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Staphylococcus aureus bacteremia (SaB) is the final common pathway of widely varying diseases, including skin/soft tissue, pneumonia, bone and joint, vascular catheter, and endovascular infections including endocarditis. However, treatment paradigms for SaB differ primarily by duration of intravenous therapy (ranging from 2–6 weeks). Little information exists to guide rapid de-escalation of low-risk patients from intravenous (IV) to oral therapy.
Investigators retrospectively examined early oral switch (EOS; within 14 days) administered at one institution to patients with low-risk SaB (healthcare-associated infection, no bacteremia lasting >72 hours, no evidence of deep infection as determined by infectious disease consultation, and no involvement of retained bioprosthetic material). Of 469 patients, 100 (21%) met low-risk criteria, of whom 84 underwent EOS (95% with methicillin-susceptible Staphylococcus aureus). Vascular catheter infections comprised 79% of cases and skin infections 10%. For the EOS group, median duration was 5 days (interquartile range, 4–6 days) for IV treatment and 10 days (IQR, 9–14 days) for oral treatment, with a median total duration of 16 days (IQR, 14–18 days); for the IV-only group, median therapy duration was 14 days (IQR, 14–17 days). Beta-lactam antibiotics were used for 86% of oral treatment courses. Outcomes between EOS and IV-only treatment were similar. Among the 81 of 84 EOS and 16 of 16 IV-only patients, no deaths attributable to SaB occurred within 90 days. SaB recurred in 3 (4%) of the EOS and 1 of the IV group.
Bupha-Intr O et al. Efficacy of early oral switch with beta-lactams for low-risk Staphylococcus aureus bacteremia. Antimicrob Agents Chemother 2020 Feb 3; [e-pub]. (https://doi.org/10.1128/AAC.02345-19)
Comment
Although limited by its small size and single-center retrospective design, this study supports cautious optimism for identifying subsets of patients with SaB who, with the expert guidance of infectious disease consultants, may be candidates for early switch to oral antimicrobial therapy. Vascular catheter and skin infections are easily identified targets for possible EOS in practice and for larger prospective clinical trials. However, enrolling such low-risk patients may bias results toward the null in clinical trials of novel IV therapies for more serious SaB, such as endovascular infections, where escalation rather than de-escalation is the treatment goal.