Clinical

Clinical question: Does the pharmacologic renin-angiotensin-aldosterone (RAAS) system blockade increase the risk for contrast-induced acute kidney injury (CI-AKI) after cardiac catheterization?

Background: Prior prospective studies have demonstrated conflicting results regarding the deleterious versus protective effects of RAAS blockade prior to cardiac catheterization.

Study design: Retrospective, propensity-score-matched cohort study.

Setting: Single-center teaching hospital in South Korea.

Synopsis: Researchers identified patients who had cardiac catheterization and applied propensity-score matching to generate cohorts of periprocedural angiotensin converting enzyme inhibitor (ACEI) and angiotensin receptor blocker (ARB) users versus non-users. CI-AKI occurred more frequently in patients treated with ACEIs/ARBs compared to those who were not (11.4% vs. 6.3%, respectively; P<0.001).

This study was limited by its observational design. Although the propensity-score matching improves the internal validity, it is possible that unaccounted confounders were present. This trial might stimulate interest in re-examining this issue in larger prospective trials, but it should not alter current practice.

Bottom line: RAAS blockade during cardiac catheterization is associated with increased risk for CI-AKI, but further randomized trials are needed to confirm this conclusion.

Citation: Rim MY, Ro H, Kang WC, et al. The effect of renin-angiotensin-aldosterone system blockade on contrast-induced acute kidney injury: a propensity-matched study. Am J Kidney Dis. 2012;60:576-582.

Clinical question: Does the pharmacologic renin-angiotensin-aldosterone (RAAS) system blockade increase the risk for contrast-induced acute kidney injury (CI-AKI) after cardiac catheterization?

Background: Prior prospective studies have demonstrated conflicting results regarding the deleterious versus protective effects of RAAS blockade prior to cardiac catheterization.

Study design: Retrospective, propensity-score-matched cohort study.

Setting: Single-center teaching hospital in South Korea.

Synopsis: Researchers identified patients who had cardiac catheterization and applied propensity-score matching to generate cohorts of periprocedural angiotensin converting enzyme inhibitor (ACEI) and angiotensin receptor blocker (ARB) users versus non-users. CI-AKI occurred more frequently in patients treated with ACEIs/ARBs compared to those who were not (11.4% vs. 6.3%, respectively; P<0.001).

This study was limited by its observational design. Although the propensity-score matching improves the internal validity, it is possible that unaccounted confounders were present. This trial might stimulate interest in re-examining this issue in larger prospective trials, but it should not alter current practice.

Bottom line: RAAS blockade during cardiac catheterization is associated with increased risk for CI-AKI, but further randomized trials are needed to confirm this conclusion.

Citation: Rim MY, Ro H, Kang WC, et al. The effect of renin-angiotensin-aldosterone system blockade on contrast-induced acute kidney injury: a propensity-matched study. Am J Kidney Dis. 2012;60:576-582.

Clinical question: Does the pharmacologic renin-angiotensin-aldosterone (RAAS) system blockade increase the risk for contrast-induced acute kidney injury (CI-AKI) after cardiac catheterization?

Background: Prior prospective studies have demonstrated conflicting results regarding the deleterious versus protective effects of RAAS blockade prior to cardiac catheterization.

Study design: Retrospective, propensity-score-matched cohort study.

Setting: Single-center teaching hospital in South Korea.

Synopsis: Researchers identified patients who had cardiac catheterization and applied propensity-score matching to generate cohorts of periprocedural angiotensin converting enzyme inhibitor (ACEI) and angiotensin receptor blocker (ARB) users versus non-users. CI-AKI occurred more frequently in patients treated with ACEIs/ARBs compared to those who were not (11.4% vs. 6.3%, respectively; P<0.001).

This study was limited by its observational design. Although the propensity-score matching improves the internal validity, it is possible that unaccounted confounders were present. This trial might stimulate interest in re-examining this issue in larger prospective trials, but it should not alter current practice.

Bottom line: RAAS blockade during cardiac catheterization is associated with increased risk for CI-AKI, but further randomized trials are needed to confirm this conclusion.

Citation: Rim MY, Ro H, Kang WC, et al. The effect of renin-angiotensin-aldosterone system blockade on contrast-induced acute kidney injury: a propensity-matched study. Am J Kidney Dis. 2012;60:576-582.

Clinical question: Did the 2008 Center for Medicare & Medicaid Services (CMS) policy denying additional payment for hospital-acquired conditions result in decreased rates of nosocomial infections?

Background: In an effort to curtail preventable complications, CMS implemented a policy of nonpayment for certain healthcare-acquired conditions beginning in October 2008. The effect of this policy on rates of nosocomial infections, including central venous catheter-associated bloodstream infections and catheter-associated urinary tract infections, is unknown.

Study design: Quasi-experimental.

Setting: Data collected from 398 hospitals participating in the National Healthcare Safety Network of the Centers for Disease Control and Prevention.

Synopsis: Investigators analyzed rates of nosocomial infections in participating hospitals before and after implementation of the 2008 nonpayment policy. The rates of decline in central venous catheter infections were not significantly different in the pre-implementation and post-implementation periods (4.8% per quarter and 4.7% per quarter, respectively; incidence-rate ratio 1.0; P=0.97). Similar results were found with regard to catheter-associated UTIs before and after policy initiation (3.9% per quarter and 0.9% per quarter, incidence-rate ratio 1.03; P=0.08). Results did not vary between states with and without mandatory reporting of nosocomial infections.

While this study’s broad scope limits the ability to draw firm conclusions, it does highlight the need for careful evaluation and quantification of the outcomes resulting from CMS’ expansion of policies for financial incentives and disincentives.

Bottom line: National rates of decline in nosocomial infections were unchanged before and after implementation of CMS’ nonpayment policy in 2008.

Citation: Lee GM, Kleinman K, Soumerai SB, et al. Effect of nonpayment for preventable infections in U.S. hospitals. N Engl J Med. 2012;367:1428-1437

Clinical question: Did the 2008 Center for Medicare & Medicaid Services (CMS) policy denying additional payment for hospital-acquired conditions result in decreased rates of nosocomial infections?

Background: In an effort to curtail preventable complications, CMS implemented a policy of nonpayment for certain healthcare-acquired conditions beginning in October 2008. The effect of this policy on rates of nosocomial infections, including central venous catheter-associated bloodstream infections and catheter-associated urinary tract infections, is unknown.

Study design: Quasi-experimental.

Setting: Data collected from 398 hospitals participating in the National Healthcare Safety Network of the Centers for Disease Control and Prevention.

Synopsis: Investigators analyzed rates of nosocomial infections in participating hospitals before and after implementation of the 2008 nonpayment policy. The rates of decline in central venous catheter infections were not significantly different in the pre-implementation and post-implementation periods (4.8% per quarter and 4.7% per quarter, respectively; incidence-rate ratio 1.0; P=0.97). Similar results were found with regard to catheter-associated UTIs before and after policy initiation (3.9% per quarter and 0.9% per quarter, incidence-rate ratio 1.03; P=0.08). Results did not vary between states with and without mandatory reporting of nosocomial infections.

While this study’s broad scope limits the ability to draw firm conclusions, it does highlight the need for careful evaluation and quantification of the outcomes resulting from CMS’ expansion of policies for financial incentives and disincentives.

Bottom line: National rates of decline in nosocomial infections were unchanged before and after implementation of CMS’ nonpayment policy in 2008.

Citation: Lee GM, Kleinman K, Soumerai SB, et al. Effect of nonpayment for preventable infections in U.S. hospitals. N Engl J Med. 2012;367:1428-1437

Clinical question: Did the 2008 Center for Medicare & Medicaid Services (CMS) policy denying additional payment for hospital-acquired conditions result in decreased rates of nosocomial infections?

Background: In an effort to curtail preventable complications, CMS implemented a policy of nonpayment for certain healthcare-acquired conditions beginning in October 2008. The effect of this policy on rates of nosocomial infections, including central venous catheter-associated bloodstream infections and catheter-associated urinary tract infections, is unknown.

Study design: Quasi-experimental.

Setting: Data collected from 398 hospitals participating in the National Healthcare Safety Network of the Centers for Disease Control and Prevention.

Synopsis: Investigators analyzed rates of nosocomial infections in participating hospitals before and after implementation of the 2008 nonpayment policy. The rates of decline in central venous catheter infections were not significantly different in the pre-implementation and post-implementation periods (4.8% per quarter and 4.7% per quarter, respectively; incidence-rate ratio 1.0; P=0.97). Similar results were found with regard to catheter-associated UTIs before and after policy initiation (3.9% per quarter and 0.9% per quarter, incidence-rate ratio 1.03; P=0.08). Results did not vary between states with and without mandatory reporting of nosocomial infections.

While this study’s broad scope limits the ability to draw firm conclusions, it does highlight the need for careful evaluation and quantification of the outcomes resulting from CMS’ expansion of policies for financial incentives and disincentives.

Bottom line: National rates of decline in nosocomial infections were unchanged before and after implementation of CMS’ nonpayment policy in 2008.

Citation: Lee GM, Kleinman K, Soumerai SB, et al. Effect of nonpayment for preventable infections in U.S. hospitals. N Engl J Med. 2012;367:1428-1437

Clinical question: How does radiofrequency ablation compare to antiarrhythmic therapy as first-line treatment for paroxysmal atrial fibrillation (AF)?

Background: Current American College of Cardiology/American Heart Association (ACC/AHA) guidelines support radiofrequency ablation in high-volume centers for select patients with symptomatic, paroxysmal AF who have failed antiarrhythmic therapy (Class I recommendation). Little data exist regarding catheter ablation as a first-line intervention.

Study design: Randomized prospective cohort study.

Setting: Multicenter Danish trial.

Synopsis: Investigators randomized patients with symptomatic paroxysmal AF who were deemed to be good candidates for rhythm control to antiarrhythmic therapy versus radiofrequency catheter ablation. Patients had seven-day Holter monitoring at three, six, 12, 18, and 24 months. There was no significant difference in the cumulative burden of AF between the antiarrhythmic and ablation groups (19% and 13%, respectively; P=0.10). Secondary outcomes including quality of life and cumulative burden of symptomatic AF did not vary significantly between the groups. Crossover was high, with 35% of patients randomized to antiarrhythmic therapy eventually undergoing catheter ablation during the trial. There was no statistically significant difference in adverse events between the two groups.

This trial lends credence to the current ACC/AHA guidelines recommending radiofrequency ablation as second-line therapy for patients with AF after failing antiarrhythmics.

Bottom line: Radiofrequency ablation and antiarrhythmic therapy have similar efficacy as first-line therapy in paroxysmal AF.

Citation: Nielsen JC, Johannessen A, Raatikainen P, et al. Radiofrequency ablation as initial therapy in paroxysmal atrial fibrillation. N Engl J Med. 2012;367:1587-1595.

Clinical question: How does radiofrequency ablation compare to antiarrhythmic therapy as first-line treatment for paroxysmal atrial fibrillation (AF)?

Background: Current American College of Cardiology/American Heart Association (ACC/AHA) guidelines support radiofrequency ablation in high-volume centers for select patients with symptomatic, paroxysmal AF who have failed antiarrhythmic therapy (Class I recommendation). Little data exist regarding catheter ablation as a first-line intervention.

Study design: Randomized prospective cohort study.

Setting: Multicenter Danish trial.

Synopsis: Investigators randomized patients with symptomatic paroxysmal AF who were deemed to be good candidates for rhythm control to antiarrhythmic therapy versus radiofrequency catheter ablation. Patients had seven-day Holter monitoring at three, six, 12, 18, and 24 months. There was no significant difference in the cumulative burden of AF between the antiarrhythmic and ablation groups (19% and 13%, respectively; P=0.10). Secondary outcomes including quality of life and cumulative burden of symptomatic AF did not vary significantly between the groups. Crossover was high, with 35% of patients randomized to antiarrhythmic therapy eventually undergoing catheter ablation during the trial. There was no statistically significant difference in adverse events between the two groups.

