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Antibiotic Therapy for Staphylococcal Bloodstream Infections: Doing the Same with Less

A treatment algorithm for staphylococcal bloodstream infections (BSIs) featuring markedly shorter antibiotic therapy than the conventional standard of care produces similar rates of success and serious adverse events. For complicated infections, the algorithm approach is better than standard care. The good news from the randomized, multinational, open-label, adjudicator-blinded trial was presented at the ID Week 2017 meeting in San Diego, California.

“The optimal duration of treatment for staphylococcal bacteremia is unknown. Long-course or short-course treatment may place the patient at risk. If treatment is too prolonged, there is a greater risk of the development of antibacterial resistance and antibiotic-associated adverse events. On the other hand, if the treatment duration is too short, there can be a greater chance of relapse due to inadequately treated infection,” said Thomas L. Holland, MD, Duke University Medical Center, Durham, North Carolina, on behalf of the Bacteremia Study Group. 

With this in mind, the researchers sought to provide clarity concerning treatment time. “Our study rationale was that a strategy to identify patients with staphylococcal BSI who can safely be treated with shorter courses of therapy would improve care,” explained Dr. Holland.

The study explored whether an algorithm that defines treatment duration for staphylococcal BSI can provide similar efficacy and safety to the standard of care while reducing antibiotic duration—“doing the same with less.”

Standard of care included an unrestricted choice of antibiotics. The length of treatment was determined by the treating clinician. The algorithm-based therapy was more stringent. Antibiotics were limited to first-choice vancomycin or daptomycin for methicillin-resistant isolates, and cefazolin or nafcillin for methicillin-susceptible isolates. The duration of therapy was dictated by the severity of infection. For simple, uncomplicated, and complicated coagulase-negative staphylococci (CoNS) infections, antibiotics were given for 0-3, 5, and 7-28 days, respectively. For uncomplicated and complicated S. aureus infections, duration of antibiotic therapy was 14 and 28-42 days, respectively. The grading of infections involved various criteria set beforehand, and not by the treating clinician.

Big advances in treatment can't make up for an inability to stop new infections, which number 5,000 per day worldwide.