A PATH TO RESUME AESTHETIC CARE EXECUTIVE SUMMARY OF PROJECT AesCert™ GUIDANCE SUPPLEMENT: PRACTICAL CONSIDERATIONS FOR AESTHETIC MEDICINE PROFESSIONALS SUPPORTING CLINIC PREPAREDNESS IN RESPONSE TO THE SARS-CoV-2 OUTBREAK.

This Project AesCert™ Guidance Supplement ("Guidance Supplement") was developed in partnership with a multi-disciplinary panel of board-certified physician and doctoral experts in the fields of Infectious Disease, Immunology, Public Health Policy, Dermatology, Facial Plastic Surgery and Plastic Surgery. The Guidance Supplement is intended to provide aesthetic medicine physicians and their staffs with a practical guide to safety considerations to support clinic preparedness for patients seeking non-surgical aesthetic treatments and procedures following the return-to-work phase of the COVID-19 pandemic, once such activity is permitted by applicable law. Many federal, state and local governmental authorities, public health agencies and professional medical societies have promulgated COVID-19 orders and advisories applicable to health care practitioners. The Guidance Supplement is intended to provide aesthetic physicians and their staffs with an additional set of practical considerations for delivering aesthetic care safely and generally conducting business responsibly in the new world of COVID-19. Aesthetic providers will face new and unique challenges as government stay-at-home orders and related commercial limitations are eased, and the U.S. economy reopens and healthcare systems transition from providing only urgent and other essential treatment to resuming routine care and elective procedures and services. The medical aesthetic specialties will therefore wish to resume practice in order to ensure high quality, expert care is available, and importantly to help promote patients' positive self-image and sense of well-being following a lengthy and stressful period of quarantine. In a number of areas, this Guidance Supplement exceeds traditional aesthetic office safety precautions, recognizing reduced tolerance in an elective treatment environment for any risk associated with COVID-19's highly variable presentation and unpredictable course. The disease has placed a disturbing number of young, otherwise healthy patients in extremis with severe respiratory and renal failure, stroke, pericarditis, neurologic deficits and other suddenly life-threatening complications, in addition to its pernicious effects on those with pre-existing morbidities and advanced age. Accordingly, the Guidance Supplement seeks to establish an elevated safety profile for providing patient care while reducing, to the greatest extent reasonably possible, the risk of infectious processes to both patients and providers. While the Guidance Supplement cannot foreclose the risk of infection, nor serve to establish or modify any standards of care, it does offer actionable risk-mitigation considerations for general office comportment and for certain non-surgical procedures typically performed in aesthetic medical settings. It is axiomatic that all such considerations are necessarily subject to the ultimate judgment of each individual healthcare professional based on patient situation, procedure details, office environment, staffing constraints, equipment and testing availability, and local legal status and public health conditions.

Endocarditis Caused by Highly Penicillin-Resistant Viridans Group Streptococci: Still Room for Vancomycin-Based Regimens.

