Methicillin-resistant Staphylococcus aureus (MRSA)
- Overview
- Theory
- Diagnosis
- Management
- Follow up
- Resources
Treatment algorithm
Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer
skin and soft-tissue infection: community-associated
debridement including abscess incision and drainage
Debridement or abscess incision and drainage should be undertaken if clinically necessary.
If the diagnosis is not yet confirmed, debrided material should be sent for culture and susceptibility testing.
Incision and drainage alone may be sufficient treatment for small abscesses (e.g., <5 cm for skin and soft tissue).
oral antibiotics
Additional treatment recommended for SOME patients in selected patient group
Concomitant antibiotic therapy may be recommended for patients who are immunocompromised, at extremes of age, or have associated comorbidities or an abscess in an area difficult to drain.[30]Liu C, Bayer A, Cosgrove SE, et al. Clinical practice guidelines by the Infectious Diseases Society of America for the treatment of methicillin-resistant Staphylococcus aureus infections in adults and children. Clin Infect Dis. 2011 Feb 1;52(3):285-92. https://academic.oup.com/cid/article/52/3/285/308819 http://www.ncbi.nlm.nih.gov/pubmed/21217178?tool=bestpractice.com [31]Daum RS, Miller LG, Immergluck L, et al. A placebo-controlled trial of antibiotics for smaller skin abscesses. N Engl J Med. 2017 Jun 29;376(26):2545-55. https://www.nejm.org/doi/full/10.1056/NEJMoa1607033 http://www.ncbi.nlm.nih.gov/pubmed/28657870?tool=bestpractice.com [32]Talan DA, Mower WR, Krishnadasan A, et al. Trimethoprim-sulfamethoxazole versus placebo for uncomplicated skin abscess. N Engl J Med. 2016 Mar 3;374(9):823-32. https://www.nejm.org/doi/full/10.1056/NEJMoa1507476 http://www.ncbi.nlm.nih.gov/pubmed/26962903?tool=bestpractice.com [34]Stevens DL, Bisno AL, Chambers HF, et al. Practice guidelines for the diagnosis and management of skin and soft tissue infections: 2014 update by the Infectious Diseases Society of America. Clin Infect Dis. 2014 Jul 15;59(2):e10-52. https://www.doi.org/10.1093/cid/ciu444 http://www.ncbi.nlm.nih.gov/pubmed/24973422?tool=bestpractice.com However, emerging evidence suggests that all patients with uncomplicated skin abscess may benefit from trimethoprim/sulfamethoxazole or clindamycin in addition to incision and drainage, rather than incision and drainage alone.[31]Daum RS, Miller LG, Immergluck L, et al. A placebo-controlled trial of antibiotics for smaller skin abscesses. N Engl J Med. 2017 Jun 29;376(26):2545-55. https://www.nejm.org/doi/full/10.1056/NEJMoa1607033 http://www.ncbi.nlm.nih.gov/pubmed/28657870?tool=bestpractice.com [32]Talan DA, Mower WR, Krishnadasan A, et al. Trimethoprim-sulfamethoxazole versus placebo for uncomplicated skin abscess. N Engl J Med. 2016 Mar 3;374(9):823-32. https://www.nejm.org/doi/full/10.1056/NEJMoa1507476 http://www.ncbi.nlm.nih.gov/pubmed/26962903?tool=bestpractice.com
Most community-associated MRSA is sensitive to oral antibiotics. Trimethoprim/sulfamethoxazole, minocycline, doxycycline, or clindamycin are first-line options. Choice of which oral antibiotic to use depends on the local antibiogram. Some experts suggest avoiding clindamycin when local resistance rates for MRSA isolates causing skin infection are greater than 10% to 15%.[35]Daum RS. Clinical practice. Skin and soft-tissue infections caused by methicillin-resistant Staphylococcus aureus. N Engl J Med. 2007 Jul 26;357(4):380-90. http://www.ncbi.nlm.nih.gov/pubmed/17652653?tool=bestpractice.com
Linezolid, tedizolid, omadacycline, and delafloxacin are alternative options.
