For localized disease in a premature or very low-birth-weight infant or more extensive disease involving multiple sites in full-term infants, intravenous vancomycin or clindamycin is recommended until bacteremia is excluded. For adults with complicated bacteremia (positive blood culture results without meeting criteria for uncomplicated bacteremia), four to six weeks of therapy is recommended, depending on the extent of infection. Empiric Rx for MRSA recommended for severe CAP (ICU admission, necrotizing or cavitary infiltrates, or empyema) Discontinue empiric Rx if cultures do not grow MRSA Duration of therapy: 7-21 days 1Rehm JAC 2008;62:1413 -21; Silverman JID 2005; 191:2149 52 Copyright Infectious Diseases Society of America (IDSA) 2011 Contact Cultures are also recommended if there is concern of a cluster or outbreak. Treatment Duration Uncomplicated bacteremia: 2 weeks Complicated bacteremia without endocarditis or osteomyelitis: at least 4 weeks Complicated bacteremia with endocarditis: at least 6 weeks Complicated bacteremia with osteomyelitis: at least 8 weeks Antibiotic options with parenteral and oral routes of administration include the following: TMP/SMX (4 mg per kg [TMP component] twice per day) in combination with rifampin (600 mg once per day), linezolid, and clindamycin (600 mg every eight hours). J Antimicrob Chemother 2015; 70:311. Rifampin is not recommended for use as a single agent or adjunctive therapy. 2011 Aug 15;84(4):455-463. For the management of endocarditis, the panel recommend to refer the current BSAC guideline on infective endocarditis. 3 0 obj Shorter durations of therapy have been demonstrated to be as effective as longer durations for many common infections; similar findings in bacteremia could enable hospitals to reduce antibiotic utilization, adverse events, resistance and costs. We performed this study to evaluate the efficacy of linezolid with or without carbapenem in salvage treatment for … Trough vancomycin monitoring is recommended for patients with serious infections or who are morbidly obese, have renal dysfunction (including those receiving dialysis), or have fluctuating volumes of distribution. Immediate, unlimited access to all AFP content. 4(August 15, 2011) The guidelines are intended for use by health care providers who care for adult and pediatric patients with MRSA infections. One study showed a mean bacteremia duration of 5 days when salvage ceftaroline monotherapy was used in staphylococcal bacteremia after glycopeptide failure. The recommended treatment for patients with meningitis is intravenous vancomycin for two weeks. The role of anticoagulation is controversial. 26 In another recent study that examined outcomes of 31 patients with persistent MRSA bacteremia treated with ceftaroline, 0% failure (0 of 10) was reported among the 10 patients who received ceftaroline combination therapy … Therapy duration: 2 weeks IV therapy from first negative blood culture Yes Yes No No 1 Renal adjustment required as appropriate-refer to Antimicrobial Stewardship inside page for dosing recommendations: The Infectious Diseases Society of America (IDSA) has released its first evidence-based guidelines on the treatment of MRSA infections. Davis et al. A person viewing it online may make one printout of the material and may use that printout only for his or her personal, non-commercial reference. Pitt bacteremia scores, malignancy, and health care exposure contributed to 30- to 90-day mortality rates, while treatment duration of >4 weeks had a protective effect. Echocardiography is recommended in children with congenital heart disease, bacteremia lasting more than two to three days, or other clinical findings suggestive of endocarditis. Barber KE, Rybak MJ, Sakoulas G. Vancomycin plus ceftaroline shows potent in vitro synergy and was successfully utilized to clear persistent daptomycin-non-susceptible MRSA bacteraemia. Holland TL, Davis JS. Empiric therapy for five to 10 days is recommended pending culture results for outpatients with purulent cellulitis. with combination therapy), followed by a consolidation phase (i.e. Empiric therapy options include intravenous vancomycin, linezolid (600 mg orally or intravenously twice per day), daptomycin (Cubicin; 4 mg per kg intravenously once per day), telavancin (Vibativ; 10 mg per kg intravenously once per day), or clindamycin (600 mg intravenously or orally three times per day). The minimum t reatment duration for S. aureus BSI is 14 days and duration of therapy is determined by the