Optimal treatment options remain unknown for infective endocarditis (IE) caused by penicillin-resistant (PEN-R) viridans group streptococcal (VGS) strains. The aims of this study were to report two cases of highly PEN-R VGS IE, perform a literature review, and evaluate various antibiotic combinations in vitro and in vivo The following combinations were tested by time-kill studies and in the rabbit experimental endocarditis (EE) model: PEN-gentamicin, ceftriaxone-gentamicin, vancomycin-gentamicin, daptomycin-gentamicin, and daptomycin-ampicillin. Case 1 was caused by Streptococcus parasanguinis (PEN MIC, 4 µg/ml) and was treated with vancomycin plus cardiac surgery. Case 2 was caused by Streptococcus mitis (PEN MIC, 8 µg/ml) and was treated with 4 weeks of vancomycin plus gentamicin, followed by 2 weeks of vancomycin alone. Both patients were alive and relapse-free after ≥6 months follow-up. For the in vitro studies, except for daptomycin-ampicillin, all combinations demonstrated both synergy and bactericidal activity against the S. parasanguinis isolate. Only PEN-gentamicin, daptomycin-gentamicin, and daptomycin-ampicillin demonstrated both synergy and bactericidal activity against the S. mitis strain. Both strains developed high-level daptomycin resistance (HLDR) during daptomycin in vitro passage. In the EE studies, PEN alone failed to clear S. mitis from vegetations, while ceftriaxone and vancomycin were significantly more effective (P < 0.001). The combination of gentamicin with PEN or vancomycin increased bacterial eradication compared to that with the respective monotherapies. In summary, two patients with highly PEN-R VGS IE were cured using vancomycin-based therapy. In vivo, regimens of gentamicin plus either ß-lactams or vancomycin were more active than their respective monotherapies. Further clinical studies are needed to confirm the role of vancomycin-based regimens for highly PEN-R VGS IE. The emergence of HLDR among these strains warrants caution in the use of daptomycin therapy for VGS IE.

High Morbidity and Mortality Among Patients With Sentinel Admission for Injection Drug Use-Related Infective Endocarditis.

BACKGROUND: Hospitalizations for individuals with injection drug use-related infective endocarditis (IDU-IE) represent an increasing portion of all patients with endocarditis. This study describes the evolving trends in demographics, clinical characteristics, rates of surgical intervention, and mortality among patients hospitalized with IE, comparing those with and without injection drug use. METHODS: This is a retrospective cohort study of patients admitted between January 1, 2007 to June 30, 2015 at a tertiary care center in Boston, Massachusetts. Endocarditis was defined by International Classification of Diseases, Ninth Revision code and verified by the modified Duke Criteria for IE. The clinical characteristics, microbiology, site of infection, complications of IE, and outcome were all abstracted by chart review. Rates of surgical consultation and surgical intervention within 90 days of admission were obtained, and assessment of surgical risk calculated was by EuroSCORE II (euroscore.org/calc). Subsequent hospitalizations for all causes were also reviewed. RESULTS: Injection drug use-related infective endocarditis occurred in younger patients with lower rates of diabetes, renal dysfunction, and prior cardiothoracic (CT) surgery than those without IDU. Injection drug use-related infective endocarditis was associated with higher rates of complications, CT surgery consultation, and surgery within 90 days for absolute surgical indication. Readmissions for endocarditis occurred in 20% of IDU-IE patients and 9% of those with non-IDU IE. All-cause 1-year mortality rates were similar (IDU-IE 16%, non-IDU IE 13%; P = .58). CONCLUSIONS: Despite younger age, fewer medical comorbidities, and fewer prior cardiac surgeries, all-cause 1-year mortality was similar for patients after sentinel admission for IDU-IE compared with non-IDU IE. Interventions in the acute hospital setting and after discharge are needed to support patients with IDU-IE, focusing on harm reduction and treatment of addiction to reduce the unexpectedly high mortality of this young population.

Hypervirulent Klebsiella pneumoniae.

Hypervirulent strains of Klebsiella pneumoniae are associated with abscess formation, commonly hepatic, and metastatic spread, even in healthy patients. We describe a case of this clinical syndrome, genotypic and phenotypic features of the isolate, and briefly review epidemiology, clinical manifestations, and pathogenesis of this underappreciated syndrome.

Hepatitis B screening in US travelers seen at the Boston area travel medicine network.

