Cir034 285.292

Clinical Practice Guidelines by the InfectiousDiseases Society of America for the Treatment ofMethicillin-Resistant Staphylococcus AureusInfections in Adults and Children: ExecutiveSummary Catherine Liu,1 Arnold Bayer,3,5 Sara E. Cosgrove,6 Robert S. Daum,7 Scott K. Fridkin,8 Rachel J. Gorwitz,9Sheldon L. Kaplan,10 Adolf W. Karchmer,11 Donald P. Levine,12 Barbara E. Murray,14 Michael J. Rybak,12,13 DavidA. Talan,4,5 and Henry F. Chambers1,2 1Department of Medicine, Division of Infectious Diseases, University of California-San Francisco, San Francisco, California; 2Division of Infectious Diseases,San Francisco General Hospital, San Francisco, CA, 3Division of Infectious Diseases, Harbor-UCLA Medical Center, Torrance, CA, 4Divisions of EmergencyMedicine and Infectious Diseases, Olive View-UCLA Medical Center, Sylmar, CA; 5Department of Medicine, David Geffen School of Medicine at Universityof California Los Angeles; 6Division of Infectious Diseases, Johns Hopkins Medical Institutions, Baltimore, Maryland; 7Department of Pediatrics, Sectionof Infectious Diseases, University of Chicago, Chicago, Illinois; 8,9Division of Healthcare Quality Promotion, Center for Emerging and Zoonotic InfectiousDiseases, Centers for Disease Control and Prevention, Atlanta, Georgia; 10Department of Pediatrics, Section of Infectious Diseases, Baylor College of Medicine, Houston, Texas; 11Division of Infectious Diseases, Beth Israel Deaconess Medicine Center, Harvard Medical School, Boston, Massachusetts;12 Department of Medicine, Division of Infectious Diseases, Wayne State University, Detroit Receiving Hospital and University Health Center, Detroit,Michigan; 13Deparment of Pharmacy Practice, Wayne State University, Detroit Michigan; and 14Division of Infectious Diseases and Center for the Study ofEmerging and Re-emerging Pathogens, University of Texas Medical School, Houston, Texas Evidence-based guidelines for the management of patients with methicillin-resistant Staphylococcus aureus (MRSA) infections were prepared by an Expert Panel of the Infectious Diseases Society of America (IDSA). Theguidelines are intended for use by health care providers who care for adult and pediatric patients with MRSAinfections. The guidelines discuss the management of a variety of clinical syndromes associated with MRSAdisease, including skin and soft tissue infections (SSTI), bacteremia and endocarditis, pneumonia, bone andjoint infections, and central nervous system (CNS) infections. Recommendations are provided regardingvancomycin dosing and monitoring, management of infections due to MRSA strains with reduced susceptibilityto vancomycin, and vancomycin treatment failures.
constitutes the first guidelines of the IDSA on the treat-ment of MRSA infections. The primary objective of these MRSA is a significant cause of both health care–associated guidelines is to provide recommendations on the man- and community-associated infections. This document agement of some of the most common clinical syndromes encountered by adult and pediatric clinicians who care for Received 28 October 2010; accepted 17 November 2010.
patients with MRSA infections. The guidelines address It is important to realize that guidelines cannot always account for individual varia- tion among patients. They are not intended to supplant physician judgment with respect issues related to the use of vancomycin therapy in the to particular patients or special clinical situations. The IDSA considers adherence to these treatment of MRSA infections, including dosing and guidelines to be voluntary, with the ultimate determination regarding their applica-tion to be made by the physician in the light of each patient's individual circumstances.
monitoring, current limitations of susceptibility testing, Correspondence: Catherine Liu, MD, Dept of Medicine, Div of Infectious and the use of alternate therapies for those patients with Diseases, University of California–San Francisco, San Francisco, California, 94102(catherine.liu@ucsf.edu).
vancomycin treatment failure and infection due to strains with reduced susceptibility to vancomycin. The guidelines Ó The Author 2011. Published by Oxford University Press on behalf of theInfectious Diseases Society of America. All rights reserved. For Permissions, do not discuss active surveillance testing or other please e-mail:journals.permissions@oup.com.
