MSSA Bacteremia

in HD: Patient Case

MARGO WHITEHEAD, PHARMD
PGY1 RESIDENT | AUGUST 2022
Learning Objectives

1. Discuss the treatment of MSSA bacteremia in a

hemodialysis patient based on IDSA guidelines.
2. Evaluate the treatment plan in a real patient case
compared to guideline-directed therapy management of
MSSA bacteremia in a hemodialysis patient.
Let’s Meet JB
JB’s Pertinent Data

JB is a 78 YOWF admitted to Ball Memorial Hospital 7/27/2022

o CC: MSSA Bacteremia
o Signs/sx: Fever, vomiting, hypotension
o HPI: Presented to the ED with fever 103.3 degrees F, heart rate
133, respiratory rate 26, blood pressure 73/39 mmHg, and MAP of
50 on 7/27/2022. Was admitted to the ICU for treatment of septic
shock and found to have MSSA bacteremia likely from indwelling
HD line (right IJ). Septic shock resolved.
o Other current problems: Hypotension, NASH cirrhosis requiring
paracentesis, not a candidate for VTE prophylaxis
JB’s PMH and Medication History

• PMH: CKD on HD, NASH cirrhosis, Afib s/p ablation, history of CVA, T2DM, HIT
• Med Hx:
o Ferrous sulfate 325 mg tablet PO daily
o Pantoprazole 40 mg tablet PO BID
o Sucralfate 1 g/10 mL susp 10 mL PO before meals and bedtime
o Atorvastatin 40 mg tablet PO at bedtime
o Mirtazapine 30 mg tablet PO at bedtime
o Vitamin B12 1000 mCg tablet PO daily
o Allopurinol 100 mg tablet PO daily
o Midodrine 10 mg tablet PO every Monday Wednesday Friday
o Oxycodone 5 mg tablet PO Q12H PRN pain
o Zinc 140 mg tablet PO daily
Physician Plan

▪ ID recommends switching IV oxacillin to IV

cefazolin to be given with dialysis at the time of
discharge as nephrology states that cefazolin is at
their disposal in the outpatient clinic
▪ Regimen will be cefazolin 2 grams IV Tuesday, 2
grams IV Thursday, and 3 grams IV Saturday for a
total duration of 4 weeks with the last dose to be
8/27
Hospital Course
SEE HANDOUT
Problem List and Prioritization

1. MSSA Bacteremia
2. Hypotension
3. NASH Cirrhosis Requiring Paracentesis
 Issue for discussion:
MSSA bacteremia in patients with
hemodialysis
 Discussion of Disease State

• Incidence: ~80,000 cases per year in the U.S.

• Etiology: Risk of bloodstream infection varies between
intravascular devices
• Clinical symptomatology: Fever, chills, hemodynamic
instability, or altered mental status

Clinical Practice Guidelines for the Diagnosis and Management of Intravascular Catheter-Related Infection: 2009 Update
by the Infectious Diseases Society of America.
 Discussion of Disease State - continued

• Lab findings: Positive blood cultures, increased WBCs

• Prognosis: For MSSA, cure rate is approximately 67%
• Complications/Sequelae: Septic shock, endocarditis

Clinical Practice Guidelines for the Diagnosis and Management of Intravascular Catheter-Related Infection: 2009 Update
by the Infectious Diseases Society of America.
 Discussion of Treatment

• Empiric antibiotics
• Remove catheter
• Rule out endocarditis - TEE
• May use antibiotic lock as adjunct
• Treatment duration:
• Uncomplicated bacteremia = 3 weeks
• Metastatic infection (endocarditis) = 6 weeks

Treatment Guidelines for Dialysis Catheter-Related Bacteremia: An Update

Management of Current Case

• Empiric antibiotics
• Remove catheter
• Rule out endocarditis - TEE
• Treatment duration: 4 weeks
Pharmacist’s Role

▪ Dose empiric vancomycin and zosyn

▪ Recommend antibiotic therapies based upon culture
sensitivities, patient allergies, and administration
considerations
▪ Assess clinical response to therapy
Review of Medications

▪ Oxacillin
▪ Nafcillin
▪ Cefazolin
Review of Literature
SEE HANDOUT
Conclusions

▪ Therapy appropriate
▪ Utilization of multidisciplinary team and
specialties
1. Lexi-Drugs/Oxacillin. Lexicomp Online. Waltham, MA: Wolters Kluwer
Health, Inc. August 6, 2022. http://online.lexi.com Accessed August 18,
2022.
2. Lexi-Drugs/Midodrine. Lexicomp Online. Waltham, MA: Wolters Kluwer
Health, Inc. August 13, 2022. http://online.lexi.com Accessed August 18,
2022.
3. Lexi-Drugs/Albumin. Lexicomp Online. Waltham, MA: Wolters Kluwer
Health, Inc. August 9, 2022. http://online.lexi.com Accessed August 18,
2022.
4. Mermel LA, Allon M, Bouza E, et al. Clinical Practice Guidelines for the
Diagnosis and Management of Intravascular Catheter-Related Infection:
2009 Update by the Infectious Diseases Society of America. Clin Infect Dis.
2009; 49(1):1-45. doi:10.1086/599376
5. Allon M. Treatment Guidelines for Dialysis Catheter-Related Bacteremia:
An Update. Am J Kidney Dis. 2009; 54(1):13-17.

6.
doi:10.1053/j.ajkd.2009.04.006
Lexi-Drugs/Nafcillin. Lexicomp Online. Waltham, MA: Wolters Kluwer
Health, Inc. July 19, 2022. http://online.lexi.com Accessed August 18,
References
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7. Lexi-Drugs/Cefazolin. Lexicomp Online. Waltham, MA: Wolters Kluwer
Health, Inc. August 12, 2022. http://online.lexi.com Accessed August 18,
2022.
8. Bidell MR, Patel N, O’Donnell JN. Optimal treatment of MSSA
bacteraemias: a meta-analysis of cefazolin versus antistaphylococcal
penicillins. Journal of Antimicrobial Chemotherapy. 2018; 73(10):2643–
2651. https://doi.org/10.1093/jac/dky259
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Susceptible Staphylococcus aureus Bacteremia: A Comparative Review of
Cefazolin versus Antistaphylococcal Penicillins. Pharmacotherapy. 2017;
37: 346-360. https://doi.org/10.1002/phar.1892
Questions?
MSSA Bacteremia
in HD: Patient Case
MARGO WHITEHEAD, PHARMD
PGY1 RESIDENT | AUGUST 2022