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18F-FDG PET/CT–Guided Treatment Duration in Patients with High-Risk Staphylococcus Aureus Bacteremia: A Proof of Principle

Current guidelines recommend intravenous antibiotic therapy for at least 4 wk in patients with high-risk Staphylococcus aureus bacteremia (SAB), because of the risk for metastatic infection. We evaluated the safety of a shorter duration of treatment in patients with high-risk SAB without signs of metastatic infection at presentation, using standard 18F-FDG PET/CT and echocardiography. Methods: Retrospective analyses were performed of patients with SAB admitted between 2013 and 2017 in 2 medical centers. Patients with risk factors for complicated bacteremia (community acquisition, persistently positive blood cultures, >72 h of fever, or foreign body materials present), a normal echocardiography result, and 18F-FDG PET/CT without signs of metastatic infection were included (cases) and compared with patients with uncomplicated bacteremia (absence of any of the risk factors and no known metastatic disease, controls). Primary outcomes were 3-mo SAB-specific mortality rate and recurrent infection. The secondary outcome was overall mortality. Results: We included 36 cases and 40 controls. Both groups had a similar treatment duration (15.9 vs. 15.4 d). No deaths occurred as a consequence of SAB in the cases, compared with 1 in the control group. One relapse occurred in the case group and 2 in the control group. Overall mortality did not differ between the groups (19.4% vs. 15.0%, P = 0.64). Conclusion: This study suggests that intravenous treatment for 2 wk in high-risk patients with SAB without endocarditis and absence of metastatic infection on 18F-FDG PET/CT is safe. A diagnostic-driven approach using 18F-FDG PET/CT to determine treatment duration in high-risk SAB seems feasible and allows tailoring treatment to individual patients.