Although the variety of ID in phenomenal, there are some diseases that recur. S. aureus pays my mortgage and if there is one organism that is my arch enemy, it would be S. aureus.

ID is also unusual as competency and knowledge of infections for non-specialists gradually shifts from knowing what you are doing to totally messing up, and for many docs it is like slowing boiling a frog. Before they are aware they have crossed into Jon Snow territory.

And S. aureus is the one bug where people mess up the most. Recently I had a two-fer. A patient is admitted with recurring MSSA bacteremia after receiving 2 weeks of vancomycin for a dialysis catheter infection where the catheter was not removed. Another who was about to be sent home on 10 days of oral TMP-Sulfa for MRSA bacteremia from a boil.

It is a sign of my age that this just irritates the hell out of me. It is not like there is no data on how to approach S. aureus bacteremia or that I and my colleagues are a page away.

Here are some rules with S. aureus bacteremia to help guide you. References available upon searching PubMed. There are exceptions, subtleties, and nuance to all of these rules, of course. But if you have not mastered the rules, you are not ready for the exceptions. Ask your local ID doc for clarification. There is only one rule in medicine that is 100% (1).

1) Community acquired S. aureus bacteremia with no focus is ALWAYS endocarditis. Period. No matter what the ECHO etc.

2) S. aureus in the urine gets there hematogenously about 30% of the time. It is not S. aureus urosepsis, it is S. aureus sepsis seeding the urine

3) S. aureus bacteremia ALWAYS gets iv therapy.

4) NEVER give a non beta-lactam (usually vancomycin) for MSSA for ease of use. Vancomycin has a 30% higher failure rate. And never, ever, use clindamycin.

5) NEVER give a beta-lactam that is not cefazolin or nafcillin/oxicillin for MSSA. Beta-lactams are superior to all other agents for MSSA.

5a) If the MIC to vancomycin is 1.0 or greater, depending on the infection and host, consider an alternative antibiotics. Which one? Ask ID.

6) If the patient has endovascular hardware, usually a valve or pacer, the endovascular hardware is presumed infected. And if the line is the source, pull the damn line.

7) The only patient who gets two weeks of IV for bacteremia is a totally normal host with a removable focus, usually a line or cellulitis/abscess, and has MSSA. Everyone else should get at least 4 weeks of IV therapy.

8) In the literature ID consultation for S. aureus bacteremia results in less cost and better outcomes in multiple studies and phone consults are not equal to a formal consults.

Seriously. We know more than you about the topic. I used to think that was not the case, but given what I have seen the last few months I am not so certain it applies to everyone.

And if you are bored, take the opportunity to email this to, well, you know who needs it.

(1) The only rule that is 100%? Anyone who refers to antibiotics as 'strong', 'big gun' or 'powerful' is an idjet who truly knows nothing about the treatment of infectious diseases. I have yet to find an exception.