Fluoroquinolones such as delafloxacin are associated with serious, disabling, and potentially irreversible adverse effects including tendonitis, tendon rupture, arthralgia, neuropathies, and other musculoskeletal or nervous system effects.[36]US Food and Drug Administration. FDA Drug Safety Communication: FDA advises restricting fluoroquinolone antibiotic use for certain uncomplicated infections; warns about disabling side effects that can occur together. May 2016 [internet publication]. https://www.fda.gov/drugs/drug-safety-and-availability/fda-drug-safety-communication-fda-advises-restricting-fluoroquinolone-antibiotic-use-certain [37]European Medicines Agency. Quinolone- and fluoroquinolone-containing medicinal products. Mar 2019 [internet publication]. https://www.ema.europa.eu/en/medicines/human/referrals/quinolone-fluoroquinolone-containing-medicinal-products The US Food and Drug Administration has also issued warnings about the increased risk of aortic dissection, significant hypoglycaemia, and mental health adverse effects in patients taking fluoroquinolones.[38]US Food and Drug Administration. FDA reinforces safety information about serious low blood sugar levels and mental health side effects with fluoroquinolone antibiotics; requires label changes. Jul 2018 [internet publication]. https://www.fda.gov/drugs/drug-safety-and-availability/fda-reinforces-safety-information-about-serious-low-blood-sugar-levels-and-mental-health-side [39]US Food and Drug Administration. FDA drug safety communication: FDA warns about increased risk of ruptures or tears in the aorta blood vessel with fluoroquinolone antibiotics in certain patients. Dec 2018 [internet publication]. https://www.fda.gov/drugs/drug-safety-and-availability/fda-warns-about-increased-risk-ruptures-or-tears-aorta-blood-vessel-fluoroquinolone-antibiotics
The benefit of antibiotics in this setting should be considered against side effects for the patient and risk of antimicrobial resistance in the community, and shared decision-making is important.[51]Vermandere M, Aertgeerts B, Agoritsas T, et al. Antibiotics after incision and drainage for uncomplicated skin abscesses: a clinical practice guideline. BMJ. 2018 Feb 6;360:k243. https://www.bmj.com/content/360/bmj.k243 http://www.ncbi.nlm.nih.gov/pubmed/29437651?tool=bestpractice.com
Lack of response to oral antibiotics is an indication for hospitalisation and intravenous antibiotics.
Treatment course: usually 7 to 14 days (except tedizolid which is 6 days, and delafloxacin which is 5 to 14 days).
Primary options
trimethoprim/sulfamethoxazole: 160/800 mg orally twice daily
OR
minocycline: 100 mg orally twice daily
OR
doxycycline: 100 mg orally twice daily
OR
clindamycin: 300-450 mg orally three to four times daily
Secondary options
linezolid: 600 mg orally twice daily
OR
tedizolid phosphate: 200 mg orally once daily for 6 days
OR
omadacycline: 450 mg orally once daily for 2 days, followed by 300 mg orally once daily
OR
delafloxacin: 450 mg orally twice daily for 5-14 days
debridement including abscess incision and drainage
A complicated infection is one where there are signs and symptoms of systemic involvement.
Debridement or abscess incision and drainage should be undertaken if clinically necessary.
If the diagnosis is not yet confirmed, debrided material should be sent for culture and susceptibility testing.
intravenous antibiotics
Treatment recommended for ALL patients in selected patient group
Intravenous antibiotics should be commenced in unstable patients showing signs of systemic infection or sepsis. Presentation of sepsis may range from non-specific or non-localised symptoms (e.g., feeling ill with a normal temperature), to severe signs with evidence of multiorgan dysfunction and septic shock. The threshold for clinical suspicion should be low. See Sepsis in adults.
Vancomycin is generally recommended as first-line therapy for complicated MRSA infection.