MRSA infection–prevention strategies in health care set- 1058-4838/2011/523-0001$37.00DOI: 10.1093/cid/cir034 tings, which are addressed in previously published MRSA Treatment Guidelines d CID 2011:52 (1 February) d 285 guidelines [1, 2]. Each section of the guidelines begins with a tetracycline (doxycycline or minocycline) (A-II), and linezolid a specific clinical question and is followed by numbered (A-II). If coverage for both b-hemolytic streptococci and recommendations and a summary of the most-relevant evidence in support of the recommendations. Areas of controversy in clindamycin alone (A-II) or TMP-SMX or a tetracycline in which data are limited or conflicting and where additional re- combination with a b-lactam (eg, amoxicillin) (A-II) or linezolid search is needed are indicated throughout the document and are highlighted in the Research Gaps section. The key recom- The use of rifampin as a single agent or as adjunctive mendations are summarized below in the Executive Summary; therapy for the treatment of SSTI is not recommended (A-III).
each topic is discussed in greater detail within the main body of For hospitalized patients with complicated SSTI (cSSTI; defined as patients with deeper soft-tissue infections, surgical/ Please note that specific recommendations on vancomycin traumatic wound infection, major abscesses, cellulitis, and dosing and monitoring are not discussed in the sections for each infected ulcers and burns), in addition to surgical debridement clinical syndrome but are collectively addressed in detail in MRSA should be considered pending culture data. Optionsinclude the following: intravenous (IV) vancomycin (A-I), oral I. What is the management of skin and soft-tissue infections (PO) or IV linezolid 600 mg twice daily (A-I), daptomycin 4 mg/ (SSTIs) in the era of community-associated MRSA (CA-MRSA)? kg/dose IV once daily (A-I), telavancin 10 mg/kg/dose IV once daily (A-I), and clindamycin 600 mg IV or PO 3 times a day (A- III). A b-lactam antibiotic (eg, cefazolin) may be considered in For a cutaneous abscess, incision and drainage is the hospitalized patients with nonpurulent cellulitis with modification primary treatment (A-II). For simple abscesses or boils, to MRSA-active therapy if there is no clinical response (A-II).
incision and drainage alone is likely to be adequate, but Seven to 14 days of therapy is recommended but should be additional data are needed to further define the role of individualized on the basis of the patient’s clinical response.
antibiotics, if any, in this setting.
Cultures from abscesses and other purulent SSTIs are Antibiotic therapy is recommended for abscesses associated recommended in patients treated with antibiotic therapy, with the following conditions: severe or extensive disease (eg, patients with severe local infection or signs of systemic illness, involving multiple sites of infection) or rapid progression in patients who have not responded adequately to initial treatment, presence of associated cellulitis, signs and symptoms of systemic and if there is concern for a cluster or outbreak (A-III).
extremes of age, abscess in an area difficult to drain (eg, face, hand, and genitalia), associated septic phlebitis, and lack of For children with minor skin infections (such as impetigo) response to incision and drainage alone (A-III).
and secondarily infected skin lesions (such as eczema, ulcers, or For outpatients with purulent cellulitis (eg, cellulitis lacerations), mupirocin 2% topical ointment can be used (A-III).
associated with purulent drainage or exudate in the absence of Tetracyclines should not be used in children ,8 years of a drainable abscess), empirical therapy for CA-MRSA is recommended pending culture results. Empirical therapy for In hospitalized children with cSSTI, vancomycin is infection due to b-hemolytic streptococci is likely to be recommended (A-II). If the patient is stable without ongoing unnecessary (A-II). Five to 10 days of therapy is recom- bacteremia or intravascular infection, empirical therapy with mended but should be individualized on the basis of the clindamycin 10–13 mg/kg/dose IV every 6–8 h (to administer For outpatients with nonpurulent cellulitis (eg, cellulitis 40 mg/kg/day) is an option if the clindamycin resistance rate is with no purulent drainage or exudate and no associated low (eg, ,10%) with transition to oral therapy if the strain is abscess), empirical therapy for infection due to b-hemolytic susceptible (A-II). Linezolid 600 mg PO/IV twice daily for streptococci is recommended (A-II). The role of CA-MRSA is children >12 years of age and 10 mg/kg/dose PO/IV every 8 h unknown. Empirical coverage for CA-MRSA is recommended for children ,12 years of age is an alternative (A-II).
in patients who do not respond to b-lactam therapy and may beconsidered in those with systemic toxicity. Five to 10 days of II. What is the management of recurrent MRSA SSTIs? therapy is recommended but should be individualized on the basis of the patient’s clinical response.
