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

ACUTE

skin and soft-tissue infection: community-associated

1st line – debridement including abscess incision and drainage

Back
ACUTE
|
skin and soft-tissue infection: community-associated
|
uncomplicated
1st line – 

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).

Consider – oral antibiotics

Back
ACUTE
|
skin and soft-tissue infection: community-associated
|
uncomplicated
Consider – 

oral antibiotics

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][31][32][34] 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][32]

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]

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][37] The Food and Drug Administration has also issued warnings about the increased risk of aortic dissection, significant hypoglycemia, and mental health adverse effects in patients taking fluoroquinolones.[38][39]

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.[50]

Lack of response to oral antibiotics is an indication for hospitalization 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

sulfamethoxazole/trimethoprim: 160 mg orally twice daily

More

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

1st line – debridement including abscess incision and drainage

Back
ACUTE
|
skin and soft-tissue infection: community-associated
|
complicated
1st line – 

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.

Plus – intravenous antibiotics

Back
ACUTE
|
skin and soft-tissue infection: community-associated
|
complicated
Plus – 

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 nonspecific or nonlocalized 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.

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][37] The Food and Drug Administration has also issued warnings about the increased risk of aortic dissection, significant hypoglycemia, and mental health adverse effects in patients taking fluoroquinolones.[38][39]

If linezolid is used, and the treatment is longer than 10 to 14 days, complete 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] 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

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 fosamil: 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

1st line – debridement including abscess incision and drainage

Back
ACUTE
|
skin and soft-tissue infection: healthcare-associated
1st line – 

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.

Plus – intravenous antibiotics

Back
ACUTE
|
skin and soft-tissue infection: healthcare-associated
Plus – 

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.

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][37] The Food and Drug Administration has also issued warnings about the increased risk of aortic dissection, significant hypoglycemia, and mental health adverse effects in patients taking fluoroquinolones.[38][39]

If linezolid is used, and the treatment is longer than 10 to 14 days, complete 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] 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

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 fosamil: 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

bacteremia

1st line – intravenous antibiotics

Back
ACUTE
|
bacteremia
1st line – 

intravenous antibiotics

Bacteremia 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] Presentation of sepsis may range from nonspecific or nonlocalized 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 bacteremia.[40]

Serum vancomycin levels must be monitored throughout treatment.

The treatment course is at least 2 weeks in cases of uncomplicated bacteremia. If complicated bacteremia 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

Tertiary options

quinupristin/dalfopristin: 7.5 mg/kg intravenously every 8 hours

Plus – removal of potential source of infection

Back
ACUTE
|
bacteremia
Plus – 

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

1st line – intravenous antibiotics

Back
ACUTE
|
pneumonia
1st line – 

intravenous antibiotics

Vancomycin is generally recommended as first-line therapy. One randomized 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]​[44]​​

Serum vancomycin levels must be monitored throughout treatment.

If linezolid is used, and the treatment is longer than 10 to 14 days, complete blood count must be monitored weekly because linezolid can cause myelosuppression.[51]

Treatment course: up to 3 weeks.

Primary options

vancomycin: 15 mg/kg intravenously every 12 hours, maximum 2000 mg/day

OR

linezolid: 600 mg intravenously every 12 hours

visceral abscess

1st line – incision and drainage

Back
ACUTE
|
visceral abscess
1st line – 

incision and drainage

Incision and drainage is paramount in the treatment of an abscess of any site.

Abscesses may occur at any site.

Plus – intravenous antibiotics

Back
ACUTE
|
visceral abscess
Plus – 

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, complete 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

1st line – intravenous antibiotics

Back
ACUTE
|
endocarditis
|
native valve endocarditis
1st line – 

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, but is not Food and Drug Administration-approved for use in native aortic and/or mitral valve endocarditis.

Linezolid is not routinely recommended for endocarditis. If it is used, it should be under consultation with an infectious disease subspecialist.

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

Consider – valve replacement or repair

Back
ACUTE
|
endocarditis
|
native valve endocarditis
Consider – 

valve replacement or repair

Treatment recommended for SOME patients in selected patient group

Surgery is indicated for heart failure, severe regurgitation, and hemodynamic instability, or abscess or fistula formation.[45]

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.

1st line – intravenous antibiotics plus oral rifampin

Back
ACUTE
|
endocarditis
|
prosthetic valve endocarditis
1st line – 

intravenous antibiotics plus oral rifampin

Intravenous vancomycin and gentamicin plus oral rifampin 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 subspecialist.