Serum vancomycin levels must be monitored throughout treatment.
Teicoplanin is recommended as an alternative first-line option with the advantages of requiring less frequent monitoring compared to vancomycin and being less nephrotoxic.
Alternative options include daptomycin, linezolid, tigecycline, telavancin, dalbavancin, tedizolid, oritavancin, ceftaroline, omadacycline, and delafloxacin. These alternatives should only be used in consultation with an infectious disease specialist.
Fluoroquinolones such as delafloxacin are associated with serious, disabling, and potentially irreversible adverse effects including tendonitis, tendon rupture, arthralgia, neuropathies, and other musculoskeletal or nervous system effects.[36]US Food and Drug Administration. FDA Drug Safety Communication: FDA advises restricting fluoroquinolone antibiotic use for certain uncomplicated infections; warns about disabling side effects that can occur together. May 2016 [internet publication]. https://www.fda.gov/drugs/drug-safety-and-availability/fda-drug-safety-communication-fda-advises-restricting-fluoroquinolone-antibiotic-use-certain [37]European Medicines Agency. Quinolone- and fluoroquinolone-containing medicinal products. Mar 2019 [internet publication]. https://www.ema.europa.eu/en/medicines/human/referrals/quinolone-fluoroquinolone-containing-medicinal-products The US Food and Drug Administration has also issued warnings about the increased risk of aortic dissection, significant hypoglycaemia, and mental health adverse effects in patients taking fluoroquinolones.[38]US Food and Drug Administration. FDA reinforces safety information about serious low blood sugar levels and mental health side effects with fluoroquinolone antibiotics; requires label changes. Jul 2018 [internet publication]. https://www.fda.gov/drugs/drug-safety-and-availability/fda-reinforces-safety-information-about-serious-low-blood-sugar-levels-and-mental-health-side [39]US Food and Drug Administration. FDA drug safety communication: FDA warns about increased risk of ruptures or tears in the aorta blood vessel with fluoroquinolone antibiotics in certain patients. Dec 2018 [internet publication]. https://www.fda.gov/drugs/drug-safety-and-availability/fda-warns-about-increased-risk-ruptures-or-tears-aorta-blood-vessel-fluoroquinolone-antibiotics
If linezolid is used, and the treatment is longer than 10 to 14 days, full blood count must be monitored weekly because linezolid can cause myelosuppression.
Quinupristin/dalfopristin should only be considered as a salvage therapy due to limited data, potential resistance, drug-drug interactions, serious adverse effects, and cost.[41]Rodvold KA, McConeghy KW. Methicillin-resistant Staphylococcus aureus therapy: past, present, and future. Clin Infect Dis. 2014 Jan;58 (suppl 1):S20-7. https://academic.oup.com/cid/article/58/suppl_1/S20/507587 http://www.ncbi.nlm.nih.gov/pubmed/24343828?tool=bestpractice.com Consultation with an infectious disease specialist is advisable.
Treatment course: usually 7 to 14 days (except dalbavancin and oritavancin which are single dose, tedizolid which is 6 days, and ceftaroline and delafloxacin which are 5 to 14 days).
Primary options
vancomycin: 15 mg/kg intravenously every 12 hours, maximum 2000 mg/day
OR
teicoplanin: 6 mg/kg intravenously every 12 hours for 3 doses, followed by 6 mg/kg every 24 hours
Secondary options
daptomycin: 4 mg/kg intravenously every 24 hours
OR
linezolid: 600 mg intravenously every 12 hours
OR
tedizolid phosphate: 200 mg intravenously every 24 hours for 6 days
OR
tigecycline: 100 mg intravenously as a single dose, followed by 50 mg every 12 hours
OR
telavancin: 10 mg/kg intravenously every 24 hours
OR
dalbavancin: 1500 mg intravenously as a single dose; or 1000 mg as a single dose followed by 500 mg one week later
OR
oritavancin: 1200 mg intravenously as a single dose
OR
ceftaroline: 600 mg intravenously every 12 hours for 5 to 14 days
OR
omadacycline: 200 mg intravenously once (or 100 mg every 12 hours) as a loading dose on day 1, followed by 100 mg every 24 hours
OR
delafloxacin: 300 mg intravenously every 12 hours for 5-14 days
Tertiary options
quinupristin/dalfopristin: 7.5 mg/kg intravenously every 12 hours
skin and soft-tissue infection: healthcare-associated
debridement including abscess incision and drainage
Debridement or incision and drainage should be undertaken if clinically necessary.