For empirical coverage of CA-MRSA in outpatients with Preventive educational messages on personal hygiene SSTI, oral antibiotic options include the following: clindamycin and appropriate wound care are recommended for all patients (A-II), trimethoprim-sulfamethoxazole (TMP-SMX) (A-II), with SSTI. Instructions should be provided to: 286 d CID 2011:52 (1 February) d Liu et al.
i. Keep draining wounds covered with clean, dry bandages ii. Contacts should be evaluated for evidence of S. aureus ii. Maintain good personal hygiene with regular bathing and a. Symptomatic contacts should be evaluated and treated (A- cleaning of hands with soap and water or an alcohol-based III); nasal and topical body decolonization strategies may be hand gel, particularly after touching infected skin or an item considered following treatment of active infection (C-III).
that has directly contacted a draining wound (A-III).
b. Nasal and topical body decolonization of asymptomatic iii. Avoid reusing or sharing personal items (eg, disposable household contacts may be considered (C-III).
razors, linens, and towels) that have contacted infected skin The role of cultures in the management of patients with Environmental hygiene measures should be considered i. Screening cultures prior to decolonization are not in patients with recurrent SSTI in the household or community routinely recommended if at least 1 of the prior infections was documented as due to MRSA (B-III).
i. Focus cleaning efforts on high-touch surfaces (ie, surfaces ii. Surveillance cultures following a decolonization regimen that come into frequent contact with people’s bare skin each are not routinely recommended in the absence of an active day, such as counters, door knobs, bath tubs, and toilet seats) that may contact bare skin or uncovered infections (C-III).
III. What is the management of MRSA bacteremia and infective ii. Commercially available cleaners or detergents appropriate for the surface being cleaned should be used according to label Bacteremia and Infective Endocarditis, Native Valve instructions for routine cleaning of surfaces (C-III).
For adults with uncomplicated bacteremia (defined as Decolonization may be considered in selected cases if: patients with positive blood culture results and the following: exclusion of endocarditis; no implanted prostheses; follow-up i. A patient develops a recurrent SSTI despite optimizing blood cultures performed on specimens obtained 2–4 days wound care and hygiene measures (C-III).
ii. Ongoing transmission is occurring among household after the initial set that do not grow MRSA; defervescence members or other close contacts despite optimizing wound within 72 h of initiating effective therapy; and no evidence of metastatic sites of infection), vancomycin (A-II) or daptomycin 6 mg/kg/dose IV once daily (AI) for at least 2 weeks. For Decolonization strategies should be offered in conjunction complicated bacteremia (defined as patients with positive blood with ongoing reinforcement of hygiene measures and may culture results who do not meet criteria for uncomplicated bacteremia), 4–6 weeks of therapy is recommended, depending i. Nasal decolonization with mupirocin twice daily for 5–10 on the extent of infection. Some experts recommend higher dosages of daptomycin at 8–10 mg/kg/dose IV once daily (B-III).
ii. Nasal decolonization with mupirocin twice daily for 5–10 For adults with infective endocarditis, IV vancomycin days and topical body decolonization regimens with a skin (A-II) or daptomycin 6 mg/kg/dose IV once daily (A-I) for 6 antiseptic solution (eg, chlorhexidine) for 5–14 days or dilute weeks is recommended. Some experts recommend higher bleach baths. (For dilute bleach baths, 1 teaspoon per gallon dosages of daptomycin at 8–10 mg/kg/dose IV once daily of water [or ¼ cup per ¼ tub or 13 gallons of water] given for 15 min twice weekly for 3 months can be considered.) Addition of gentamicin to vancomycin is not recom- mended for bacteremia or native valve infective endocarditis(A-II).
Oral antimicrobial therapy is recommended for the Addition of rifampin to vancomycin is not recommen- treatment of active infection only and is not routinely re- ded for bacteremia or native valve infective endocarditis (A-I).
commended for decolonization (A-III). An oral agent in A clinical assessment to identify the source and extent of combination with rifampin, if the strain is susceptible, may be the infection with elimination and/or debridement of other considered for decolonization if infections recur despite above sites of infection should be conducted (A-II).
Additional blood cultures 2–4 days after initial positive In cases where household or interpersonal transmission cultures and as needed thereafter are recommended to document clearance of bacteremia (A-II).
i. Personal and environmental hygiene measures in the Echocardiography is recommended for all adult patient and contacts are recommended (A-III).
patients with bacteremia. Transesophageal echocardiography MRSA Treatment Guidelines d CID 2011:52 (1 February) d 287 (TEE) is preferred over transthoracic echocardiography (TTE) In patients with MRSA pneumonia complicated by empyema, antimicrobial therapy against MRSA should be used Evaluation for valve replacement surgery is recommen- in conjunction with drainage procedures (A-III).
ded if large vegetation (.10 mm in diameter), occurrence of >1 embolic event during the first 2 weeks of therapy, severevalvular insufficiency, valvular perforation or dehiscence, In children, IV vancomycin is recommended (A-II). If decompensated heart failure, perivalvular or myocardial the patient is stable without ongoing bacteremia or intravas- abscess, new heart block, or persistent fevers or bacteremia cular infection, clindamycin 10–13 mg/kg/dose IV every 6–8 h (to administer 40 mg/kg/day) can be used as empirical therapyif the clindamycin resistance rate is low (eg, ,10%) with transition to oral therapy if the strain is susceptible (A-II).
