Staphylococcus Aureus Infection Treatment & Management

Updated: Jul 27, 2021
  • Author: Elizabeth P Baorto, MD, MPH; Chief Editor: Russell W Steele, MD  more...
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Medical Care

Because community-associated methicillin-resistant Staphylococcus aureus (CA-MRSA) causes more than one half of all staphylococcal infections in most communities, empiric therapy with penicillins or cephalosporins may be inadequate. [7] Some experts recommend combination therapy with a penicillinase-resistant penicillin or cephalosporin (in case the organism is methicillin-sensitive S aureus [MSSA]) [8] and clindamycin or a quinolone. Others suggest use of clindamycin, trimethoprim-sulfamethoxazole (TMP-SMX), rifampin, doxycycline, or a quinolone. Finally, because of concerns about induction of resistance, some recommend using TMP-SMX and rifampin in combination, rather than singly. As data accumulate, clindamycin may become the preferred outpatient antibiotic therapy (compared with TMP-SMX) in regions with a relatively low incidence of clindamycin resistance. [9] Recently, treatment guidelines have been published. [10]

A randomized, double-blind study by Thwaites et al that included 758 patients with S aureus bacteremia assigned adjunctive rifampicin or a placebo, reported no overall benefit in adjunctive rifampicin over standard antibiotic therapy. [123]

Impetigo, folliculitis, furuncle, carbuncle

Impetigo and other minor skin infections (ie, superficial or localized infections) may be treated with a topical agent such as mupirocin or retapamulin. However, most CA-MRSA strains are or readily become resistant to mupirocin. More extensive or serious skin disease and bullous impetigo are treated with oral antistaphylococcal agents, as noted above. [11, 124, 125, 126, 127]

Scalded skin syndrome (Ritter disease)

As with any S aureus toxin–mediated disease, treatment should aim to eradicate the focus of infection and end toxin production. Administer large doses of intravenous antistaphylococcal agents, such as oxacillin (150 mg/kg/d), or a first-generation cephalosporin, such as cefazolin (100 mg/kg/d). In vitro, clindamycin has been shown to inhibit the synthesis of TSST-1 and is extremely effective in combination with one of the agents mentioned above. Children with denuded skin should be touched as little as possible. Topical antimicrobial agents have little use, because skin damage is self-limited once systemic antibiotics are administered.


Empirically, initiating a semisynthetic penicillin (eg, oxacillin [150 mg/kg/d]) and clindamycin (30-40 mg/kg/d) is a good choice for most cases of community-acquired osteomyelitis. In patients with allergy to penicillin, a first-generation cephalosporin and clindamycin (30-40 mg/kg/d) are an excellent alternative. Use vancomycin or linezolid when the other drugs mentioned are absolutely not tolerated or when resistance or the clinical course dictates. The duration of therapy is a controversial topic in the literature, but the consensus among multiple authors is that the minimum effective treatment time is 4-6 weeks. A switch to oral therapy is acceptable if the child is able to take oral antibiotics, is afebrile, and if he or she has demonstrated a good clinical response to parenteral antibiotics. [13]

Septic arthritis

As in osteomyelitis, initiate an appropriate antistaphylococcal drug (eg, oxacillin, which is penicillinase resistant; clindamycin; cefazolin) parenterally. These antibiotics readily reach joint fluid, and the concentration in the joint fluid is 30% of the serum value. Therapy usually continues for at least 4 weeks. Duration of parenteral therapy is often debated. Some authors have demonstrated efficacy with 1 week of parenteral therapy followed with 3 weeks of oral therapy. Consider a switch to oral therapy based on the considerations mentioned above. Joint fluid that reaccumulates should be removed, and a sample should be cultured to assess the efficacy of therapy and to make the patient more comfortable.


Duration of therapy for endocarditis, which is a life-threatening infection, is at least 4 weeks. [128]

The combination of a beta-lactam and an aminoglycoside (usually gentamicin) is advocated, because it increases bacterial killing in vitro and in animal models of endocarditis. In patients with MRSA, combinations of vancomycin with aminoglycosides should be used. In all cases the aminoglycoside is only added for the first 3 days.

Rifampin, because of its lipid solubility, is another potent agent when used in combination with nafcillin and gentamicin or vancomycin and gentamicin, especially in patients with prosthetic valve endocarditis. Rifampin should never be used alone because resistance can develop.

The response to therapy is usually slow, and patients may continue to have bacteremia, fever, and leukocytosis for at least a week after therapy is initiated.

Some authors recommend obtaining blood cultures after the end of therapy.

Treatment with antibiotics is specific to the etiologic agent and its characteristics. For more information, see Endocarditis, Bacterial.


Surgical Care

Skin and soft tissue infections

Drainage of any collections of pus is of paramount importance. [12] For small abscesses in afebrile toddlers and children, drainage alone may suffice, since treatment with efficacious and nonefficacious systemic antibacterial therapy was equivalent if adequate drainage had occurred. [129] Placement of a subcutaneous drain, rather than formal incision and drainage, has proven successful. [130]


Surgery is usually indicated to drain purulent material from the subperiosteal space or if infected foreign material is present.

Septic arthritis

In an infant, septic arthritis of the hip and shoulder is a surgical emergency; these joints should be drained as soon as possible to prevent bony destruction. In addition, if a large amount of fibrin, tissue debris, or loculation is present, preventing adequate drainage with needle aspiration, the joint should be surgically drained.


If endocarditis occurs in the presence of an intracardiac foreign body, it may require removal.

Toxic shock syndrome (TSS)

All potential foci of infection should be explored and surgically drained.


Remove the infected intravenous line in patients who are immunocompromised or severely ill or when infection is impossible to eradicate medically.



In a 5-year multicenter study, the introduction of practices to eliminate Staphylococcus aureus significantly reduced the rate of complex S aureus infection at surgical sites, from 0.36% to 0.20%. The study included 38,049 patients who underwent 42,534 operations (cardiac surgery or hip or knee arthroplasty); 28,218 operations were performed before the intervention was implemented and 14,316 were performed during the intervention period. [131, 132]

For the intervention, patients were screened for S aureus in the month before surgery. Those with positive screens were asked to apply intranasal mupirocin and to bathe with chlorhexidine for 5 days before surgery. Patients with methicillin-sensitive S aureus received perioperative prophylactic cefazolin, and those with MRSA received cefazolin and vancomycin. Patients who were negative for S aureus bathed with chlorhexidine the night before and the morning of surgery, and received cefazolin. [131, 132]

A population-based study by Smit et al reported that current statin users had a 27% lower risk of community-acquired Staphylococcus aureus bacteremia and that long-term use was particularly associated with lower risk. [133, 134]