254 Chapter 11 Challenges in Staphylococcus aureus bacteremia management The management of patients with S. aureus bacteremia is a complex challenge for healthcare professionals. Once the pathogen has entered the bloodstream, S. aureus has the potential to cause devastating damage to the human body. Uncomplicated S. aureus bacteremia does exist, but is very difficult to distinguish from an early phase of complicated disease and probably less prevalent than previously thought [7]. Many uncertainties need to be addressed to make decisions in diagnostic- and treatment paths. While managing uncertainties is inherent to practicing medicine, the erratic course of S. aureus bacteremia can amplify the usual burden of unpredictability. Even with the best available treatments, complications such as kidney injury or persistent bacteremia frequently occur in these patients. The mortality risk is high and has not substantially decreased in the past decades [8]. For equally lethal diseases such as coronary artery disease, mortality has significantly decreased following largely standardized management by guidelines, based on data from randomized controlled trials [9, 10]. Unfortunately, no such thing has happened yet for S. aureus bacteremia. In chapter 6, we conducted a survey on the management of S. aureus bacteremia. This study illustrated the strength of using social media and being part of a professional network to understand global medical practices: within 20 days, over 2,000 physicians from 71 countries responded to the survey. In terms of content, the study showed that even the most basic aspects of treating patients with this disease differ profoundly between geographic regions. Differences existed in firstchoice antibiotics for methicillin-susceptible S. aureus (MSSA) bacteremia, addition of rifampin for prosthetic device infections, the use of a 18F-FDG PET/CT scan, and route of antibiotic administration. Moreover, the definition of ‘persistent SAB’ varied widely between continents, ranging from two days to over seven days of positive blood cultures. The lack of a global standard in the management of S. aureus bacteremia could be a result of the limited clinical trials with robust data. Despite its frequent occurrence, fewer than 3500 patients have been enrolled in published S. aureus bacteremia randomized trials over the past 20 years [11]. Apart from scarcity of clinical evidence, other factors such as cultural differences, type of healthcare insurance, (out-of-pocket) costs, and availability of resources also potentially influence the heterogeneity of management. Multinational clinical trials such as the Staphylococcus aureus Network Adaptive Platform (SNAP) are thus essential to standardize clinical definitions, identify treatment strategies, and improve patient outcomes of this common and frequently lethal infection [11]. Identifying a broadly accepted definition of persistent S. aureus bacteremia would not only be helpful in clinical decision-making, but also in harmonizing the terminology and outcomes used in clinical research.
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