IV vancomycin plus rifampin 300 mg PO/IV every 8 h Linezolid 600 mg PO/IV twice daily for children >12 years of for at least 6 weeks plus gentamicin 1 mg/kg/dose IV every 8 h age and 10 mg/kg/dose every 8 h for children ,12 years of age is Early evaluation for valve replacement surgery is V. What is the management of MRSA bone and joint infections? Surgical debridement and drainage of associated soft- tissue abscesses is the mainstay of therapy and should be In children, vancomycin 15 mg/kg/dose IV every 6 h is recommended for the treatment of bacteremia and infective The optimal route of administration of antibiotic endocarditis (A-II). Duration of therapy may range from 2 to 6 therapy has not been established. Parenteral, oral, or initial weeks depending on source, presence of endovascular infection, parenteral therapy followed by oral therapy may be used and metastatic foci of infection. Data regarding the safety and depending on individual patient circumstances (A-III).
efficacy of alternative agents in children are limited, although Antibiotics available for parenteral administration in- daptomycin 6–10 mg/kg/dose IV once daily may be an option clude IV vancomycin (B-II) and daptomycin 6 mg/kg/dose IV (C-III). Clindamycin or linezolid should not be used if there is once daily (B-II). Some antibiotic options with parenteral and concern for infective endocarditis or endovascular source of oral routes of administration include the following: TMP-SMX infection but may be considered in children whose bacteremia 4 mg/kg/dose (TMP component) twice daily in combination rapidly clears and is not related to an endovascular focus (B-III).
with rifampin 600 mg once daily (B-II), linezolid 600 mg twice Data are insufficient to support the routine use of daily (B-II), and clindamycin 600 mg every 8 h (B-III).
combination therapy with rifampin or gentamicin in children Some experts recommend the addition of rifampin with bacteremia or infective endocarditis (C-III); the decision 600 mg daily or 300–450 mg PO twice daily to the antibiotic to use combination therapy should be individualized.
chosen above (B-III). For patients with concurrent bacter- Echocardiogram is recommended in children with con- emia, rifampin should be added after clearance of bacteremia.
genital heart disease, bacteremia more than 2–3 days in duration, The optimal duration of therapy for MRSA osteomye- or other clinical findings suggestive of endocarditis (A-III).
litis is unknown. A minimum 8-week course is recommended(A-II). Some experts suggest an additional 1–3 months (and IV. What is the management of MRSA pneumonia? possibly longer for chronic infection or if debridement is not performed) of oral rifampin-based combination therapy with For hospitalized patients with severe community- TMP-SMX, doxycycline-minocycline, clindamycin, or a fluo- acquired pneumonia defined by any one of the following: (1) roquinolone, chosen on the basis of susceptibilities (C-III).
a requirement for intensive care unit (ICU) admission, (2) Magnetic resonance imaging (MRI) with gadolinium is the imaging modality of choice, particularly for detection of necrotizing or cavitary infiltrates, or (3) empyema, empirical early osteomyelitis and associated soft-tissue disease (A-II).
therapy for MRSA is recommended pending sputum and/or Erythrocyte sedimentation rate (ESR) and/or C-reactive pro- tein (CRP) level may be helpful to guide response to therapy For health care–associated MRSA (HA-MRSA) or CA- MRSA pneumonia, IV vancomycin (A-II) or linezolid 600 mg PO/IV twice daily (A-II) or clindamycin 600 mg PO/IV 3 times daily (B-III), if the strain is susceptible, is recommended for 7– Drainage or debridement of the joint space should 21 days, depending on the extent of infection.
288 d CID 2011:52 (1 February) d Liu et al.
For septic arthritis, refer to antibiotic choices for VI. What is the management of MRSA infections of the CNS? osteomyelitis (recommendation 37 above). A 3–4-week course IV vancomycin for 2 weeks is recommended (B-II).
Some experts recommend the addition of rifampin 600 mg daily or 300–450 mg twice daily (B-III).
