Staphylococcus












































































































Infection First-line drugsa Second-line drugsa,b Comments
Folliculitis, impetigo Mupirocin Community-acquired MRSA
(CA-MRSA) causes >50% outpatient SSTI
Simple abscesses Incision and drainage
Cellulitis
Outpatient Rx
Treat for 5–10 d
Nonpurulent Dicloxacillin, 250 mg, or Clindamycin, 300 mg q6h
Cephalexin, 250 mg
PO q6h
Purulent TMP–SMX,160/800 mg PO q12h Linezolid, 600 mg PO q12h Suspect CA-MRSA if cellulitis has pus present
Clindamycin, 300 mg q6h Doxycycline 100 mg PO q 12
Inpatient Rx See moderate to severe wound infections Treat IV until patient afebrile and nontoxic, then switch to oral agent
Moderate to severe wound infections
Inpatients
MSSA
MRSA
Nafcillin, 2 g q4h, or Cefazolin, 2 g IV q8h
Vancomycin, 1 g IV q12h
Vancomycin, 1 g IV q12h
Linezolid, 600 mg PO q12h
Daptomycin, 4 mg/kg IV q24h
Drainage and culture of abscesses essential for resolution
Treat minimum 7–14 d based on extent of infection and response
Monitor vancomycin troughs
Aim for 10–15 µg/mL
Osteomyelitis
MSSA
MRSA
Nafcillin, 2 g IV q4h, or Cefazolin, 2 g IV q8h
Vancomycin, 1 g IV q12h
Vancomycin, 1 g IV q12h
Daptomycin, 4 mg/kg IV q24h
Linezolid, 600 mg PO q12h
Vertebral osteomyelitis, with or without paraspinous or epidural abscess, often requires longer duration of therapy
Treat IV 6–8 wk followed by an oral regimen
Monitor vancomycin troughs
Aim for 15–20 µg/mL
Septic arthritis
MSSA
MRSA
Nafcillin, 2 g q4h, or Cefazolin, 2 g IV q8h
Vancomycin, 1 g IV q12h
Vancomycin, 1 g IV q12h
Daptomycin, 4 mg/kg IV q24h
Linezolid, 600 mg PO q12h
Repeated needle aspiration, arthroscopic drainage, or operative drainage of joint fluid essential for resolution of infection
Treat 3–4 wk
Pneumonia
MSSA
MRSA
Nafcillin, 2 g IV q4h
Vancomycin 1 g IV q12h
Vancomycin, 1 g IV q12h
Linezolid, 600 mg IV/PO q12h
Empyema, when present, must be drained
Treat 7–21 d
Daptomycin not effective
Bacteremia
MSSA
MRSA
Nafcillin 2 g IV q4h (see text for discussion regarding length of therapy)
Vancomycin 1 g IV q12h
(see text for discussion)
Vancomycin, 1 g IV q12h (see text for discussion regarding length of therapy)
Daptomycin, 6 mg/kg IV q24h (see text)
Length of therapy depends on source of bacteremia and whether visceral foci of infection, including endocarditis, are present.
Careful diagnostic workup and clinical assessment of the patient is essential regarding length of therapy



Abbreviations: MSSA = methicillin-susceptible Staphylococcus aureus; MRSA = methicillin-resistant Staphylococcus aureus; SSTI = skin and soft-tissue infection; TMP–SMX = trimethoprim–sulfamethoxazole.




a Usual adult doses. Doses of cefazolin and vancomycin dependent on renal function. Linezolid, monitor complete blood count weekly. Daptomycin, monitor creatine phosphokinase 1×–2× weekly.



b Second-line drugs used mostly for patients allergic or intolerant to β-lactam antibiotics.



Superficial infections such as impetigo may be treated with topical agents such as mupirocin. Incision and drainage alone is generally reserved for small localized abscesses in healthy patients; it is not clear that antibiotic use improves the outcome from infection. Initial empiric treatment with systemic antibiotics is recommended when infection is extensive, involves multiple sites, is in an area that is difficult to drain, or is rapidly progressive. Antibiotic therapy should be considered in older adults, diabetics, patients with human immunodeficiency virus (HIV) or neoplasms, or in patients with symptoms and signs of systemic illness or septic phlebitis.


In most instances where antibiotic therapy is warranted, empiric treatment should be directed against MRSA. Culture of abscess or purulent exudate should be performed in patients with severe infection or signs and symptoms of systemic illness, those who do not respond to initial treatment, and in suspected outbreak settings.


For patients with less severe infection who can take and tolerate oral medications, empiric therapy with TMP–SMX, doxycycline or minocycline, clindamycin, and linezolid can be considered. In patients with systemic toxicity and rapidly progressive or worsening infection, empiric IV vancomycin, daptomycin, telavancin, ceftaroline, and linezolid can be given.

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Jun 18, 2016 | Posted by in INFECTIOUS DISEASE | Comments Off on Staphylococcus
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