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
...ecting a Treatment Re...
...ble 1. Recommendations for the Treatment...
...Soft Tissue Infections (SSTI)* - Outpatie...
...infections (impetigo, secondarily inf...
...scesses, furuncles, carbunclesIncision and drain...
...mpiric therapy for CA-MRSA purulent cellulitis (...
...ndamycin (Cleocin®, others) Adult...
...SMX‡ (Bactrim®) Adult Dose: 1-2 DS tab P...
...Adult Dose: 100 mg PO bid Pediatri...
...ocycline (Minocin®) Adult Dose: 200 mg x 1,...
...vox®) Adult Dose: 600 mg PO bid...
...tic streptococci purulent cellulitis (...
...mpiric therapy for β-hemolytic streptoco...
..., cephalexin,‡ dicloxacillin) Adult...
...actam (eg, amoxicillin) and ‡TMP-SMX‡ (...
...(Zyvox®) Adult Dose: 600 mg PO bid Pedi...
...amycin Cleocin®, others) Adult Dose...
...ft Tissue Infections (SSTI)* - Inpatients...
...omplicated SSTI (patients with de...
...ment and antibiotics Treat for 7-14 days.†(,...
...taroline fosamil (Teflaro®) was FDA...
...§ Adult Dose: 15-20 mg/kg/dose IV...
...(Zyvox®) Adult Dose: 600 mg PO/IV bid...
...omycin‡ (Cubicin®) Adult Dose:...
...in‡ (Vibativ®) Adult Dose: 10 mg/kg/dose IV...
...damycin (Cleocin®, others) Adult Dose: 600...
...Please see Management of Recurrent MRSA Skin an...
...neumon...
...therapy is recommended for severe community-acqui...
...ICU, necrotizing or cavitary infilt...
...ibiotic Treatment of HA-MRSA or CA-MRSA pn...
...ycinठAdult Dose: 15-20 mg/kg/dose IV q8-12h...
...nezolid (Zyvox®) Adult Dose: 600 mg PO/...
...(Cleocin®, others) Adult Dose: 600...
...emia and Infective Endocarditis...
Bacteremia||
...ssessment to identify the source a...
...§ Adult Dose: 15-20 mg/kg/dose IV...
...ycin‡ (Cubicin®) Adult Dose: 6 mg/kg/dos...
Persistent bacteremiaPlease see Persistent...
...ive endocarditis, native v...
...for valve replacement surgery is recommen...
...ctive endocarditis, prosthetic valveVa...
...ntral Nervous System Infectio...
...eningitis...
...unt infection, shunt removal is recommended,...
...ibiotic Treatme...
...§ Adult Dose: 15-20 mg/kg/dose IV q8-12h...
...®) Adult Dose: 600 mg PO/IV bid...
...-SMX‡ (Bactrim®) Adult Dose: 5 mg/...
...commend the addition of rifampin 600 mg da...
...subdural empyema, spinal epidural abscess...
...cal evaluation for incision and dra...
...iotic Treatmen...
...mycinठAdult Dose: 15-20 mg/...
...lid (Zyvox®) Adult Dose: 600 mg PO/IV bid Pe...
...rim®) Adult Dose: 5 mg/kg/dose PO/IV...
...perts recommend the addition of rif...
...bosis of cavernous or dural venous sinu...
...uation for incision and drainage of cont...
...biotic Treatment...
...ycinठAdult Dose: 15-20 mg/kg/dose...
...ezolid (Zyvox®) Adult Dose: 600 m...
TMP-SMX‡ (Bactrim®) Adult Dose: 5 m...
...perts recommend the addition of rifam...
...e and Joint Infections...
...steomyelit...
...ridement and drainage of associated s...
Treat adults for ≥ 8 weeks; ( A ,...
...r 4-6 weeks. If no debridement, continue for 12 w...
...ntibiotic Trea...
...comycinठAdult Dose: 15-20 mg/kg/dose IV q8...
...omycin‡ (Cubicin®) Adult Dose: 6...
...(Zyvox®) Adult Dose: 600 mg PO/IV bid Pe...
...n (Cleocin®, others) Adult Dose: 600 mg PO...
...‡ (Bactrim®) and rifampin Adult Dose: TMP-S...
...xperts recommend the addition of rifampin...
...ance imaging (MRI) with gadolinium is the imagi...
...throcyte sedimentation rate (ESR) and...
...eptic arthr...
...debridement of the joint space should alway...
...ibiotic Treatm...
...mycinठAdult Dose: 15-20 mg/kg/dose IV q8...
...omycin‡ (Cubicin®) Adult Dose: 6 mg/k...
...(Zyvox®) Adult Dose: 600 mg PO/IV bi...
...ycin (Cleocin®, others) Adult Dose: 600 m...
...€¡ (Bactrim®) Adult Dose: 3.5--4...
...vice-related Osteoarticular Infecti...
Early-ons...
...prosthetic joint infections, unstable implants or...
...spinal implant infections (≤30 day...
...al implant infections (>30 days after surgery)Anti...
...ong-term oral suppressive antibiotics (eg,...
...r details please see antibiotic recommen...
...The use of rifampin as a single agent or...
...rom abscesses and other purulent SS...
...€¡ Adjust dose for renal impairment â...
...: 2 gm/dose. In seriously ill patients co...
...e to the potential emergence of fluor...
...Based on the extent of disease and the pati...
...eat blood cultures 2-4 days after initi...
...nditions in which Antimicrobial Therapy is Recomm...
...Recurrent MRSA Skin and Soft Tissue Infection...
...ining wounds covered with clean, dry band...
...aintain good personal hygiene with regular bath...
...reusing or sharing personal items (eg, raz...
...fforts on high-touch surfaces that may contact bar...
...ially available cleaners or detergents appropri...
...evelops a recurrent SSTI despite optimizing wound...
...ansmission is occurring among household me...
...decolonization with mupirocin twice daily fo...
...onization with mupirocin twice daily for 5-10 day...
...microbial therapy is recommended for the tre...
...agent in combination with rifampin, if...
...nvironmental hygiene measures in the patient and...
...c contacts should be evaluated for evidenc...
...asal and topical body decolonization strat...
...ening cultures prior to decolonization are NOT rou...
...urveillance cultures following a dec...
...Infections in Neonates...
...atal pustulosis
...cases with localized disease, topica...
...calized disease in a premature or very low birthw...
...tal MRSA sepsi...
...n is recommended, dosing as outlined in th...
...cin and linezolid are alternatives for non...
...comycin Monitoring...
...in concentrations are the most accurate...
...gh concentrations should be obtained at...
...ious infections such as bacteremia, infective e...
...t patients with SSTI who have normal renal...
...mycin monitoring is recommended for serious i...
...tinuous infusion vancomycin regimens...
...fficacy and safety of targeting trou...
Vancomycin Susceptibili...
There is considerable variability in MIC resul...
...with a vancomycin MIC ≤2, eg, “susceptible...
...isolates with a vancomycin MIC > 2 mcg/mL, eg,...
...MRSA Bacteremia and Vancomycin Treatment Failur...
...earch for and removal of other foci o...
...aptomycin, if the isolate is suscepti...
...d susceptibility to vancomycin and daptomyc...