Treatment of Coagulase-Negative Staphylococcal Infections

Initial Empiric Therapy

The Infectious Diseases Society of America recommends starting with vancomycin empirically because most CoNS are methicillin-resistant, particularly in healthcare-associated infections 1
Target vancomycin trough levels of 10-15 mg/L for most CoNS infections, as recommended by the European Society of Cardiology 2

The Infectious Diseases Society of America recommends switching to a semisynthetic penicillin (nafcillin, oxacillin, or flucloxacillin) if susceptibility testing shows methicillin susceptibility, because beta-lactams are superior to vancomycin for susceptible organisms 1
First-generation cephalosporins like cefazolin are acceptable alternatives for patients with non-immediate penicillin allergies, according to the Infectious Diseases Society of America 1

The Infectious Diseases Society of America recommends treating for 5-7 days with systemic antibiotics if the catheter is removed 1
Treat for 10-14 days with systemic antibiotics plus antibiotic lock therapy if a non-tunneled catheter is retained, as recommended by the Infectious Diseases Society of America 1
Treat for 7 days of systemic therapy plus 14 days of antibiotic lock therapy if a tunneled catheter or implantable device is retained, according to the Infectious Diseases Society of America 1

The American Heart Association recommends treating for a minimum of 6 weeks with vancomycin plus rifampin, adding gentamicin for the first 2 weeks 2, 3
Vancomycin dosing: 30 mg/kg/day IV in 2 divided doses, targeting trough 10-20 μg/mL, as recommended by the American Heart Association 3
Rifampin: 900 mg/day IV or PO in 3 divided doses, according to the American Heart Association 3
Gentamicin: 3 mg/kg/day IV/IM in 2-3 divided doses for first 2 weeks only, as recommended by the American Heart Association 3
If gentamicin-resistant, substitute with an aminoglycoside to which the organism is susceptible, or consider a fluoroquinolone if susceptible, according to the American Heart Association 3

The European Society of Cardiology recommends treating for 6 weeks with vancomycin (if methicillin-resistant) or a beta-lactam (if susceptible) 2
Combination therapy with aminoglycosides is not routinely recommended for native valve CoNS endocarditis, according to the Infectious Diseases Society of America 1

The Centers for Disease Control and Prevention recommend not using vancomycin for single positive blood cultures when contamination is likely 4
Do not continue vancomycin if repeat cultures are negative—CoNS are common contaminants and require ≥2 positive cultures within 48 hours to confirm true bacteremia, as recommended by the Centers for Disease Control and Prevention 4
The Infectious Diseases Society of America recommends not using combination therapy with vancomycin plus gentamicin or rifampin for routine CoNS infections—reserve combinations for prosthetic valve endocarditis only 1
Persistent fever or positive cultures after 72 hours of appropriate therapy mandates catheter removal, according to the Infectious Diseases Society of America 1

The Infectious Diseases Society of America recommends removing the catheter immediately if: persistent bacteremia after 72 hours of appropriate antibiotics, septic thrombophlebitis, endocarditis, tunnel infection, or pocket infection of implantable devices 1
Treatment failure (persistent fever, positive cultures, or relapse after antibiotic discontinuation) is an absolute indication for catheter removal, according to the Infectious Diseases Society of America 1