What is the recommended treatment for a patient with a blood culture positive for Brevibacterium luteolum?

Treatment of Brevibacterium luteolum Bacteremia

For blood cultures positive for Brevibacterium luteolum, initiate empirical vancomycin therapy immediately while awaiting susceptibility results, as this organism demonstrates high resistance to common beta-lactams and trimethoprim-sulfamethoxazole but remains susceptible to vancomycin. 1

Initial Management and Diagnosis

• Obtain paired blood cultures from both the catheter (if present) and a peripheral vein before starting antibiotics 2
• Use alcohol, iodine tincture, or alcoholic chlorhexidine (0.5%) for skin preparation, allowing adequate drying time to avoid contamination 2
• Confirm true bacteremia rather than contamination by obtaining multiple positive culture sets, as Brevibacterium is considered a less virulent organism similar to other coryneform bacteria 2, 1

Empirical Antibiotic Therapy

Start vancomycin immediately as the first-line agent for Brevibacterium infections 1. This recommendation is based on:

• High resistance rates to trimethoprim-sulfamethoxazole, clindamycin, and common beta-lactams in Brevibacterium species 1
• Vancomycin being the most commonly used and successful antimicrobial in reported cases 1
• Similar treatment approach to other catheter-related bloodstream infections with Gram-positive organisms 2, 3

Alternative agents if vancomycin cannot be used:

• Aminoglycosides (gentamicin) have shown efficacy in Brevibacterium infections 1
• Daptomycin can be considered in cases of higher nephrotoxicity risk 2

Catheter Management Decision Algorithm

Indications for IMMEDIATE catheter removal 2:

• Severe sepsis or septic shock at presentation
• Persistent bacteremia >72 hours despite appropriate antibiotics
• Presence of tunnel infection or port abscess
• Development of suppurative thrombophlebitis or endocarditis
• Metastatic complications

Catheter salvage may be attempted if 2, 4:

• Patient is hemodynamically stable
• Blood cultures clear within 48-72 hours of antibiotic initiation
• No evidence of tunnel infection, port abscess, or metastatic infection
• Limited alternative venous access sites

Important caveat: One case report documented successful treatment of Brevibacterium bacteremia with antibiotics alone without catheter removal, with blood cultures clearing within 48 hours 4. However, this represents a single case and should not be considered standard practice.

Antibiotic Lock Therapy

If catheter salvage is attempted:

• Add antibiotic lock therapy (ALT) in addition to systemic antibiotics 2, 5
• Duration: 7-14 days 2, 5
• Dwell time: ≥12 hours (minimum 8 hours per day), not exceeding 48 hours before reinstallation 2

Treatment Duration

For uncomplicated bacteremia with catheter removal:

• 10-14 days after resolution of signs of infection and negative blood cultures 2, 5

For complicated infections:

• 4-6 weeks if positive cultures persist >72 hours after catheter removal 2, 5
• 4-6 weeks for endocarditis or suppurative thrombophlebitis 2
• 6-8 weeks for osteomyelitis 2

Monitoring and Follow-up

• Obtain repeat blood cultures every 24-48 hours until clearance is documented 2
• Count treatment days from the first day blood cultures are negative 2
• For patients with retained catheters, obtain surveillance blood cultures 1 week after completing antibiotics 2
• Consider transesophageal echocardiography (TEE) if bacteremia persists >72 hours or if there are signs of endocarditis, though this is less commonly required for Brevibacterium than for S. aureus 2

Critical Pitfalls to Avoid

• Do not use empirical linezolid for catheter-related infections—it is not recommended 2
• Do not delay obtaining cultures before starting antibiotics, as this reduces diagnostic yield 3, 6
• Do not switch to cefazolin even if susceptibility testing suggests susceptibility, as Brevibacterium shows high resistance to common beta-lactams 1
• Do not assume contamination based on a single positive culture in an immunocompromised patient or patient with a central venous catheter—Brevibacterium is an opportunistic pathogen in these populations 7, 1
• Adjust therapy based on susceptibility results once available, but vancomycin typically remains the agent of choice 1

Special Populations

For patients with malignancy or end-stage renal disease on peritoneal dialysis (the most common predisposing factors for Brevibacterium infections):

• Maintain high clinical suspicion 1
• Consider infectious diseases consultation at initiation of therapy 2
• Monitor closely for treatment failure, as mortality is approximately 10% in reported cases 1