| We make no recommendations for |
•the treatment of impetigo and boils caused by MRSA. •the treatment of deep eye and CNS infection. |
| We do not recommend |
•the use of nasal mupirocin alone for clearance of nasal carriage in patients, or staff, who also have skin breaks. [Category IB] |
|
•the use of oral vancomycin as prophylaxis or part of clearance regimens for MRSA. [Category II] |
| We recommend that |
•if a threshold of 10% resistance in staphylococci is exceeded isoxazolyl penicillins and cephalosporins are not used for empirical treatment of serious staphylococcal infection. [Category II] |
|
•step-down therapy to flucloxacillin or cloxacillin from glycopeptides and linezolid should be used wherever possible once antibiotic susceptibilities of S. aureus are known. [Category II] |
|
•Belgian recommendations on empirical use of glycopeptides are followed except that on surgical prophylaxis where epidemiological criteria also influence choice of agents [Category IB] and on neutropenic patients with a past history of MRSA and obvious line sepsis. |
| In skin and soft tissue infections |
•in the UK, tetracyclines should be more widely used in adults for treatment unless infections are so severe as to carry a high risk of bacteraemia or endocarditis. [Category IB] |
|
•glycopeptides or linezolid be considered for use where the risk of bacteraemia is high. [Category IA] |
|
•in infections that have failed therapy with single active agents, combined use of rifampicin and fusidic acid, or glycopeptides and fusidic acid or glycopeptides and rifampicin be considered but only where these antibiotics remain active in vitro. Formal clinical trials of the use of these combinations are needed. [Category II] |
|
•clindamycin be considered for use in treatment of MRSA susceptible to erythromycin because emergence of clindamycin resistance requires two mutations and its bioavailability is better. [Category IB] |
|
•iv glycopeptides or linezolid are used in severe iv site infection and that other oral agents are used in mild infections. [Category IB] |
| In urinary infections |
•tetracyclines are considered as first-line agents for the treatment of urinary infections caused by susceptible MRSA, with trimethoprim or nitrofurantoin as alternatives. [Category II] |
| In bone and joint infections |
•glycopeptides be used for parenteral treatment particularly of multiresistant MRSA and combination with rifampicin or fusidic acid should be considered. [Category IB] |
|
•combination therapy with two antibiotics that remain active in vitro should be used where monotherapy has failed. Agents that may be used in such combinations include rifampicin, a fluoroquinolone, trimethoprim or fusidic acid. Such a combination may be considered as first-line therapy if the strain is susceptible to both agents. [Category II] |
|
•clindamycin may be considered for treatment of infection with erythromycin-susceptible variants and can be used orally. [Category IB] |
| In bacteraemia |
•a minimum duration of 14 days' treatment with glycopeptides or linezolid for uncomplicated bacteraemia. Longer treatment will be required in patients with, or at higher risk of, endocarditis, and echocardiographic assessment is important. [Category IA] |
| In respiratory infections |
•infections in bronchiectasis should be treated with non-glycopeptide agents according to in vitro susceptibilities as suggested for cellulitis. [Category II] |
|
•particular care is taken to improve the certainty of diagnosis of lower respiratory tract infection as distinct from colonization. |
|
•the use of either glycopeptides or linezolid for pneumonic infections where MRSA is the aetiological agent. [Category IA] |
| In eye infections |
•gentamicin or chloramphenicol may be used for superficial eye infections. [Category IB] |
| In clearance of carriage |
•a large double-blind placebo-controlled study, is needed to confirm whether mupirocin remains useful in clearing carriage in patients or staff when low-level mupirocin resistance is present. This study should be multicentre and matched for presence of skin lesions. |
|
•mupirocin should only be used with a systemically active agent in treatment of patients with carriage, or infection, at extra-nasal sites. [Category II] |
| In surgical site prophylaxis |
•patients who require surgery and have a history of MRSA colonization or infection without documented eradication receive glycopeptide prophylaxis alone or in combination with other antibiotics active against other potential pathogens. The use of glycopeptides may also be considered if there is an appreciable risk that patients' MRSA carriage may have recurred or they come from facilities with a high prevalence of MRSA. [Category II] |
|
•the use of aminoglycosides is reassessed in patients not expected to have MRSA colonization for prophylaxis of staphylococcal infections. |