This trial lends credence to the current ACC/AHA guidelines recommending radiofrequency ablation as second-line therapy for patients with AF after failing antiarrhythmics.

Bottom line: Radiofrequency ablation and antiarrhythmic therapy have similar efficacy as first-line therapy in paroxysmal AF.

Citation: Nielsen JC, Johannessen A, Raatikainen P, et al. Radiofrequency ablation as initial therapy in paroxysmal atrial fibrillation. N Engl J Med. 2012;367:1587-1595.

Clinical question: How does radiofrequency ablation compare to antiarrhythmic therapy as first-line treatment for paroxysmal atrial fibrillation (AF)?

Background: Current American College of Cardiology/American Heart Association (ACC/AHA) guidelines support radiofrequency ablation in high-volume centers for select patients with symptomatic, paroxysmal AF who have failed antiarrhythmic therapy (Class I recommendation). Little data exist regarding catheter ablation as a first-line intervention.

Study design: Randomized prospective cohort study.

Setting: Multicenter Danish trial.

Synopsis: Investigators randomized patients with symptomatic paroxysmal AF who were deemed to be good candidates for rhythm control to antiarrhythmic therapy versus radiofrequency catheter ablation. Patients had seven-day Holter monitoring at three, six, 12, 18, and 24 months. There was no significant difference in the cumulative burden of AF between the antiarrhythmic and ablation groups (19% and 13%, respectively; P=0.10). Secondary outcomes including quality of life and cumulative burden of symptomatic AF did not vary significantly between the groups. Crossover was high, with 35% of patients randomized to antiarrhythmic therapy eventually undergoing catheter ablation during the trial. There was no statistically significant difference in adverse events between the two groups.

This trial lends credence to the current ACC/AHA guidelines recommending radiofrequency ablation as second-line therapy for patients with AF after failing antiarrhythmics.

Bottom line: Radiofrequency ablation and antiarrhythmic therapy have similar efficacy as first-line therapy in paroxysmal AF.

Citation: Nielsen JC, Johannessen A, Raatikainen P, et al. Radiofrequency ablation as initial therapy in paroxysmal atrial fibrillation. N Engl J Med. 2012;367:1587-1595.

Research on seriously ill, hospitalized, Medicare-age patients finds that those who received inpatient consultations from a multidisciplinary, palliative-care team (including a physician, nurse, and social worker) had lower 30-day hospital readmission rates.¹ Ten percent of discharged patients who received the palliative-care consult were readmitted within 30 days at an urban HMO medical center in Los Angeles County during the same period, even though they were sicker than the overall discharged population.

Receipt of hospice care or home-based palliative-care services following discharge was also associated with significantly lower rates of readmissions, suggesting opportunities for systemic cost savings from earlier access to longitudinal, or ongoing, palliative-care services, says Susan Enguidanos, MPH, PhD, assistant professor of gerontology at the University of Southern California in Los Angeles. Patients discharged from the hospital without any follow-up care in the home had higher odds of readmission.

“Hospitals and medical centers should seriously consider an inpatient palliative care consultation team for many reasons, mostly arising from findings from other studies that have demonstrated improved quality of life, pain and symptom management, satisfaction with medical care, and other promising outcomes,” Dr. Enguidanos says. “Our study suggests that longitudinal palliative care is also associated with the lower readmission rate.”

References

1. Enguidanos S, Vesper E, Lorenz K. 30-day readmissions among seriously ill older adults. J Palliat Med. 2012;15(12):1356-1361.
2. The Advisory Board Company. Mastering the cardiovascular care continuum: strategies for bridging divides among providers and across time. The Advisory Board Company website. Available at: http://www.advisory.com/Research/Cardiovascular-Roundtable/Studies/2012/Mastering-the-Cardiovascular-Care-Continuum. Accessed Jan. 8, 2013.
3. Misky G, Carlson T, Klem P, et al. Development and implementation of a clinical care pathway for acute VTE reduces hospital utilization and cost at an urban tertiary care center [abstract]. J Hosp Med. 2012;7 Suppl 2:S66-S67.
4. Versel N. Health IT holds key to better care integration. Information Week website. Available at: http://www.informationweek.com/healthcare/interoperability/health-it-holds-key-to-better-care-integ/240012443. Accessed Jan. 8, 2013.
5. Office of Inspector General. Early Assessment Finds That CMS Faces Obstacles in Overseeing the Medicare EHR Incentive Program. Office of Inspector General website. Available at: https://oig.hhs.gov/oei/reports/oei-05-11-00250.asp. Accessed Jan. 8, 2013.

Research on seriously ill, hospitalized, Medicare-age patients finds that those who received inpatient consultations from a multidisciplinary, palliative-care team (including a physician, nurse, and social worker) had lower 30-day hospital readmission rates.¹ Ten percent of discharged patients who received the palliative-care consult were readmitted within 30 days at an urban HMO medical center in Los Angeles County during the same period, even though they were sicker than the overall discharged population.

Receipt of hospice care or home-based palliative-care services following discharge was also associated with significantly lower rates of readmissions, suggesting opportunities for systemic cost savings from earlier access to longitudinal, or ongoing, palliative-care services, says Susan Enguidanos, MPH, PhD, assistant professor of gerontology at the University of Southern California in Los Angeles. Patients discharged from the hospital without any follow-up care in the home had higher odds of readmission.

“Hospitals and medical centers should seriously consider an inpatient palliative care consultation team for many reasons, mostly arising from findings from other studies that have demonstrated improved quality of life, pain and symptom management, satisfaction with medical care, and other promising outcomes,” Dr. Enguidanos says. “Our study suggests that longitudinal palliative care is also associated with the lower readmission rate.”

References

1. Enguidanos S, Vesper E, Lorenz K. 30-day readmissions among seriously ill older adults. J Palliat Med. 2012;15(12):1356-1361.
2. The Advisory Board Company. Mastering the cardiovascular care continuum: strategies for bridging divides among providers and across time. The Advisory Board Company website. Available at: http://www.advisory.com/Research/Cardiovascular-Roundtable/Studies/2012/Mastering-the-Cardiovascular-Care-Continuum. Accessed Jan. 8, 2013.
3. Misky G, Carlson T, Klem P, et al. Development and implementation of a clinical care pathway for acute VTE reduces hospital utilization and cost at an urban tertiary care center [abstract]. J Hosp Med. 2012;7 Suppl 2:S66-S67.
4. Versel N. Health IT holds key to better care integration. Information Week website. Available at: http://www.informationweek.com/healthcare/interoperability/health-it-holds-key-to-better-care-integ/240012443. Accessed Jan. 8, 2013.
5. Office of Inspector General. Early Assessment Finds That CMS Faces Obstacles in Overseeing the Medicare EHR Incentive Program. Office of Inspector General website. Available at: https://oig.hhs.gov/oei/reports/oei-05-11-00250.asp. Accessed Jan. 8, 2013.

Research on seriously ill, hospitalized, Medicare-age patients finds that those who received inpatient consultations from a multidisciplinary, palliative-care team (including a physician, nurse, and social worker) had lower 30-day hospital readmission rates.¹ Ten percent of discharged patients who received the palliative-care consult were readmitted within 30 days at an urban HMO medical center in Los Angeles County during the same period, even though they were sicker than the overall discharged population.

Receipt of hospice care or home-based palliative-care services following discharge was also associated with significantly lower rates of readmissions, suggesting opportunities for systemic cost savings from earlier access to longitudinal, or ongoing, palliative-care services, says Susan Enguidanos, MPH, PhD, assistant professor of gerontology at the University of Southern California in Los Angeles. Patients discharged from the hospital without any follow-up care in the home had higher odds of readmission.

“Hospitals and medical centers should seriously consider an inpatient palliative care consultation team for many reasons, mostly arising from findings from other studies that have demonstrated improved quality of life, pain and symptom management, satisfaction with medical care, and other promising outcomes,” Dr. Enguidanos says. “Our study suggests that longitudinal palliative care is also associated with the lower readmission rate.”

References

1. Enguidanos S, Vesper E, Lorenz K. 30-day readmissions among seriously ill older adults. J Palliat Med. 2012;15(12):1356-1361.
2. The Advisory Board Company. Mastering the cardiovascular care continuum: strategies for bridging divides among providers and across time. The Advisory Board Company website. Available at: http://www.advisory.com/Research/Cardiovascular-Roundtable/Studies/2012/Mastering-the-Cardiovascular-Care-Continuum. Accessed Jan. 8, 2013.
3. Misky G, Carlson T, Klem P, et al. Development and implementation of a clinical care pathway for acute VTE reduces hospital utilization and cost at an urban tertiary care center [abstract]. J Hosp Med. 2012;7 Suppl 2:S66-S67.
4. Versel N. Health IT holds key to better care integration. Information Week website. Available at: http://www.informationweek.com/healthcare/interoperability/health-it-holds-key-to-better-care-integ/240012443. Accessed Jan. 8, 2013.
5. Office of Inspector General. Early Assessment Finds That CMS Faces Obstacles in Overseeing the Medicare EHR Incentive Program. Office of Inspector General website. Available at: https://oig.hhs.gov/oei/reports/oei-05-11-00250.asp. Accessed Jan. 8, 2013.

Data reported at the American Heart Association’s scientific sessions in Los Angeles in November suggest that when a cardiologist, rather than a hospitalist, is the attending physician for a hospitalized heart failure patient, readmission is less likely. Casey M. Lawler, MD, FACC, a cardiologist at the Minneapolis Heart Institute, says her center began establishing protocols to improve heart failure readmissions rates five years ago, after determining that many patients did not understand their diagnosis or treatment. “Thus, we became much more involved in post-discharge care,” including the phoning of discharged patients and follow-up with primary-care providers.

When the heart failure patients’ attending physicians were cardiologists, their readmission rate was 16%, versus 27.1% with hospitalists, even though their severity of illness was higher. Length of stay was similar for both groups and total mean costs were higher for the patients managed by cardiologists. “Although these results reveal that specialists have a positive impact on readmission rates, an overhaul to an entire healthcare system’s treatment of [heart failure] patients—from admission to post-discharge follow-up—is required to truly impact preventable readmissions,” Dr. Lawler asserted.

In the Minneapolis study, 65% of the 2,300 heart failure patients were managed by hospitalists, and 35% by cardiologists. A recent national survey of advanced heart failure programs found that cardiologists managed the care of acute HF patients more than 60 percent of the time.²

References

1. Enguidanos S, Vesper E, Lorenz K. 30-day readmissions among seriously ill older adults. J Palliat Med. 2012;15(12):1356-1361.
2. The Advisory Board Company. Mastering the cardiovascular care continuum: strategies for bridging divides among providers and across time. The Advisory Board Company website. Available at: http://www.advisory.com/Research/Cardiovascular-Roundtable/Studies/2012/Mastering-the-Cardiovascular-Care-Continuum. Accessed Jan. 8, 2013.
3. Misky G, Carlson T, Klem P, et al. Development and implementation of a clinical care pathway for acute VTE reduces hospital utilization and cost at an urban tertiary care center [abstract]. J Hosp Med. 2012;7 Suppl 2:S66-S67.
4. Versel N. Health IT holds key to better care integration. Information Week website. Available at: http://www.informationweek.com/healthcare/interoperability/health-it-holds-key-to-better-care-integ/240012443. Accessed Jan. 8, 2013.
5. Office of Inspector General. Early Assessment Finds That CMS Faces Obstacles in Overseeing the Medicare EHR Incentive Program. Office of Inspector General website. Available at: https://oig.hhs.gov/oei/reports/oei-05-11-00250.asp. Accessed Jan. 8, 2013.

