eMedicine Specialties > Infectious Diseases > Bacterial Infections

Staphylococcal Infections: Treatment & Medication

Author: Thomas Herchline, MD, Professor of Medicine, Wright State University Boonshoft School of Medicine; Medical Director, Public Health, Dayton and Montgomery County, Ohio
Contributor Information and Disclosures

Updated: Aug 20, 2008

Treatment

Medical Care

Promptly start antimicrobial therapy when S aureus infection is documented or strongly suspected. Temporary intravascular devices should be promptly removed if infection is suspected.8 Long-term intravascular devices should be removed if infection with S aureus is documented.

Multiple decolonization regimens have been used in patients with recurrent staphylococcal infection. Treatment with topical mupirocin, chlorhexidine gluconate washes, and oral rifampin plus doxycycline for 7 days eradicated methicillin-resistant S aureus (MRSA) colonization in hospitalized patients.9

Surgical Care

Abscesses must be drained. Infections involving a prosthetic joint usually require removal of the prosthesis. Other infections involving a prosthetic device, such as a prosthetic heart valve or implanted intravascular device, may or may not require removal of the device.

Medication

Historically, isolates resistant to oxacillin (commonly referred to as methicillin-resistant S aureus [MRSA]) were resistant to most agents other than vancomycin, but these isolates were limited to nosocomial infections. More recently, many reports have described community-acquired MRSA infections that have been susceptible to various non–beta-lactam antibiotics. As such, patients with serious staphylococcal infections should be initially started on agents active against MRSA until susceptibility results are available. Many coagulase-negative staphylococci are oxacillin-resistant. The duration of treatment and the use of synergistic combinations depend on the type of infection encountered. Endocarditis due to S aureus may require a prolonged course of antibiotics.

Although many strains of MRSA that cause community-acquired infection are susceptible to trimethoprim-sulfamethoxazole, treatment with trimethoprim-sulfamethoxazole has been associated with clinical failure, especially in the presence of significant tissue damage.10

Vancomycin-resistant isolates have been reported; isolates with an increased minimum inhibitory concentration (MIC) to vancomycin are becoming more common. Increased dosing of vancomycin (trough >15 mcg/mL) may be required to treat infections with these isolates.11

Antibiotics

Empiric antimicrobial therapy must be comprehensive and should cover all likely pathogens in the context of the clinical setting.


Nafcillin (Nafcil, Unipen, Nallpen)

Preferred therapy for methicillin-susceptible S aureus (MSSA) staphylococci infections. Use parenteral therapy initially in severe infections. Oxacillin may be substituted for nafcillin based on hospital formulary. Change to oral therapy as condition warrants.

Adult

1-2 g IV q4h

Pediatric

100-200 mg/kg/d IV divided q4h

Associated with warfarin resistance when administered concurrently; effects may decrease with bacteriostatic action of tetracycline derivatives

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

To optimize therapy, determine causative organisms and susceptibility; duration of treatment should be at least 14 days in all patients with S aureus bacteremia to prevent sequelae (eg, endocarditis, osteomyelitis)


Vancomycin (Vancocin, Vancoled)

Indicated for patients who cannot receive penicillins and cephalosporins or have infections with resistant staphylococci. To lessen the risk for toxicity, assay vancomycin trough levels after third dose drawn 0.5 h prior to next dosing. Use CrCl to adjust dose in patients diagnosed with renal impairment.

Adult

1 g or 15 mg/kg IV q12h

Pediatric

30-40 mg/kg/d IV divided q12h

Erythema, histaminelike flushing, and anaphylactic reactions may occur when administered with anesthetic agents; taken concurrently with aminoglycosides, risk of nephrotoxicity may increase above that with aminoglycoside monotherapy; effects in neuromuscular blockade may be enhanced when coadministered with nondepolarizing muscle relaxants

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Infuse slowly, rapid infusion may cause hypotension or tingling and flushing (red man syndrome); red man syndrome is caused by IV infusion that is too rapid but rarely happens when dose is administered as 2-h IV administration or with PO or IP administration; red man syndrome is not an allergic reaction; caution in renal failure and neutropenia


Cefazolin (Ancef, Kefzol)

First-generation semisynthetic cephalosporin that arrests bacterial cell wall synthesis, inhibiting bacterial growth. Primarily active against skin flora, including S aureus (MSSA). Typically used alone for skin and skin-structure coverage. IV and IM dosing regimens are similar.