If the diagnosis is not yet confirmed, debrided material should be sent for culture and susceptibility testing.
intravenous antibiotics
Treatment recommended for ALL patients in selected patient group
Vancomycin is generally recommended as first-line therapy.
Serum vancomycin levels must be monitored throughout treatment.
Teicoplanin is recommended as an alternative first-line option with the advantages of requiring less frequent monitoring compared to vancomycin and being less nephrotoxic.
Alternative options include daptomycin, linezolid, tedizolid, tigecycline, telavancin, dalbavancin, oritavancin, ceftaroline, omadacycline, and delafloxacin. These alternatives should only be used in consultation with an infectious disease specialist.
Fluoroquinolones such as delafloxacin are associated with serious, disabling, and potentially irreversible adverse effects including tendonitis, tendon rupture, arthralgia, neuropathies, and other musculoskeletal or nervous system effects.[36]US Food and Drug Administration. FDA Drug Safety Communication: FDA advises restricting fluoroquinolone antibiotic use for certain uncomplicated infections; warns about disabling side effects that can occur together. May 2016 [internet publication]. https://www.fda.gov/drugs/drug-safety-and-availability/fda-drug-safety-communication-fda-advises-restricting-fluoroquinolone-antibiotic-use-certain [37]European Medicines Agency. Quinolone- and fluoroquinolone-containing medicinal products. Mar 2019 [internet publication]. https://www.ema.europa.eu/en/medicines/human/referrals/quinolone-fluoroquinolone-containing-medicinal-products The US Food and Drug Administration has also issued warnings about the increased risk of aortic dissection, significant hypoglycaemia, and mental health adverse effects in patients taking fluoroquinolones.[38]US Food and Drug Administration. FDA reinforces safety information about serious low blood sugar levels and mental health side effects with fluoroquinolone antibiotics; requires label changes. Jul 2018 [internet publication]. https://www.fda.gov/drugs/drug-safety-and-availability/fda-reinforces-safety-information-about-serious-low-blood-sugar-levels-and-mental-health-side [39]US Food and Drug Administration. FDA drug safety communication: FDA warns about increased risk of ruptures or tears in the aorta blood vessel with fluoroquinolone antibiotics in certain patients. Dec 2018 [internet publication]. https://www.fda.gov/drugs/drug-safety-and-availability/fda-warns-about-increased-risk-ruptures-or-tears-aorta-blood-vessel-fluoroquinolone-antibiotics
If linezolid is used, and the treatment is longer than 10 to 14 days, full blood count must be monitored weekly because linezolid can cause myelosuppression.
Quinupristin/dalfopristin should only be considered as a salvage therapy due to limited data, potential resistance, drug-drug interactions, serious adverse effects, and cost.[41]Rodvold KA, McConeghy KW. Methicillin-resistant Staphylococcus aureus therapy: past, present, and future. Clin Infect Dis. 2014 Jan;58 (suppl 1):S20-7. https://academic.oup.com/cid/article/58/suppl_1/S20/507587 http://www.ncbi.nlm.nih.gov/pubmed/24343828?tool=bestpractice.com Consultation with an infectious disease specialist is advisable.
Treatment course: usually 7 to 14 days (except dalbavancin and oritavancin which are single dose, tedizolid which is 6 days, and ceftaroline and delafloxacin which are 5 to 14 days).
