Should empiric coverage of Staphylococcus aureus bacteremia (SAB) routinely include an anti-staphyloccal β-lactam?

Although there are no clinical trials comparing  therapy with vancomycin and β-lactam to vancomycin alone in the empiric treatment of S. aureus bacteremia (SAB), combination therapy has been advocated by some based on reports of reduced morbidity and mortality (1). More recently however, a retrospective study involving 122 hospitals failed to find superiority of vancomycin-β-lactam combination therapy compared to vancomycin alone for empiric therapy of SAB (2).

We do know that despite its activity against methicillin-susceptible S. aureus (MSSA), vancomycin is less bactericidal (3), with a higher rate of relapse than anti-staphylococcal β-lactams in the treatment of established SAB (4).

So although it may not be clear if we need to empirically place all of our patients suspected of SAB on a vancomycin-β-lactam from the get go,  once MSSA has been confirmed, vancomycin should be dropped in favor of an anti-staphylococcal β-lactam.

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  1. McConeghy KW, Bleasdale SC, Rodvold KA. The empirical combination of vancomycin and a β-lactam for staphylococcal bacteremia. Clin Infect Dis 2013;57:1760-5.
  2. McDaniel JS, Perencevich EN, Diekema DJ, et al. Comparative effectiveness of beta-lactams versus vancomycin for treatment of methicillin-susceptible Staphylococcus aureus bloodstream infections among 122 hospitals. Clin Infect Dis 2015;61:361-7. 
  3. Fernandez Guerrero ML, de Gorgolas M. Comparative activity of cloxacillin and vancomycin against methicillin-susceptible Staphylococcus aureus experimental endocarditis. J Antimicrob Chemother 2006;58:1066-1069.
  4. Chang F-Y, Peacock JE, Musher DM, et al. Staphylococcus aureus bacteremia: recurrence and the impact of antibiotic treatment in a prospective multicenter study. Medicine (Baltimore) 2003;82:333-9.
Should empiric coverage of Staphylococcus aureus bacteremia (SAB) routinely include an anti-staphyloccal β-lactam?

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