1、IDSA GUIDELINESClinicalPracticeGuidelinesbytheInfectiousDiseasesSociety of America for the Treatment of Methicillin-Resistant Staphylococcus aureus Infections in Adultsand ChildrenCatherine Liu,1Arnold Bayer,3,5Sara E. Cosgrove,6Robert S. Daum,7Scott K. Fridkin,8Rachel J. Gorwitz,9Sheldon L. Kaplan,
2、10Adolf W. Karchmer,11Donald P. Levine,12Barbara E. Murray,14Michael J. Rybak,12,13DavidA. Talan,4,5and Henry F. Chambers1,21Department of Medicine, Division of Infectious Diseases, University of California-San Francisco, San Francisco, California;2Division of Infectious Diseases,San Francisco Gener
3、al 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 Angele
4、s;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
5、 Disease Control and Prevention, Atlanta, Georgia;10Department of Pediatrics, Section of Infectious Diseases, Baylor College ofMedicine, Houston, Texas;11Division of Infectious Diseases, Beth Israel Deaconess Medicine Center, Harvard Medical School, Boston, Massachusetts;12Department of Medicine, Di
6、vision of Infectious Diseases, Wayne State University, Detroit Receiving Hospital and University Health Center, Detroit,Michigan;13Deparment of Pharmacy Practice, Wayne State University, Detroit Michigan; and14Division of Infectious Diseases and Center for the Study ofEmerging and Re-emerging Pathog
7、ens, University of Texas Medical School, Houston, TexasEvidence-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
8、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 infect
9、ions, 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.EXECUTIVE SUMMARYMRSA is a significant cause of both hea
10、lth careassociatedand community-associated infections. This documentconstitutes the first guidelines of the IDSA on the treat-ment of MRSA infections. The primary objective of theseguidelines is to provide recommendations on the man-agement of some of the most common clinical syndromesencountered by
11、 adult and pediatric clinicians who care forpatients with MRSA infections. The guidelines addressissues related to the use of vancomycin therapy in thetreatment of MRSA infections, including dosing andmonitoring, current limitations of susceptibility testing,and the use of alternate therapies for th
12、ose patients withvancomycin treatment failure and infection due to strainswith reduced susceptibility to vancomycin. The guidelinesdo not discuss active surveillance testing or otherMRSA infectionprevention strategies in health care set-tings, which are addressed in previously publishedguidelines 1,
13、 2. Each section of the guidelines beginswith a specific clinical question and is followed bynumbered recommendations and a summary of themost-relevant evidence in support of the recom-mendations. Areas of controversy in which data areReceived 28 October 2010; accepted 17 November 2010.Correspondenc
14、e: Catherine Liu, MD, Dept of Medicine, Div of InfectiousDiseases, University of CaliforniaSan Francisco, San Francisco, California, 94102(catherine.liuucsf.edu).Clinical Infectious Diseases 2011;52(3):e18e55C211 The Author 2011. Published by Oxford University Press on behalf of theInfectious Diseas
15、es Society of America. All rights reserved. For Permissions,please e-mail:.1058-4838/2011/523-0001$37.00DOI: 10.1093/cid/ciq146e18dCID 2011:52 (1 February)dLiu et alby guest on March 3, 2016http:/cid.oxfordjournals.org/Downloaded from limited or conflicting and where additional research is needed ar
16、eindicated throughout the document and are highlighted in theResearch Gaps section. The key recommendations are summa-rized below in the Executive Summary; each topic is discussed ingreater detail within the main body of the guidelines.Please note that specific recommendations on vancomycindosing an
17、d monitoring are not discussed in the sections for eachclinical syndrome but are collectively addressed in detail inSection VIII.I. What is the management of skin and soft-tissue infections(SSTIs) in the era of community-associated MRSA (CA-MRSA)?SSTIs1. For a cutaneous abscess, incision and drainag