Primary options
vancomycin: 15 mg/kg intravenously every 12 hours, maximum 2000 mg/day
OR
teicoplanin: 6 mg/kg intravenously every 12 hours for 3 doses, followed by 6 mg/kg every 24 hours
Secondary options
daptomycin: 4 mg/kg intravenously every 24 hours
OR
linezolid: 600 mg intravenously every 12 hours
OR
tedizolid phosphate: 200 mg intravenously every 24 hours for 6 days
OR
tigecycline: 100 mg intravenously as a single dose, followed by 50 mg every 12 hours
OR
telavancin: 10 mg/kg intravenously every 24 hours
OR
dalbavancin: 1500 mg intravenously as a single dose; or 1000 mg as a single dose followed by 500 mg one week later
OR
oritavancin: 1200 mg intravenously as a single dose
OR
ceftaroline: 600 mg intravenously every 12 hours for 5 to 14 days
OR
omadacycline: 200 mg intravenously once (or 100 mg every 12 hours) as a loading dose on day 1, followed by 100 mg every 24 hours
OR
delafloxacin: 300 mg intravenously every 12 hours for 5-14 days
Tertiary options
quinupristin/dalfopristin: 7.5 mg/kg intravenously every 12 hours
bacteraemia
intravenous antibiotics
Bacteraemia is often accompanied by signs and symptoms of sepsis. Sepsis is defined as life-threatening organ dysfunction caused by a dysregulated host response to an infection.[23]Singer M, Deutschman CS, Seymour CW, et al. The Third International Consensus Definitions for sepsis and septic shock (Sepsis-3). JAMA. 2016 Feb 23;315(8):801-10. https://www.doi.org/10.1001/jama.2016.0287 http://www.ncbi.nlm.nih.gov/pubmed/26903338?tool=bestpractice.com Presentation of sepsis may range from non-specific or non-localised symptoms (e.g., feeling ill with a normal temperature), to severe signs with evidence of multiorgan dysfunction and septic shock. The threshold for clinical suspicion should be low. See Sepsis in adults.
Vancomycin is generally recommended as first-line therapy for MRSA bacteraemia.[40]Brown NM, Goodman AL, Horner C, et al. Treatment of methicillin-resistant Staphylococcus aureus (MRSA): updated guidelines from the UK. JAC Antimicrob Resist. 2021 Mar;3(1):dlaa114. https://academic.oup.com/jacamr/article/3/1/dlaa114/6127118 http://www.ncbi.nlm.nih.gov/pubmed/34223066?tool=bestpractice.com
Serum vancomycin levels must be monitored throughout treatment.
Teicoplanin is recommended as an alternative first-line option with the advantages of requiring less frequent monitoring compared to vancomycin and being less nephrotoxic.
The treatment course is at least 2 weeks in cases of uncomplicated bacteraemia. If complicated bacteraemia is present, 4-6 weeks of therapy is recommended.
Primary options
vancomycin: 15 mg/kg intravenously every 12 hours, maximum 2000 mg/day
Secondary options
daptomycin: 6 mg/kg intravenously every 24 hours
OR
linezolid: 600 mg intravenously every 12 hours
OR
teicoplanin: 6 mg/kg intravenously every 12 hours for 3 doses, followed by 6 mg/kg every 24 hours
Tertiary options
quinupristin/dalfopristin: 7.5 mg/kg intravenously every 8 hours
removal of potential source of infection
Treatment recommended for ALL patients in selected patient group
Identification and removal of potential sources of infection, such as intravascular catheters, is prudent.