Data reported at the American Heart Association’s scientific sessions in Los Angeles in November suggest that when a cardiologist, rather than a hospitalist, is the attending physician for a hospitalized heart failure patient, readmission is less likely. Casey M. Lawler, MD, FACC, a cardiologist at the Minneapolis Heart Institute, says her center began establishing protocols to improve heart failure readmissions rates five years ago, after determining that many patients did not understand their diagnosis or treatment. “Thus, we became much more involved in post-discharge care,” including the phoning of discharged patients and follow-up with primary-care providers.

When the heart failure patients’ attending physicians were cardiologists, their readmission rate was 16%, versus 27.1% with hospitalists, even though their severity of illness was higher. Length of stay was similar for both groups and total mean costs were higher for the patients managed by cardiologists. “Although these results reveal that specialists have a positive impact on readmission rates, an overhaul to an entire healthcare system’s treatment of [heart failure] patients—from admission to post-discharge follow-up—is required to truly impact preventable readmissions,” Dr. Lawler asserted.

In the Minneapolis study, 65% of the 2,300 heart failure patients were managed by hospitalists, and 35% by cardiologists. A recent national survey of advanced heart failure programs found that cardiologists managed the care of acute HF patients more than 60 percent of the time.²

References

1. Enguidanos S, Vesper E, Lorenz K. 30-day readmissions among seriously ill older adults. J Palliat Med. 2012;15(12):1356-1361.
2. The Advisory Board Company. Mastering the cardiovascular care continuum: strategies for bridging divides among providers and across time. The Advisory Board Company website. Available at: http://www.advisory.com/Research/Cardiovascular-Roundtable/Studies/2012/Mastering-the-Cardiovascular-Care-Continuum. Accessed Jan. 8, 2013.
3. Misky G, Carlson T, Klem P, et al. Development and implementation of a clinical care pathway for acute VTE reduces hospital utilization and cost at an urban tertiary care center [abstract]. J Hosp Med. 2012;7 Suppl 2:S66-S67.
4. Versel N. Health IT holds key to better care integration. Information Week website. Available at: http://www.informationweek.com/healthcare/interoperability/health-it-holds-key-to-better-care-integ/240012443. Accessed Jan. 8, 2013.
5. Office of Inspector General. Early Assessment Finds That CMS Faces Obstacles in Overseeing the Medicare EHR Incentive Program. Office of Inspector General website. Available at: https://oig.hhs.gov/oei/reports/oei-05-11-00250.asp. Accessed Jan. 8, 2013.

Data reported at the American Heart Association’s scientific sessions in Los Angeles in November suggest that when a cardiologist, rather than a hospitalist, is the attending physician for a hospitalized heart failure patient, readmission is less likely. Casey M. Lawler, MD, FACC, a cardiologist at the Minneapolis Heart Institute, says her center began establishing protocols to improve heart failure readmissions rates five years ago, after determining that many patients did not understand their diagnosis or treatment. “Thus, we became much more involved in post-discharge care,” including the phoning of discharged patients and follow-up with primary-care providers.

When the heart failure patients’ attending physicians were cardiologists, their readmission rate was 16%, versus 27.1% with hospitalists, even though their severity of illness was higher. Length of stay was similar for both groups and total mean costs were higher for the patients managed by cardiologists. “Although these results reveal that specialists have a positive impact on readmission rates, an overhaul to an entire healthcare system’s treatment of [heart failure] patients—from admission to post-discharge follow-up—is required to truly impact preventable readmissions,” Dr. Lawler asserted.

In the Minneapolis study, 65% of the 2,300 heart failure patients were managed by hospitalists, and 35% by cardiologists. A recent national survey of advanced heart failure programs found that cardiologists managed the care of acute HF patients more than 60 percent of the time.²

References

1. Enguidanos S, Vesper E, Lorenz K. 30-day readmissions among seriously ill older adults. J Palliat Med. 2012;15(12):1356-1361.
2. The Advisory Board Company. Mastering the cardiovascular care continuum: strategies for bridging divides among providers and across time. The Advisory Board Company website. Available at: http://www.advisory.com/Research/Cardiovascular-Roundtable/Studies/2012/Mastering-the-Cardiovascular-Care-Continuum. Accessed Jan. 8, 2013.
3. Misky G, Carlson T, Klem P, et al. Development and implementation of a clinical care pathway for acute VTE reduces hospital utilization and cost at an urban tertiary care center [abstract]. J Hosp Med. 2012;7 Suppl 2:S66-S67.
4. Versel N. Health IT holds key to better care integration. Information Week website. Available at: http://www.informationweek.com/healthcare/interoperability/health-it-holds-key-to-better-care-integ/240012443. Accessed Jan. 8, 2013.
5. Office of Inspector General. Early Assessment Finds That CMS Faces Obstacles in Overseeing the Medicare EHR Incentive Program. Office of Inspector General website. Available at: https://oig.hhs.gov/oei/reports/oei-05-11-00250.asp. Accessed Jan. 8, 2013.

A poster presented at HM12 in San Diego last April describes a standardized, systematic, multidisciplinary clinical pathway for treating acute VTE (venous thromboembolism) in an urban hospital serving a high proportion of the uninsured.³ Implementing the pathway in February 2011 “dramatically reduced hospital utilization and cost, particularly among uninsured patients,” who were previously shown to have increased length of stay, cost, and emergency department recidivism, says lead author Gregory Misky, MD, a hospitalist at the University of Colorado Denver.

The pathway—which aimed to standardize all VTE care from hospital presentation to post-discharge follow-up—contained multiple components, including education for staff, enhanced communication processes, written order sets, and a series of formal and informal meetings held with community providers, such as the clinics where these patients get their follow-up primary care. Dr. Misky collaborated with his university’s anticoagulation clinic to help identify primary-care physicians and clinics and arrange follow-up outpatient appointments much sooner than the patients could have obtained by themselves.

The prospective study compared 135 VTE patients presenting to the emergency department or admitted to a medicine service and receiving care under the pathway, compared with 234 VTE patients prior to its introduction. Length of stay dropped to 2.5 days from 4.2, and for uninsured patients it dropped even more, to 2.2 days from 5.5.

Dr. Misky says the data gathered since the San Diego conference “continue to show good results in resource utilization, particularly for the uninsured, with emergency department visits and readmissions slashed.” Readmissions have dropped to 5.2% from 9.8%—and to 3.5% from 11.6% for uninsured VTE patients. He suggests that the clinical pathway approach likely has implications for other diseases as well.

References

1. Enguidanos S, Vesper E, Lorenz K. 30-day readmissions among seriously ill older adults. J Palliat Med. 2012;15(12):1356-1361.
2. The Advisory Board Company. Mastering the cardiovascular care continuum: strategies for bridging divides among providers and across time. The Advisory Board Company website. Available at: http://www.advisory.com/Research/Cardiovascular-Roundtable/Studies/2012/Mastering-the-Cardiovascular-Care-Continuum. Accessed Jan. 8, 2013.
3. Misky G, Carlson T, Klem P, et al. Development and implementation of a clinical care pathway for acute VTE reduces hospital utilization and cost at an urban tertiary care center [abstract]. J Hosp Med. 2012;7 Suppl 2:S66-S67.
4. Versel N. Health IT holds key to better care integration. Information Week website. Available at: http://www.informationweek.com/healthcare/interoperability/health-it-holds-key-to-better-care-integ/240012443. Accessed Jan. 8, 2013.
5. Office of Inspector General. Early Assessment Finds That CMS Faces Obstacles in Overseeing the Medicare EHR Incentive Program. Office of Inspector General website. Available at: https://oig.hhs.gov/oei/reports/oei-05-11-00250.asp. Accessed Jan. 8, 2013.

A poster presented at HM12 in San Diego last April describes a standardized, systematic, multidisciplinary clinical pathway for treating acute VTE (venous thromboembolism) in an urban hospital serving a high proportion of the uninsured.³ Implementing the pathway in February 2011 “dramatically reduced hospital utilization and cost, particularly among uninsured patients,” who were previously shown to have increased length of stay, cost, and emergency department recidivism, says lead author Gregory Misky, MD, a hospitalist at the University of Colorado Denver.

The pathway—which aimed to standardize all VTE care from hospital presentation to post-discharge follow-up—contained multiple components, including education for staff, enhanced communication processes, written order sets, and a series of formal and informal meetings held with community providers, such as the clinics where these patients get their follow-up primary care. Dr. Misky collaborated with his university’s anticoagulation clinic to help identify primary-care physicians and clinics and arrange follow-up outpatient appointments much sooner than the patients could have obtained by themselves.

The prospective study compared 135 VTE patients presenting to the emergency department or admitted to a medicine service and receiving care under the pathway, compared with 234 VTE patients prior to its introduction. Length of stay dropped to 2.5 days from 4.2, and for uninsured patients it dropped even more, to 2.2 days from 5.5.

Dr. Misky says the data gathered since the San Diego conference “continue to show good results in resource utilization, particularly for the uninsured, with emergency department visits and readmissions slashed.” Readmissions have dropped to 5.2% from 9.8%—and to 3.5% from 11.6% for uninsured VTE patients. He suggests that the clinical pathway approach likely has implications for other diseases as well.

References

1. Enguidanos S, Vesper E, Lorenz K. 30-day readmissions among seriously ill older adults. J Palliat Med. 2012;15(12):1356-1361.
2. The Advisory Board Company. Mastering the cardiovascular care continuum: strategies for bridging divides among providers and across time. The Advisory Board Company website. Available at: http://www.advisory.com/Research/Cardiovascular-Roundtable/Studies/2012/Mastering-the-Cardiovascular-Care-Continuum. Accessed Jan. 8, 2013.
3. Misky G, Carlson T, Klem P, et al. Development and implementation of a clinical care pathway for acute VTE reduces hospital utilization and cost at an urban tertiary care center [abstract]. J Hosp Med. 2012;7 Suppl 2:S66-S67.
4. Versel N. Health IT holds key to better care integration. Information Week website. Available at: http://www.informationweek.com/healthcare/interoperability/health-it-holds-key-to-better-care-integ/240012443. Accessed Jan. 8, 2013.
5. Office of Inspector General. Early Assessment Finds That CMS Faces Obstacles in Overseeing the Medicare EHR Incentive Program. Office of Inspector General website. Available at: https://oig.hhs.gov/oei/reports/oei-05-11-00250.asp. Accessed Jan. 8, 2013.

A poster presented at HM12 in San Diego last April describes a standardized, systematic, multidisciplinary clinical pathway for treating acute VTE (venous thromboembolism) in an urban hospital serving a high proportion of the uninsured.³ Implementing the pathway in February 2011 “dramatically reduced hospital utilization and cost, particularly among uninsured patients,” who were previously shown to have increased length of stay, cost, and emergency department recidivism, says lead author Gregory Misky, MD, a hospitalist at the University of Colorado Denver.

The pathway—which aimed to standardize all VTE care from hospital presentation to post-discharge follow-up—contained multiple components, including education for staff, enhanced communication processes, written order sets, and a series of formal and informal meetings held with community providers, such as the clinics where these patients get their follow-up primary care. Dr. Misky collaborated with his university’s anticoagulation clinic to help identify primary-care physicians and clinics and arrange follow-up outpatient appointments much sooner than the patients could have obtained by themselves.

The prospective study compared 135 VTE patients presenting to the emergency department or admitted to a medicine service and receiving care under the pathway, compared with 234 VTE patients prior to its introduction. Length of stay dropped to 2.5 days from 4.2, and for uninsured patients it dropped even more, to 2.2 days from 5.5.

Dr. Misky says the data gathered since the San Diego conference “continue to show good results in resource utilization, particularly for the uninsured, with emergency department visits and readmissions slashed.” Readmissions have dropped to 5.2% from 9.8%—and to 3.5% from 11.6% for uninsured VTE patients. He suggests that the clinical pathway approach likely has implications for other diseases as well.

