Clinical scenario | Antimicrobial regimens | |
Our preferred regimen(s) | Alternate regimen(s) | |
Health care-associated MRSA infection |
| Consultation with an expert in infectious diseases is recommended. The preferred regimen varies with clinical features, including the site of infection and the antibiotic susceptibilities of the isolateΔ. Possibilities include (only if isolate is susceptible):
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Community-associated MRSA infection | ||
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| Consultation with an expert in infectious diseases is recommended. Alternate agents include ceftaroline◊, daptomycin◊§, or linezolid◊¥. |
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| One of the following:
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| One of the following:
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MRSA: methicillin-resistant S. aureus; IV: intravenously; TMP-SMX: trimethoprim sulfamethoxazole; CNS: central nervous system; AUC: area under the curve.
* Alternative dosing is suggested for clinicians/institutions who follow AUC-guided therapeutic monitoring for vancomycin for serious MRSA infections as suggested by consensus guidelines[6]; this strategy requires input from a clinical pharmacist, who will provide recommendations for initial dosing. Refer to UpToDate content on invasive staphylococcal infections in children for details of trough-guided and AUC-guided vancomycin dosing.
¶ For prosthetic valve endocarditis, we add gentamicin 1 mg/kg three times per day IV and rifampin 10 mg/kg orally or IV twice per day (maximum daily dose 600 mg) for the first two weeks of treatment. For other device-related infections (eg, spinal instrumentation, pacemaker, cochlear implant, baclofen pump, prosthetic joint), we add rifampin orally or 10 mg/kg IV twice per day (maximum daily dose 600 mg) for up to two months if rifampin is tolerated and the device remains in place.
Δ Alternatives to vancomycin for CNS infections include linezolid◊, daptomycin◊, or TMP-SMX.[1] Daptomycin should not be used for children with concomitant pneumonia.
◊ Experience with these agents in children is limited. Consultation with an expert in infectious diseases may be warranted.
§ Daptomycin should not be used in children with concomitant pulmonary involvement. Daptomycin is active in vitro against multidrug-resistant gram-positive organisms, including S. aureus, but is not well studied in children. It is approved by the US Food and Drug Administration for the treatment of complicated skin and skin-structure infections in patients ≥1 year of age, the treatment of S. aureus bacteremia in children 1 through 17 years of age, and the treatment of S. aureus bacteremia (including right-sided endocarditis) in patients ≥18 years of age. Dosing for other indications is not well established.
¥ Cases of apparent failures of linezolid to treat or prevent endocarditis in patients with intravascular MRSA infection have been described. Refer to UpToDate content on treatment of invasive S. aureus infections in children for details.
‡ For pneumonia complicating influenza, addition of a second anti-MRSA agent (eg, clindamycin, ceftaroline, linezolid) within the first 24 hours of admission may be associated with decreased mortality. Refer to UpToDate content on treatment of invasive S. aureus infections in children for details.Do you want to add Medilib to your home screen?