pneumonia
intravenous antibiotics
Vancomycin is generally recommended as first-line therapy. One randomised controlled study suggested that linezolid might be more effective than vancomycin for the treatment of MRSA pneumonia, although the 60-day mortality was similar for the vancomycin and linezolid groups.[40]Brown NM, Goodman AL, Horner C, et al. Treatment of methicillin-resistant Staphylococcus aureus (MRSA): updated guidelines from the UK. JAC Antimicrob Resist. 2021 Mar;3(1):dlaa114. https://academic.oup.com/jacamr/article/3/1/dlaa114/6127118 http://www.ncbi.nlm.nih.gov/pubmed/34223066?tool=bestpractice.com [45]Wunderink RG, Niederman MS, Kollef MH, et al. Linezolid in methicillin-resistant Staphylococcus aureus nosocomial pneumonia: a randomized, controlled study. Clin Infect Dis. 2012 Mar 1;54(5):621-9. http://cid.oxfordjournals.org/content/54/5/621.long http://www.ncbi.nlm.nih.gov/pubmed/22247123?tool=bestpractice.com
Serum vancomycin levels must be monitored throughout treatment.
Teicoplanin is recommended as an alternative first-line option as per UK National Institute for Health and Care Excellence guidelines, with the advantages of requiring less frequent monitoring compared to vancomycin and being less nephrotoxic.[44]National Institute for Health and Care Excellence. Pneumonia (hospital-acquired): antimicrobial prescribing. Sep 2019 [internet publication]. https://www.nice.org.uk/guidance/ng139
If linezolid is used, and the treatment is longer than 10 to 14 days, full blood count must be monitored weekly because linezolid can cause myelosuppression.[52]Drew RH. Emerging options for treatment of invasive, multidrug-resistant Staphylococcus aureus infections. Pharmacotherapy. 2007 Feb;27(2):227-49. http://www.ncbi.nlm.nih.gov/pubmed/17253914?tool=bestpractice.com
Treatment course: up to 3 weeks.
Primary options
vancomycin: 15 mg/kg intravenously every 12 hours, maximum 2000 mg/day
OR
teicoplanin: 6 mg/kg intravenously every 12 hours for 3 doses, followed by 6 mg/kg every 24 hours
OR
linezolid: 600 mg intravenously every 12 hours
visceral abscess
incision and drainage
Incision and drainage is paramount in the treatment of an abscess of any site.
Abscesses may occur at any site.
intravenous antibiotics
Treatment recommended for ALL patients in selected patient group
Antibiotics are given when the patient exhibits signs of systemic infection or underlying comorbidities, or at the discretion of the treating physician.
Vancomycin is generally recommended as first-line therapy.
Serum vancomycin levels must be monitored throughout treatment.
If linezolid is used, and the treatment is longer than 10 to 14 days, full blood count must be monitored weekly because linezolid can cause myelosuppression.
Treatment course: 7 to 14 days.
Primary options
vancomycin: 15 mg/kg intravenously every 12 hours, maximum 2000 mg/day
Secondary options
daptomycin: 6 mg/kg intravenously every 24 hours
OR
linezolid: 600 mg intravenously every 12 hours
OR
tigecycline: 100 mg intravenously as a single dose, followed by 50 mg every 12 hours
Tertiary options
quinupristin/dalfopristin: 7.5 mg/kg intravenously every 12 hours
endocarditis
intravenous antibiotics
Vancomycin is generally recommended as first-line therapy.
Serum vancomycin levels must be monitored throughout treatment.
Daptomycin may be used for native tricuspid valve endocarditis.
Linezolid is not routinely recommended for endocarditis. If it is used, it should be under consultation with an infectious disease sub-specialist.
Treatment course: 4 to 6 weeks.
Primary options
vancomycin: 15 mg/kg intravenously every 12 hours, maximum 2000 mg/day
Secondary options
daptomycin: 6 mg/kg intravenously every 24 hours
valve replacement or repair
Additional treatment recommended for SOME patients in selected patient group
Surgery is indicated for heart failure, severe regurgitation, and haemodynamic instability or abscess or fistula formation.[46]Writing Committee Members., Otto CM, Nishimura RA, et al. 2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. J Am Coll Cardiol. 2021 Feb 2;77(4):e25-e197. https://www.doi.org/10.1016/j.jacc.2020.11.018 http://www.ncbi.nlm.nih.gov/pubmed/33342586?tool=bestpractice.com
Heart failure is the indication for surgery in most cases of those with endocarditis. Combined medical and surgical therapy has been shown to lower the mortality compared with medical therapy alone.
intravenous antibiotics plus oral rifampicin
Intravenous vancomycin and gentamicin plus oral rifampicin are used in combination for prosthetic valve endocarditis.
