Review article
Empirical therapy in Methicillin-resistant Staphylococcus Aureus infections: An Up-To-Date approach

https://doi.org/10.1016/j.jiac.2016.02.012Get rights and content

Abstract

Methicillin-resistant Staphylococcus aureus (MRSA) continues to be an important pathogen worldwide, with high prevalence of infection in both community and hospital settings. Timely and appropriate choice of empirical therapy in the setting of MRSA infection is imperative due to the high rate of associated morbidity and mortality with MRSA infections. Initial choices should be made based on the site and severity of the infection, most notably moderate skin and soft tissue infections which may be treated with oral antibiotics (trimethoprim-sulfamethoxazole, clindamycin, doxycycline/minocycline, linezolid) in the outpatient setting, versus choice of parenteral therapy in the inpatient setting of more invasive or severe disease. Though the current recommendations continue to strongly rely on vancomycin as a standard empiric choice in the setting of severe/invasive infections, alternative therapies exist with studies supporting their non-inferiority. This includes the use of linezolid in pneumonia and severe skin and skin structure infections (SSSI) and daptomycin for MRSA bacteremia, endocarditis, SSSIs and bone/joint infections. Additionally, concerns continue to arise in regards to vancomycin, such as increasing isolate MICs, and relatively high rates of clinical failures with vancomycin. Thus, the growing interest in vanomycin alternatives, such as ceftaroline, ceftobribole, dalbavancin, oritavancin, and tedizolid, and their potential role in treating MRSA infections.

Section snippets

Bacteremia

MRSA bacteremia and resulting or resultant infective endocarditis warrant the most immediate initiation of antimicrobials. Despite various concerns regarding increased resistance and creeping MICs, suboptimal killing, and challenging dosing pharmacokinetics that may require patient individualization; vancomycin remains the first line therapy for these invasive MRSA infections. Daptomycin has demonstrated non-inferiority to vancomycin and could be considered empirically in the setting of

Skin infections

In the United States, MRSA is the most common cultured organism in the setting of skin–infection lesions [114], [115]. Following the epidemiologic pattern of these infections, a majority of CA-MRSA infections are skin and soft tissue infection (SSTI) [116], [117], [118]. For this reason, empiric selections of antimicrobials in the setting of moderate SSTI are most applicable for CA-MRSA. For any SSTI (including MRSA) with abscess formation, the recommended primary management is incision and

Pneumonia

In any case of pneumonia where MRSA is a suspected pathogen, empiric therapy with vancomycin or linezolid should be initiated. Wunderink et al. have demonstrated that in the setting of MRSA nosocomial pneumonia, those patients treated with linezolid achieved greater clinical efficacy at the end of study, in comparison with patients treated with dose-adjusted vancomycin, though 60-day mortality was similar in the two treatment groups [36]. Additionally, this study demonstrated improved

Bone-joint infections

Appropriate initial management of bone and joint infections due to MRSA, including osteomyelitis, includes surgical debridement with drainage of any adjacent abscess, and initiation of antimicrobial therapy. Following initial surgical management, vancomycin or daptomycin are the preferred initial antimicrobials [10], [125]. This is despite concerns noting high rates of failure associated with vancomycin [126], though these high rates of failure have led to some expert recommendations for

Conflict of interest

AV has no conflict of interest. JS serves as a consultant for Merck and Allergan and owns stock in Pfizer.

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