type of bacteremia (complicated vs. uncomplicated) b. Uncomplicated: Treat for 14 days from negative blood cultures i. The role of cultures in managing recurrent skin and soft-tissue infections is limited. endobj For late-onset infections (more than 30 days after surgery), device removal is recommended. Treatment for seven to 14 days is recommended, but Tetracyclines are not recommended for children younger than eight years. Evaluation for valve replacement surgery is recommended if any of the following are present: large vegetation (greater than 10 mm in diameter), occurrence of one or more embolic events during the first two weeks of therapy, severe valvular insufficiency, valvular perforation or dehiscence, decompensated heart failure, perivalvular or myocardial abscess, new heart block, or persistent fevers or bacteremia. The mainstay of therapy for osteomyelitis is surgical debridement with drainage of associated soft-tissue abscesses. Current MRSA bacteremia practice guidelines by the Infectious Disease Society of America (IDSA) recommend the use of vancomycin or daptomycin as first-line treatment options for bacteremia (2). Guideline source: Infectious Diseases Society of America, Published source: Clinical Infectious Diseases, February 1, 2011, Available at: http://cid.oxfordjournals.org/content/early/2011/01/04/cid.ciq146.full. Strategies for decolonization include nasal decolonization with mupirocin twice per day for five to 10 days, or nasal decolonization with mupirocin twice per day for five to 10 days plus topical body decolonization with a skin antiseptic solution (e.g., chlorhexidine [Peridex]) for five to 14 days or dilute bleach baths. Daptomycin (6 mg per kg intravenously once per day) and linezolid are alternative therapies. Shunt removal is recommended in cases of central nervous system shunt infection, and the shunt should not be replaced until cerebrospinal fluid cultures are repeatedly negative. Copyright © 2020 American Academy of Family Physicians. PIRATE RCT found that 30-day rates of clinical failure for CRP-guided antibiotic treatment duration (discontinuation once CRP declined by 75%), fixed 7-day treatment were non-inferior to fixed 14-day treatment in patients with uncomplicated Gram-negative bacteremia. If the strain is susceptible, transition to oral therapy is advised. <>>> Regular bathing is advised, as well as hand washing with soap and water or an alcohol-based hand gel, especially after touching infected skin or an item that has been in contact with a draining wound. The duration of therapy may range from two to six weeks depending on the source, the presence of endovascular infection, and metastatic foci of infection. Treatment for seven to 14 days is recommended, but should be individualized to the patient's clinical response. MRSA bacteremia Nafcillin MSSA bacteremia Therapy duration: 4-6 weeks IV therapy from first negative blood culture Complicated bacteremia6? Linezolid is an alternative option. Concern arises, however, when bacteremia continues despite the use of these agents. Treatment Duration for Staphylococcus aureus Bacteremia a. For adults with infective endocarditis, intravenous vancomycin or daptomycin (6 mg per kg intravenously once per day for six weeks) is recommended. Antibiotic options for parenteral administration include intravenous vancomycin and daptomycin (6 mg per kg intravenously once per day). The effectiveness and safety of targeting trough concentrations of 15 to 20 mcg per mL in children require additional study, but should be considered in those with serious infections, such as bacteremia, infective endocarditis, osteomyelitis, meningitis, pneumonia, or severe skin and soft-tissue infections. 3 Similarly, the therapeutic duration for coagulase-negative staphylococcus bacteremia is based on limited evidence but ranges from 0 to 3 days for simple bacteremia … Illnesses caused by MRSA include skin and soft-tissue infections, bacteremia and endocarditis, pneumonia, bone and joint infections, central nervous system disease, and toxic shock and sepsis syndromes. %PDF-1.5 Patients can be transitioned to oral therapy if the strain is susceptible. �҅�u�� �� Data regarding the safety and effectiveness of alternative agents in children are limited, although daptomycin (6 to 10 mg per kg intravenously once per day) may be an option. An oral agent in combination with rifampin, if the strain is susceptible, may be considered if infections recur despite these measures. Infection from β-hemolytic streptococci