Adult

1 g IV q8h

Pediatric

50-100 mg/kg/d IV divided q8h

Probenecid prolongs effect; coadministration with aminoglycosides may increase renal toxicity; may yield false-positive result from urine dip test for glucose

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Adjust dose in renal impairment; superinfections and promotion of nonsusceptible organisms may occur with prolonged use or repeated therapy


Clindamycin (Cleocin)

Lincosamide for treatment of serious skin and soft tissue staphylococci infections. Also effective against aerobic and anaerobic streptococci (except enterococcal) (MSSA). Inhibits bacterial growth, possibly by blocking dissociation of peptidyl t-RNA from ribosomes, causing RNA-dependent protein synthesis to arrest.

Adult

150-300 mg PO q8h
300-600 mg IV q8h

Pediatric

25-40 mg/kg/d PO/IV divided tid

Increases duration of neuromuscular blockade induced by tubocurarine and pancuronium; erythromycin may antagonize effects; antidiarrheals may delay absorption

Documented hypersensitivity; regional enteritis, ulcerative colitis, or hepatic impairment (use caution)

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Increases duration of neuromuscular blockade induced by tubocurarine and pancuronium; erythromycin may antagonize effects; antidiarrheals may delay absorption; all antimicrobials have been associated with development of pseudomembranous colitis


Dicloxacillin (Dycill, Dynapen)

Binds to one or more penicillin-binding proteins, which, in turn, inhibits synthesis of bacterial cell walls. For treatment of infections caused by penicillinase-producing staphylococci susceptible to methicillin (MSSA). Also active against most nonenterococcal streptococci. May use to initiate therapy when staphylococcal infection is suggested.

Adult

500 mg PO q6h

Pediatric

25 mg/kg/d PO divided q6h

Decreases efficacy of oral contraceptives; increases effects of anticoagulants; probenecid and disulfiram may increase penicillin levels

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Monitor PT in patients taking anticoagulant medications; toxicity may increase in patients with renal impairment; usefulness limited by need for frequent dosing


Trimethoprim-sulfamethoxazole (Bactrim, Bactrim DS, Septra, Septra DS)

Inhibits bacterial growth by inhibiting synthesis of dihydrofolic acid. Active against most staphylococci (MSSA), including some strains resistant to methicillin (MRSA).

Adult

160/800 mg PO q12h

Pediatric

<2 years: Do not administer
>2 years: 6-12 mg of trimethoprim/kg/d PO divided bid

May increase PT when used with warfarin (perform coagulation tests and adjust dose accordingly); coadministration with dapsone may increase blood levels of both drugs; coadministration of diuretics increases incidence of thrombocytopenia purpura in elderly persons; phenytoin levels may increase with coadministration; may potentiate effects of methotrexate in bone marrow depression; hypoglycemic response to sulfonylureas may increase with coadministration; may increase levels of zidovudine

Documented hypersensitivity; megaloblastic anemia due to folate deficiency

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Discontinue at first appearance of skin rash or sign of adverse reaction; obtain CBC counts frequently; discontinue therapy if significant hematologic changes occur; goiter, diuresis, and hypoglycemia may occur with sulfonamides; prolonged IV infusions or high doses may cause bone marrow depression (if signs occur, give 5-15 mg/d leucovorin); caution in folate deficiency (eg, chronic alcoholism, elderly, anticonvulsant therapy, malabsorption syndrome); hemolysis may occur in persons with G-6-PD deficiency
Persons with AIDS may not tolerate or respond to TMP-SMZ; caution in renal or hepatic impairment (perform urinalyses and renal function tests during therapy); give fluids to prevent crystalluria and stone formation


Minocycline (Minocin)

Inhibits protein synthesis and thus bacterial growth by binding to 30S and possibly 50S ribosomal subunits of susceptible bacteria. Active against MSSA/MRSA. Less active against coagulase-negative staphylococci. Doxycycline (Vibramycin) may be used in place of minocycline

Adult

100 mg PO/IV q12-24h

Pediatric

2-4 mg/kg/d PO divided bid

Bioavailability decreases slightly with antacids containing aluminum, calcium, magnesium, iron, or bismuth subsalicylate; tetracyclines can increase hypoprothrombinemic effects of anticoagulants; tetracyclines can decrease effects of oral contraceptives, causing breakthrough bleeding and increased risk of pregnancy

Pregnancy

D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus

Precautions

Tetracycline use during tooth development (last half of pregnancy through 8 y) can cause permanent discoloration of teeth


Linezolid (Zyvox)

Prevents formation of functional 70S initiation complex, which is essential for bacterial translation process. Bacteriostatic against staphylococci (MSSA/MRSA).

