How should a patient with new fevers, rash, facial swelling, and positive Methicillin-resistant Staphylococcus epidermidis (MRSE) blood cultures be treated?

Management of MRSA Bacteremia with Fever, Rash, and Facial Swelling

For a 22-year-old male with fever, rash, facial swelling, and positive MRSE blood cultures, immediate treatment should include vancomycin plus antipseudomonal antibiotics such as cefepime, a carbapenem (imipenem-cilastatin, meropenem, or doripenem), or piperacillin-tazobactam. 1

Initial Assessment and Workup

• Obtain complete blood count, comprehensive metabolic panel, and additional blood cultures to document clearance of bacteremia 1
• Perform echocardiography to rule out endocarditis - transesophageal echocardiography is preferred for higher sensitivity 1
• Evaluate for potential sources of infection including skin lesions, indwelling catheters, or recent procedures 1
• Assess for metastatic foci of infection with appropriate imaging based on symptoms 2
• Consider the possibility of drug reaction with eosinophilia and systemic symptoms (DRESS) syndrome, which can present with fever, rash, and facial swelling similar to sepsis 3

Antimicrobial Treatment

Initial Empiric Therapy

• Start vancomycin IV immediately (loading dose of 25-30 mg/kg, followed by 15-20 mg/kg every 8-12 hours) 1
• Add an antipseudomonal agent such as cefepime, a carbapenem, or piperacillin-tazobactam 1
• Consider daptomycin (6-10 mg/kg IV once daily) as an alternative to vancomycin, particularly if the patient has renal impairment 1, 4

Once Susceptibilities Are Available

• For confirmed MRSE bacteremia, continue vancomycin or daptomycin 1
• If vancomycin MIC is >1 mg/L, consider switching to an alternative agent such as daptomycin 1
• Monitor vancomycin trough levels (target 15-20 mg/L for serious infections) 1

Duration of Therapy

• For uncomplicated bacteremia (no endocarditis, no implanted prostheses, negative follow-up blood cultures, defervescence within 72 hours), treat for at least 2 weeks 1
• For complicated bacteremia, treat for 4-6 weeks depending on the extent of infection 1
• Obtain follow-up blood cultures 2-4 days after initial positive cultures to document clearance of bacteremia 1

Management of Skin Manifestations

• For the rash and facial swelling, consider both infectious and non-infectious etiologies 1
• If the rash appears to be cellulitis or erysipelas, continue appropriate antimicrobial therapy 1
• If drug reaction is suspected (worsening rash despite appropriate antimicrobial therapy), consider discontinuation of potential offending agents and initiation of corticosteroids 3
• For severe skin manifestations suggestive of necrotizing soft tissue infection, urgent surgical consultation for possible debridement is essential 1

Source Control

• Remove any potentially infected intravascular devices 1
• Drain any identified abscesses or collections 1
• Perform surgical debridement if necrotizing soft tissue infection is suspected 1

Monitoring and Follow-up

• Monitor clinical response including fever curve, resolution of rash and facial swelling 1
• Repeat blood cultures to document clearance of bacteremia 1
• Monitor for complications such as endocarditis, septic arthritis, or vertebral osteomyelitis 2
• Assess renal function regularly if using vancomycin 1

Special Considerations

• The combination of fever, rash, and facial swelling with positive blood cultures requires urgent attention as it may represent severe sepsis or drug reaction 3
• Coagulase-negative staphylococci (like MRSE) are often considered contaminants, but multiple positive blood cultures in the setting of clinical symptoms should be treated as true infection 1, 5
• Consider the possibility of DRESS syndrome, particularly if the patient has been on antibiotics and develops progressive rash, facial swelling, and end-organ damage 3