For early-onset (,2 months after surgery) or acute Alternatives include the following: linezolid 600 mg PO/IV hematogenous prosthetic joint infections involving a stable twice daily (B-II) or TMP-SMX 5 mg/kg/dose IV every 8–12 h implant with short duration (<3 weeks) of symptoms and debridement (but device retention), initiate parenteral therapy For CNS shunt infection, shunt removal is recommen- (refer to antibiotic recommendations for osteomyelitis) plus ded, and it should not be replaced until cerebrospinal fluid rifampin 600 mg daily or 300–450 mg PO twice daily for 2 (CSF) cultures are repeatedly negative (A-II).
weeks followed by rifampin plus a fluoroquinolone, TMP- SMX, a tetracycline or clindamycin for 3 or 6 months for hips Brain abscess, subdural empyema, spinal epidural abscess and knees, respectively (A-II). Prompt debridement with device Neurosurgical evaluation for incision and drainage is removal whenever feasible is recommended for unstable implants, late-onset infections, or in those with long duration IV vancomycin for 4–6 weeks is recommended (B-II).
Some experts recommend the addition of rifampin 600 mg For early-onset spinal implant infections (<30 days after daily or 300–450 mg twice daily (B-III).
surgery) or implants in an actively infected site, initial Alternatives include the following: linezolid 600 mg PO/IV parenteral therapy plus rifampin followed by prolonged oral twice daily (B-II) and TMP-SMX 5 mg/kg/dose IV every 8–12 h therapy is recommended (B-II). The optimal duration of parenteral and oral therapy is unclear; the latter should be Septic Thrombosis of Cavernous or Dural Venous Sinus continued until spine fusion has occurred (B-II). For late-onset infections (.30 days after implant placement), device removal Surgical evaluation for incision and drainage of contig- uous sites of infection or abscess is recommended whenever whenever feasible is recommended (B-II).
Long-term oral suppressive antibiotics (eg, TMP-SMX, possible (A-II). The role of anticoagulation is controversial.
a tetracycline, a fluoroquinolone [which should be given in IV vancomycin for 4–6 weeks is recommended (B-II).
Some experts recommend the addition of rifampin 600 mg conjunction with rifampin due to the potential emergence of daily or 300–450 mg twice daily (B-III).
fluoroquinolone resistance, particularly if adequate surgical Alternatives include the following: linezolid 600 mg PO/IV debridement is not possible should be given in conjunction twice daily (B-II) and TMP-SMX 5 mg/kg/dose IV every 8–12 h with rifampin], or clindamycin) with or without rifampin may be considered in selected cases, particularly if device removal IV vancomycin is recommended (A-II).
For children with acute hematogenous MRSA osteomye- VII. What is the role of adjunctive therapies for the treatment of litis and septic arthritis, IV vancomycin is recommended (A-II). If the patient is stable without ongoing bacteremia or intravascular Protein synthesis inhibitors (eg, clindamycin and line- infection, clindamycin 10–13 mg/kg/dose IV every 6–8 h (to zolid) and intravenous immunoglobulin (IVIG) are not administer 40 mg/kg/day) can be used as empirical therapy if the routinely recommended as adjunctive therapy for the manage- clindamycin resistance rate is low (eg, ,10%) with transition to ment of invasive MRSA disease (A-III). Some experts may oral therapy if the strain is susceptible (A-II). The exact consider these agents in selected scenarios (eg, necrotizing duration of therapy should be individualized, but typically pneumonia or severe sepsis) (C-III).
a minimum 3–4-week course is recommended for septic arthritis and a 4–6-week course is recommended for osteomyelitis.
VIII. What are the recommendations for vancomycin dosing and Alternatives to vancomycin and clindamycin include the following: daptomycin 6 mg/kg/day IV once daily (C-III) or These recommendations are based on a consensus statement of linezolid 600 mg PO/IV twice daily for children >12 years of the American Society of Health-System Pharmacists, the IDSA, age and 10 mg/kg/dose every 8 h for children ,12 years of age and The Society of Infectious Diseases Pharmacists on guidelines MRSA Treatment Guidelines d CID 2011:52 (1 February) d 289 i. If the patient has had a clinical and microbiologic response IV vancomycin 15–20 mg/kg/dose (actual body weight) to vancomycin, then it may be continued with close follow-up every 8–12 h, not to exceed 2 g per dose, is recommended in ii. If the patient has not had a clinical or microbiologic patients with normal renal function (B-III).
response to vancomycin despite adequate debridement and In seriously ill patients (eg, those with sepsis, meningitis, removal of other foci of infection, an alternative to vancomycin pneumonia, or infective endocarditis) with suspected MRSA infection, a loading dose of 25–30 mg/kg (actual body weight) For isolates with a vancomycin MIC .2 lg/mL (eg, may be considered. (Given the risk of red man syndrome and vancomycin-intermediate S. aureus [VISA] or vancomycin- possible anaphylaxis associated with large doses of vancomycin, resistant S. aureus [VRSA]), an alternative to vancomycin one should consider prolonging the infusion time to 2 h and use of an antihistamine prior to administration of the loading X. What is the management of persistent MRSA bacteremia and vancomycin treatment failures in adult patients? Trough vancomycin concentrations are the most A search for and removal of other foci of infection, accurate and practical method to guide vancomycin dosing drainage or surgical debridement is recommended (A-III).