References

1. Enguidanos S, Vesper E, Lorenz K. 30-day readmissions among seriously ill older adults. J Palliat Med. 2012;15(12):1356-1361.
2. The Advisory Board Company. Mastering the cardiovascular care continuum: strategies for bridging divides among providers and across time. The Advisory Board Company website. Available at: http://www.advisory.com/Research/Cardiovascular-Roundtable/Studies/2012/Mastering-the-Cardiovascular-Care-Continuum. Accessed Jan. 8, 2013.
3. Misky G, Carlson T, Klem P, et al. Development and implementation of a clinical care pathway for acute VTE reduces hospital utilization and cost at an urban tertiary care center [abstract]. J Hosp Med. 2012;7 Suppl 2:S66-S67.
4. Versel N. Health IT holds key to better care integration. Information Week website. Available at: http://www.informationweek.com/healthcare/interoperability/health-it-holds-key-to-better-care-integ/240012443. Accessed Jan. 8, 2013.
5. Office of Inspector General. Early Assessment Finds That CMS Faces Obstacles in Overseeing the Medicare EHR Incentive Program. Office of Inspector General website. Available at: https://oig.hhs.gov/oei/reports/oei-05-11-00250.asp. Accessed Jan. 8, 2013.

Number of meals served annually to patients, visitors, and staff by 155 leading U.S. hospitals, which are adopting new standards and criteria for nutritional care at their facilities in order to promote healthier meal options for patients and in their cafeterias. These hospitals belong to the Healthier Hospitals initiative.

(healthierhospitals.org/) led by the Partnership for a Healthier America, a group working to end childhood obesity. Among its goals are to increase the proportion of fruits and vegetables in hospitals’ food purchasing, to remove deep fat-fried products by the end of 2015, and to take advantage of the buying power and community influence hospitals can leverage to increase demand for healthier food.

1. Enguidanos S, Vesper E, Lorenz K. 30-day readmissions among seriously ill older adults. J Palliat Med. 2012;15(12):1356-1361.
2. The Advisory Board Company. Mastering the cardiovascular care continuum: strategies for bridging divides among providers and across time. The Advisory Board Company website. Available at: http://www.advisory.com/Research/Cardiovascular-Roundtable/Studies/2012/Mastering-the-Cardiovascular-Care-Continuum. Accessed Jan. 8, 2013.
3. Misky G, Carlson T, Klem P, et al. Development and implementation of a clinical care pathway for acute VTE reduces hospital utilization and cost at an urban tertiary care center [abstract]. J Hosp Med. 2012;7 Suppl 2:S66-S67.
4. Versel N. Health IT holds key to better care integration. Information Week website. Available at: http://www.informationweek.com/healthcare/interoperability/health-it-holds-key-to-better-care-integ/240012443. Accessed Jan. 8, 2013.
5. Office of Inspector General. Early Assessment Finds That CMS Faces Obstacles in Overseeing the Medicare EHR Incentive Program. Office of Inspector General website. Available at: https://oig.hhs.gov/oei/reports/oei-05-11-00250.asp. Accessed Jan. 8, 2013.

Number of meals served annually to patients, visitors, and staff by 155 leading U.S. hospitals, which are adopting new standards and criteria for nutritional care at their facilities in order to promote healthier meal options for patients and in their cafeterias. These hospitals belong to the Healthier Hospitals initiative.

(healthierhospitals.org/) led by the Partnership for a Healthier America, a group working to end childhood obesity. Among its goals are to increase the proportion of fruits and vegetables in hospitals’ food purchasing, to remove deep fat-fried products by the end of 2015, and to take advantage of the buying power and community influence hospitals can leverage to increase demand for healthier food.

1. Enguidanos S, Vesper E, Lorenz K. 30-day readmissions among seriously ill older adults. J Palliat Med. 2012;15(12):1356-1361.
2. The Advisory Board Company. Mastering the cardiovascular care continuum: strategies for bridging divides among providers and across time. The Advisory Board Company website. Available at: http://www.advisory.com/Research/Cardiovascular-Roundtable/Studies/2012/Mastering-the-Cardiovascular-Care-Continuum. Accessed Jan. 8, 2013.
3. Misky G, Carlson T, Klem P, et al. Development and implementation of a clinical care pathway for acute VTE reduces hospital utilization and cost at an urban tertiary care center [abstract]. J Hosp Med. 2012;7 Suppl 2:S66-S67.
4. Versel N. Health IT holds key to better care integration. Information Week website. Available at: http://www.informationweek.com/healthcare/interoperability/health-it-holds-key-to-better-care-integ/240012443. Accessed Jan. 8, 2013.
5. Office of Inspector General. Early Assessment Finds That CMS Faces Obstacles in Overseeing the Medicare EHR Incentive Program. Office of Inspector General website. Available at: https://oig.hhs.gov/oei/reports/oei-05-11-00250.asp. Accessed Jan. 8, 2013.

Number of meals served annually to patients, visitors, and staff by 155 leading U.S. hospitals, which are adopting new standards and criteria for nutritional care at their facilities in order to promote healthier meal options for patients and in their cafeterias. These hospitals belong to the Healthier Hospitals initiative.

(healthierhospitals.org/) led by the Partnership for a Healthier America, a group working to end childhood obesity. Among its goals are to increase the proportion of fruits and vegetables in hospitals’ food purchasing, to remove deep fat-fried products by the end of 2015, and to take advantage of the buying power and community influence hospitals can leverage to increase demand for healthier food.

1. Enguidanos S, Vesper E, Lorenz K. 30-day readmissions among seriously ill older adults. J Palliat Med. 2012;15(12):1356-1361.
2. The Advisory Board Company. Mastering the cardiovascular care continuum: strategies for bridging divides among providers and across time. The Advisory Board Company website. Available at: http://www.advisory.com/Research/Cardiovascular-Roundtable/Studies/2012/Mastering-the-Cardiovascular-Care-Continuum. Accessed Jan. 8, 2013.
3. Misky G, Carlson T, Klem P, et al. Development and implementation of a clinical care pathway for acute VTE reduces hospital utilization and cost at an urban tertiary care center [abstract]. J Hosp Med. 2012;7 Suppl 2:S66-S67.
4. Versel N. Health IT holds key to better care integration. Information Week website. Available at: http://www.informationweek.com/healthcare/interoperability/health-it-holds-key-to-better-care-integ/240012443. Accessed Jan. 8, 2013.
5. Office of Inspector General. Early Assessment Finds That CMS Faces Obstacles in Overseeing the Medicare EHR Incentive Program. Office of Inspector General website. Available at: https://oig.hhs.gov/oei/reports/oei-05-11-00250.asp. Accessed Jan. 8, 2013.

Click here to listen to Scott Strassels, PhD, PharmD, BCPS, an assistant professor in the College of Pharmacy at the University of Texas at Austin and a board member of the American Pain Society, discuss the risks and rewards of opioid therapies, and why continuing education is important for all clinicians.

Click here to listen to Scott Strassels, PhD, PharmD, BCPS, an assistant professor in the College of Pharmacy at the University of Texas at Austin and a board member of the American Pain Society, discuss the risks and rewards of opioid therapies, and why continuing education is important for all clinicians.

Click here to listen to Scott Strassels, PhD, PharmD, BCPS, an assistant professor in the College of Pharmacy at the University of Texas at Austin and a board member of the American Pain Society, discuss the risks and rewards of opioid therapies, and why continuing education is important for all clinicians.

Clinical question: What is the relationship between variation in resource utilization and outcomes in children with community-acquired pneumonia (CAP)?

Background: Variation in clinical care, particularly when driven by provider preferences, often highlights opportunities for improvement in the quality of our care. CAP is one of the most common reasons for hospitalization in children. The relationship between variation in care processes, utilization, and outcomes in pediatric CAP is not well defined.

Study design: Retrospective database review.

Setting: Twenty-nine freestanding children's hospitals.

Synopsis: The Pediatric Health Information System (PHIS) database was used to review utilization and outcomes data on 43,819 children admitted with nonsevere CAP during a five-year period. Substantial degrees of variation in test ordering, empiric antibiotic selection, length of stay (LOS), and 14-day readmissions were found. An association was noted between increased resource utilization—specifically, ordering of diagnostic tests—and longer LOS.

The association between increased resource utilization and LOS has been suggested in other work in respiratory illness in children. Although the retrospective nature of this work precludes detailed resolution of whether confounding by severity was an issue, this appears unlikely based on the relatively homogeneous patient populations and hospital types. Additional limitations of this work exist, and include an inability to further assess the appropriateness of the testing that was ordered—as well as relatively crude rankings of hospitals based on resource utilization. Nevertheless, in an era where a premium is placed on finding value in clinical medicine, these results should prompt further exploration of the link between testing and LOS in children hospitalized with CAP.

Bottom line: Unnecessary testing in children hospitalized with pneumonia may lead to longer LOS.

Citation: Brogan TV, Hall M, Williams DJ, et al. Variability in processes of care and outcomes among children hospitalized with community-acquired pneumonia. Ped Infect Dis J. 2012;31:1036-1041.

Reviewed by Pediatric Editor Mark Shen, MD, SFHM, medical director of hospital medicine at Dell Children's Medical Center, Austin, Texas.

Clinical question: What is the relationship between variation in resource utilization and outcomes in children with community-acquired pneumonia (CAP)?

Background: Variation in clinical care, particularly when driven by provider preferences, often highlights opportunities for improvement in the quality of our care. CAP is one of the most common reasons for hospitalization in children. The relationship between variation in care processes, utilization, and outcomes in pediatric CAP is not well defined.

Study design: Retrospective database review.

Setting: Twenty-nine freestanding children's hospitals.

Synopsis: The Pediatric Health Information System (PHIS) database was used to review utilization and outcomes data on 43,819 children admitted with nonsevere CAP during a five-year period. Substantial degrees of variation in test ordering, empiric antibiotic selection, length of stay (LOS), and 14-day readmissions were found. An association was noted between increased resource utilization—specifically, ordering of diagnostic tests—and longer LOS.

The association between increased resource utilization and LOS has been suggested in other work in respiratory illness in children. Although the retrospective nature of this work precludes detailed resolution of whether confounding by severity was an issue, this appears unlikely based on the relatively homogeneous patient populations and hospital types. Additional limitations of this work exist, and include an inability to further assess the appropriateness of the testing that was ordered—as well as relatively crude rankings of hospitals based on resource utilization. Nevertheless, in an era where a premium is placed on finding value in clinical medicine, these results should prompt further exploration of the link between testing and LOS in children hospitalized with CAP.

Bottom line: Unnecessary testing in children hospitalized with pneumonia may lead to longer LOS.

Citation: Brogan TV, Hall M, Williams DJ, et al. Variability in processes of care and outcomes among children hospitalized with community-acquired pneumonia. Ped Infect Dis J. 2012;31:1036-1041.

Reviewed by Pediatric Editor Mark Shen, MD, SFHM, medical director of hospital medicine at Dell Children's Medical Center, Austin, Texas.

Clinical question: What is the relationship between variation in resource utilization and outcomes in children with community-acquired pneumonia (CAP)?

Background: Variation in clinical care, particularly when driven by provider preferences, often highlights opportunities for improvement in the quality of our care. CAP is one of the most common reasons for hospitalization in children. The relationship between variation in care processes, utilization, and outcomes in pediatric CAP is not well defined.

Study design: Retrospective database review.

Setting: Twenty-nine freestanding children's hospitals.

Synopsis: The Pediatric Health Information System (PHIS) database was used to review utilization and outcomes data on 43,819 children admitted with nonsevere CAP during a five-year period. Substantial degrees of variation in test ordering, empiric antibiotic selection, length of stay (LOS), and 14-day readmissions were found. An association was noted between increased resource utilization—specifically, ordering of diagnostic tests—and longer LOS.

