Methicillin-Resistant Staphylococcus aureus (MRSA)

Publication Date: February 1, 2011

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

Selecting a Treatment...

...ble 1. Recommendations for the Treatment of MR...

...in and Soft Tissue Infections (SSTI)* - Outpat...

...ections (impetigo, secondarily infected...

...cles, carbunclesIncision and drainage (I & D)...

...ic therapy for CA-MRSA purulent cellulitis (c...

...Cleocin®, others) Adult Dose: 300-450 mg PO...

...‡ (Bactrim®) Adult Dose: 1-2 DS tab...

...ult Dose: 100 mg PO bid Pediatric...

...ocycline (Minocin®) Adult Dose: 200 mg...

...Zyvox®) Adult Dose: 600 mg PO bid P...

...-hemolytic streptococci purulent cellulitis (...

...rapy for β-hemolytic streptococci...

...ctam (eg, cephalexin,‡ dicloxacillin) Adul...

...eg, amoxicillin) and ‡TMP-SMX‡ (Bact...

...(Zyvox®) Adult Dose: 600 mg PO bid Pediat...

...lindamycin Cleocin®, others) Adult...

...Soft Tissue Infections (SSTI)* - Inpatients...

...ed SSTI (patients with deeper soft tissu...

...gical debridement and antibiotics Treat for 7...

...fosamil (Teflaro®) was FDA approved for ‡ABS...

...ycinठAdult Dose: 15-20 mg/kg/dose IV q8-...

...Zyvox®) Adult Dose: 600 mg PO/IV bi...

...mycin‡ (Cubicin®) Adult Dose: 4...

...‡ (Vibativ®) Adult Dose: 10 mg/...

...in (Cleocin®, others) Adult Dose: 6...

...current SSTIPlease see Management of Recurr...

Pneumoni...

...herapy is recommended for severe community-acq...

...ecrotizing or cavitary infiltrates,...

...reatment of HA-MRSA or CA-MRSA pneumonia...

...cinठAdult Dose: 15-20 mg/kg/dose IV...

...id (Zyvox®) Adult Dose: 600 mg PO/IV b...

...mycin (Cleocin®, others) Adult Dose: 600 mg PO/...

...remia and Infective Endoca...

...cteremia||...

A clinical assessment to identify the source...

...ancomycinठAdult Dose: 15-20 mg/kg/dos...

...in‡ (Cubicin®) Adult Dose: 6 m...

...stent bacteremiaPlease see Persistent M...

...fective endocarditis, nat...

...for valve replacement surgery is recommended...

...ocarditis, prosthetic valveVancomycin...

...rvous System Infections...

...ingitis...

...NS shunt infection, shunt removal is rec...

...ibiotic Treatment...

... Adult Dose: 15-20 mg/kg/dose IV...

...lid (Zyvox®) Adult Dose: 600 mg PO/IV bid...

...trim®) Adult Dose: 5 mg/kg/dose PO...

...s recommend the addition of rifampin 600 mg daily...

..., subdural empyema, spinal epidural absce...

...cal evaluation for incision and drainage is recom...

...ntibiotic Treatmen...

...omycinठAdult Dose: 15-20 mg/kg/d...

...id (Zyvox®) Adult Dose: 600 mg PO/IV...

...trim®) Adult Dose: 5 mg/kg/dose PO/IV q8-12h...

...commend the addition of rifampin 600 mg daily o...

...c thrombosis of cavernous or dural venous...

...evaluation for incision and drainage of contiguo...

...iotic Treatment...

...ycinठAdult Dose: 15-20 mg/kg/dose IV q...

...x®) Adult Dose: 600 mg PO/IV bid Pediatric Do...

...X‡ (Bactrim®) Adult Dose: 5 mg/kg/dose PO...

...erts recommend the addition of rifampin...

...and Joint Infectio...

...steomyeliti...

...al debridement and drainage of associated...

...for ≥ 8 weeks; ( A , II )659...

...6 weeks. If no debridement, continue for 12...

...tibiotic Treat...

...§ Adult Dose: 15-20 mg/kg/dose IV q8-1...

Daptomycin‡ (Cubicin®) Adult Dose: 6 mg/kg/...

...(Zyvox®) Adult Dose: 600 mg PO/I...

...in (Cleocin®, others) Adult Dos...

...X‡ (Bactrim®) and rifampin Adult Dose...

...commend the addition of rifampin 600 m...

...resonance imaging (MRI) with gadoli...

...mentation rate (ESR) and/or C-reactiv...

...ptic arthritis...

...debridement of the joint space shoul...

...biotic Treatme...

...Adult Dose: 15-20 mg/kg/dose IV q8-...

... (Cubicin®) Adult Dose: 6 mg/kg/day...

...id (Zyvox®) Adult Dose: 600 mg PO/I...

...amycin (Cleocin®, others) Adult Dose: 600 m...

...ctrim®) Adult Dose: 3.5--4 mg/kg/dose PO/IV...

...related Osteoarticular Infections...

...y-onset (...

...prosthetic joint infections, unstable imp...

...al implant infections (≤30 days after surge...

...l implant infections (>30 days aft...

...suppressive antibiotics (eg, TMP-SMX¶,...

...s please see antibiotic recommendations fo...

...of rifampin as a single agent or as ad...

...es from abscesses and other purulent S...

... Adjust dose for renal impairment – see Pre...

...2 gm/dose. In seriously ill patient...

...to the potential emergence of fluoroquino...

† Based on the extent of disease and t...

...| Repeat blood cultures 2-4 days after ini...


...nditions in which Antimicrobial Therapy is Rec...


...ent of Recurrent MRSA Skin and Soft Tissue In...

...draining wounds covered with clean...

...personal hygiene with regular bathing...

...ng or sharing personal items (eg, ra...

...fforts on high-touch surfaces that...

...ally available cleaners or detergents appropria...

...evelops a recurrent SSTI despite op...

...nsmission is occurring among household members...

...sal decolonization with mupirocin twice daily for...

...asal decolonization with mupirocin twice...

...ral antimicrobial therapy is recommended for t...

...in combination with rifampin, if susceptibl...

...nal and environmental hygiene measu...

...tacts should be evaluated for evidence...

...sal and topical body decolonization strategi...

...res prior to decolonization are NOT...

...rveillance cultures following a decolonizatio...


...ctions in Neonates...

...al pustulosis...

For mild cases with localized disease, topical...

...ized disease in a premature or very...

Neonatal MRSA sepsi...

...n is recommended, dosing as outlined in the...

...indamycin and linezolid are alternativ...


...mycin Monitoring...

...ycin concentrations are the most accurate and pra...

...ough concentrations should be obtained at st...

...fections such as bacteremia, infective...

...or most patients with SSTI who have...

...vancomycin monitoring is recommended f...

...nfusion vancomycin regimens are not rec...

The efficacy and safety of targeting tr...

Vancomycin Susceptibilit...

...here is considerable variability in MIC...

...isolates with a vancomycin MIC ≤2, eg, “sus...

...or isolates with a vancomycin MIC > 2...

...A Bacteremia and Vancomycin Treatme...

A search for and removal of other foc...

...se daptomycin, if the isolate is susce...

...susceptibility to vancomycin and daptomy...