(B-II). Serum trough concentrations should be obtained at High-dose daptomycin (10 mg/kg/day), if the isolate is steady state conditions, prior to the fourth or fifth dose.
susceptible, in combination with another agent (e.g. gentamicin Monitoring of peak vancomycin concentrations is not 1 mg/kg IV every 8 h, rifampin 600 mg PO/IV daily or 300-450 mg PO/IV twice daily, linezolid 600 mg PO/IV BID, For serious infections, such as bacteremia, infective TMP-SMX 5 mg/kg IV twice daily, or a beta-lactam antibiotic) endocarditis, osteomyelitis, meningitis, pneumonia, and severe SSTI (eg, necrotizing fasciitis) due to MRSA, vancomycin If reduced susceptibility to vancomycin and daptomycin trough concentrations of 15–20 lg/mL are recommended are present, options may include the following: quinupristin- For most patients with SSTI who have normal renal dalfopristin 7.5 mg/kg/dose IV every 8 h, TMP-SMX 5 mg/kg/ function and are not obese, traditional doses of 1 g every 12 h dose IV twice daily, linezolid 600 mg PO/IV twice daily, or are adequate, and trough monitoring is not required (B-II).
telavancin 10 mg/kg/dose IV once daily (C-III). These options Trough vancomycin monitoring is recommended for may be given as a single agent or in combination with other serious infections and patients who are morbidly obese, have renal dysfunction (including those receiving dialysis), or have XI. What is the management of MRSA infections in neonates? fluctuating volumes of distribution (A-II).
Continuous infusion vancomycin regimens are not For mild cases with localized disease, topical treatment with mupirocin may be adequate in full-term neonates and For localized disease in a premature or very low- Data are limited to guide vancomycin dosing in birthweight infant or more-extensive disease involving multiple children. IV vancomycin 15 mg/kg/dose every 6 h is sites in full-term infants, IV vancomycin or clindamycin is recommended in children with serious or invasive disease recommended, at least initially, until bacteremia is excluded The efficacy and safety of targeting trough concentrations of 15–20 lg/mL in children requires additional study but should be considered in those with serious infections, such as IV vancomycin is recommended, dosing as outlined in bacteremia, infective endocarditis, osteomyelitis, meningitis, pneumonia, and severe SSTI (ie, necrotizing fasciitis) (B-III).
Clindamycin and linezolid are alternatives for non- IX. How should results of vancomycin susceptibility testing be The prevalence of MRSA has steadily increased since the first For isolates with a vancomycin minimum inhibitory clinical isolate was described in 1961, with an estimated 94,360 concentration (MIC) <2 lg/mL (eg, susceptible according to cases of invasive MRSA disease in the United States in 2005 [5].
Clinical and Laboratory Standards Institute [CLSI] breakpoints), Initially almost exclusively health care–associated, by the mid- the patient’s clinical response should determine the continued 1990s, MRSA strains were reported as causing infections among use of vancomycin, independent of the MIC (A-III).
previously healthy individuals in the community who lacked 290 d CID 2011:52 (1 February) d Liu et al.
health care–associated risk factors [6]. Unlike HA-MRSA, these so-called CA-MRSA isolates are susceptible to many non–ß- The Expert Panel wishes to express its gratitude to Drs. Gordon Archer, lactam antibiotics. Furthermore, they are genetically distinct Frank Lowy, and Brad Spellberg for their thoughtful reviews of earlier drafts from HA-MRSA isolates and contain a novel cassette element, of the guideline. The Expert Panel also recognizes the following for theirimportant contributions in identifying critical gaps where funding of re- SCCmec IV and exotoxin, Panton-Valentine leukocidin (PVL).
search is needed to advance clinical treatment and care: William Burman, The epidemiology of MRSA has become increasingly complex as David M. Margolis, and Louis B. Rice (IDSA Research Committee), Stanley CA-MRSA and HA-MRSA strains have co-mingled both in the C. Deresinski (IDSA SPGC), and Padma Natarajan (IDSA staff). Thefindings and conclusions of this report are those of the authors and do not community and in health care facilities [7, 8]. Not unexpectedly, necessarily represent the official position of the Centers for Disease Control MRSA disease has had an enormous clinical and economic The wide spectrum of illness caused by MRSA includes SSTIs, search grants and has served as a consultant to Cubist, Ortho-McNeil, bacteremia and endocarditis, pneumonia, bone and joint in- Pfizer, Theravance, and Targanta. S. E. C. has received honoraria from fections, CNS disease, and toxic shock and sepsis syndromes.
