Recommendations for the Treatment of Methicillin-Resistant Staphylococcus aureus (MRSA)¶
Source [@Liu2011ClinicalPractice]
| Manifestation | Treatment | Adult dose | Pediatric dose | Class^ | Comment |
|---|---|---|---|---|---|
| Skin and soft-tissue infection (SSTI) | |||||
| Abscess, furuncles, carbuncles | Incision and drainage | AII | For simple abscesses or boils, incision and drainage is likely adequate. Please refer to Table 2 for conditions in which antimicrobial therapy is recommended after incision and drainage of an abscess due to CA-MRSA. | ||
| Purulent cellulitis (defined as cellulitis associated with purulent drainage or exudate in the absence of a drainable abscess) | Clindamycin | 300–450 mg PO TID | 10–13 mg/kg/dose PO every 6–8 h, not to exceed 40 mg/kg/day | AII | Clostridium difficile–associated disease may occur more frequently, compared with other oral agents. |
| TMP-SMX | 1–2 DS tab PO BID | Trimethoprim 4–6 mg/kg/dose, sulfamethoxazole 20–30 mg/kg/dose PO every 12 h | AII | TMP-SMX is pregnancy category C/D and not recommended for women in the third trimester of pregnancy and for children <2 months of age. | |
| Doxycycline | 100 mg PO BID | ≤45kg: 2 mg/kg/dose PO every 12 h >45kg: adult dose | AII | Tetracyclines are not recommended for children under 8 years of age and are pregnancy category D. | |
| Minocycline | 200 mg × 1, then 100 mg PO BID | 4 mg/kg PO × 1, then 2 mg/kg/dose PO every 12 h | AII | ||
| Linezolid | 600 mg PO BID | 10 mg/kg/dose PO every 8 h, not to exceed 600 mg/dose | AII | More expensive compared with other alternatives | |
| Nonpurulent cellulitis (defined as cellulitis with no purulent drainage or exudate and no associated abscess) | β-lactam (eg, cephalexin and dicloxacillin) | 500 mg PO QID | Please refer to Red Book | AII | Empirical therapy for β-hemolytic streptococci is recommended (AII). Empirical coverage for CA-MRSA is recommended in patients who do not respond to β-lactam therapy and may be considered in those with systemic toxicity. |
| Clindamycin | 300–450 mg PO TID | 10–13 mg/kg/dose PO every 6–8 h, not to exceed 40 mg/kg/day | AII | Provide coverage for both β-hemolytic streptococci and CA-MRSA | |
| β-lactam (eg, amoxicillin) and/or TMP-SMX or a tetracycline | Amoxicillin: 500 PO mg TID See above for TMP-SMX and tetracycline dosing | Please refer to Red Book See above for TMP-SMX and tetracycline dosing | AII | Provide coverage for both β-hemolytic streptococci and CA-MRSA | |
| Linezolid | 600 mg PO BID | 10 mg/kg/dose PO every 8 h, not to exceed 600 mg/dose | AII | Provide coverage for both B-hemolytic streptococci and CA-MRSA | |
| Complicated SSTI | Vancomycin | 15–20 mg/kg/dose IV every 8–12 h | 15 mg/kg/dose IV every 6 h | AI/AII | |
| Linezolid | 600 mg PO/IV BID | 10 mg/kg/dose PO/IV every 8 h, not to exceed 600 mg/dose | AI/AII | For children ≥12 years of age, 600 mg PO/IV BID. Pregnancy category C | |
| Daptomycin | 4 mg/kg/dose IV QD | Ongoing study | AI/ND | The doses under study in children are 5 mg/kg (ages 12–17 years), 7 mg/kg (ages 7–11 years), 9 mg/kg (ages 2–6 years) (Clinicaltrials.gov NCT 00711802). Pregnancy category B. | |
| Telavancin | 10 mg/kg/dose IV QD | ND | AI/ND | Pregnancy category C | |
| Clindamycin | 600 mg PO/IV TID | 10–13 mg/kg/dose PO/IV every 6–8 h, not to exceed 40 mg/kg/day | AIII/AII | Pregnancy category B | |
| Bacteremia and infective endocarditis | |||||
| Bacteremia | Vancomycin | 15–20 mg/kg/dose IV every 8–12 h | 15 mg/kg/dose IV every 6 h | AII | The addition of gentamicin (AII) or rifampin (AI) to vancomycin is not routinely recommended. |
| Daptomycin | 6 mg/kg/dose IV QD | 6–10 mg/kg/dose IV QD | AI/CIII | For adult patients, some experts recommend higher dosages of 8–10 mg/kg/dose IV QD (BIII). Pregnancy category B. | |
| Infective endocarditis, native valve | Same as for bacteremia | ||||
| Infective endocarditis, prosthetic valve | Vancomycin and gentamicin and rifampin | 15–20 mg/kg/dose IV every 8–12 h | 15 mg/kg/dose IV every 6 h | BIII | |