Serum vancomycin and gentamicin levels must be monitored throughout treatment. Both vancomycin and gentamicin can cause ototoxicity and nephrotoxicity.
Linezolid is not routinely recommended for endocarditis. If it is used, it should be under consultation with an infectious disease sub-specialist.
Primary options
vancomycin: 15 mg/kg intravenously every 12 hours, maximum 2000 mg/day
and
gentamicin: 1 mg/kg intravenously every 8 hours for 14 days
and
rifampicin: 300 mg orally every 8 hours for 6 weeks
valve replacement or repair
Additional treatment recommended for SOME patients in selected patient group
Surgery is indicated for heart failure, severe regurgitation, and haemodynamic instability or abscess or fistula formation.[46]Writing Committee Members., Otto CM, Nishimura RA, et al. 2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. J Am Coll Cardiol. 2021 Feb 2;77(4):e25-e197. https://www.doi.org/10.1016/j.jacc.2020.11.018 http://www.ncbi.nlm.nih.gov/pubmed/33342586?tool=bestpractice.com
Patients would need to be stabilised before undergoing repair or replacement.
septic arthritis
intravenous antibiotics ± oral rifampicin
Rifampicin should always be used in combination and never alone.
Serum vancomycin levels must be monitored.
Treatment course: 6 weeks.
Primary options
vancomycin: 15 mg/kg intravenously every 12 hours, maximum 2000 mg/day
OR
teicoplanin: 12 mg/kg intravenously every 12 hours for 3-5 doses, followed by 12 mg/kg every 24 hours
OR
vancomycin: 15 mg/kg intravenously every 12 hours, maximum 2000 mg/day
or
teicoplanin: 12 mg/kg intravenously every 12 hours for 3-5 doses, followed by 12 mg/kg every 24 hours
-- AND --
rifampicin: 300 mg orally every 12 hours
Secondary options
ciprofloxacin: 400 mg intravenously every 12 hours; 750 mg orally every 12 hours
and
rifampicin: 300 mg orally every 12 hours
OR
levofloxacin: 750 mg intravenously/orally every 12 hours
and
rifampicin: 300 mg orally every 12 hours
Tertiary options
daptomycin: 6 mg/kg intravenously every 24 hours
OR
daptomycin: 6 mg/kg intravenously every 24 hours
and
rifampicin: 300 mg orally every 12 hours
surgical drainage
Treatment recommended for ALL patients in selected patient group
Treatment should be done in consultation with orthopaedic surgeons.
intravenous antibiotics ± oral rifampicin
The efficacy of medical therapy is unclear, as there are no randomised trials.[53]Anguita-Alonso P, Hanssen AD, Patel R. Prosthetic joint infection. Expert Rev Anti Infect Ther. 2005 Oct;3(5):797-804. http://www.ncbi.nlm.nih.gov/pubmed/16207171?tool=bestpractice.com
The use of antibiotics may be suppressive or curative.
Removal of the prosthesis should be considered for eradication of MRSA.
Rifampicin should always be used in combination and never alone.
Serum vancomycin levels must be monitored.
Treatment course: 6 weeks.
