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Therapeutic Options for Adult Patients With Persistent Methicillin-Susceptible Staphylococcus aureus Bacteremia: A Narrative Review

Objective: To compare the efficacy of antimicrobial therapies used in the management of persistent methicillin-susceptible Staphylococcus aureus (MSSA) bacteremia.

Data sources: A literature search using the PubMed database (inception to December 2022) was conducted using the search terms "Staphylococcus aureus bacteremia," "methicillin-susceptible Staphylococcus aureus bacteremia," "persistent methicillin-susceptible Staphylococcus aureus bacteremia," and "refractory methicillin-susceptible Staphylococcus aureus bacteremia ." In addition, therapeutic agents which could be used as treatment for MSSA including "nafcillin," "oxacillin," "cefazolin," "ceftaroline," "gentamicin," "rifampin," and "daptomycin" were also combined with the aforementioned search terms to capture data using these agents.

Study selection/data extraction: Clinical data were limited to those published in the English language. Articles and abstracts were considered for inclusion in addition to ongoing trials identified through ClinicalTrials.gov.

Data synthesis: A total of 78 articles were reviewed including 17 in vitro or animal model studies and 39 studies including patient data. The remaining 22 articles included guidelines, review articles, and editorials. Recent data evaluating use of dual β-lactam regimens for persistent MSSA bacteremia were limited to 8 case reports or case series.

Relevance to patient care and clinical practice: At present, there is little guidance on how to best manage patients with persistent MSSA bacteremia. This narrative review collates the available data to assist clinicians in selecting the best possible antimicrobial regimen when facing this clinical conundrum.

Conclusions: Modification of antimicrobial therapy, in conjunction with source control and infectious diseases consultation, may all be necessary to sterilize blood cultures in patients with persistent MSSA bacteremia.

Comments：

Based on the literature review, there is limited evidence to guide the management of persistent MSSA bacteremia. However, available data suggest that a combination of antibiotics targeting MSSA, such as nafcillin, oxacillin, cefazolin, or ceftaroline, in addition to a second agent such as gentamicin, rifampin, or daptomycin may be effective in some cases. In particular, recent case reports and case series suggest that the use of dual β-lactam regimens may be effective in treating persistent MSSA bacteremia. It is important to consider the source of the infection and implement appropriate source control measures in conjunction with antimicrobial therapy. Consultation with an infectious diseases specialist may also be beneficial in guiding therapy. Overall, individualized treatment plans should be developed based on the patient's clinical status and microbiological data.

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Anti-infection