| 1 mg/kg/dose IV every 8 h | 1 mg/kg/dose IV every 8 h | ||||
| 300 mg PO/IV every 8 h | 5 mg/kg/dose PO/IV every 8 h | ||||
| Persistent bacteremia | Please see text | ||||
| Pneumonia | |||||
| Vancomycin | 15–20 mg/kg/dose IV every 8–12 h | 15 mg/kg/dose IV every 6 h | AII | ||
| Linezolid | 600 mg PO/IV BID | 10 mg/kg/dose PO/IV every 8 h, not to exceed 600 mg/dose | AII | For children ≥12 years, 600 mg PO/IV BID. Pregnancy category C. | |
| Clindamycin | 600 mg PO/IV TID | 10–13 mg/kg/dose PO/IV every 6–8 h, not to exceed 40 mg/kg/day | BIII/AII | Pregnancy category B. | |
| Bone and joint infections | |||||
| Osteomyelitis | Vancomycin | 15–20 mg/kg/dose IV every 8–12 h | 15 mg/kg/dose IV every 6 h | BII/AII | Surgical debridement and drainage of associated soft-tissue abscesses is the mainstay of therapy. (AII). Some experts recommend the addition of rifampin 600 mg QD or 300–450 mg BID to the chosen antibiotic (BIII). For children ≥12 years of age, linezolid 600 mg PO/IV BID should be used. A single-strength and DS tablet of TMP-SMX contains 80 mg and 160 mg of TMP, respectively. For an 80-kg adult, 2 DS tablets achieves a dose of 4 mg/kg. |
| Daptomycin | 6 mg/kg/day IV QD | 6–10 mg/kg/day IV QD | BII/CIII | ||
| Linezolid | 600 mg PO/IV BID | 10 mg/kg/dose PO/IV every 8 h, not to exceed 600 mg/dose | BII/CIII | ||
| Clindamycin | 600 mg PO/IV TID | 10–13 mg/kg/dose PO/IV every 6–8 h, not to exceed 40 mg/kg/day | BIII/AII | ||
| TMP-SMX and rifampin | 3.5–4.0 mg/kg/dose PO/IV every 8–12 h | ND | BII/ND | ||
| 600 mg PO QD | |||||
| Septic arthritis | Vancomycin | 15–20 mg/kg/dose IV every 8–12 h | 15 mg/kg/dose IV every 6 h | BII/AII | Drainage or debridement of the joint space should always be performed (AII). |
| Daptomycin | 6 mg/kg/day IV QD | 6–10 mg/kg/dose IV QD | BII/CIII | ||
| Linezolid | 600 mg PO/IV BID | 10 mg/kg/dose PO/IV every 8 h, not to exceed 600 mg/dose | BII/CIII | ||
| Clindamycin | 600 mg PO/IV TID | 10–13 mg/kg/dose PO/IV every 6–8 h, not to exceed 40 mg/kg/day | BIII/AII | ||
| TMP-SMX | 3.5–4.0 mg/kg/dose PO/IV every 8–12 h | ND | BIII/ND | ||
| Prosthetic joint, spinal implant infections | Please see text | ||||
| Central nervous system infections | |||||
| Meningitis | Vancomycin | 15–20 mg/kg/dose IV every 8–12 h | 15 mg/kg/dose IV every 6 h | BII | Some experts recommend the addition of rifampin 600 mg QD or 300–450 mg BID to vancomycin for adult patients (BIII). For children ≥12 years of age, linezolid 600 mg BID. |
| Linezolid | 600 mg PO/IV BID | 10 mg/kg/dose PO/IV every 8 h, not to exceed 600 mg/dose | BII | ||
| TMP-SMX | 5 mg/kg/dose PO/IV every 8-12 h | ND | CIII/ND | ||
| Brain abscess, subdural empyema, spinal epidural abscess | Vancomycin | 15–20 mg/kg/dose IV every 8–12 h | 15 mg/kg/dose IV every 6 h | BII | Some experts recommend the addition of rifampin 600 mg QD or 300–450 mg BID to vancomycin for adult patients (BIII). For children ≥12 years of age, linezolid 600 mg BID. |
| Linezolid | 600 mg PO/IV BID | 10 mg/kg/dose PO/IV every 8 h, not to exceed 600 mg/dose | BII | ||
| TMP-SMX | 5 mg/kg/dose PO/IV every 8–12 h | ND | CIII/ND | ||
| Septic thrombosis of cavernous or dural venous sinus | Vancomycin | 15–20 mg/kg/dose IV every 8–12 h | 15 mg/kg/dose IV every 6 h | BII | Some experts recommend the addition of rifampin 600 mg QD or 300–450 mg BID to vancomycin for adult patients (BIII). For children ≥12 years of age, linezolid 600 mg BID |
| Linezolid | 600 mg PO/IV BID | 10 mg/kg/dose PO/IV every 8 h, not to exceed 600 mg/dose | BII | ||
| TMP-SMX | 5 mg/kg/dose PO/IV every 8-12 h | ND | CIII/ND |
NOTE. BID, twice daily; CA-MRSA, community-associated MRSA; DS, double strength; IV, intravenous; ND, no data; PO, oral; QD, every day; TID, 3 times per day; TMP-SMX, trimethoprim-sulfamethoxazole.
^Classification of the strength of recommendation and quality of evidence applies to adult and pediatric patients unless otherwise specified. A backslash (/) followed by the recommendation strength and evidence grade will denote any differences in pediatric classification.