Forest and RibX, has served as a consultant for Merck and has receivedresearch support from Astellas, Cubist and AdvanDx. R.D. has received CA-MRSA was the most common cause of SSTI in a geo- research funding from Pfizer, Clorox, Sanofi Pasteur, Sage, and GeneOhm.
graphically diverse network of emergency departments in the S.L.K. has received grant funding from Pfizer, has served as MRSA Lead- United States [11]; however, there may be differences in local ership Advisor to Pfizer, and is participating in a pediatric daptomycinstudy. A.W.K. has received honoraria and grants from Cubist Pharma- epidemiology to consider when implementing these guidelines.
ceuticals, Merck, Wyeth, and Pfizer and has served as a consultant for SSTIs may range in clinical presentation from a simple abscess Cubist Pharmaceuticals, Theravance, Astellas, Pfizer, Merck, and Ortho- or cellulitis to deeper soft-tissue infections, such as pyomyositis, McNeil and has owned stock from Cubist Pharmaceutical, Pfizer, andJohnson and Johnson. D.P.L. has received research support from Cubist, necrotizing fasciitis, and mediastinitis as a complication of ret- Johnson & Johnson, and Theravance and has served as a speaker for Cubist.
ropharyngeal abscess [12–15]. Bacteremia accompanies the B.E.M. has served as a consultant and received research support from majority (75%) of cases of invasive MRSA disease [5]. A mul- Johnson & Johnson, Astellas, Pfizer, Cubist, Theravance, Targanta, Sanofi-Aventis, Vicuron Pharmaceuticals, and Wyeth-Ayerst. M.R. has received titude of disease manifestations have been described, including, grants and or has served as a consultant speaker for the Pfizer, Cubist, but not limited to, infective endocarditis; myocardial, peri- Theravance/Astellas, Targanta, and Johnson & Johnson. D.A.T. has servedon the advisory board to Pfizer, Ortho-McNeil, Astellas, Schering-Plough, nephric, hepatic, and splenic abscesses; septic thrombophlebitis and Replidyne. All other authors: no conflicts.
with and without pulmonary emboli [16]; necrotizing pneu-monia [17–21]; osteomyelitis complicated by subperiosteal ab- scesses; venous thrombosis and sustained bacteremia [16, 22, 23]; severe ocular infections, including endophthalmitis [24]; 1. Calfee DP, Salgado CD, Classen D, et al. Strategies to prevent trans- mission of methicillin-resistant Staphylococcus aureus in acute care sepsis with purpura fulminans [25]; and Waterhouse-Frider- hospitals. Infect Control Hosp Epidemiol 2008; 29(Suppl 1):S62–S80.
2. Anderson DJ, Kaye KS, Classen D, et al. Strategies to prevent surgical The Expert Panel addressed the following clinical questions in site infections in acute care hospitals. Infect Control Hosp Epidemiol 3. Rybak M, Lomaestro B, Rotschafer JC, et al. Therapeutic monitoring of I. What is the management of SSTIs in the CA-MRSA era? vancomycin in adult patients: a consensus review of the AmericanSociety of Health-System Pharmacists, the Infectious Diseases Society II. What is the management of recurrent MRSA SSTIs? of America, and the Society of Infectious Diseases Pharmacists. Am J III. What is the management of MRSA bacteremia and 4. Rybak MJ, Lomaestro BM, Rotschafer JC, et al. Vancomycin thera- peutic guidelines: a summary of consensus recommendations from the IV. What is the management of MRSA pneumonia? Infectious Diseases Society of America, the American Society of V. What is the management of MRSA bone and joint Health-System Pharmacists, and the Society of Infectious Diseases Pharmacists. Clin Infect Dis 2009; 49:325–7.
VI. What is the management of MRSA infections of the CNS? 5. Klevens RM, Morrison MA, Nadle J, et al. Invasive methicillin-resistant Staphylococcus aureus infections in the United States. JAMA 2007; VII. What is the role of adjunctive therapies for the treatment 6. Herold BC, Immergluck LC, Maranan MC, et al. Community-acquired VIII. What are the recommendations for vancomycin dosing methicillin-resistant Staphylococcus aureus in children with no identi-fied predisposing risk. JAMA 1998; 279:593–8.