18、e is theprimary treatment (A-II). For simple abscesses or boils,incision and drainage alone is likely to be adequate, butadditional data are needed to further define the role ofantibiotics, if any, in this setting.2. Antibiotic therapy is recommended for abscessesassociated with the following condit
19、ions: severe or extensivedisease (eg, involving multiple sites of infection) or rapidprogression in presence of associated cellulitis, signs andsymptoms of systemic illness, associated comorbidities orimmunosuppression, extremes of age, abscess in an areadifficult to drain (eg, face, hand, and genit
20、alia), associatedseptic phlebitis, and lack of response to incision and drainagealone (A-III).3. For outpatients with purulent cellulitis (eg, cellulitisassociated with purulent drainage or exudate in the absence ofa drainable abscess), empirical therapy for CA-MRSA isrecommended pending culture res
21、ults. Empirical therapy forinfection due to b-hemolytic streptococci is likely to beunnecessary (A-II). Five to 10 days of therapy is recom-mended but should be individualized on the basis of thepatients clinical response.4. For outpatients with nonpurulent cellulitis (eg, cellulitiswith no purulent
22、 drainage or exudate and no associatedabscess), empirical therapy for infection due to b-hemolyticstreptococci is recommended (A-II). The role of CA-MRSA isunknown. Empirical coverage for CA-MRSA is recommendedin patients who do notrespond tob-lactam therapyand may beconsidered in those with systemi
23、c toxicity. Five to 10 days oftherapy is recommended but should be individualized on thebasis of the patients clinical response.5. For empirical coverage of CA-MRSA in outpatients withSSTI, oral antibiotic options include the following: clindamycin(A-II), trimethoprim-sulfamethoxazole (TMP-SMX) (A-I
24、I),a tetracycline (doxycycline or minocycline) (A-II), and linezolid(A-II). If coverage for both b-hemolytic streptococci andCA-MRSA is desired, options include the following:clindamycin alone (A-II) or TMP-SMX or a tetracycline incombination with a b-lactam (eg, amoxicillin) (A-II) or linezolidalon
25、e (A-II).6. The use of rifampin as a single agent or as adjunctivetherapy for the treatment of SSTI is not recommended (A-III).7. For hospitalized patients with complicated SSTI (cSSTI;defined as patients with deeper soft-tissue infections, surgical/traumatic wound infection, major abscesses, cellul
26、itis, andinfected ulcers and burns), in addition to surgical debridementand broad-spectrum antibiotics, empirical therapy forMRSA should be considered pending culture data. Optionsinclude the following: intravenous (IV) vancomycin (A-I), oral(PO) or IV linezolid 600 mg twice daily (A-I), daptomycin4
27、 mg/kg/dose IV once daily (A-I), telavancin 10 mg/kg/dose IVonce daily (A-I), and clindamycin 600 mg IV or PO 3 timesa day (A-III).Ab-lactam antibiotic (eg, cefazolin) may beconsidered in hospitalized patients with nonpurulent cellulitiswith modification to MRSA-active therapy if there is no clinica
28、lresponse (A-II). Seven to 14 days of therapy is recommendedbut should be individualized on the basis of the patientsclinical response.8. Cultures from abscesses and other purulent SSTIs arerecommended in patients treated with antibiotic therapy,patients with severe local infection or signs of syste
29、mic illness,patientswhohavenotrespondedadequatelytoinitialtreatment,and if there is concern for a cluster or outbreak (A-III).Pediatric considerations9. For children with minor skin infections (such as impetigo)and secondarily infected skin lesions (such as eczema, ulcers, orlacerations),mupirocin2%
30、topicalointmentcanbeused(A-III).10. Tetracyclines should not be used in children,8 years ofage (A-II).11. In hospitalized children with cSSTI, vancomycin isrecommended (A-II). If the patient is stable without ongoingbacteremia or intravascular infection, empirical therapy withclindamycin 1013 mg/kg/
31、dose IV every 68 h (to administer40 mg/kg/day) is an option if the clindamycin resistance rate islow (eg, ,10%) with transition to oral therapy if the strain issusceptible (A-II). Linezolid 600 mg PO/IV twice daily forchildren 12 years of age and 10 mg/kg/dose PO/IV every 8 hfor children ,12 years o
