Methicillin-Resistant Staphylococcus aureus (MRSA)
Key Points
Key Points
- Methicillin-resistant Staphylococcus aureus (MRSA (MRSA) is a significant cause of both healthcare (HA-MRSA) and community-associated
(CA-MRSA) infections with an enormous clinical and economic impact. - MRSA causes a wide spectrum of illness including skin and soft tissue infections (SSTIs), bacteremia and endocarditis, pneumonia, bone and joint infections, central nervous system disease, toxic shock and sepsis syndromes.
- The management of all MRSA infections should include identification, elimination and/or debridement of the primary source and other sites of infection when possible (eg, drainage of abscesses, removal of central venous catheters, debridement of osteomyelitis, etc.).
- In patients with MRSA bacteremia, follow-up blood cultures 2-4 days
after initial positive cultures and as needed thereafter are recommended to document clearance of bacteremia. - To optimize serum trough concentrations in adult patients, vancomycin should be dosed according to actual body weight (15-20 mg/kg/dose every 8-12 hours), not to exceed 2 grams per dose. Trough monitoring is recommended to achieve target concentrations of 15-20 mcg/mL in patients with serious MRRSA infections and to ensure target concentrations in those who are morbidly obese, have renal dysfunction, or have fluctuating volumes of distribution. The efficacy and safety of targeting higher trough concentrations in children requires further study but should be considered in those with severe sepsis or persistent bacteremia.
- When an alternative to vancomycin is being considered for use, in vitro susceptibility should be confirmed and documented in the medical record.
- For methicillin-sensitive S. aureus (MSSA) infections, a β-lactam antibiotic is the drug of choice in the absence of allergy.
Photo - MRSA
Selecting a Treatment Regimen
...electing a Treatment...
...1. Recommendations for the Treatment of M...
...and Soft Tissue Infections (SSTI)* -...
...or skin infections (impetigo, secondarily infect...
...esses, furuncles, carbunclesIncision and dr...
Empiric therapy for CA-MRSA purulent celluli...
...in (Cleocin®, others) Adult Dose: 300-450 mg PO...
...SMX‡ (Bactrim®) Adult Dose: 1-2 DS tab...
...Adult Dose: 100 mg PO bid Pediatric...
...cycline (Minocin®) Adult Dose: 200 mg x 1, then...
...yvox®) Adult Dose: 600 mg PO bid...
...lytic streptococci purulent cellulitis (ce...
...mpiric therapy for β-hemolytic stre...
...lactam (eg, cephalexin,‡ dicloxacillin) Adul...
...ctam (eg, amoxicillin) and ‡TMP-SMX‡ (BactrimÂ...
...lid (Zyvox®) Adult Dose: 600 mg PO b...
...leocin®, others) Adult Dose: 300-450 mg...
...issue Infections (SSTI)* - Inpatients...
...ated SSTI (patients with deeper soft ti...
...debridement and antibiotics Treat for 7-1...
...ftaroline fosamil (Teflaro®) was FDA app...
...ठAdult Dose: 15-20 mg/kg/dose I...
...(Zyvox®) Adult Dose: 600 mg PO/IV bid P...
...in‡ (Cubicin®) Adult Dose: 4 mg/kg/dose IV...
...Vibativ®) Adult Dose: 10 mg/kg/dose...
Clindamycin (Cleocin®, others) Adult Dose...
...ent SSTIPlease see Management of Recu...
...eumonia
...piric MRSA therapy is recommended for severe c...
...= ICU, necrotizing or cavitary infiltrates, or...
...tibiotic Treatment of HA-MRSA or...
...ठAdult Dose: 15-20 mg/kg/dose IV...
...olid (Zyvox®) Adult Dose: 600 mg PO/IV b...
...leocin®, others) Adult Dose: 600 mg PO...
...cteremia and Infective Endocardi...
Bacterem...
...inical assessment to identify the source an...
...omycinठAdult Dose: 15-20 mg/kg/dose IV q8-1...
...omycin‡ (Cubicin®) Adult Dose: 6 mg/kg/dose...
...ent bacteremiaPlease see Persistent MRSA Bac...
...ndocarditis, native valv...
...aluation for valve replacement surgery is re...
...e endocarditis, prosthetic valveVancomyc...
...Nervous System Infections...
...ningitis...
...infection, shunt removal is recommended, an...
...ibiotic Treatmen...
...comycinठAdult Dose: 15-20 mg/kg/dose...
...ezolid (Zyvox®) Adult Dose: 600 mg PO/I...