does not usually require empiric therapy. MRSA-active therapy may be modified if there is no clinical response. The Infectious Disease Society of America (IDSA) guidelines for methicillin resistant S. aureus (MRSA) infection recommended that patients with complicated bacteremia should be administered antimicrobials for at least four to six weeks, whereas adults with uncomplicated S. aureus bacteremia required antimicrobial treatment for only two weeks . A total of 88 of the 219 (40%) patients experienced treatment failure. Early evaluation for valve replacement surgery is recommended. Four adult patients from the community presented to a large urban hospital (John H. Stroger Jr. Hospital of Cook County, Chicago, IL) with septic pulmonary emboli and community-acquired methicillin-resistant Staphylococcus aureus (CA-MRSA) bacteremia from December 2005 to February 2007. For most patients with skin and soft-tissue infections who have normal renal function and are not obese, traditional dosages of 1 g every 12 hours are adequate, and trough monitoring is not required. In patients with MRSA pneumonia complicated by empyema, antimicrobial therapy should be used with drainage procedures. If the child is stable without ongoing bacteremia or intravascular infection, empiric therapy with clindamycin (10 to 13 mg per kg intravenously every six to eight hours for a total of 40 mg per kg per day) is an option if the resistance rate is less than 10 percent. CASE REPORT. <> Want to use this article elsewhere? Serum trough concentrations should be obtained at steady state conditions, before the fourth or fifth dose. MRSA-active therapy may be modified if there is no clinical response. Long-term oral suppressive antibiotics (e.g., TMP/SMX, a tetracycline, a fluoroquinolone in conjunction with rifampin, clindamycin) with or without rifampin may be considered, particularly if device removal is not possible. http://cid.oxfordjournals.org/content/early/2011/01/04/cid.ciq146.full. <>/ExtGState<>/Font<>/ProcSet[/PDF/Text/ImageB/ImageC/ImageI] >>/Annots[ 43 0 R] /MediaBox[ 0 0 792 612] /Contents 4 0 R/Group<>/Tabs/S/StructParents 0>> monotherapy). If the patient is stable without ongoing bacteremia or intravascular infection, clindamycin (10 to 13 mg per kg intravenously every six to eight hours for a total of 40 mg per kg per day) can be used as empiric therapy if the clindamycin resistance rate is low (e.g., less than 10 percent). The recommended treatment is vancomycin (15 mg per kg intravenously every six hours) in children with serious or invasive disease. Dilute bleach baths can be made with 1 teaspoon of bleach per 1 gallon of water (or one-fourth cup per one-fourth bathtub or 13 gallons of water) and are given for 15 minutes twice per week for three months. M�j�Z�bn5I�>�R�q:3}(I�Q�W}���|��mƭ�oA���cwh!���I�ma��� ,�I�WB. Physicians should provide instructions on personal hygiene and wound care for patients with skin and soft-tissue infections. Copyright © 2011 by the American Academy of Family Physicians. All rights Reserved. Consider a minimum duration of 14 days of antibiotic therapy for uncomplicated bacteraemia and a minimum duration of 28 days for complicated bacteraemia caused by MRSA (weak recommendation)." Children with MRSA infections of the central nervous system should be treated with intravenous vancomycin. Patients should also avoid reusing or sharing items that that have touched infected skin (e.g., disposable razors, linens, towels). 6. To see the full article, log in or purchase access. Some experts recommend higher dosages of daptomycin (8 to 10 mg per kg intravenously once per day). The Infectious Diseases Society of America recommends re-evaluation of treatment when meticillin-resistant S aureus (MRSA) bacteraemia persists for 7 days despite active antibiotic therapy 17 based on two studies in which a median duration of 7–9 days was reported in … These may be given as a single agent or in combination with other antibiotics. In addition, the incorporation of combination therapy for MRSA bacteremia should be accompanied by the reminder that antimicrobial therapy does not need to be uniform for the entire duration, with an early intensive phase in high inoculum infections (e.g. Recommended treatment is intravenous vancomycin for four to six weeks. This content is owned by the AAFP. If the patient is stable without ongoing bacteremia or intra-vascular infection, clindamycin (10 to 13 mg per kg intravenously every six to eight hours for a total of 40 mg per kg per day) can be used as empiric therapy if the resistance rate is low (e.g., less than 10 percent), with transition to oral therapy if the strain is susceptible. Alternatives include linezolid and TMP/SMX. Surveillance cultures after a decolonization regimen are not routinely recommended if there is no active infection. 