The association between increased resource utilization and LOS has been suggested in other work in respiratory illness in children. Although the retrospective nature of this work precludes detailed resolution of whether confounding by severity was an issue, this appears unlikely based on the relatively homogeneous patient populations and hospital types. Additional limitations of this work exist, and include an inability to further assess the appropriateness of the testing that was ordered—as well as relatively crude rankings of hospitals based on resource utilization. Nevertheless, in an era where a premium is placed on finding value in clinical medicine, these results should prompt further exploration of the link between testing and LOS in children hospitalized with CAP.

Bottom line: Unnecessary testing in children hospitalized with pneumonia may lead to longer LOS.

Citation: Brogan TV, Hall M, Williams DJ, et al. Variability in processes of care and outcomes among children hospitalized with community-acquired pneumonia. Ped Infect Dis J. 2012;31:1036-1041.

Reviewed by Pediatric Editor Mark Shen, MD, SFHM, medical director of hospital medicine at Dell Children's Medical Center, Austin, Texas.

Case

An 82-year-old man with non-Hodgkin’s lymphoma in remission and a history of congestive heart failure and hypertension presents with one week of generalized malaise and intermittent fevers. Vitals show a temperature of 101oF, blood pressure of 130/60 mmHg, and heart rate of 100. His exam is notable for an erythematous and tender chest port site, with no murmurs. Blood cultures drawn upon presentation show gram-positive cocci speciated to Staphylococcus aureus. What are the next steps in management of this patient?

Overview

S. aureus bacteremia (SAB) is a common infectious cause of morbidity and mortality worldwide, causing both community-acquired and hospital-acquired bacteremia. In the U.S. alone, it accounts for 23% of all bloodstream infections and is the bacterial pathogen most strongly associated with death.¹ Mortality rates are approximately 42% in those with methicillin-resistant S. aureus (MRSA) bacteremia and 28% in those with methicillin-sensitive S. aureus (MSSA) bacteremia.²

Recognizing the severity of SAB, the Infectious Disease Society of America (IDSA) published treatment guidelines in 2011 to help direct the clinical care of this disease process.³ However, the majority of the recommendations are based on observational studies and expert opinion, as less than 1,500 patients have been enrolled in randomized controlled trials specifically targeted to investigate the treatment of SAB.⁴

Review of the Data

A clinically significant SAB usually is defined as the isolation of S. aureus from a venous blood culture with associated symptoms and signs of systemic infection.5 As SAB contamination is rare and can be associated with multiple complications, including metastatic infections, embolic stroke, recurrent infection, and death, any finding of a positive blood culture must be taken seriously.⁴

SAB treatment is multifaceted and should focus on the removal of any nidus of infection, such as a catheter or a prosthetic device, the use of prolonged antimicrobial therapy, and the evaluation of potential complications. In a retrospective study, Johnson et al showed that failure to remove the source is one of the strongest independent predictors of relapse in patients with SAB.⁶ However, 10% to 40% of patients have no identifiable focus, which increases the impetus to evaluate for complications.^7-8 Overall, approximately one-third of patients with SAB develop metastatic complications, either from hematogenous seeding or local extension of infection.⁹

In addition to advanced age and such comorbid conditions as cirrhosis, the strongest predictor of complications is a positive blood culture at 48 to 96 hours after an initial positive blood culture, as shown in a large prospective cohort study by Fowler et al.^7,10-11 Additional independent risk factors (see Table 1) include community acquisition (likely due to prolonged duration of bacteremia), skin examination suggesting the presence of acute systemic infection, and persistent fever at 72 hours after the first positive blood culture. Patients with even one of these risk factors are at high risk for a complicated course (which occurs in about 35%). In a case-control study, Chihara et al showed that S. aureus bacteruria in the absence of urinary tract pathology or recent urinary tract instrumentation might be associated with threefold increased mortality compared with those without bacteriuria, even after adjustment for comorbid conditions.¹²

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Antimicrobial Treatment

The initial choice of antibiotic therapy for SAB must take into account the MRSA prevalence in the community and hospital. If suspicion is high enough for MRSA, the IDSA’s 2011 guidelines suggest treatment with vancomycin or daptomycin.³ Although there are no published RCTs to support a particular antibiotic regimen, there are trials to suggest that a delay in treatment could be harmful. One study, by Lordis et al, showed that a delay in treatment, as defined by treatment after 44.75 hours, was associated with a longer hospital stay, with the delayed treatment group being hospitalized for 20.2 days and the early treatment group being hospitalized for 14.3 days.¹³ A delay in treatment was also found to be an independent predictor of mortality.¹³

Once susceptibilities are known, it is important to appropriately tailor antibiotics, as studies have shown lower treatment failure rates with the use of beta-lactam antibiotics when compared with empiric MRSA coverage.^14-15 In one prospective study of 123 hemodialysis patients with MSSA bacteremia, Stryjewski et al showed that those treated with vancomycin were at higher risk of experiencing treatment failure than those treated with cefazolin.¹⁵ In another prospective observational study of 505 patients with SAB, Chang et al found that treatment with nafcillin was superior to vancomycin in preventing persistent bacteremia or relapse for MSSA bacteremia.14 These studies highlight the benefits of adjusting the empirically selected antibiotics, as narrowing the spectrum can result in less treatment failure.

If susceptibilities confirm MRSA, the IDSA recommends continued treatment with vancomycin or daptomycin.³ Although vancomycin is most commonly used, partly because of low cost and familiarity, Fowler et al published a study of 246 patients with SAB with or without endocarditis, assigning them to treatment with daptomycin, initial low-dose gentamicin plus vancomycin or an antistaphylococcal penicillin.¹⁶ The study found that daptomycin was not inferior to the other therapies, confirming that daptomycin is a reasonable choice in the treatment of MRSA infections.

Oral antibiotics are an option to treat SAB when necessary. A RCT by Heldman et al of 85 intravenous drug users with SAB (and suspected right-sided endocarditis, 65% of which had HIV) showed similar efficacy of ciprofloxacin plus rifampin versus standard intravenous therapy.¹⁷ A subsequent randomized trial of 104 patients with SAB comparing oral fleroxacin plus rifampin against conventional intravenous therapy also showed similar cure rates, with the added benefit of earlier discharge.¹⁸ Furthermore, in a meta-analysis of five randomized studies by Shorr et al (see Table 2), linezolid was found to have outcomes that were not inferior to vancomycin (clinical cure/microbiological success of 56%/69% in the linezolid group and 46%/73% in the vancomycin group).¹⁹

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Treatment Duration

Recommendations for the duration of antibiotic treatment for SAB are mainly based on observational studies, which show mixed results. In one study done in the 1950s, about two-thirds of cases of SAB were associated with endocarditis, and longer courses of intravenous therapy (greater than four weeks) were recommended.²⁰

More recently, with the increasing rates of catheter-related SAB and its relatively high rate of expeditious blood culture clearance, a shorter duration has been evaluated in several studies. In 1992, an analysis of published data and a retrospective case series concluded that fewer than 10 days of intravenous antibiotics might be associated with an increased risk of recurrence, but 10 to 14 days of intravenous therapy was effective for most cases of catheter-associated SAB.⁵ In another prospective study, Fowler et al found that a seven-day course of intravenous antibiotic therapy may be sufficient for simple, catheter-related infections.²¹ A subsequent prospective study by Jensen et al reported that a course of antibiotic therapy of less than 14 days might be associated with higher mortality compared to a longer course.⁹ A prospective study of 276 patients by Thomas et al found there was no relationship between relapse and duration of treatment (seven to 15 days) in catheter-related SAB, concluding that more than 14 days of antibiotic therapy was unnecessary.²²

Per IDSA guidelines, uncomplicated SAB (no implanted prosthesis, negative blood cultures within two to four days, defervescence within 72 hours of initiating therapy, and lack of metastatic complication) can be treated with a two-week course of antibiotics, while complicated bacteremia (any of above criteria) should be treated within four to six weeks.³

Monitoring for Complications: Echos

Based on the IDSA guidelines, echocardiography is recommended in all patients with bacteremia, with a preference of transesophageal echocardiography (TEE) over transthoracic echocardiography (TTE).³ More recently, Kaasch et al developed simple criteria to identify patients with nosocomial SAB at low risk for infective endocarditis based on two prospective cohort studies.²³ Lack of any of these criteria, which include prolonged bacteremia of more than four days’ duration, presence of a permanent intracardiac device, hemodialysis dependency, spinal infection and nonvertebral osteomyelitis, along with a negative TTE indicates that a TEE is not necessary (see Table 3). However, these patients need close follow-up to ensure that bacteremia clears and no new signs or symptoms concerning for metastatic infection develop.

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ID Consultation

Several studies have shown that ID consultation not only improves adherence to evidence-based management of SAB, but it also reduces mortality.^24-27 In a recent prospective cohort study in a tertiary-care center, even after adjusting for pre-existing comorbidities and severity of disease, an ID consult was associated with a 56% reduction in 28-day mortality.²⁴ The patients who were followed by an ID consult service were more likely to receive appropriate duration of antibiotics (81% vs. 29%, respectively) and undergo appropriate workup for the evaluation of metastatic infections (34% and 8%, respectively). This study concluded that routine ID consult should be considered in patients with SAB, especially those with severe illness and multiple comorbid conditions.

Back to the Case

The patient was started on empiric therapy with vancomycin and serial blood cultures were obtained. He remained hemodynamically stable but febrile, with persistently positive blood and urine cultures. Given concern for the port being the source of his infection, his chest port was removed. A high-quality TTE was performed and was unremarkable.

ID was consulted. Blood cultures subsequently grew MSSA and vancomycin was switched to cefazolin 2g every eight hours. On hospital Day 5, his fever resolved and blood cultures turned negative. There were no clinical signs or symptoms for metastatic infections. A PICC line was placed after blood cultures remained negative for 48 hours. The decision was made to treat him with four weeks of antibiotics from his last positive blood culture, with follow-up in ID clinic.

Bottom Line

SAB is a common worldwide cause of morbidity and mortality. Treatment should include removing the nidus if present, finding and administering the appropriate antimicrobial therapy, evaluating for possible complications, and consulting with ID.

Dr. Ward is an assistant professor, Dr. Kim a clinical instructor, and Dr. Stojan a clinical lecturer at the University of Michigan Health System in Ann Arbor.

Acknowledgement

The authors would like to thank Dr. Jeffrey Rohde for reviewing the manuscript.

