboli ! Culture grew MRSA ! Vancomycin IV given ! Eventually met a friendly neighborhood CTS ! UDS with Meth and Amphetamines

STAPHYLOCOCCUS AUREUS SKIN AND SOFT TISSUE INFECTIONS (SSTI)

! Skin and soft tissue infection ! We have all seen this one at least once. ! Can be very problematic in the outpatient setting ! Can lead to severe invasive infections ! Of course can be recurrent and effect everyone

in the house. ! Can be spread in a community

STAPHYLOCOCCUS AUREUS SSTI

! MRSA USA 300, an epidemiologic tracking device ! Clonal propagation from a strain that

appeared in 1995 ! Recent article showed the close relatedness

of strains being spread in Manhattan 2004-9 ! National Acad Sci USA 2014 May

6;111:6738

ILLUSTRATIVE CASE

! Recently a 9yo with a MRSA skin lesion on her back !Family attempted to express the infection

!The child presented 1 week later prostrate with fever 101

!Severe back pain

!Epidural abscess found

ILLUSTRATIVE CASE STAPHYLOCOCCUS AUREUS SSTI

! For a cutaneous abscess, incision and drainage is the primary treatment

! For simple abscesses or boils, incision and drainage alone is likely to be adequate

! Antibiotic therapy is recommended for !severe disease

!Rapid progression with cellulitis, systemic illness

!comorbidities !abscess difficult to drain !septic phlebitis !lack of response to incision and drainage

STAPHYLOCOCCUS AUREUS SSTI

! For purulent lesion empirical therapy for CA-MRSA is ! Five to 10 days of therapy is recommended

! Oral antibiotic ! Clindamycin (D-test and Erythromycin) ! Trimethoprim-sulfamethoxazole ! Tetracyclline, Oxazolidinones, Glycopeptides

! MSSA best treatment is beta-lactam (not amoxicillin) ! Use of rifampin as a single agent not recommended

RECURRENT STAPHYLOCOCCUS AUREUS SSTI.

! Decolonization does it Work? ! Hygiene and decreasing risk of exposure

!Walmart, Bathrooms, Gas stations etc ! Life span of Staph on surface? ! Household contacts? ! Animals? See Emerg Infect Disease 2007;13:1834 ! Recent article in CID 2014, June 1;58:1540 on this topic ! See IDSA Guidelines on MRSA treatment

RECURRENT STAPHYLOCOCCUS AUREUS SSTI.

! Article to look at ! New England Journal Medicine 2010;362:9-17 ! New England Journal Medicine 2013;368:533-42 ! New England Journal Medicine 2013;638:2255-65 ! Clinical Infectious Disease 2014 June;58:1540

STAPHYLOCOCCUS AUREUS PNEUMONIA

! Suspect for hospitalized patients with severe CAP ! ICU admission ! Necrotizing or cavitary infiltrates ! Empyema ! Beta lactam for MSSA

STAPHYLOCOCCUS AUREUS PNEUMONIA

! Initial choice of treatment is IV vancomycin for MRSA ! Watch MIC to vancomycin in MRSA strain ! Linezolid 600 mg PO/IV twice daily ! Clindamycin 600 mg PO/IV 3 times daily ! Ceftaroline 600mg IV Q12 hours ! Don’t use Daptomycin

STAPHYLOCOCCUS AUREUS PNEUMONIA

! MSSA treatment of choice is beta-lactam (not amoxicillin)

! 7–21 days, depending on the extent of infection ! Check Flu PCR of sputum as well in the right season ! Remember Staphylococcus produces 208

different toxins ! Tissue destruction is name of game

ILLUSTRATIVE CASE

! 65 yo female admitted for right knee pain. ! Acute onset 3 days ago ! Associated fever 102, WBC 14,000 ! PMHX: Right prosthetic joint replacement 2 years

ago. ! What do you think is wrong? ! What is your next step?

ILLUSTRATIVE CASE

! Arthrocentesis 50,000 WBC, 98% neutrophils ! Gram stain with GPC in clusters ! Now what?

ILLUSTRATIVE CASE

! She reports a PCN allergy when she was 5. ! Does this change your plan?

PCN ALLERGY

! PCN versus Cephalosporin drug reaction ! General understanding is around 10-15% risk of

cross reactivity ! New information is constantly changing ! Recently in J Emerg Med. 2012 May;42(5):612-20.

literature review showed a 1% risk in dissimilar medications.

! Always feel free to ask an ID or pharmacist.

ILLUSTRATIVE CASE

! Bacterial culture grows Staphylococcal aureus. ! What if it is Oxacillin susceptible? ! What if it was Oxacillin resistant? What does this

mean for your treatment? ! You place her on the right antibiotics and then

call your friendly Orthopedic surgeon and Infectious Disease doctor.

STAPHYLOCOCCUS AUREUS BONE AND JOINT INFECTIONS

! Surgical debridement and drainage of associated soft tissue, abscesses is the mainstay of therapy

! Optimal route of administration not established. ! Parenteral, oral, or initial IV followed by oral?

! Ancef and Nafcillin are choice for MSSA ! Call a friendly Orthopedic surgeon and Infectious

disease doctor for help. ! Prosthetic joint infections require unique treatment

decisions ! Single or 2 stage?

STAPHYLOCOCCUS AUREUS BONE AND JOINT INFECTIONS

! MRSA ! IV Vancomycin ! IV Daptomycin ! TMP-SMX BID

! Oxazolidinones, with caveats. ! Clindamycin ! Not Tigecycline or Glycopeptides at this time ! Rifampin, please call Infectious Disease prior, never

use alone, ! Remember drug-drug interactions

STAPHYLOCOCCUS AUREUS CNS INFECTIONS

! REMOVE infection! ! REMOVE Devices as able! ! Treat with Vanco for MRSA ! Nafcillin for MSSA ( Ancef?) ! Duration is variable ! If using alternative agents, talk to your

neighborhood ID doctor, it really is Complex. ! Remember blood brain barrier exists for a reason

THINGS TO REMEMBER ABOUT STAPHYLOCOCCUS AUREUS.

! Beta-lactam for MSSA ! Vanco for MRSA

! Watch Renal function and Trough ! 10-15 or >15 trough

! Watch MIC for Vancomycin, beware and be aware ! Talk to your Friendly ID doctor

! Daptomycin has limitations ! Not for lungs ! Monitor CK

THINGS TO REMEMBER ABOUT STAPHYLOCOCCUS AUREUS

! Watch Erythromycin sensitivity ! This is important for use of Clindamycin ! D-test will help resolve

! Linezolid has its place, Tedezolid has its place ! Duration of treatment increases neurotoxicity,

not recoverable, it is a mitochondrial toxicity ! Fluoroquinolones and Tetracyclines work in adults,

fearful in children ! Glycopeptides have a place too.

SCARY THINGS TO THINK ABOUT

! Antibiotic resistance genes are Ubiquitous in Soil Microorganism ! Nature 2014 May 29;509:612

! TheCost of Surgical Site Infections ! Jama 2014, May 21

! Can animals carry Staphylococcus aureus infection? ! Drug resistance can occur on treatment, even

appropriate treatment. ! Quorum sensing does exist, bacterial burden of infection

does matter.

THANKS

! See the IDSA practice guidelines for complete information contained in this Lecture

! Some pictures obtained from Open source and CDC I do not own those images.

STAPHYLOCOCCUS LUGDUNENSIS

! Community acquired infections ! Coag negative staphylococcus organism ! Almost never a contaminant ! Causes staphylococcus aureus type infections ! Hardware ! Blood ! Surgery and Mortality risk ! Oxacillin susceptible though