8. A collection of Practice Guidelines published in AFP is available at https://www.aafp.org/afp/practguide. ized patients with nonpurulent cellulitis. In addition to common clinical syndromes, the guidelines address treatment with vancomycin, limitations of susceptibility testing, and alternative therapies. The prevalence of methicillin-resistant Staphylococcus aureus (MRSA) in the United States continues to increase, with more than 94,000 cases of invasive disease reported in 2005. / Journals The duration of therapy should be individualized, but a minimum of three to four weeks is recommended for patients with septic arthritis, and four to six weeks for patients with osteomyelitis. Combination Therapy for MRSA Bacteremia: To ß or Not to ß? If household or interpersonal transmission is suspected, patients and contacts should be instructed to practice personal and environmental hygiene measures. Coverage of guidelines from other organizations does not imply endorsement by AFP or the AAFP. The optimal route of administration of antibiotic therapy has not been established; parenteral, oral, or initial parenteral therapy followed by oral therapy may be used, depending on patient circumstances. Additional blood cultures two to four days after initial positive cultures and as needed thereafter are recommended to document clearance of bacteremia. Clindamycin and linezolid should not be used if there is concern of infective endocarditis or an endovascular source of infection, although they may be considered in children with bacteremia that rapidly clears and is not related to an endovascular focus. Measuring erythrocyte sedimentation rate, C-reactive protein level, or both may help guide the response to therapy. A search for and removal of other foci of infection, drainage, or surgical debridement is recommended. Some experts recommend adding rifampin. In children, intravenous vancomycin is recommended for treating MRSA pneumonia. Alternatives include linezolid or TMP/SMX (5 mg per kg intravenously every eight to 12 hours). Vancomycin is recommended in hospitalized children. <> For early-onset spinal implant infections (30 days or less after surgery) or implants in an actively infected site, initial parenteral therapy plus rifampin followed by prolonged oral therapy is recommended. For patients with concurrent bacteremia, rifampin should be added after bacteremia has cleared. / For hospitalized patients with complicated skin and soft-tissue infections (i.e., deeper soft-tissue infections, surgical or traumatic wound infection, major abscesses, cellulitis, or infected ulcers and burns), empiric therapy for MRSA should be considered pending culture results, in addition to surgical debridement and broad-spectrum antibiotics. High-dose daptomycin (10 mg per kg per day), if the isolate is susceptible, in combination with another agent (e.g., gentamicin, rifampin, linezolid, TMP/SMX, a beta-lactam antibiotic) should be considered. Median MRSA bacteremia duration was 4.8 days for standard of care and 9.3 for DAP-CPT. Don't miss a single issue. Vancomycin trough concentrations of 15 to 20 mcg per mL are recommended in patients with serious infections, such as bacteremia, infective endocarditis, osteomyelitis, meningitis, pneumonia, or severe skin and soft-tissue infections (e.g., necrotizing fasciitis) caused by MRSA. Current recommendations, based on low-quality evidence, recommend 4 to 6 weeks for complicated S aureus bacteremia and a minimum of 14 days after the first negative surveillance blood culture result for uncomplicated bacteremia. Antibiotics are recommended for patients who have abscesses associated with severe or extensive disease (e.g., multiple sites of infection) or rapid progression in the presence of associated cellulitis; signs and symptoms of systemic illness; associated comorbidities or immunosuppression; very young or very old age; abscesses in areas difficult to drain (e.g., face, hand, genitalia); associated septic phlebitis; or lack of response to incision and drainage alone. Recommendations for vancomycin dosing are based on a consensus statement of the American Society of Health-System Pharmacists, the IDSA, and the Society of Infectious Diseases