Staphylococcal sepsis: new guidelines

Abstract

Infectious diseases physicians are frequently asked for advice about the management of Staphylococcus aureus infections. What should we do if a patient with S. aureus skin and soft-tissue infection is slow to respond to treatment? How do you manage recurrent furunculosis? How long should we treat someone with a staphylococcal bone or joint infection, particularly if a prosthetic hip or knee is involved? How come many patients with S. aureus bacteraemia don’t have an apparent source? Should we carry out a transoesophageal echocardiogram in everyone with a positive blood culture for S. aureus? Does everyone with S. aureus endocarditis need 4 weeks of intravenous antibiotics and valve replacement? If a pacemaker or defibrillator is infected with S. aureus must it be removed, and could this infection have been prevented? Do the same answers apply to vascular grafts and stents? Has toxic shock syndrome disappeared along with super absorbent tampons? Modern day medical practice in hospitals mandates widespread use of intravascular catheters; what should we do if one becomes infected with S. aureus? Can we leave it in and fix the problem with antibiotics? Which anti-staphylococcal drugs have the greatest potency? Doesn’t flucloxacillin cause liver disease and isn’t phlebitis common with intravenous dicloxacillin? When should we use rifampicin? How common is the newly emergent community acquired non-multiresistant MRSA? Should we be using vancomycin as empirical therapy for all staphylococcal infections? And what about vancomycin resistance and vancomycin intermediate S. aureus (VISA) and what has that got to do with credit cards? A person who knows the answers to all of these questions is wise indeed. For the rest of us this month's issue of the Internal Medicine Journal contains a supplement in the form of a CD-ROM on S. aureus infections: a modern approach to diagnosis and treatment. The supplement may not provide all the answers to the above questions but it does provide an evidence-based approach to help us make clinical decisions − the reasoning behind recommendations related to S. aureus infection. Sixty years ago, an English policeman was the first to receive penicillin for S. aureus infection. Treatment was initially successful but the patient eventually succumbed to sepsis. Ever since that time, S. aureus has presented patients and health care workers with increasingly complex challenges. This supplement deals with these challenges as they exist today in both community and hospital practice. The supplement is the first of its kind for the Internal Medicine Journal and our publishers Blackwell deserve commendation for bringing it to fruition. The supplement was jointly produced by the Australian Society for Antimicrobials (ASA) and the Australasian Society for Infectious Diseases (ASID) and was conceived by the ASA S. aureus working party. The eight authors from Australia and New Zealand, ably led by Iain Gosbell1, have worked diligently to produce a monograph which is up to date and practical. We commend the CD as a very useful resource which will help us all understand the clinical aspects of S. aureus infections and their management.