7. Liu C, Graber CJ, Karr M, et al. A population-based study of the IX. How should results of vancomycin susceptibility testing be incidence and molecular epidemiology of methicillin-resistant Staph- ylococcus aureus disease in San Francisco, 2004–2005. Clin Infect Dis X. What is the management of persistent MRSA bacteremia 8. D’Agata EM, Webb GF, Horn MA, et al. Modeling the invasion of community-acquired methicillin-resistant Staphylococcus aureus into XI. What is the management of MRSA in neonates? hospitals. Clin Infect Dis 2009; 48:274–84.
MRSA Treatment Guidelines d CID 2011:52 (1 February) d 291 9. Purcell K, Fergie J, Peterson MD. Economic impact of the community- 18. Hageman JC, Uyeki TM, Francis JS, et al. Severe community-acquired acquired methicillin-resistant Staphylococcus aureus epidemic on the pneumonia due to Staphylococcus aureus, 2003-04 influenza season.
Driscoll Children’s Health Plan. Pediatr Infect Dis J 2006; 25:178–80.
10. Noskin GA, Rubin RJ, Schentag JJ, et al. The burden of Staphylococcus 19. Centers for Disease Control and Prevention. Severe methicillin-re- aureus infections on hospitals in the United States: an analysis of the sistant Staphylococcus aureus community-acquired pneumonia associ- 2000 and 2001 Nationwide Inpatient Sample Database. Arch Intern ated with influenza–Louisiana Georgia, December 2006-January 2007.
MMWR Morb Mortal Wkly Rep 2007; 56:325–9.
11. Moran GJ, Krishnadasan A, Gorwitz RJ, et al. Methicillin-resistant S.
20. Gonzalez BE, Hulten KG, Dishop MK, et al. Pulmonary manifestations aureus infections among patients in the emergency department. N Engl in children with invasive community-acquired Staphylococcus aureus 12. Lee TC, Carrick MM, Scott BG, et al. Incidence and clinical charac- infection. Clin Infect Dis 2005; 41:583–90.
teristics of methicillin-resistant Staphylococcus aureus necrotizing fas- 21. Finelli L, Fiore A, Dhara R, et al. Influenza-associated pediatric mor- ciitis in a large urban hospital. Am J Surg 2007; 194:809–12; discussion, tality in the United States: increase of Staphylococcus aureus co- infection. Pediatrics 2008; 122:805–11.
13. Pannaraj PS, Hulten KG, Gonzalez BE, et al. Infective pyomyositis and 22. Arnold SR, Elias D, Buckingham SC, et al. Changing patterns of acute myositis in children in the era of community-acquired, methicillin- hematogenous osteomyelitis and septic arthritis: emergence of com- resistant Staphylococcus aureus infection. Clin Infect Dis 2006; 43:953–60.
munity-associated methicillin-resistant Staphylococcus aureus. J Pediatr 14. Miller LG, Perdreau-Remington F, Rieg G, et al. Necrotizing fasciitis caused by community-associated methicillin-resistant Staphylococcus 23. Crary SE, Buchanan GR, Drake CE, et al. Venous thrombosis and aureus in Los Angeles. N Engl J Med 2005; 352:1445–53.
thromboembolism in children with osteomyelitis. J Pediatr 2006; 15. Wright CT, Stocks RM, Armstrong DL, et al. Pediatric mediastinitis as a complication of methicillin-resistant Staphylococcus aureus retro- 24. Rutar T, Chambers HF, Crawford JB, et al. Ophthalmic manifestations pharyngeal abscess. Arch Otolaryngol Head Neck Surg 2008; of infections caused by the USA300 clone of community-associated methicillin-resistant Staphylococcus aureus. Ophthalmology 2006; 16. Gonzalez BE, Teruya J, Mahoney DH Jr., et al. Venous thrombosis associated with staphylococcal osteomyelitis in children. Pediatrics 25. Kravitz GR, Dries DJ, Peterson ML, et al. Purpura fulminans due to 17. Francis JS, Doherty MC, Lopatin U, et al. Severe community-onset Staphylococcus aureus. Clin Infect Dis 2005; 40:941–7.
pneumonia in healthy adults caused by methicillin-resistant Staphylo- 26. Adem PV, Montgomery CP, Husain AN, et al. Staphylococcus aureus coccus aureus carrying the Panton-Valentine leukocidin genes. Clin sepsis and the Waterhouse-Friderichsen syndrome in children. N Engl J 292 d CID 2011:52 (1 February) d Liu et al.

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