Consensus document on controversial issues in the diagnosis and treatment of bloodstream infections and endocarditis.
BACKGROUND
The treatment of severe bloodstream infections (sepsis, endocarditis, and infections of vascular prostheses) caused by Gram-positive microorganisms is made even more difficult by the emergence of resistant strains. The introduction of new antibiotics with activity against these strains has created new opportunities, but many controversial issues remain.


OBJECTIVE
The aim of this GISIG (Gruppo Italiano di Studio sulle Infezioni Gravi) working group - a panel of multidisciplinary experts - was to define recommendations for some controversial issues using an evidence-based and analytical approach. The controversial issues concerned the duration of therapy and role of aminoglycosides and teicoplanin in the treatment of Gram-positive bacterial endocarditis, the optimal use of the new antibiotics in the treatment of bloodstream infections caused by resistant Gram-positive strains, and the use of microbiological techniques (i.e., bactericidal serum testing and synergy testing) and of pharmacokinetic data (e.g., monitoring of plasma levels of antibiotics) in the treatment of difficult-to-treat Gram-positive bloodstream infections.


METHODS
A systematic literature search of randomized controlled trials and/or non-randomized studies was performed mainly using the MEDLINE database. A matrix was created to extract evidence from original studies using the CONSORT method to evaluate randomized clinical trials and the Newcastle-Ottawa Quality Assessment Scale for non-randomized studies. The GRADE method for grading the quality of evidence and strength of recommendation was applied.
Boumis
Evangelo
E
Istituto Nazionale per le Malattie Infettive, I.R.C.C.S. Lazzaro Spallanzani, Roma, Italy. evangelo.boumis@inmi.it
Gesu
Giovanni
G
Menichetti
Francesco
F
Ranieri
Marco
M
Rinaldi
Mauro
M
Suter
Fredy
F
Nicastri
Emanuele
E
Lauria
Francesco N
FN
Carosi
Giampiero
G
Moroni
Mauro
M
Ippolito
Giuseppe
G
D000900:Anti-Bacterial Agents / Q000494:pharmacology / Q000627:therapeutic use*; D016470:Bacteremia / Q000175:diagnosis* / Q000188:drug therapy* / Q000382:microbiology; D002986:Clinical Trials as Topic; D024881:Drug Resistance, Bacterial; D004697:Endocarditis, Bacterial / Q000175:diagnosis* / Q000188:drug therapy* / Q000382:microbiology; D006094:Gram-Positive Bacteria / Q000187:drug effects* / Q000302:isolation & purification; D016908:Gram-Positive Bacterial Infections / Q000175:diagnosis / Q000188:drug therapy / Q000382:microbiology; D006801:Humans; D016032:Randomized Controlled Trials as Topic
D000900:Anti-Bacterial Agents