References

1. Shorr AF, Tabak YP, Killian AD, et al. Healthcare-associated bloodstream infection: a distinct entity? Insights from a large U.S. database. Crit Care Med. 2006;34:3588-3595.
2. Mylotte JM, McDermott C, Spooner JA. Prospective study of 114 consecutive episodes of Staphylococcus aureus bacteremia. Rev Infect Dis. 1987;9:891-907.
3. Liu C, Bayer A, Cosgrove SE, et al. Clinical practice guidelines by the Infectious Diseases Society of America for the treatment of methicillin-resistant Staphylococcus aureus infections in adults and children. Clin Infect Dis. 2011;52(3).
4. Naber CK, Baddour LM, Giamarellos-Bourboulis EJ, et al. Clinical consensus conference: survey on gram-positive bloodstream infections with a focus on Staphylococcus aureus. Clin Infect Dis. 2011;52(3):285-292.
5. Thwaites GE, Edgeworth JD, Gkrania-Klotsas E, et al. Clinical management of Staphylococcus bacteremia. Lancet Infect Dis. 2011;11(3):208-222.
6. Johnson LB, Almoujahed MO, Ilg K, et al. Staphylococcus aureus bacteremia: compliance with standard treatment, long-term outcome and predictors of relapse. Scand J Infec Dis. 2003;35(11-12):782-789.
7. Fowler VG Jr., Olsen MK, Corey GR, et al. Clinical identifiers of complicated Staphylococcus aureus bacteremia. Arch Intern Med. 2003;163:2066-2072.
8. Mylotte JM, Tayara A. Staphylococcus aureus bacteremia: predictors of 30-day mortality in a large cohort. Clin Infect Dis. 2000;31:1170-1174.
9. Jensen AG, Wachmann CH, Espersen F, et al. Treatment and outcome of Staphylococcus aureus bacteremia: a prospective study of 278 cases. Arch Intern Med. 2002;162(1):25-32.
10. Malani PN, Rana MM, Banerjee M, et al. Staphylococcus aureus bloodstream infections: the association between age and mortality and functional status. J Am Geriatr Soc. 2008;56(8):1485-1489.
11. Kim SH, Park WB, Lee KD, et al. Outcome of Staphylococcus aureus bacteremia in patients with eradicable foci versus noneradicable foci. Clin Infect Dis. 2003;37(6):794-799.
12. Chihara S. Popovich KJ, Weinstein RA, et al. Staphylococcus aureus bacteriuria as a prognosticator for outcome of Staphylococcus aureus bacteremia: a case control study. BMC Inf Dis. 2010;10:225.
13. Lodise TP, McKinnon PS, Swiderski L, Rybak MJ. Outcomes analysis of delayed antibiotic treatment for hospital-acquired Staphylococcus aureus bacteremia. Clin Infect Dis. 2003;36:1418-1423.
14. Chang FY, Peacock JE Jr., Musher DM, et al. Staphylococcus aureus bacteremia: recurrence and the impact of antibiotic treatment in a prospective multicenter study. Medicine (Baltimore). 2003;82:333.
15. Stryjewski ME, Szczech LA, Benjamin DK Jr., et al. Use of vancomycin or first-generation cephalosporins for the treatment of hemodialysisdependent patients with methicillin-susceptible Staphylococcus aureus bacteremia. Clin Infect Dis. 2007;44:190-196.
16. Fowler VG Jr., Boucher HW, Corey GR, et al. Daptomycin versus standard therapy for bacteremia and endocarditis caused by Staphylococcus aureus. N Engl J Med. 2006;355:653.
17. Heldman AW, Hartert TV, Ray SC, et al. Oral antibiotic treatment of right-sided staphylococcal endocarditis in injection drug users: prospective randomized comparison with parenteral therapy. Am J Med. 1996;101:68-76.
18. Schrenzel J, Harbarth S, Schockmel G, et al. A randomized clinical trial to compare fleroxacin-rifampicin with flucloxacillin or vancomycin for the treatment of Staphylococcal infection. Clin Infect Dis. 2004;39:1285-1292.
19. Shorr AF, Kunkel MJ, Kollef M. Linezolid versus vancomycin for Staphylococcus aureus bacteraemia: pooled analysis of randomized studies. J Antimicrob Chemother. 2005;56:923-929.
20. Wilson R, Hamburger M. Fifteen years’ experience with Staphylococcus septicemia in a large city hospital; analysis of fifty-five cases in the Cincinnati General Hospital 1940 to 1954. Am J Med. 1957;22:437-457.
21. Fowler VG Jr., Sanders LL, Sexton DJ, et al. Outcome of Staphylococcus aureus bacteremia according to compliance with recommendation of infectious disease specialists: experience with 244 patients. Clin Infect Dis. 1998;27:478-486.
22. Thomas MG, Morris AJ. Cannula-associated Staphylococcus aureus bacteremia: outcome in relation to treatment. Intern Med J. 2005;35:319-330.
23. Kaasch AJ, Fowler VG Jr, Rieg S, et al. Use of a simple criteria set for guiding echocardiography in nosocomidal Staphylococcus aureus bacteremia. Clin Infect Dis. 2011;53:1-9.
24. Honda H, Krauss MJ, Jones JC, et al. The value of infectious disease consultation in Staphylococcus aureus bacteremia. Am J Med. 2010;123:631-637.
25. Nagao M, Iinuma Y, Saito T, et al. Close cooperation between infectious disease physicians and attending physicians can result in better management and outcome for patients with Staphylococcus aureus bacteremia. Euro Soc Clin Microbiology Infect Dis. 2010;16:1783-1788.
26. Fowler VG Jr., Sanders LL, Sexton DJ, et al. Outcome of Staphylococcus aureus bacteremia according to compliance with recommendations of infectious diseases specialist: experience with 244 patients. Clin Infect Dis. 1998;27(3):478-486.
27. Jenkins TC, Price CS, Sabel AL et al. Impact of routine infectious diseases service consultation on the evaluation, management, and outcome of Staphylococcus aureus bacteremia. Clin Infect Dis. 2008;46(7):1000-1008.

Case

An 82-year-old man with non-Hodgkin’s lymphoma in remission and a history of congestive heart failure and hypertension presents with one week of generalized malaise and intermittent fevers. Vitals show a temperature of 101oF, blood pressure of 130/60 mmHg, and heart rate of 100. His exam is notable for an erythematous and tender chest port site, with no murmurs. Blood cultures drawn upon presentation show gram-positive cocci speciated to Staphylococcus aureus. What are the next steps in management of this patient?

Overview

S. aureus bacteremia (SAB) is a common infectious cause of morbidity and mortality worldwide, causing both community-acquired and hospital-acquired bacteremia. In the U.S. alone, it accounts for 23% of all bloodstream infections and is the bacterial pathogen most strongly associated with death.¹ Mortality rates are approximately 42% in those with methicillin-resistant S. aureus (MRSA) bacteremia and 28% in those with methicillin-sensitive S. aureus (MSSA) bacteremia.²

Recognizing the severity of SAB, the Infectious Disease Society of America (IDSA) published treatment guidelines in 2011 to help direct the clinical care of this disease process.³ However, the majority of the recommendations are based on observational studies and expert opinion, as less than 1,500 patients have been enrolled in randomized controlled trials specifically targeted to investigate the treatment of SAB.⁴

Review of the Data

A clinically significant SAB usually is defined as the isolation of S. aureus from a venous blood culture with associated symptoms and signs of systemic infection.5 As SAB contamination is rare and can be associated with multiple complications, including metastatic infections, embolic stroke, recurrent infection, and death, any finding of a positive blood culture must be taken seriously.⁴

SAB treatment is multifaceted and should focus on the removal of any nidus of infection, such as a catheter or a prosthetic device, the use of prolonged antimicrobial therapy, and the evaluation of potential complications. In a retrospective study, Johnson et al showed that failure to remove the source is one of the strongest independent predictors of relapse in patients with SAB.⁶ However, 10% to 40% of patients have no identifiable focus, which increases the impetus to evaluate for complications.^7-8 Overall, approximately one-third of patients with SAB develop metastatic complications, either from hematogenous seeding or local extension of infection.⁹

In addition to advanced age and such comorbid conditions as cirrhosis, the strongest predictor of complications is a positive blood culture at 48 to 96 hours after an initial positive blood culture, as shown in a large prospective cohort study by Fowler et al.^7,10-11 Additional independent risk factors (see Table 1) include community acquisition (likely due to prolonged duration of bacteremia), skin examination suggesting the presence of acute systemic infection, and persistent fever at 72 hours after the first positive blood culture. Patients with even one of these risk factors are at high risk for a complicated course (which occurs in about 35%). In a case-control study, Chihara et al showed that S. aureus bacteruria in the absence of urinary tract pathology or recent urinary tract instrumentation might be associated with threefold increased mortality compared with those without bacteriuria, even after adjustment for comorbid conditions.¹²

click for large version

Antimicrobial Treatment

The initial choice of antibiotic therapy for SAB must take into account the MRSA prevalence in the community and hospital. If suspicion is high enough for MRSA, the IDSA’s 2011 guidelines suggest treatment with vancomycin or daptomycin.³ Although there are no published RCTs to support a particular antibiotic regimen, there are trials to suggest that a delay in treatment could be harmful. One study, by Lordis et al, showed that a delay in treatment, as defined by treatment after 44.75 hours, was associated with a longer hospital stay, with the delayed treatment group being hospitalized for 20.2 days and the early treatment group being hospitalized for 14.3 days.¹³ A delay in treatment was also found to be an independent predictor of mortality.¹³

Once susceptibilities are known, it is important to appropriately tailor antibiotics, as studies have shown lower treatment failure rates with the use of beta-lactam antibiotics when compared with empiric MRSA coverage.^14-15 In one prospective study of 123 hemodialysis patients with MSSA bacteremia, Stryjewski et al showed that those treated with vancomycin were at higher risk of experiencing treatment failure than those treated with cefazolin.¹⁵ In another prospective observational study of 505 patients with SAB, Chang et al found that treatment with nafcillin was superior to vancomycin in preventing persistent bacteremia or relapse for MSSA bacteremia.14 These studies highlight the benefits of adjusting the empirically selected antibiotics, as narrowing the spectrum can result in less treatment failure.

If susceptibilities confirm MRSA, the IDSA recommends continued treatment with vancomycin or daptomycin.³ Although vancomycin is most commonly used, partly because of low cost and familiarity, Fowler et al published a study of 246 patients with SAB with or without endocarditis, assigning them to treatment with daptomycin, initial low-dose gentamicin plus vancomycin or an antistaphylococcal penicillin.¹⁶ The study found that daptomycin was not inferior to the other therapies, confirming that daptomycin is a reasonable choice in the treatment of MRSA infections.

Oral antibiotics are an option to treat SAB when necessary. A RCT by Heldman et al of 85 intravenous drug users with SAB (and suspected right-sided endocarditis, 65% of which had HIV) showed similar efficacy of ciprofloxacin plus rifampin versus standard intravenous therapy.¹⁷ A subsequent randomized trial of 104 patients with SAB comparing oral fleroxacin plus rifampin against conventional intravenous therapy also showed similar cure rates, with the added benefit of earlier discharge.¹⁸ Furthermore, in a meta-analysis of five randomized studies by Shorr et al (see Table 2), linezolid was found to have outcomes that were not inferior to vancomycin (clinical cure/microbiological success of 56%/69% in the linezolid group and 46%/73% in the vancomycin group).¹⁹

click for large version

Treatment Duration

Recommendations for the duration of antibiotic treatment for SAB are mainly based on observational studies, which show mixed results. In one study done in the 1950s, about two-thirds of cases of SAB were associated with endocarditis, and longer courses of intravenous therapy (greater than four weeks) were recommended.²⁰

More recently, with the increasing rates of catheter-related SAB and its relatively high rate of expeditious blood culture clearance, a shorter duration has been evaluated in several studies. In 1992, an analysis of published data and a retrospective case series concluded that fewer than 10 days of intravenous antibiotics might be associated with an increased risk of recurrence, but 10 to 14 days of intravenous therapy was effective for most cases of catheter-associated SAB.⁵ In another prospective study, Fowler et al found that a seven-day course of intravenous antibiotic therapy may be sufficient for simple, catheter-related infections.²¹ A subsequent prospective study by Jensen et al reported that a course of antibiotic therapy of less than 14 days might be associated with higher mortality compared to a longer course.⁹ A prospective study of 276 patients by Thomas et al found there was no relationship between relapse and duration of treatment (seven to 15 days) in catheter-related SAB, concluding that more than 14 days of antibiotic therapy was unnecessary.²²

Per IDSA guidelines, uncomplicated SAB (no implanted prosthesis, negative blood cultures within two to four days, defervescence within 72 hours of initiating therapy, and lack of metastatic complication) can be treated with a two-week course of antibiotics, while complicated bacteremia (any of above criteria) should be treated within four to six weeks.³

Monitoring for Complications: Echos

Based on the IDSA guidelines, echocardiography is recommended in all patients with bacteremia, with a preference of transesophageal echocardiography (TEE) over transthoracic echocardiography (TTE).³ More recently, Kaasch et al developed simple criteria to identify patients with nosocomial SAB at low risk for infective endocarditis based on two prospective cohort studies.²³ Lack of any of these criteria, which include prolonged bacteremia of more than four days’ duration, presence of a permanent intracardiac device, hemodialysis dependency, spinal infection and nonvertebral osteomyelitis, along with a negative TTE indicates that a TEE is not necessary (see Table 3). However, these patients need close follow-up to ensure that bacteremia clears and no new signs or symptoms concerning for metastatic infection develop.

click for large version

ID Consultation

Several studies have shown that ID consultation not only improves adherence to evidence-based management of SAB, but it also reduces mortality.^24-27 In a recent prospective cohort study in a tertiary-care center, even after adjusting for pre-existing comorbidities and severity of disease, an ID consult was associated with a 56% reduction in 28-day mortality.²⁴ The patients who were followed by an ID consult service were more likely to receive appropriate duration of antibiotics (81% vs. 29%, respectively) and undergo appropriate workup for the evaluation of metastatic infections (34% and 8%, respectively). This study concluded that routine ID consult should be considered in patients with SAB, especially those with severe illness and multiple comorbid conditions.