Adult

400-600 mg PO/IV q12h

Pediatric

Not established

May cause hypertension when used concomitantly with adrenergic agents, including pseudoepinephrine, sympathomimetic agents, vasopressors, or dopaminergic agents (reduce dose of dopamine or epinephrine if concurrent use required); serotonin syndrome may occur if used concomitantly with serotonergic agents, including TCAs, meperidine, dextromethorphan, trazodone, venlafaxine, and selective serotonin reuptake inhibitors

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Has mild MAOI properties and has potential to have same interactions as other MAOIs; caution in uncontrolled hypertension, pheochromocytoma, carcinoid syndrome, or untreated hyperthyroidism and in and patients who are at increased risk for bleeding, have preexisting thrombocytopenia, receive concomitant medications that may decrease platelet count or function, or who may require > 2 wk of therapy (monitor platelet counts); unnecessary use may lead to development of resistance to drug


Quinupristin/dalfopristin (Synercid)

Belongs to the streptogramin group of antibiotics. Mechanism of action is similar to macrolides/lincosamides. Inhibits protein synthesis and is usually bacteriostatic. Also an option for methicillin-resistant S aureus (MRSA) infections.

Adult

7.5 mg/kg IV q8h

Pediatric

Not established

May decrease elimination and increase toxicity of cyclosporine A, midazolam, nifedipine, terfenadine astemizole, cisapride, alfentanil, alosetron, alprazolam, carbamazepine, delavirdine, diazepam, diltiazem, disopyramide, dofetilide, donepezil, erythromycin, ethinyl estradiol, felodipine, fexofenadine, indinavir, lidocaine, lovastatin, methylprednisolone, nevirapine, norethindrone, quinidine, ritonavir, saquinavir, simvastatin, tacrolimus, triazolam, trimetrexate, verapamil, vinblastine, and, possibly, other drugs

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Arthralgias and myalgias are common and may be severe; venous irritation common when administered through a peripheral line; administration through central venous line recommended; asymptomatic elevation of unconjugated bilirubin level may occur


Daptomycin (Cubicin)

Indicated to treat complicated skin and skin structure infections caused by S aureus (including MRSA strains), Streptococcus pyogenes, Streptococcus agalactiae, Streptococcus dysgalactiae, and Enterococcus faecalis. Also indicated for right-sided endocarditis due to S aureus. First of new antibiotic class called cyclic lipopeptides. Binds to bacterial membranes and causes rapid membrane potential depolarization, thereby inhibiting protein, DNA, and RNA synthesis and ultimately causing cell death.

Adult

CrCl >30 mL/min: 4 mg/kg IV q24h infused over 30 min
CrCl <30 mL/min: 4 mg/kg IV q48h (including hemodialysis or CAPD)

Pediatric

<18 years: Not established
>18 years: Administer as in adults

Coadministration with tobramycin slightly increases daptomycin Cmax and AUC and decreases tobramycin Cmax and AUC; may experience additive effects with other drugs (eg, HMG-CoA reductase inhibitors), causing myopathy

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Decrease dose with renal function <30 mL/min; pseudomembranous colitis may occur; may cause muscle pain or weakness; monitor CK levels and discontinue daptomycin with elevated CK and unexplained myopathy or marked CK elevation (10-times upper limits of reference range); not indicated for pneumonia (higher death rate in daptomycin-treated patients during phase III trials); not compatible with dextrose-containing solutions


Tigecycline (Tygacil)

A glycylcycline antibiotic that is structurally similar to tetracycline antibiotics. Inhibits bacterial protein translation by binding to 30S ribosomal subunit, and blocks entry of amino-acyl tRNA molecules in ribosome A site. Indicated for complicated skin and skin structure infections and complicated intra-abdominal infections. Active against S aureus (including MRSA), as well as most streptococci, enterococci (including VRE), and gram-negative organisms (including anaerobes).

