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Staphylococcus epidermidis Infection

Ezra Lee; Fatima Anjum.

Author Information and Affiliations

Last Update: April 27, 2023.

Continuing Education Activity

Staphylococcus epidermidis is a common symbiont bacterium that can become infectious once
inside the human host. They are among the most common causes of nosocomial infection in the
United States and can lead to serious complications. This activity reviews the evaluation and
treatment of Staphylococcus epidermidis infection and explains the role of the interprofessional
team in managing patients with this condition.

Objectives:

Identify the etiology of Staphylococcus epidermidis infection.

Describe the pathophysiology of Staphylococcus epidermidis infection.

Explain the common presentation of a patient with Staphylococcus epidermidis infection.

Outline the management considerations for patients with Staphylococcus epidermidis

infection.

Access free multiple choice questions on this topic.

Introduction
Staphylococcus epidermidis is a coagulase-negative, gram-positive cocci bacteria that form
clusters. It is also a catalase-positive and facultative anaerobe. They are the most common
coagulase-negative Staphylococcus species that live on the human skin. In its natural
environments such as the human skin or mucosa, they are usually harmless.[1] Many times, these
coagulase-negative staph species invade the human body via prosthetic devices, at which point a
small number of microbes travel down the prosthetic device to the bloodstream. The bacteria,
then, can produce biofilms that help to protect them from host defense or antimicrobials.[2]

The belief is that Staphylococcus epidermidis is one of the most common causes of nosocomial
infection, with infection rates as high as those of Staphylococcus aureus.[3]

Etiology
Staphylococcus epidermidis is usually a symbiont that is harmless in its natural environment.
[4] However, it is an opportunistic pathogen that can cause virulence once it invades the human
body via medical and prosthetic devices. Bacteremia from the Staphylococcus epidermidis and
other coagulase-negative staphylococcus species arise most commonly by indwelling medical
device contamination.[5] When placing a prosthetic device in a human body, the bacteria from
the human skin can colonize the medical devices and enter the bloodstream.

Epidemiology

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Staphylococcus epidermidis is among the most common causes of nosocomial blood infections.
[5] Patients with prosthetic valves, cardiac devices, central lines, catheters, and IV drug use are at
most risk of being infected with these species. It is also highly prevalent among neonates.[6]

Pathophysiology
One of the crucial factors allowing coagulase-negative species to survive in a harsh environment
is the production of the biofilm. Biofilm formation occurs with initial adhesion to a foreign
surface or endothelium, which leads to accumulation into multicellular structures.[4] Once
formed, biofilm protects against innate host defense via protective exopolymers called poly-y-
glutamic acid.[4] Other exotoxins and endotoxins also appear to cause immune reaction and
virulence inside the host, one of which is a PSM peptide toxin that encodes methicillin-resistant
island.[7]

History and Physical

Staphylococcus epidermidis can manifest in many ways once inside the human host, including
localized and systemic infections. Below are some of the most common diseases.

Intravascular Catheter Infections

Staphylococcus epidermidis and other coagulase-negative staphs are one of the leading causes of
catheter-related bloodstream infection. The infection largely occurs as the bacteria migrate from
the patient’s skin to the surface of the catheter, but they also can migrate via luminal surfaces.
[8] For patients with catheter infection, they may present with localized symptoms such as
inflammation, erythema, or purulence around the insertion of the catheter. They also can present
with systemic signs such as fever, hypotension, and other signs concerning sepsis.

Infectious Endocarditis

Staphylococcus epidermidis ranks as one of the most common species to cause infective
endocarditis in both the prosthetic valve and the native valve. Up to 40% of cases of prosthetic
valve endocarditis (PVE) are due to coagulase-negative staph.[9] Once the bacteria produce
biofilm within the cardiac valves, it can accumulate and form vegetations.[10][11] Patients with
endocarditis can present with fever, chills, malaise, night sweats, and dyspnea.[12] On physical
exam, the patient can present with cardiac murmurs along with petechiae and/or splinter
hemorrhages. Uncommonly, other clinical manifestations include Janeway lesions, Osler nodes,
and Roth spots.