BACKGROUND: Persons born in countries with hepatitis B surface antigen (HBsAg) prevalence ≥2% have increased risk for unrecognized hepatitis B virus (HBV) infection. Testing at pre-travel consultations is a strategy to identify previously undiagnosed HBV infections. Using records of travelers seen at the Boston Area Travel Medicine Network (BATMN) sites, we assessed how these travel clinics currently assess HBV status, describe test results, and describe characteristics of those tested and immunized for HBV. METHODS: Demographic data and trip information were collected for all travelers seen at the BATMN sites from June 2008 through July 2010. Proportions of those tested for HBV were determined, and differences between those tested and not tested were analyzed. RESULTS: Among 13,732 travelers enrolled during the study period, 2,134 (16%) were born in HBV-risk countries (HBsAg prevalence ≥2%); 532/2134 (25%) had previous HBV test results and 230 (11%) had tests performed at the travel clinic visit. Past results showed that 33/453 (7.3%) were HBV-infected (HBsAg+), 252/481 (52.4%) were immune (anti-HBs+, HBsAg-), 164/303 (54.1%) were susceptible (anti-HBs-, HBsAg-, anti-HBc-), and 38/314 (12.1%) had possible HBV exposure (anti-HBc+, HBsAg-, anti-HBs-). Among 230 travelers tested during the travel clinic visit, 7/213 (3.3%) were HBV-infected, 95/218 (43.6%) were immune, 106/179 (59.2%) were susceptible, and 10/182 (5.5%) had possible HBV exposure. CONCLUSION: The travel clinic offers an opportunity to capture, identify, and educate infected persons unaware of their infection, educate those with known results, and initiate preventive action (eg, vaccination) for those still susceptible.

Bloodstream infections: the problem and the challenge.

Bloodstream infections (BSI) are an indisputable cause of morbidity and mortality. These infections may originate in the community setting among healthy individuals or among patients actively receiving healthcare as on dialysis, chemotherapy, etc. The largest numbers of BSI, however, are nosocomial. Rates of nosocomial BSI are highest in ICU's but the greatest numbers of cases occur in non-ICU settings. Many are catheter related. Application of simple principles of intravenous catheter placement and maintenance can markedly reduce nosocomial BSI. Although treatment of BSI can be difficult, the greatest challenge is preventing these infections.

Clinical presentation, etiology, and outcome of infective endocarditis in the 21st century: the International Collaboration on Endocarditis-Prospective Cohort Study.

BACKGROUND: We sought to provide a contemporary picture of the presentation, etiology, and outcome of infective endocarditis (IE) in a large patient cohort from multiple locations worldwide. METHODS: Prospective cohort study of 2781 adults with definite IE who were admitted to 58 hospitals in 25 countries from June 1, 2000, through September 1, 2005. RESULTS: The median age of the cohort was 57.9 (interquartile range, 43.2-71.8) years, and 72.1% had native valve IE. Most patients (77.0%) presented early in the disease (<30 days) with few of the classic clinical hallmarks of IE. Recent health care exposure was found in one-quarter of patients. Staphylococcus aureus was the most common pathogen (31.2%). The mitral (41.1%) and aortic (37.6%) valves were infected most commonly. The following complications were common: stroke (16.9%), embolization other than stroke (22.6%), heart failure (32.3%), and intracardiac abscess (14.4%). Surgical therapy was common (48.2%), and in-hospital mortality remained high (17.7%). Prosthetic valve involvement (odds ratio, 1.47; 95% confidence interval, 1.13-1.90), increasing age (1.30; 1.17-1.46 per 10-year interval), pulmonary edema (1.79; 1.39-2.30), S aureus infection (1.54; 1.14-2.08), coagulase-negative staphylococcal infection (1.50; 1.07-2.10), mitral valve vegetation (1.34; 1.06-1.68), and paravalvular complications (2.25; 1.64-3.09) were associated with an increased risk of in-hospital death, whereas viridans streptococcal infection (0.52; 0.33-0.81) and surgery (0.61; 0.44-0.83) were associated with a decreased risk. CONCLUSIONS: In the early 21st century, IE is more often an acute disease, characterized by a high rate of S aureus infection. Mortality remains relatively high.

Incidence of and preoperative risk factors for Staphylococcus aureus bacteremia and chest wound infection after cardiac surgery.

