Antimicrobial Stewardship (AMS)

• All patients should have an echocardiogram to rule out endocarditis.  If the transthoracic echocardiogram (TTE) is negative a transesophageal echocardiogram (TEE) is required to rule out endocarditis. 
• Identify any indwelling prosthetic devices (e.g. orthopedic hardware, cardiac device) and inspect for infection
• Source and extent of infection should be determined through careful history, physical exam and imaging as needed 

Last reviewed April 2018

• Infectious Diseases consultation recommended
• Mortality rate: 10-30%
• Remove focus of infection if possible e.g. catheter-associated infection
• Repeat blood cultures q48hours until negative to demonstrate sterilization 
• MRSA bacteremia cases with high vancomycin minimum inhibitory concentrations (MIC) ≥2 mcg/mL should be referred to Infectious Diseases

Last reviewed April 2018

• Cloxacillin 2 g IV q4h
• Cefazolin 2 g IV q8h (adjust for renal function) 
• Vancomycin is recommended if known or at risk of MRSA: injection drug use, abscesses, known MRSA colonization, previous MRSA infection
  • Loading dose: 25 mg/kg total body weight (TBW) IV x 1 followed by
  • Maintenance dose: 15 mg/kg TBW IV q8-12hours (adjust for renal function)
  • Maintain trough level of 15-20 mg/L 

Last reviewed April 2018

• Cefazolin 2g IV q8h (adjust for renal function) may be appropriate in patients with history of penicillin allergy as it does not share similar side chain with any penicillin
• Vancomycin IV
• Daptomycin IV – if cannot use beta-lactam or vancomycin 

Last reviewed April 2018

• Dependent on presence or absence of complications
• 14 days IV therapy minimum counting from first negative blood culture can be considered if ALL of the following criteria for uncomplicated S. aureus bacteremia are met:
  • Infective endocarditis has been excluded, no implanted prostheses are present, follow-up cultures drawn 2-4 days after initial set are sterile, patient is afebrile within 72 hrs of antibiotic therapy, no evidence of metastatic infection present
• 4-6 weeks IV therapy recommended for all complicated cases  

Last reviewed April 2018

For patients with febrile neutropenia, please see Febrile Neutropenia guidelines for management considerations. 

Last reviewed April 2018

1. Holland TL, Arnold C, Fowler VG Jr. Clinical management of Staphylococcus aureus bacteremia: a review. JAMA. 2014 Oct; 312(13):1330-41.

2. Liu C, Bayer A, Cosgrove SE, Daum RS, Fridkin SK, Gorwitz RJ 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):e18.

3. Van Hal SJ, Lodise TP, Paterson DL. The clinical significance of vancomycin minimum inhibitory concentration in Staphylococcus aureus infections: a systematic review and meta-analysis. Clin Infect Dis. 2012 Mar;54(6):755-71.

4. Van Hal SJ, et al. Predictors of Mortality in Staphylococcus aureus Bacteremia. Clin Microbiol Rev. 2012; 25 (2): 362-86.

5. Local Antibiograms:https://library.nshealth.ca/AMS/Antibiograms

Last reviewed April 2018

• C. glabrata is usually resistant to fluconazole and should be treated with an echinocandin
• C. krusei is resistant to fluconazole and should be treated with an echinocandin

Last reviewed November 2018

• If yeast suspected, draw a set of blood cultures from two different sites
• Candida in blood should generally NOT be considered a contaminant

Last reviewed November 2018

• Infectious Diseases (ID) consultation is recommended; particularly if an endovascular or device-related infection suspected
• Replace all central lines as soon as possible
• Ophthalmology assessment is recommended to rule out ophthalmic disease within 1 week of therapy (or after neutrophil count recovery in neutrophenic patient)
• Collect 2 aerobic blood culture bottles every 48 hours until negative to demonstrate sterilization

Last reviewed November 2018

• Fluconazole if patient is NOT critically ill (i.e. hemodynamically stable) and unlikely to have a fluconazole-resistant Candida (no azole exposure within three months):
  • Fluconazole 800 mg IV/PO x 1, then 400 mg IV/PO once daily (adjust for renal function)
• An echinocandin:
  • Caspofungin 70 mg IV x initial dose on day 1; subsequent dosing 50 mg IV daily 
• Amphotericin B:
  • Amphotericin B lipisomal (AmBisome) 5 mg/kg IV daily 

Last reviewed November 2018

Minimum 2 weeks after first negative blood culture in absence of metastatic complications

Last reviewed November 2018

• Febrile patients with hematologic malignancy recovering from neutropenia are at risk of chronic disseminated (hepatosplenic) candidiasis
• Echinocandins do not achieve high urinary concentrations
• Candida in respiratory secretions and catheter urine in asymptomatic patients is usually colonization and rarely requires therapy
• Consider endocarditis if blood cultures consistently positive, persistent fever despite therapy, new heart murmur or embolic phenomena
• Microbiology report S-DD (susceptible-dose dependent):
  • Susceptibility depends on maximum blood levels. This requires a higher fluconazole dose than the standard dosing in adults with normal renal function. ID should be consulted if fluconazole is used in this situation. 

Last reviewed November 2018

1. Pappas, PG, Kauffman, CA, Andes, DR, et al. Clinical Practice Guideline for the Management of Candidiasis: 2016 Update by the Infectious Diseases Society of America. Clin Infect Dis. 2016 62(4): e1-50.

2. Local Antibiograms.

3. CLSI M60-ED1:2017 Performance Standards for Antifungal Susceptibility Testing of Yeasts.

Last reviewed November 2018