Cardiac Devices, Prosthetic Joints, and CNS Shunt Infection

Staphylococcus epidermidis can cause infections from implantation of medical devices such as
cardiac devices, orthopedic devices, and CNS shunt. Up to 20% of patients with cardiac devices
can become infected and can show signs of erythema, pain, purulence around the site of the
infection, and sepsis.[8] For patients with prosthetic joint infection, they can present with pain
and purulence around the site of the insertion of the prosthesis.

Shunt infection may present without symptoms, but can also cause headache, dizziness, nausea,
vomiting, and altered mental status.

Evaluation

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For patients suspected of having catheter-related bloodstream infections, blood cultures are
necessary before starting antibiotics. The recommendation is to draw cultures from both the
peripheral vein and the catheter site for the most reliable results.[13][14][15] Given that
coagulase-negative staphs are frequently encountered as contaminants in blood cultures, having
two bottles of blood culture positive with these species will increase the positive predictive
value[16].

Patients suspected of having endocarditis based on a clinical picture will also require blood
cultures and echocardiogram. At least three blood culture sets are recommended from separate
venipuncture sites.[17]

An echocardiogram is imperative in the diagnosis of endocarditis. A transthoracic

echocardiogram (TTE) is the initial step, which has a high sensitivity to 75% and specificity of
about 100%.[18] If TTE is inconclusive and there is high clinical suspicion for endocarditis, then
a transesophageal echocardiogram (TEE) can be done for further workup.

Treatment / Management
Treatment for Staphylococcus epidermidis infection largely depends on the type and severity of
the infection. Patients with systemic infection warrant parenteral therapy. Resistance to
methicillin is present in more than 80% of the coagulase-negative staph isolates.[19] The choice
of empiric therapy for staphylococcus epidermidis infection would be IV vancomycin, as
methicillin resistance should be assumed. If the pathogen is methicillin-susceptible, then
treatment can be narrowed to beta-lactam antibiotics such as nafcillin and oxacillin. The duration
of the therapy depends on the clinical presentation. Usually, prosthetic and medical devices
require removal to control the source of the infection.

Differential Diagnosis
Bacteremia secondary to:

Staphylococcus aureus

Other coagulase-negative staph

Gram-negative bacteria

Streptococcal species

Septic thrombophlebitis

Viral infection

Osteomyelitis

Culture negative endocarditis

Prognosis
The prognosis depends on the type of infection and the patient’s comorbidities at the time of
infection. In neonates with low birth weight, mortality due to S. epidermidis sepsis was as high
as 4.8% and 9.4%.[20] For those with coagulase-negative staph endocarditis, the mortality rate
can be high as 36%.[8]

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Complications
Sepsis and septic shock are complications with high mortality that can arise with catheter-related
infections. The mortality rate for septic shock can up to 20 to 30%.[21] Prosthetic valve
endocarditis or native valve endocarditis can lead to complications, including septic emboli,
mycotic aneurysm, perivalvular abscess, and heart failure.[8]

Deterrence and Patient Education

Patients who are undergoing procedures or surgery that requires implantation of prosthetic or
medical devices should receive education about the possibility of the infection with
Staphylococcus epidermidis. If patients are knowledgeable about common signs and symptoms
of the infection, then it will lead to faster evaluation and treatment, which will overall lead to
reduced mortality and complications.

Enhancing Healthcare Team Outcomes

Staphylococcus epidermidis, a common bacterium found on the human flora, are innocuous
species that can become virulent once inside the host. This species of bacteria can have different
consequences in an infected individual, and it requires a great deal of coordination between
various medical staff to treat the infection.

Early consult with the infectious disease team will aid in starting the patient on the initial
treatment. If the clinical picture is concerning for endocarditis, a cardiologist can provide a
further evaluation with imaging such as TTE or TEE. Also, it is useful to have a pharmacist
specializing in infectious disease to overlook the type and dosage of the medication based on the
patient’s comorbidities.

Because one of the main methods of invasion for Staphylococcus epidermidis is through
prosthetic and medical devices, following strict aseptic techniques during a procedure is
necessary. A systemic review showed that an effective infection control team requires a multi-
disciplinary team consisting of nurses, physicians trained in infection control, microbiologist,
and data manager. For an institution to implement an efficacious protocol and system, it requires
constant training in frontline staff with education, surveillance, and feedback.[22] [Level 2]

Review Questions

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Disclosure: Ezra Lee declares no relevant financial relationships with ineligible companies.

Disclosure: Fatima Anjum declares no relevant financial relationships with ineligible companies.

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