OBJECTIVE: Staphylococcus aureus infections after cardiac surgery result in significant morbidity and mortality. Identifying patients at elevated risk for these infections preoperatively could facilitate efforts to reduce infection rates. The objectives of this study were to estimate the incidence of postoperative S. aureus infections in cardiac surgery patients, to identify preoperative risk factors for these infections, and to establish a patient risk profile by means of data available to clinicians prior to surgery. DESIGN: Cohort study. SETTING: Eight medical centers that participate in the Society of Thoracic Surgeons National Cardiac Database. PATIENTS: Patients who were undergoing elective cardiac surgery during the period January 1, 2000 through December 31, 2004. METHODS: Clinical and microbiological data from 16,386 patients were combined. Multivariable stepwise logistic regression analysis was performed to predict S. aureus infection, which was defined by culture results. RESULTS: Of the 16,386 patients, 205 (1.3%) developed S. aureus bloodstream or chest wound infection within 90 days after surgery. On multivariable analysis, bootstrap-validated preoperative risk factors for S. aureus bloodstream or chest wound infection included a body mass index greater than 40 (adjusted odds ratio [aOR], 1.9 [95% confidence interval {CI}, 1.1-3.2]), chronic renal failure (aOR, 1.8 [95% CI, 1.1-2.9]), and chronic lung disease (aOR, 1.4 [95% CI, 1.0-2.0]). Only 8 patients had all 3 risk factors. CONCLUSIONS: Although preoperative risk factors can be easily identified, the majority of patients who developed S. aureus infections after cardiac surgery did not have any risk factors. Preventive measures should not be restricted to a select group of cardiac surgery patients and should rather address the entire patient population.

Non-HACEK gram-negative bacillus endocarditis.

BACKGROUND: Infective endocarditis caused by non-HACEK (species other than Haemophilus species, Actinobacillus actinomycetemcomitans, Cardiobacterium hominis, Eikenella corrodens, or Kingella species) gram-negative bacilli is rare, is poorly characterized, and is commonly considered to be primarily a disease of injection drug users. OBJECTIVE: To describe the clinical characteristics and outcomes of patients with non-HACEK gram-negative bacillus endocarditis in a large, international, contemporary cohort of patients. DESIGN: Observations from the International Collaboration on Infective Endocarditis Prospective Cohort Study (ICE-PCS) database. SETTING: 61 hospitals in 28 countries. PATIENTS: Hospitalized patients with definite endocarditis. MEASUREMENTS: Characteristics of non-HACEK gram-negative bacillus endocarditis cases were described and compared with those due to other pathogens. RESULTS: Among the 2761 case-patients with definite endocarditis enrolled in ICE-PCS, 49 (1.8%) had endocarditis (20 native valve, 29 prosthetic valve or device) due to non-HACEK, gram-negative bacilli. Escherichia coli (14 patients [29%]) and Pseudomonas aeruginosa (11 patients [22%]) were the most common pathogens. Most patients (57%) with non-HACEK gram-negative bacillus endocarditis had health care-associated infection, whereas injection drug use was rare (4%). Implanted endovascular devices were frequently associated with non-HACEK gram-negative bacillus endocarditis compared with other causes of endocarditis (29% vs. 11%; P < 0.001). The in-hospital mortality rate of patients with endocarditis due to non-HACEK gram-negative bacilli was high (24%) despite high rates of cardiac surgery (51%). LIMITATIONS: Because of the small number of patients with non-HACEK gram-negative bacillus endocarditis in each treatment group and the lack of long-term follow-up, strong treatment recommendations are difficult to make. CONCLUSION: In this large, prospective, multinational cohort, more than one half of all cases of non-HACEK gram-negative bacillus endocarditis were associated with health care contact. Non-HACEK gram-negative bacillus endocarditis is not primarily a disease of injection drug users.

Diagnosis and treatment of diabetic foot infections.

