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系统综述： Staphylococcus aureusbacteraemia management: where do we stand and where are we going? 金葡菌菌血症的管理：我们身在何处，将去何方？ 10.1136/ebmed-2014-110122 Pamela A Moise,1 GeorgeSakoulas2 1.Departmentof Medical Affairs, Cubist Pharmaceuticals, Lexington, Massachusetts, USA; 2.Universityof California San Diego, La Jolla, California, USA Correspondenceto: Dr Pamela A Moise, Department of Medical Affairs, Cubist Pharmaceuticals,65 Hayden Avenue, Lexington, MA 02421, USA; Pamela.Moise@cubist.com Commentaryon: Holland TL, Arnold C, Fowler VG Jr. Clinical management of Staphylococcusaureus bacteraemia: a review. JAMA 2014;312:1330–41. Context背景 Staphylococcusaureus is a common cause of bacteraemia from hospita-lised patients in the USA.It is also a very prevalent bacterial pathogen among clinical isolates fromoutpatients. Despite our technological innovations within and outside of thepractice of science and medicine in the past two decades, mortality due to S.aureus bacteremia (SaB) has not changed during this time, remaining at about20%. The goals of this review were to determine which patients with SaB needtransesophageal echocardiography (TEE) and to determine the optimal antibioticregimen. 在美国，SA是住院患者菌血症最常见的病原菌。同样是门诊患者最常见的临床病原菌。过去二十多年，虽然医学和科学实践内外在不断革新技术，但在此期间，SA菌血症的死亡率没有任何改变，仍然保持在约20%。该综述的目的是判断哪些SA菌血症患者需要做经食管超声心动图（TEE），来确定最优抗菌治疗方案。 Methods方法 Thislargely narrative review by Holland and colleagues provides a thorough literaturereview on the clinical data on which therapeutic and diagnostic standards inthe management of this disease are based. PubMed, EMBASE and the CochraneTrials Register were searched through May 2014. References of included studieswere also reviewed. Studies were restricted to English language and adultpopulation. No meta-analysis was performed. Holland及其同事的这项大型叙述式综述，针对SA菌血症管理的有关治疗和诊断标准相关临床数据，进行了一个全面的文献综述。2014年5月检索了PubMed,EMBASE 和Cochrane试验登记。对于研究中包括的参考文献也进行了综述。纳入的研究仅限于语言为英文和研究对象为成 人的研究。没有进行Meta分析。 Findings结果 Thefirst strategy reviewed in detail in this paper is the utility of TEE inpatients with SaB. In this assessment, the authors agreed with the currentstandard of care that all patients with SaB have an echocardiogram, with theoption to forego a TEE if: (1) patients had negative blood cultures within 4days; (2) no haemodialysis dependence; (3) no secondary foci of infection; (4)no clinical signs of endocarditis. Subsequently, the majority of the paperfocused on the evaluation of the optimal antibiotic therapy formethicillin-resistant S. aureus (MRSA) bacteremia. This was done based oncareful scrutiny of 24 papers that fulfilled exclusionary criteria and qualityreview. The authors conclude that: (1) vancomycin or daptomycin are first-linetherapies for MRSA bacteremia; (2) duration of therapy should default to 4–6weeks unless the patient fulfils criteria for uncomplicated bacteraemia(endocarditis excluded; no implanted prostheses; negative blood cultures in2–4days; afebrile within 3 days of therapy; no evidence of metastaticinfection). The authors also provide an evaluation oftrimethoprim/sulfamethoxa-zole, linezolid and combination therapy. 首先，该论文详细综述了TEE策略在SA菌血症患者中的效用。在评估中，作者赞同目前的诊疗标准，即所有SA菌血症患者均做超声心动图，以下患者不做TEE：（1）4天内血培养阴性的患者；（2）不依赖血液透析的患者；（3）没有继发感染灶的患者；（4）无感染性心内膜炎临床体征的患者。其次，该论文重点评估了MRSA菌血症的最优抗菌药物治疗方案。