Back to the Case

The patient was started on empiric therapy with vancomycin and serial blood cultures were obtained. He remained hemodynamically stable but febrile, with persistently positive blood and urine cultures. Given concern for the port being the source of his infection, his chest port was removed. A high-quality TTE was performed and was unremarkable.

ID was consulted. Blood cultures subsequently grew MSSA and vancomycin was switched to cefazolin 2g every eight hours. On hospital Day 5, his fever resolved and blood cultures turned negative. There were no clinical signs or symptoms for metastatic infections. A PICC line was placed after blood cultures remained negative for 48 hours. The decision was made to treat him with four weeks of antibiotics from his last positive blood culture, with follow-up in ID clinic.

Bottom Line

SAB is a common worldwide cause of morbidity and mortality. Treatment should include removing the nidus if present, finding and administering the appropriate antimicrobial therapy, evaluating for possible complications, and consulting with ID.

Dr. Ward is an assistant professor, Dr. Kim a clinical instructor, and Dr. Stojan a clinical lecturer at the University of Michigan Health System in Ann Arbor.

Acknowledgement

The authors would like to thank Dr. Jeffrey Rohde for reviewing the manuscript.

References

1. Shorr AF, Tabak YP, Killian AD, et al. Healthcare-associated bloodstream infection: a distinct entity? Insights from a large U.S. database. Crit Care Med. 2006;34:3588-3595.
2. Mylotte JM, McDermott C, Spooner JA. Prospective study of 114 consecutive episodes of Staphylococcus aureus bacteremia. Rev Infect Dis. 1987;9:891-907.
3. Liu C, Bayer A, Cosgrove SE, et al. Clinical practice guidelines by the Infectious Diseases Society of America for the treatment of methicillin-resistant Staphylococcus aureus infections in adults and children. Clin Infect Dis. 2011;52(3).
4. Naber CK, Baddour LM, Giamarellos-Bourboulis EJ, et al. Clinical consensus conference: survey on gram-positive bloodstream infections with a focus on Staphylococcus aureus. Clin Infect Dis. 2011;52(3):285-292.
5. Thwaites GE, Edgeworth JD, Gkrania-Klotsas E, et al. Clinical management of Staphylococcus bacteremia. Lancet Infect Dis. 2011;11(3):208-222.
6. Johnson LB, Almoujahed MO, Ilg K, et al. Staphylococcus aureus bacteremia: compliance with standard treatment, long-term outcome and predictors of relapse. Scand J Infec Dis. 2003;35(11-12):782-789.
7. Fowler VG Jr., Olsen MK, Corey GR, et al. Clinical identifiers of complicated Staphylococcus aureus bacteremia. Arch Intern Med. 2003;163:2066-2072.
8. Mylotte JM, Tayara A. Staphylococcus aureus bacteremia: predictors of 30-day mortality in a large cohort. Clin Infect Dis. 2000;31:1170-1174.
9. Jensen AG, Wachmann CH, Espersen F, et al. Treatment and outcome of Staphylococcus aureus bacteremia: a prospective study of 278 cases. Arch Intern Med. 2002;162(1):25-32.
10. Malani PN, Rana MM, Banerjee M, et al. Staphylococcus aureus bloodstream infections: the association between age and mortality and functional status. J Am Geriatr Soc. 2008;56(8):1485-1489.
11. Kim SH, Park WB, Lee KD, et al. Outcome of Staphylococcus aureus bacteremia in patients with eradicable foci versus noneradicable foci. Clin Infect Dis. 2003;37(6):794-799.
12. Chihara S. Popovich KJ, Weinstein RA, et al. Staphylococcus aureus bacteriuria as a prognosticator for outcome of Staphylococcus aureus bacteremia: a case control study. BMC Inf Dis. 2010;10:225.
13. Lodise TP, McKinnon PS, Swiderski L, Rybak MJ. Outcomes analysis of delayed antibiotic treatment for hospital-acquired Staphylococcus aureus bacteremia. Clin Infect Dis. 2003;36:1418-1423.
14. Chang FY, Peacock JE Jr., Musher DM, et al. Staphylococcus aureus bacteremia: recurrence and the impact of antibiotic treatment in a prospective multicenter study. Medicine (Baltimore). 2003;82:333.
15. Stryjewski ME, Szczech LA, Benjamin DK Jr., et al. Use of vancomycin or first-generation cephalosporins for the treatment of hemodialysisdependent patients with methicillin-susceptible Staphylococcus aureus bacteremia. Clin Infect Dis. 2007;44:190-196.
16. Fowler VG Jr., Boucher HW, Corey GR, et al. Daptomycin versus standard therapy for bacteremia and endocarditis caused by Staphylococcus aureus. N Engl J Med. 2006;355:653.
17. Heldman AW, Hartert TV, Ray SC, et al. Oral antibiotic treatment of right-sided staphylococcal endocarditis in injection drug users: prospective randomized comparison with parenteral therapy. Am J Med. 1996;101:68-76.
18. Schrenzel J, Harbarth S, Schockmel G, et al. A randomized clinical trial to compare fleroxacin-rifampicin with flucloxacillin or vancomycin for the treatment of Staphylococcal infection. Clin Infect Dis. 2004;39:1285-1292.
19. Shorr AF, Kunkel MJ, Kollef M. Linezolid versus vancomycin for Staphylococcus aureus bacteraemia: pooled analysis of randomized studies. J Antimicrob Chemother. 2005;56:923-929.
20. Wilson R, Hamburger M. Fifteen years’ experience with Staphylococcus septicemia in a large city hospital; analysis of fifty-five cases in the Cincinnati General Hospital 1940 to 1954. Am J Med. 1957;22:437-457.
21. Fowler VG Jr., Sanders LL, Sexton DJ, et al. Outcome of Staphylococcus aureus bacteremia according to compliance with recommendation of infectious disease specialists: experience with 244 patients. Clin Infect Dis. 1998;27:478-486.
22. Thomas MG, Morris AJ. Cannula-associated Staphylococcus aureus bacteremia: outcome in relation to treatment. Intern Med J. 2005;35:319-330.
23. Kaasch AJ, Fowler VG Jr, Rieg S, et al. Use of a simple criteria set for guiding echocardiography in nosocomidal Staphylococcus aureus bacteremia. Clin Infect Dis. 2011;53:1-9.
24. Honda H, Krauss MJ, Jones JC, et al. The value of infectious disease consultation in Staphylococcus aureus bacteremia. Am J Med. 2010;123:631-637.
25. Nagao M, Iinuma Y, Saito T, et al. Close cooperation between infectious disease physicians and attending physicians can result in better management and outcome for patients with Staphylococcus aureus bacteremia. Euro Soc Clin Microbiology Infect Dis. 2010;16:1783-1788.
26. Fowler VG Jr., Sanders LL, Sexton DJ, et al. Outcome of Staphylococcus aureus bacteremia according to compliance with recommendations of infectious diseases specialist: experience with 244 patients. Clin Infect Dis. 1998;27(3):478-486.
27. Jenkins TC, Price CS, Sabel AL et al. Impact of routine infectious diseases service consultation on the evaluation, management, and outcome of Staphylococcus aureus bacteremia. Clin Infect Dis. 2008;46(7):1000-1008.

Case

An 82-year-old man with non-Hodgkin’s lymphoma in remission and a history of congestive heart failure and hypertension presents with one week of generalized malaise and intermittent fevers. Vitals show a temperature of 101oF, blood pressure of 130/60 mmHg, and heart rate of 100. His exam is notable for an erythematous and tender chest port site, with no murmurs. Blood cultures drawn upon presentation show gram-positive cocci speciated to Staphylococcus aureus. What are the next steps in management of this patient?

Overview

S. aureus bacteremia (SAB) is a common infectious cause of morbidity and mortality worldwide, causing both community-acquired and hospital-acquired bacteremia. In the U.S. alone, it accounts for 23% of all bloodstream infections and is the bacterial pathogen most strongly associated with death.¹ Mortality rates are approximately 42% in those with methicillin-resistant S. aureus (MRSA) bacteremia and 28% in those with methicillin-sensitive S. aureus (MSSA) bacteremia.²

Recognizing the severity of SAB, the Infectious Disease Society of America (IDSA) published treatment guidelines in 2011 to help direct the clinical care of this disease process.³ However, the majority of the recommendations are based on observational studies and expert opinion, as less than 1,500 patients have been enrolled in randomized controlled trials specifically targeted to investigate the treatment of SAB.⁴

Review of the Data

A clinically significant SAB usually is defined as the isolation of S. aureus from a venous blood culture with associated symptoms and signs of systemic infection.5 As SAB contamination is rare and can be associated with multiple complications, including metastatic infections, embolic stroke, recurrent infection, and death, any finding of a positive blood culture must be taken seriously.⁴

SAB treatment is multifaceted and should focus on the removal of any nidus of infection, such as a catheter or a prosthetic device, the use of prolonged antimicrobial therapy, and the evaluation of potential complications. In a retrospective study, Johnson et al showed that failure to remove the source is one of the strongest independent predictors of relapse in patients with SAB.⁶ However, 10% to 40% of patients have no identifiable focus, which increases the impetus to evaluate for complications.^7-8 Overall, approximately one-third of patients with SAB develop metastatic complications, either from hematogenous seeding or local extension of infection.⁹

In addition to advanced age and such comorbid conditions as cirrhosis, the strongest predictor of complications is a positive blood culture at 48 to 96 hours after an initial positive blood culture, as shown in a large prospective cohort study by Fowler et al.^7,10-11 Additional independent risk factors (see Table 1) include community acquisition (likely due to prolonged duration of bacteremia), skin examination suggesting the presence of acute systemic infection, and persistent fever at 72 hours after the first positive blood culture. Patients with even one of these risk factors are at high risk for a complicated course (which occurs in about 35%). In a case-control study, Chihara et al showed that S. aureus bacteruria in the absence of urinary tract pathology or recent urinary tract instrumentation might be associated with threefold increased mortality compared with those without bacteriuria, even after adjustment for comorbid conditions.¹²

click for large version

Antimicrobial Treatment

The initial choice of antibiotic therapy for SAB must take into account the MRSA prevalence in the community and hospital. If suspicion is high enough for MRSA, the IDSA’s 2011 guidelines suggest treatment with vancomycin or daptomycin.³ Although there are no published RCTs to support a particular antibiotic regimen, there are trials to suggest that a delay in treatment could be harmful. One study, by Lordis et al, showed that a delay in treatment, as defined by treatment after 44.75 hours, was associated with a longer hospital stay, with the delayed treatment group being hospitalized for 20.2 days and the early treatment group being hospitalized for 14.3 days.¹³ A delay in treatment was also found to be an independent predictor of mortality.¹³

Once susceptibilities are known, it is important to appropriately tailor antibiotics, as studies have shown lower treatment failure rates with the use of beta-lactam antibiotics when compared with empiric MRSA coverage.^14-15 In one prospective study of 123 hemodialysis patients with MSSA bacteremia, Stryjewski et al showed that those treated with vancomycin were at higher risk of experiencing treatment failure than those treated with cefazolin.¹⁵ In another prospective observational study of 505 patients with SAB, Chang et al found that treatment with nafcillin was superior to vancomycin in preventing persistent bacteremia or relapse for MSSA bacteremia.14 These studies highlight the benefits of adjusting the empirically selected antibiotics, as narrowing the spectrum can result in less treatment failure.