EXECUTIVE SUMMARY: 1. Foot infections in patients with diabetes cause substantial morbidity and frequent visits to health care professionals and may lead to amputation of a lower extremity. 2. Diabetic foot infections require attention to local (foot) and systemic (metabolic) issues and coordinated management, preferably by a multidisciplinary foot-care team (A-II). The team managing these infections should include, or have ready access to, an infectious diseases specialist or a medical microbiologist (B-II). 3. The major predisposing factor to these infections is foot ulceration, which is usually related to peripheral neuropathy. Peripheral vascular disease and various immunological disturbances play a secondary role. 4. Aerobic Gram-positive cocci (especially Staphylococcus aureus) are the predominant pathogens in diabetic foot infections. Patients who have chronic wounds or who have recently received antibiotic therapy may also be infected with Gram-negative rods, and those with foot ischemia or gangrene may have obligate anaerobic pathogens. 5. Wound infections must be diagnosed clinically on the basis of local (and occasionally systemic) signs and symptoms of inflammation. Laboratory (including microbiological) investigations are of limited use for diagnosing infection, except in cases of osteomyelitis (B-II). 6. Send appropriately obtained specimens for culture before starting empirical antibiotic therapy in all cases of infection, except perhaps those that are mild and previously untreated (B-III). Tissue specimens obtained by biopsy, ulcer curettage, or aspiration are preferable to wound swab specimens (A-I). 7. Imaging studies may help diagnose or better define deep, soft-tissue purulent collections and are usually needed to detect pathological findings in bone. Plain radiography may be adequate in many cases, but MRI (in preference to isotope scanning) is more sensitive and specific, especially for detection of soft-tissue lesions (A-I). 8. Infections should be categorized by their severity on the basis of readily assessable clinical and laboratory features (B-II). Most important among these are the specific tissues involved, the adequacy of arterial perfusion, and the presence of systemic toxicity or metabolic instability. Categorization helps determine the degree of risk to the patient and the limb and, thus, the urgency and venue of management. 9. Available evidence does not support treating clinically uninfected ulcers with antibiotic therapy (D-III). Antibiotic therapy is necessary for virtually all infected wounds, but it is often insufficient without appropriate wound care. 10. Select an empirical antibiotic regimen on the basis of the severity of the infection and the likely etiologic agent(s) (B-II). Therapy aimed solely at aerobic Gram-positive cocci may be sufficient for mild-to-moderate infections in patients who have not recently received antibiotic therapy (A-II). Broad-spectrum empirical therapy is not routinely required but is indicated for severe infections, pending culture results and antibiotic susceptibility data (B-III). Take into consideration any recent antibiotic therapy and local antibiotic susceptibility data, especially the prevalence of methicillin-resistant S. aureus (MRSA) or other resistant organisms. Definitive therapy should be based on both the culture results and susceptibility data and the clinical response to the empirical regimen (C-III). 11. There is only limited evidence with which to make informed choices among the various topical, oral, and parenteral antibiotic agents. Virtually all severe and some moderate infections require parenteral therapy, at least initially (C-III). Highly bioavailable oral antibiotics can be used in most mild and in many moderate infections, including some cases of osteomyelitis (A-II). Topical therapy may be used for some mild superficial infections (B-I). 12. Continue antibiotic therapy until there is evidence that the infection has resolved but not necessarily until a wound has healed. Suggestions for the duration of antibiotic therapy are as follows: for mild infections, 12 weeks usually suffices, but some require an additional 12 weeks; for moderate and severe infections, usually 24 weeks is sufficient, depending on the structures involved, the adequacy of debridement, the type of soft-tissue wound cover, and wound vascularity (A-II); and for osteomyelitis, generally at least 46 weeks is required, but a shorter duration is sufficient if the entire infected bone is removed, and probably a longer duration is needed if infected bone remains (B-II). 13. If an infection in a clinically stable patient fails to respond to 1 antibiotic courses, consider discontinuing all antimicrobials and, after a few days, obtaining optimal culture specimens (C-III). 14. Seek surgical consultation and, when needed, intervention for infections accompanied by a deep abscess, extensive bone or joint involvement, crepitus, substantial necrosis or gangrene, or necrotizing fasciitis (A-II). Evaluating the limb's arterial supply and revascularizing when indicated are particularly important. Surgeons with experience and interest in the field should be recruited by the foot-care team, if possible. 15. Providing optimal wound care, in addition to appropriate antibiotic treatment of the infection, is crucial for healing (A-I). This includes proper wound cleansing, debridement of any callus and necrotic tissue, and, especially, off-loading of pressure. There is insufficient evidence to recommend use of a specific wound dressing or any type of wound healing agents or products for infected foot wounds. 16. Patients with infected wounds require early and careful follow-up observation to ensure that the selected medical and surgical treatment regimens have been appropriate and effective (B-III). 17. Studies have not adequately defined the role of most adjunctive therapies for diabetic foot infections, but systematic reviews suggest that granulocyte colony-stimulating factors and systemic hyperbaric oxygen therapy may help prevent amputations (B-I). These treatments may be useful for severe infections or for those that have not adequately responded to therapy, despite correcting for all amenable local and systemic adverse factors. 18. Spread of infection to bone (osteitis or osteomyelitis) may be difficult to distinguish from noninfectious osteoarthropathy. Clinical examination and imaging tests may suffice, but bone biopsy is valuable for establishing the diagnosis of osteomyelitis, for defining the pathogenic organism(s), and for determining the antibiotic susceptibilities of such organisms (B-II). 19. Although this field has matured, further research is much needed. The committee especially recommends that adequately powered prospective studies be undertaken to elucidate and validate systems for classifying infection, diagnosing osteomyelitis, defining optimal antibiotic regimens in various situations, and clarifying the role of surgery in treating osteomyelitis (A-III).

