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Q J Med 1998; 91:41–47
Community-acquired Staphylococcus aureus bacteraemia in patients who do not abuse intravenous drugs P.A. WILLCOX, B.L. RAYNER and D.A. WHITELAW From the Department of Medicine, Groote Schuur Hospital and University of Cape Town, Observatory, South Africa
Summary Despite advances in antimicrobial therapy and intensive care support, Staphylococcus aureus continues to cause significant morbidity and mortality. We studied community-acquired S. aureus bacteraemia in a population where intravenous drug abuse is extremely uncommon, prospectively reviewing all such patients (n=113) admitted to Groote Schuur Hospital from February 1986 to January 1991. Overall mortality was 35%. Factors associated with poor outcome were: confusion on presentation, failure to mount a febrile response, acute renal failure, adult respiratory distress syndrome, shock, endocarditis, disseminated intravascular coagulation and platelet count of 105 S. aureus per ml. Patients were questioned regarding intravenous drug abuse and possible venepuncture sites inspected.
Antimicrobial treatment Decisions regarding specific antimicrobials and duration of treatment were the responsibility of the attending physicians. Treatment was considered appropriate if S. aureus was sensitive to the antibiotics administered, the dose was adequate and the route of administration was initially intravenous. Prompt treatment occurred if the appropriate antibiotic was given within 24 h of admission and delayed if after this period. Treatment was also analysed in relation to the use of single or dual antistaphylococcal antibiotic therapy. In this analysis patients receiving inappropriate treatment or those dying within 24 h of appropriate treatment were excluded. Those receiving a second antistaphylococcal agent after 48 h after the initiation of the first, were considered to have received single therapy.
Clinical variables Categories of underlying disease were defined using the criteria of McCabe and Jackson into rapidly fatal (i.e. patients with acute leukaemia), ultimately fatal (disease fatal within 5 years), non-fatal (disease not fatal within 5 years) and none.15 Patients were considered to have endocarditis if they fulfilled the criteria proposed by Durack et al.16 Symptoms prior to admission were recorded, with special reference to fever, sweats, rigors, confusion, vomiting, diarrhoea and pain. The highest and lowest temperatures, lowest blood pressure and highest pulse were recorded in the first 24 h. In addition, the total leukocyte count, haemoglobin, platelets, liver and renal function were noted. Disseminated intravascular coagulation (DIC) was defined as both a platelet count 1.5;17 hepatic failure as a total bilirubin >42 mmol/l, and an aspartate aminotransferase and alanine aminotransferase level twice normal, or an INR >1.5;17 adult respiratory distress syndrome (ARDS) as a chest radiograph picture of pulmonary oedema, PaO
