124 Chapter 6 Discussion This study shows that even the most basic aspects of treating patients with SAB differ profoundly between geographic regions. This variation was most marked in fundamental aspects of decision-making for SAB treatment, including antibiotic choice for MSSA bacteremia, addition of rifampin for prosthetic device infections, and route of administration. An anti-staphylococcal penicillin was treatment of choice for MSSA bacteremia in Europe and Oceania but a distant second to cefazolin in North America. The evidence for superiority of either of the 2 is limited to cohort studies with conflicting results and with underrepresentation of complicated disease [7, 8], emphasizing the need for randomized trials. The role of adjunctive rifampin in patients with prosthetic material infections also differed by continent. This controversy persists despite the availability of published society guidelines that recommend the use of rifampin in S. aureus infections involving prosthetic valves and arthroplasties [9, 10]. However, the recommendation to use rifampin for prosthetic valve infective endocarditis has a very limited evidence base [11]. Thus, well-designed randomized trials are needed to define any potential role of adjunctive rifampin in prosthesis-associated SAB. Importantly, the wide range of practices regarding the use of rifampin in this survey demonstrates the presence of the global equipoise necessary to ethically conduct such a trial. The practice of prescribing part of the treatment course for SAB with oral antibiotics was well accepted in all continents except North America, where only a minority of physicians would consider its routine use. This infrequent use of oral therapy in the United States may be due in part to a high prevalence of MRSA, the presence of a well-organized outpatient parenteral antimicrobial therapy system, or concerns related to medical malpractice. This lack of global consensus on the role of oral switch therapy is also reflected by the lack of consensus on which setting in which it should be considered. In fact, only the criteria of “source control” and “absence of central nervous system infection” were considered essential for oral switch by a clear majority. By contrast, all other listed criteria were regarded as essential by approximately half of the respondents—which implies that these were considered non-essential by the other half. Because oral switch therapy has potential to decrease the number of adverse drug events, catheter-associated problems and costs, and the fact that the survey respondents are in equipoise on the question, the need for a welldesigned randomized trial seems clear. Current studies such as SABATO and SNAP might provide answers in the future [12, 13].
RkJQdWJsaXNoZXIy MTk4NDMw