...actrim®) Adult Dose: 5 mg/kg/dose PO/...
...ome experts recommend the addition of rifampin 600...
...abscess, subdural empyema, spinal epidural...
...aluation for incision and drainage is recommend...
...ibiotic Treatmen...
...ठAdult Dose: 15-20 mg/kg/dose IV q8-12h P...
...ezolid (Zyvox®) Adult Dose: 600 mg PO/IV...
...-SMX‡ (Bactrim®) Adult Dose: 5 mg/kg/d...
...perts recommend the addition of rifamp...
...thrombosis of cavernous or dural venous s...
...tion for incision and drainage of contiguous site...
...otic Treatment...
...ncomycinठAdult Dose: 15-20 mg/...
...(Zyvox®) Adult Dose: 600 mg PO/IV...
...MX‡ (Bactrim®) Adult Dose: 5 m...
...me experts recommend the addition of rifampin 600...
...ne and Joint Infections...
...steomyeliti...
...ement and drainage of associated soft tissue ab...
...dults for ≥ 8 weeks; ( A , II )659...
...ildren for 4-6 weeks. If no debridement, continue...
...biotic Treatment...
...mycinठAdult Dose: 15-20 mg/kg/dose IV...
...mycin‡ (Cubicin®) Adult Dose: 6 mg/kg/day I...
...vox®) Adult Dose: 600 mg PO/IV bid Pe...
...indamycin (Cleocin®, others) Adult Dose: 600 mg...
...‡ (Bactrim®) and rifampin Adu...
...recommend the addition of rifampin 6...
...ance imaging (MRI) with gadolinium is the ima...
...sedimentation rate (ESR) and/or C-re...
...tic arthrit...
...ridement of the joint space should alwa...
...biotic Treatment...
...nठAdult Dose: 15-20 mg/kg/d...
...mycin‡ (Cubicin®) Adult Dose:...
...id (Zyvox®) Adult Dose: 600 mg PO/...
...eocin®, others) Adult Dose: 600...
...¡ (Bactrim®) Adult Dose: 3.5--4 mg/kg/d...
...-related Osteoarticular Infections
...rly-onset...
...rosthetic joint infections, unstable implants...
...y-onset spinal implant infections (≤30 days afte...
...onset spinal implant infections (>30 days after su...
...-term oral suppressive antibiotics (eg, TMP-SMX...
...ails please see antibiotic recommendations for de...
...rifampin as a single agent or as adjuncti...
...res from abscesses and other purulent SSTI a...
...dose for renal impairment – see...
.../dose. In seriously ill patients c...
...the potential emergence of fluoroquinol...
...ed on the extent of disease and the...
...od cultures 2-4 days after initial positive cult...
...dix 1. Conditions in which Antimicrobial The...
...nt of Recurrent MRSA Skin and Soft T...
...draining wounds covered with clean...
...ood personal hygiene with regular bath...
...id reusing or sharing personal items (eg, razors,...
...efforts on high-touch surfaces that may c...
...ercially available cleaners or deterg...
...t develops a recurrent SSTI despite optimizing wo...
...transmission is occurring among household mem...
...ization with mupirocin twice daily for 5-10 days....
Nasal decolonization with mupirocin twice daily...
...al therapy is recommended for the treatmen...
...al agent in combination with rifampin, if...
...ironmental hygiene measures in the patient and con...
...ymptomatic contacts should be evaluat...
...cal body decolonization strategies may be...
...g cultures prior to decolonization are NOT routi...
...veillance cultures following a decolonization reg...
...ctions in Neonates...
Neonatal pustul...
...with localized disease, topical treatment...
...ized disease in a premature or very low birthw...
...natal MRSA sepsis...
IV vancomycin is recommended, dosing as outline...
...mycin and linezolid are alternatives f...
...ancomycin Monit...
...gh vancomycin concentrations are the most acc...
...concentrations should be obtained at stea...
...rious infections such as bacteremia, i...
...nts with SSTI who have normal renal function...
...omycin monitoring is recommended for serious infec...
...ion vancomycin regimens are not reco...
...nd safety of targeting trough concentrations...
...comycin Susceptibility Tes...
...There is considerable variability in...
...solates with a vancomycin MIC ≤2, eg, “suscep...
...with a vancomycin MIC > 2 mcg/mL, eg, v...
...tent MRSA Bacteremia and Vancomycin Treatment...
...arch for and removal of other foci of infection...
...dose daptomycin, if the isolate is...
...reduced susceptibility to vancomycin and dap...