Adult

Infuse each dose over 30-60 min
100 mg IV once, then 50 mg IV q12h
Severe hepatic impairment (ie, Child Pugh class C): 100 mg IV once, then 25 mg IV q12h

Pediatric

<18 years: Not established
>18 years: Administer as in adults

Coadministration decreases warfarin clearance and increases warfarin Cmax and AUC (monitor aPTT and INR); coadministration of antibiotics with oral contraceptives may decrease contraceptive effect

Pregnancy

D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus

Precautions

Caution in severe hepatic impairment (reduce dose); may adversely effect tooth development; may permit clostridia overgrowth, resulting in antibiotic-associated colitis

More on Staphylococcal Infections

Overview: Staphylococcal Infections
Differential Diagnoses & Workup: Staphylococcal Infections
Treatment & Medication: Staphylococcal Infections
Follow-up: Staphylococcal Infections
Multimedia: Staphylococcal Infections
References
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Further Reading

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Keywords

staphylococcal infections, staph infection, MRSA, Staphylococcus aureus, S aureus, methicillin-resistant S aureus, methicillin-resistant Staphylococcus aureus, staphylococci, gram-positive cocci, S aureus bacteremia, staphylococcal toxic shock syndrome, Staphylococcus epidermis, S epidermis, staphylococcal skin infections, staphylococcal folliculitis, staphylococcal furuncles, staphylococcal bullous impetigo, staphylococcal wound infections, staphylococcal scalded skin syndrome, staphylococcal soft-tissue infections, staphylococcal pyomyositis, staphylococcal septic bursitis, staphylococcal septic arthritis, staphylococcal toxic shock syndrome, TSS, staphylococcal endocarditis, staphylococcal osteomyelitis, staphylococcal pneumonia, staphylococcal food poisoning, staphylococcal prosthetic infections, coagulase-negative staphylococci, staphylococcal urinary tract infection, UTI

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Contributor Information and Disclosures

Author

Thomas Herchline, MD, Professor of Medicine, Wright State University Boonshoft School of Medicine; Medical Director, Public Health, Dayton and Montgomery County, Ohio
Thomas Herchline, MD is a member of the following medical societies: American College of Physicians, American Society for Microbiology, and Infectious Diseases Society of America
Disclosure: Nothing to disclose.

Medical Editor

Klaus-Dieter Lessnau, MD, FCCP, Clinical Associate Professor of Medicine, New York University School of Medicine; Medical Director, Pulmonary Physiology Laboratory; Director of Research in Pulmonary Medicine, Department of Medicine, Section of Pulmonary Medicine, Lenox Hill Hospital
Klaus-Dieter Lessnau, MD, FCCP is a member of the following medical societies: American College of Chest Physicians, American College of Physicians, American Medical Association, American Society for Artificial Internal Organs, American Thoracic Society, Physicians for Social Responsibility, and Society of Critical Care Medicine
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

John L Brusch, MD, FACP, Assistant Professor of Medicine, Harvard Medical School; Consulting Staff, Department of Medicine and Infectious Disease Service, Cambridge Health Alliance
John L Brusch, MD, FACP is a member of the following medical societies: American College of Physicians and Infectious Diseases Society of America
Disclosure: Nothing to disclose.

CME Editor

Eleftherios Mylonakis, MD, Clinical and Research Fellow, Department of Internal Medicine, Division of Infectious Diseases, Massachusetts General Hospital
Eleftherios Mylonakis, MD is a member of the following medical societies: American Association for the Advancement of Science, American College of Physicians, American Society for Microbiology, and Infectious Diseases Society of America
Disclosure: Nothing to disclose.

Chief Editor

Burke A Cunha, MD, Professor of Medicine, State University of New York School of Medicine at Stony Brook; Chief, Infectious Disease Division, Winthrop-University Hospital
Burke A Cunha, MD is a member of the following medical societies: American College of Chest Physicians, American College of Physicians, and Infectious Diseases Society of America
Disclosure: Nothing to disclose.

 
 
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