Pharmacists. In children, intravenous vancomycin (15 mg per kg every six hours) is recommended for treating bacteremia and infective endocarditis. Vancomycin (VAN) is often used to treat methicillin-resistant Staphylococcus aureus (MRSA) bacteremia despite a high incidence of microbiological failure. The use of 3–5 days of low-dose synergistic gentamicin with vancomycin for the treatment of MRSA bacteremia and native-valve endocarditis has not been shown to improve patient outcomes, although it appears to reduce the duration of bacteremia by ∼1 day in patients with MSSA native-valve endocarditis [ 51, 52 ]. [14]. Combination therapy is another option being explored. Am Fam Physician. Get Permissions, Access the latest issue of American Family Physician. Options for treating both β-hemolytic streptococci and community-associated MRSA include clindamycin alone, TMP/SMX or a tetracycline in combination with a beta-lactam antibiotic (e.g., amoxicillin), or linezolid alone. In children with minor skin infections (e.g., impetigo) or secondarily infected lesions (e.g., eczema, ulcers, lacerations), treatment with mupirocin 2% topical cream (Bactroban) is recommended. Adding gentamicin or rifampin to vancomycin is not recommended in patients with bacteremia or native valve infective endocarditis. Drainage or debridement of the joint space should be performed. For patients with septic arthritis, the antibiotic choices for osteomyelitis are recommended; a three- to four-week course of therapy is suggested. Patients with infective endocarditis and a prosthetic valve should be treated with intravenous vancomycin and rifampin (300 mg orally or intravenously every eight hours for at least six weeks), plus gentamicin (1 mg per kg intravenously every eight hours for two weeks). Some experts recommend adding rifampin (600 mg per day, or 300 to 450 mg twice per day). x��][o�8�~����Ei���wi4�NzLvz�Y�C��]��ė�������9��XiJ2� 8UE}:R���o�۷o>������������ͯ'��||���_�*����o8|b�R���8�y���Ǜ�˝*>�}�ʶ���/o�����+�J��(]hQ��W�z�୎/�ۯ�_��S��Ğ������3���sm�c��9`ny�������W?�w�V�'�-��">+��)�n+mO�@_m��>�� �}�|*ۜ�[�6�%�����df��-��f�Ro�ʭ�\�[c��O��O�_�bq�5�(|��У�ZU���,'%S���S0����W��G���7xV������]ɤ���5}? 4 0 obj Recommended treatment is intravenous vancomycin for four to six weeks. 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). The optimal duration of parenteral and oral therapy is unclear; oral therapy should be continued until spinal fusion has occurred. Pseudomonas and Acinetobacter) Magnetic resonance imaging with gadolinium is the imaging modality of choice for detecting early osteomyelitis and associated soft-tissue disease. The combination therapy group showed shorter duration of MRSA bacteremia and there was no difference in 28- and The optimal duration of therapy for MRSA osteomyelitis is unknown, although a minimum of eight weeks is recommended. Sign up for the free AFP email table of contents. Alternatives include linezolid and TMP/SMX. Gram-negative coverage and empiric MRSA coverage • De-escalation • Short course therapy for everyone = 7 days • Regardless of infecting organism (ex. 2 0 obj Duration of treatment for uncomplicated SAB vs complicated SAB o Patients meeting the definition of complicated SAB who receive “short course” therapy (ie, 2 weeks), are at higher risk for relapse and metastatic complications to include, but not limited to, infective Home This material may not otherwise be downloaded, copied, printed, stored, transmitted or reproduced in any medium, whether now known or later invented, except as authorized in writing by the AAFP. This rate “seems kind of high, but, if you look at some of the other MRSA agents for bacteremia (vancomycin, for example), it usually has a treatment failure rate around 60%,” Dr. Britt said. Age remained a significant risk factor for death at >90 days, while admission leukocytosis was protective. Uncomplicated bacteremia is defined as positive blood culture results and the following: exclusion of endocarditis; no implanted prostheses; follow-up blood cultures performed on specimens obtained two to four days after the initial set that do not grow MRSA; defervescence within 72 hours of initiating effective therapy; and no evidence of metastatic sites of infection. Bacteremia Treatment. For isolates with a vancomycin minimal inhibitory concentration greater than 2 mcg per mL (e.g., vancomycin-intermediate S. aureus, vancomycin-resistant S. aureus), an alternative agent should be prescribed.
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