Prosthetic joint infections.

Success in the treatment of infected orthopedic prosthesis requires the best surgical approach in combination with prolonged optimum targeted antimicrobial therapy. In choosing the surgical option, one must consider the type of infection, condition of the bone stock and soft tissue, the virulence and antimicrobial susceptibility of the pathogen, the general health and projected longevity of the patient, and the experience of the surgeon. If surgery is not possible, an alternative is long-term oral antimicrobial suppression to maintain a functioning prosthesis. Treatment must be individualized for a specific infection in a specific patient.

Circulating resistin levels are not associated with fat redistribution, insulin resistance, or metabolic profile in patients with the highly active antiretroviral therapy-induced metabolic syndrome.

CONTEXT: The mechanisms underlying the development of the highly active antiretroviral therapy (HAART)-induced metabolic syndrome remain to be fully elucidated. OBJECTIVE: The objective of this study was to investigate whether the adipocyte-secreted hormone, resistin, is associated with anthropometric and metabolic abnormalities of the HAART-induced metabolic syndrome. DESIGN, SETTING, AND PATIENTS: We conducted a cross-sectional study of 227 HIV-positive patients (37 women and 190 men) recruited from the infectious diseases clinics. On the basis of history, physical examination, dual-energy x-ray absorptiometry, and single-slice computed tomography, patients were classified into four groups: non-fat redistribution (n = 85), fat accumulation (n = 42), fat wasting (n = 35), and mixed fat redistribution (n = 56). MAIN OUTCOME MEASURES: The main outcome measures were serum resistin levels and anthropometric and metabolic variables. RESULTS: Mean serum resistin levels were not significantly different among subjects with fat accumulation, fat wasting, or mixed fat redistribution or between these groups and the non-fat redistribution group. We found a weak, but significant, positive correlation between resistin and percent total body fat (r = 0.20; P < 0.01), total extremity fat (r = 0.18; P < 0.01), and abdominal sc fat (r = 0.19; P < 0.01), but not abdominal visceral fat (r = -0.10; P = 0.16) or waist to hip ratio (r = -0.05; P = 0.43). When adjustments were made for gender (women, 3.92 +/- 2.71 ng/ml; men, 2.96 +/- 2.61 ng/ml; P = 0.05), correlations between resistin and the above parameters were no longer significant. Importantly, resistin levels were not correlated with fasting glucose, insulin, homeostasis model assessment of insulin resistance index, triglycerides, or cholesterol levels in the whole group. CONCLUSIONS: Resistin is related to gender, but is unlikely to play a major role in the insulin resistance and metabolic abnormalities of the HAART-induced metabolic syndrome.