Primary options
vancomycin: 15 mg/kg intravenously every 12 hours, maximum 2000 mg/day
OR
teicoplanin: 12 mg/kg intravenously every 12 hours for 3-5 doses, followed by 12 mg/kg every 24 hours
OR
vancomycin: 15 mg/kg intravenously every 12 hours, maximum 2000 mg/day
or
teicoplanin: 12 mg/kg intravenously every 12 hours for 3-5 doses, followed by 12 mg/kg every 24 hours
-- AND --
rifampicin: 300 mg orally every 12 hours
Secondary options
ciprofloxacin: 400 mg intravenously every 12 hours; 750 mg orally every 12 hours
and
rifampicin: 300 mg orally every 12 hours
OR
levofloxacin: 750 mg intravenously/orally every 12 hours
and
rifampicin: 300 mg orally every 12 hours
Tertiary options
daptomycin: 6 mg/kg intravenously every 24 hours
OR
daptomycin: 6 mg/kg intravenously every 24 hours
and
rifampicin: 300 mg orally every 12 hours
surgical drainage
Treatment recommended for ALL patients in selected patient group
Should be done under consultation with orthopaedic surgeons.
joint replacement
Additional treatment recommended for SOME patients in selected patient group
For those patients non-responsive to antibiotic treatment, removal of the affected joint may be necessary.[54]Esposito S, Leone S. Prosthetic joint infections: microbiology, diagnosis, management and prevention. Int J Antimicrob Agents. 2008 Oct;32(4):287-93. http://www.ncbi.nlm.nih.gov/pubmed/18617373?tool=bestpractice.com Treatment should be done in consultation with orthopaedic surgeons.
urinary tract infection (UTI)
oral antibiotics
Uncomplicated UTIs may present with symptoms of dysuria and fever without evidence of sepsis.
Urine culture and sensitivities should help guide treatment, especially if MRSA is suspected.
Consider an evaluation for endovascular infection in patients who have a UTI caused by MRSA without a urinary catheter in place and without recent urinary tract instrumentation.
Treatment course: 7 to 14 days.
Primary options
trimethoprim/sulfamethoxazole: 160/800 mg orally twice daily
OR
minocycline: 100 mg orally twice daily
OR
doxycycline: 100 mg orally twice daily
OR
clindamycin: 300-450 mg orally every 6-8 hours
intravenous antibiotics
In situations where patients have evidence of sepsis or are hospitalised, treatment typically starts with vancomycin. Teicoplanin is recommended as an alternative first-line option, with the advantages of requiring less frequent monitoring compared to vancomycin and being less nephrotoxic. Alternative antibiotics may be used depending on sensitivities obtained from cultures.
Serum vancomycin levels must be monitored throughout treatment.
Treatment course: 7 or 14 days.
Primary options
vancomycin: 15 mg/kg intravenously every 12 hours, maximum 2000 mg/day
OR
teicoplanin: 6 mg/kg intravenously every 12 hours for 3 doses, followed by 6 mg/kg every 24 hours
osteomyelitis
intravenous antibiotics + superficial/surgical debridement
Treatment includes culture-directed antibiotic therapy and superficial or surgical debridement. If immediate treatment is required before debridement and cultures, empiric broad-spectrum antibiotics may be initiated and the regimen modified when the results of cultures and sensitivity tests are known. If an empiric regimen has been initiated, it should be discontinued for 3 days before the collection of samples for cultures.
Primary options
vancomycin: 30 mg/kg intravenously every 24 hours divided into 2 doses for 6 weeks
OR
teicoplanin: 12 mg/kg intravenously every 12 hours for 3-5 doses, followed by 12 mg/kg every 24 hours
Secondary options
daptomycin: 6 mg/kg intravenously every 24 hours for 6 weeks
recurrent skin and soft-tissue MRSA infections in colonised patients
bactericidal cleansing + nasal instillation of mupirocin
In the setting of recurrent skin and soft-tissue MRSA infections, the first step is reinforcement of infection control strategies. Decolonisation with chlorhexidine in combination with nasal instillation of mupirocin can also be considered.
Primary options
chlorhexidine topical: (2% to 4%) applied as a body wash from the neck down as a single application
and
mupirocin topical: (2%) apply to the anterior nares twice daily for 5-7 days
Choose a patient group to see our recommendations
Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups. See disclaimer
Use of this content is subject to our disclaimer