If susceptibilities confirm MRSA, the IDSA recommends continued treatment with vancomycin or daptomycin.³ Although vancomycin is most commonly used, partly because of low cost and familiarity, Fowler et al published a study of 246 patients with SAB with or without endocarditis, assigning them to treatment with daptomycin, initial low-dose gentamicin plus vancomycin or an antistaphylococcal penicillin.¹⁶ The study found that daptomycin was not inferior to the other therapies, confirming that daptomycin is a reasonable choice in the treatment of MRSA infections.

Oral antibiotics are an option to treat SAB when necessary. A RCT by Heldman et al of 85 intravenous drug users with SAB (and suspected right-sided endocarditis, 65% of which had HIV) showed similar efficacy of ciprofloxacin plus rifampin versus standard intravenous therapy.¹⁷ A subsequent randomized trial of 104 patients with SAB comparing oral fleroxacin plus rifampin against conventional intravenous therapy also showed similar cure rates, with the added benefit of earlier discharge.¹⁸ Furthermore, in a meta-analysis of five randomized studies by Shorr et al (see Table 2), linezolid was found to have outcomes that were not inferior to vancomycin (clinical cure/microbiological success of 56%/69% in the linezolid group and 46%/73% in the vancomycin group).¹⁹

click for large version

Treatment Duration

Recommendations for the duration of antibiotic treatment for SAB are mainly based on observational studies, which show mixed results. In one study done in the 1950s, about two-thirds of cases of SAB were associated with endocarditis, and longer courses of intravenous therapy (greater than four weeks) were recommended.²⁰

More recently, with the increasing rates of catheter-related SAB and its relatively high rate of expeditious blood culture clearance, a shorter duration has been evaluated in several studies. In 1992, an analysis of published data and a retrospective case series concluded that fewer than 10 days of intravenous antibiotics might be associated with an increased risk of recurrence, but 10 to 14 days of intravenous therapy was effective for most cases of catheter-associated SAB.⁵ In another prospective study, Fowler et al found that a seven-day course of intravenous antibiotic therapy may be sufficient for simple, catheter-related infections.²¹ A subsequent prospective study by Jensen et al reported that a course of antibiotic therapy of less than 14 days might be associated with higher mortality compared to a longer course.⁹ A prospective study of 276 patients by Thomas et al found there was no relationship between relapse and duration of treatment (seven to 15 days) in catheter-related SAB, concluding that more than 14 days of antibiotic therapy was unnecessary.²²

Per IDSA guidelines, uncomplicated SAB (no implanted prosthesis, negative blood cultures within two to four days, defervescence within 72 hours of initiating therapy, and lack of metastatic complication) can be treated with a two-week course of antibiotics, while complicated bacteremia (any of above criteria) should be treated within four to six weeks.³

Monitoring for Complications: Echos

Based on the IDSA guidelines, echocardiography is recommended in all patients with bacteremia, with a preference of transesophageal echocardiography (TEE) over transthoracic echocardiography (TTE).³ More recently, Kaasch et al developed simple criteria to identify patients with nosocomial SAB at low risk for infective endocarditis based on two prospective cohort studies.²³ Lack of any of these criteria, which include prolonged bacteremia of more than four days’ duration, presence of a permanent intracardiac device, hemodialysis dependency, spinal infection and nonvertebral osteomyelitis, along with a negative TTE indicates that a TEE is not necessary (see Table 3). However, these patients need close follow-up to ensure that bacteremia clears and no new signs or symptoms concerning for metastatic infection develop.

click for large version

ID Consultation

Several studies have shown that ID consultation not only improves adherence to evidence-based management of SAB, but it also reduces mortality.^24-27 In a recent prospective cohort study in a tertiary-care center, even after adjusting for pre-existing comorbidities and severity of disease, an ID consult was associated with a 56% reduction in 28-day mortality.²⁴ The patients who were followed by an ID consult service were more likely to receive appropriate duration of antibiotics (81% vs. 29%, respectively) and undergo appropriate workup for the evaluation of metastatic infections (34% and 8%, respectively). This study concluded that routine ID consult should be considered in patients with SAB, especially those with severe illness and multiple comorbid conditions.

Back to the Case

The patient was started on empiric therapy with vancomycin and serial blood cultures were obtained. He remained hemodynamically stable but febrile, with persistently positive blood and urine cultures. Given concern for the port being the source of his infection, his chest port was removed. A high-quality TTE was performed and was unremarkable.

ID was consulted. Blood cultures subsequently grew MSSA and vancomycin was switched to cefazolin 2g every eight hours. On hospital Day 5, his fever resolved and blood cultures turned negative. There were no clinical signs or symptoms for metastatic infections. A PICC line was placed after blood cultures remained negative for 48 hours. The decision was made to treat him with four weeks of antibiotics from his last positive blood culture, with follow-up in ID clinic.

Bottom Line

SAB is a common worldwide cause of morbidity and mortality. Treatment should include removing the nidus if present, finding and administering the appropriate antimicrobial therapy, evaluating for possible complications, and consulting with ID.

Dr. Ward is an assistant professor, Dr. Kim a clinical instructor, and Dr. Stojan a clinical lecturer at the University of Michigan Health System in Ann Arbor.

Acknowledgement

The authors would like to thank Dr. Jeffrey Rohde for reviewing the manuscript.

References

1. Shorr AF, Tabak YP, Killian AD, et al. Healthcare-associated bloodstream infection: a distinct entity? Insights from a large U.S. database. Crit Care Med. 2006;34:3588-3595.
2. Mylotte JM, McDermott C, Spooner JA. Prospective study of 114 consecutive episodes of Staphylococcus aureus bacteremia. Rev Infect Dis. 1987;9:891-907.
3. Liu C, Bayer A, Cosgrove SE, et al. Clinical practice guidelines by the Infectious Diseases Society of America for the treatment of methicillin-resistant Staphylococcus aureus infections in adults and children. Clin Infect Dis. 2011;52(3).
4. Naber CK, Baddour LM, Giamarellos-Bourboulis EJ, et al. Clinical consensus conference: survey on gram-positive bloodstream infections with a focus on Staphylococcus aureus. Clin Infect Dis. 2011;52(3):285-292.
5. Thwaites GE, Edgeworth JD, Gkrania-Klotsas E, et al. Clinical management of Staphylococcus bacteremia. Lancet Infect Dis. 2011;11(3):208-222.
6. Johnson LB, Almoujahed MO, Ilg K, et al. Staphylococcus aureus bacteremia: compliance with standard treatment, long-term outcome and predictors of relapse. Scand J Infec Dis. 2003;35(11-12):782-789.
7. Fowler VG Jr., Olsen MK, Corey GR, et al. Clinical identifiers of complicated Staphylococcus aureus bacteremia. Arch Intern Med. 2003;163:2066-2072.
8. Mylotte JM, Tayara A. Staphylococcus aureus bacteremia: predictors of 30-day mortality in a large cohort. Clin Infect Dis. 2000;31:1170-1174.
9. Jensen AG, Wachmann CH, Espersen F, et al. Treatment and outcome of Staphylococcus aureus bacteremia: a prospective study of 278 cases. Arch Intern Med. 2002;162(1):25-32.
10. Malani PN, Rana MM, Banerjee M, et al. Staphylococcus aureus bloodstream infections: the association between age and mortality and functional status. J Am Geriatr Soc. 2008;56(8):1485-1489.
11. Kim SH, Park WB, Lee KD, et al. Outcome of Staphylococcus aureus bacteremia in patients with eradicable foci versus noneradicable foci. Clin Infect Dis. 2003;37(6):794-799.
12. Chihara S. Popovich KJ, Weinstein RA, et al. Staphylococcus aureus bacteriuria as a prognosticator for outcome of Staphylococcus aureus bacteremia: a case control study. BMC Inf Dis. 2010;10:225.
13. Lodise TP, McKinnon PS, Swiderski L, Rybak MJ. Outcomes analysis of delayed antibiotic treatment for hospital-acquired Staphylococcus aureus bacteremia. Clin Infect Dis. 2003;36:1418-1423.
14. Chang FY, Peacock JE Jr., Musher DM, et al. Staphylococcus aureus bacteremia: recurrence and the impact of antibiotic treatment in a prospective multicenter study. Medicine (Baltimore). 2003;82:333.
15. Stryjewski ME, Szczech LA, Benjamin DK Jr., et al. Use of vancomycin or first-generation cephalosporins for the treatment of hemodialysisdependent patients with methicillin-susceptible Staphylococcus aureus bacteremia. Clin Infect Dis. 2007;44:190-196.
16. Fowler VG Jr., Boucher HW, Corey GR, et al. Daptomycin versus standard therapy for bacteremia and endocarditis caused by Staphylococcus aureus. N Engl J Med. 2006;355:653.
17. Heldman AW, Hartert TV, Ray SC, et al. Oral antibiotic treatment of right-sided staphylococcal endocarditis in injection drug users: prospective randomized comparison with parenteral therapy. Am J Med. 1996;101:68-76.
18. Schrenzel J, Harbarth S, Schockmel G, et al. A randomized clinical trial to compare fleroxacin-rifampicin with flucloxacillin or vancomycin for the treatment of Staphylococcal infection. Clin Infect Dis. 2004;39:1285-1292.
19. Shorr AF, Kunkel MJ, Kollef M. Linezolid versus vancomycin for Staphylococcus aureus bacteraemia: pooled analysis of randomized studies. J Antimicrob Chemother. 2005;56:923-929.
20. Wilson R, Hamburger M. Fifteen years’ experience with Staphylococcus septicemia in a large city hospital; analysis of fifty-five cases in the Cincinnati General Hospital 1940 to 1954. Am J Med. 1957;22:437-457.
21. Fowler VG Jr., Sanders LL, Sexton DJ, et al. Outcome of Staphylococcus aureus bacteremia according to compliance with recommendation of infectious disease specialists: experience with 244 patients. Clin Infect Dis. 1998;27:478-486.
22. Thomas MG, Morris AJ. Cannula-associated Staphylococcus aureus bacteremia: outcome in relation to treatment. Intern Med J. 2005;35:319-330.
23. Kaasch AJ, Fowler VG Jr, Rieg S, et al. Use of a simple criteria set for guiding echocardiography in nosocomidal Staphylococcus aureus bacteremia. Clin Infect Dis. 2011;53:1-9.
24. Honda H, Krauss MJ, Jones JC, et al. The value of infectious disease consultation in Staphylococcus aureus bacteremia. Am J Med. 2010;123:631-637.
25. Nagao M, Iinuma Y, Saito T, et al. Close cooperation between infectious disease physicians and attending physicians can result in better management and outcome for patients with Staphylococcus aureus bacteremia. Euro Soc Clin Microbiology Infect Dis. 2010;16:1783-1788.
26. Fowler VG Jr., Sanders LL, Sexton DJ, et al. Outcome of Staphylococcus aureus bacteremia according to compliance with recommendations of infectious diseases specialist: experience with 244 patients. Clin Infect Dis. 1998;27(3):478-486.
27. Jenkins TC, Price CS, Sabel AL et al. Impact of routine infectious diseases service consultation on the evaluation, management, and outcome of Staphylococcus aureus bacteremia. Clin Infect Dis. 2008;46(7):1000-1008.