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

rifampin: 300 mg orally every 8 hours for 6 weeks

Consider – valve replacement or repair

Back
ACUTE
|
endocarditis
|
prosthetic valve endocarditis
Consider – 

valve replacement or repair

Treatment recommended for SOME patients in selected patient group

Surgery is indicated for heart failure, severe regurgitation, and hemodynamic instability or abscess or fistula formation.[45]

Patients would need to be stabilized before undergoing repair or replacement.

septic arthritis

1st line – intravenous antibiotics ± oral rifampin

Back
ACUTE
|
septic arthritis
|
native joints
1st line – 

intravenous antibiotics ± oral rifampin

Rifampin 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

vancomycin: 15 mg/kg intravenously every 12 hours, maximum 2000 mg/day

and

rifampin: 300 mg orally every 12 hours

Secondary options

ciprofloxacin: 400 mg intravenously every 12 hours; 750 mg orally every 12 hours

and

rifampin: 300 mg orally every 12 hours

OR

levofloxacin: 750 mg intravenously/orally every 12 hours

and

rifampin: 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

rifampin: 300 mg orally every 12 hours

Plus – surgical drainage

Back
ACUTE
|
septic arthritis
|
native joints
Plus – 

surgical drainage

Treatment recommended for ALL patients in selected patient group

Treatment should be done in consultation with orthopedic surgeons.

1st line – intravenous antibiotics ± oral rifampin

Back
ACUTE
|
septic arthritis
|
prosthetic joints
1st line – 

intravenous antibiotics ± oral rifampin

The efficacy of medical therapy is unclear, as there are no randomized trials.[52]

The use of antibiotics may be suppressive or curative.

Removal of the prosthesis should be considered for eradication of MRSA.

Rifampin 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

vancomycin: 15 mg/kg intravenously every 12 hours, maximum 2000 mg/day

and

rifampin: 300 mg orally every 12 hours

Secondary options

ciprofloxacin: 400 mg intravenously every 12 hours; 750 mg orally every 12 hours

and

rifampin: 300 mg orally every 12 hours

OR

levofloxacin: 750 mg intravenously/orally every 12 hours

and

rifampin: 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

rifampin: 300 mg orally every 12 hours

Plus – surgical drainage

Back
ACUTE
|
septic arthritis
|
prosthetic joints
Plus – 

surgical drainage

Treatment recommended for ALL patients in selected patient group

Should be done under consultation with orthopedic surgeons.

Consider – joint replacement

Back
ACUTE
|
septic arthritis
|
prosthetic joints
Consider – 

joint replacement

Treatment recommended for SOME patients in selected patient group

For those patients nonresponsive to antibiotic treatment, removal of the affected joint may be necessary.[53] Treatment should be done in consultation with orthopedic surgeons.

urinary tract infection (UTI)

1st line – oral antibiotics

Back
ACUTE
|
urinary tract infection (UTI)
|
uncomplicated
1st line – 

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 for MRSA UTI in the absence of instrumentation of the urological tract.

Treatment course: 7 to 14 days.

Primary options

sulfamethoxazole/trimethoprim: 160 mg orally twice daily

More

OR

minocycline: 100 mg orally twice daily

OR

doxycycline: 100 mg orally twice daily

OR

clindamycin: 300-450 mg orally every 6-8 hours

1st line – intravenous antibiotics

Back
ACUTE
|
urinary tract infection (UTI)
|
complicated
1st line – 

intravenous antibiotics

In situations where patients have evidence of sepsis or are hospitalized, treatment typically starts with vancomycin. Alternative antibiotics may be used depending on sensitivities obtained from cultures.

Serum vancomycin levels must be monitored throughout treatment.

Treatment course: 7 to 14 days.

Primary options

vancomycin: 15 mg/kg intravenously every 12 hours, maximum 2000 mg/day

osteomyelitis

1st line – intravenous antibiotics + superficial/surgical debridement

Back
ACUTE
|
osteomyelitis
1st line – 

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

Secondary options

daptomycin: 6 mg/kg intravenously every 24 hours for 6 weeks

ONGOING

recurrent skin and soft-tissue MRSA infections in colonized patients

1st line – bactericidal cleansing + nasal instillation of mupirocin

Back
ONGOING
|
recurrent skin and soft-tissue MRSA infections in colonized patients
1st line – 

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. Decolonization 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

back arrow

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