The impact of methicillin resistance in Staphylococcus aureus bacteremia on patient outcomes: mortality, length of stay, and hospital charges.

OBJECTIVE: To evaluate the impact of methicillin resistance in Staphylococcus aureus on mortality, length of hospitalization, and hospital charges. DESIGN: A cohort study of patients admitted to the hospital between July 1, 1997, and June 1, 2000, who had clinically significant S. aureus bloodstream infections. SETTING: A 630-bed, urban, tertiary-care teaching hospital in Boston, Massachusetts. PATIENTS: Three hundred forty-eight patients with S. aureus bacteremia were studied; 96 patients had methicillin-resistant S. aureus (MRSA). Patients with methicillin-susceptible S. aureus (MSSA) and MRSA were similar regarding gender, percentage of nosocomial acquisition, length of hospitalization, ICU admission, and surgery before S. aureus bacteremia. They differed regarding age, comorbidities, and illness severity score. RESULTS: Similar numbers of MRSA and MSSA patients died (22.9% vs 19.8%; P = .53). Both the median length of hospitalization after S. aureus bacteremia for patients who survived and the median hospital charges after S. aureus bacteremia were significantly increased in MRSA patients (7 vs 9 days, P = .045; 19,212 dollars vs 26,424 dollars, P = .008). After multivariable analysis, compared with MSSA bacteremia, MRSA bacteremia remained associated with increased length of hospitalization (1.29 fold; P = .016) and hospital charges (1.36 fold; P = .017). MRSA bacteremia had a median attributable length of stay of 2 days and a median attributable hospital charge of 6916 dollars. CONCLUSION: Methicillin resistance in S. aureus bacteremia is associated with significant increases in length of hospitalization and hospital charges.

Detection of Staphylococcus aureus in peripheral blood stem cell cultures after sterilization of standard blood cultures.

We report central venous catheter (CVC)-associated Staphylococcus aureus bacteremia detected by apheresis product culture after sterilization of standard blood cultures. A 64-year-old man with non-Hodgkin's lymphoma underwent peripheral blood stem cell (PBSC) collection. Five days after placement of a CVC, inflammation was evident at the insertion site. The CVC was removed and cephalexin was begun. Discharge at the site contained neutrophils and gram-positive cocci in pairs and clusters. Cultures of the discharge, of blood drawn via the CVC, of the CVC tip and of the apheresis product collected that day grew methicillin-susceptible S. aureus (MSSA). Cephalexin was discontinued in favor of oxacillin. Three days after removal of the CVC, PBSC collections were resumed via a contralateral CVC. Three sets of standard blood cultures drawn the day the new CVC was placed and the following day were negative, yet apheresis product cultures from each of these days grew MSSA. PBSC collections were halted, the CVC was removed, and oxacillin was continued via a peripherally inserted central catheter. Transesophageal echocardiography after two weeks of therapy revealed thickened mitral leaflets and damage to the posterior leaflet. Transthoracic echocardiography 11 weeks preceding this study had demonstrated normal mitral valve anatomy and function. Oxacillin was continued for six weeks, after which PBSC collections were resumed. Pulsed-field gel electrophoresis of the MSSA isolates revealed a clonal pattern. Cultures of apheresis product may be more sensitive to the presence of bacteremia than standard blood cultures, and they should guide clinical decisions when the bacteria isolated are potential pathogens or suggest clinical infection.