作者进行了严格审查，对符合排除和质量评价的24篇论文进行了综述，得出如下结论：（1）万古霉素或达托霉素为治疗MRSA菌血症的一线药物；（2）治疗疗程应默认为4-6周，除非患者符合无并发症菌血症的标准（排除心内膜炎、无假体植入、2-4天内血培养阴性、治疗3天内无发热、无感染转移证据）。作者还对甲氧苄氨嘧啶/复方磺胺甲噁唑、利奈唑胺和联合治疗进行了评估。 Commentary评论 Probablythe most important reminder offered in this paper is the fact that whilescience and technology continues to move forward in so many facets of our dailylives, management of SaB has not changed in decades other than the addition of daptomycinand linezolid to the therapeutic armamentarium, the former receiving Food andDrug Administration (FDA) and clinical endorsement. While in-depth clinicalevaluations are needed, science has yet to be effectively translated intoclinical practice. Our lack of progress in this field requires us are-evaluation of our position and what our next steps should be. 也许本文提出的一个最重要的提醒是这样一个事实，在过去几十年里，在科学技术推动我们日常生活的许多方面继续向前的同时，而SA菌血症的管理却没有改变，除了采用了达托霉素和利奈唑胺作为治疗方法以外，前者正接受FDA的临床备案。在需要进一步进行临床评估的同时，科学已经被有效地转化为临床实践。在这方面缺乏进展，需要我们重新评估我们目前身在何处，将去何方。 Implicationsfor practice实践建议 SaBrepresents such a heterogeneous group of patients that perhaps we should startviewing SaB as a symptom rather than a disease state. S. aureus is such acomplex pathogen that our goal moving forward should be on defining diagnosticsand therapeutics based on the characteristic host-pathogen relationship definedby the specific diseases. Examining the role of TEE in different patientpopulations likely may yield different results. From a therapeutic standpoint,our understanding of the see-saw effect with daptomycin and vancomycin on oneside and β-lactams on the other offers a very promising avenue in daptomycinplus β-lactam therapy that may stand out above other antibiotic combinations.The 2014 Sanford Guide1 endorses daptomycin plus β-lactams in treatment ofpersistent MRSA bacteraemia due to vancomycin-intermediately susceptiblestrains. Much work remains to be done on which patients and at what time pointto pull the trigger on this more potent yet cumbersome regimen. As pointed outin this review, some studies suggest infectious disease consultation offers asignificant clinical benefit in the treatment of SaB. The data suggest that thereis an element of clinician experience and expertise that goes beyond diagnostictests and antibiotics that may be critical towards improving patient outcome inSaB. SA菌血症代表的是一群异质患者，也许我们应该开始把SA菌血症视为一种临床症状而不是疾病。SA是一种复杂的病原菌，我们的前进目标应该根据宿主－病原菌的关系特征来界定诊断和治疗，而不是界定某种疾病。检查在不同患者中TEE所起的作用，很可能会产生不同的结果。从治疗的角度来看，我们对于一边是达托霉素和万古霉素，另一边是β内酰胺类药物的这种治疗效果的摇摆不定的认识，提示达托霉素和β内酰胺类药物联合应用，相较于其他抗菌药物联合使用，具有光明的前景。2014年桑福德指南赞同达托霉素和β内酰胺类药物联合应用于治疗万古霉素中介MRSA所致持续菌血症。对于哪些患者，在什么时间节点启动更强有力且繁琐的治疗方案，我们还有很多工作要做。正如综述所述，一些研究表明，感染性疾病会诊对于SA 菌血症的治疗提供了很重要的临床益处。数据表明，临床经验和专业知识，超越诊断试验和抗菌药物，也许是促进患者愈后最关键的因素。 Contributors贡献者 PAMand GS were involved in the drafting and editing the commentary, and haveapproved the final submitted version. PAM和GS参与起草和评论编辑，以及审核终稿。 Funding资金 GShas received research grant support to his institution from Forrest andspeaking honoraria from Cubist and Forest. GS获得了来自Forrest对其机构的科研资助，以及来自Cubist和Forest的演讲酬金。 Competinginterests利益冲突 PM isan employer and shareholder of Cubist Pharmaceuticals. PM是Cubist制药公司的雇主和股东。 原文请看：Evid Based Med. 2015 Apr 20.pii: ebmed-2014-110122. doi: 10.1136/ebmed-2014-110122. [Epub ahead of print]
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