32、f age is an alternative (A-II).II. What is the management of recurrent MRSA SSTIs?Recurrent SSTIs12. Preventive educational messages on personal hygieneand appropriate wound care are recommended for all patientswith SSTI. Instructions should be provided to:i. Keep draining wounds covered with clean,
33、 dry bandages(A-III).ii. Maintain good personal hygiene with regular bathing andcleaning of hands with soap and water or an alcohol-basedMRSA Treatment GuidelinesdCID 2011:52 (1 February)de19by guest on March 3, 2016http:/cid.oxfordjournals.org/Downloaded from hand gel, particularly after touching i
34、nfected skin or an itemthat has directly contacted a draining wound (A-III).iii. Avoid reusing or sharing personal items (eg, disposablerazors, linens, and towels) that have contacted infected skin(A-III).13. Environmental hygiene measures should be consideredin patients with recurrent SSTI in the h
35、ousehold or communitysetting:i. Focus cleaning efforts on high-touch surfaces (ie, surfacesthat come into frequent contact with peoples bare skin eachday, such as counters, door knobs, bath tubs, and toilet seats)that may contact bare skin or uncovered infections (C-III).ii. Commercially available c
36、leaners or detergents appropriatefor the surface being cleaned should be used according to labelinstructions for routine cleaning of surfaces (C-III).14. Decolonization may be considered in selected cases if:i. A patient develops a recurrent SSTI despite optimizingwound care and hygiene measures (C-
37、III).ii. Ongoing transmission is occurring among householdmembers or other close contacts despite optimizing woundcare and hygiene measures (C-III).15. Decolonizationstrategiesshouldbeofferedinconjunctionwith ongoing reinforcement of hygiene measures and mayinclude the following:i. Nasal decolonizat
38、ion with mupirocin twice daily for 510days (C-III).ii. Nasal decolonization with mupirocin twice daily for 510days and topical body decolonization regimens with a skinantiseptic solution (eg, chlorhexidine) for 514 days or dilutebleach baths. (For dilute bleach baths, 1 teaspoon per gallonof water o
39、r cup per tub or 13 gallons of water givenfor 15 min twice weekly for C243 months can be considered.)(C-III).16. Oral antimicrobial therapy is recommended for thetreatment of active infection only and is not routinely re-commended for decolonization (A-III). An oral agent incombination with rifampin
40、, if the strain is susceptible, may beconsidered for decolonization if infections recur despite abovemeasures (CIII).17. In cases where household or interpersonal transmissionis suspected:i. Personal and environmental hygiene measures in thepatient and contacts are recommended (A-III).ii. Contacts s
41、hould be evaluated for evidence of S. aureusinfection:a. Symptomatic contacts should be evaluated and treated (A-III); nasal and topical body decolonization strategies may beconsidered following treatment of active infection (C-III).b. Nasal and topical body decolonization of asymptomatichousehold c
42、ontacts may be considered (C-III).18. The role of cultures in the management of patients withrecurrent SSTI is limited:i. Screening cultures prior to decolonization are notroutinely recommended if at least 1 of the prior infectionswas documented as due to MRSA (B-III).ii. Surveillance cultures follo
43、wing a decolonization regimenare not routinely recommended in the absence of an activeinfection (B-III).III. What is the management of MRSA bacteremia and infectiveendocarditis?Bacteremia and Infective Endocarditis, Native Valve19. For adults with uncomplicated bacteremia (defined aspatients with po
44、sitive blood culture results and the following:exclusion of endocarditis; no implanted prostheses; follow-upblood cultures performed on specimens obtained 24 daysafter the initial set that do not grow MRSA; defervescencewithin 72 h of initiating effective therapy; and no evidence ofmetastatic sites
45、of infection), vancomycin (A-II) or daptomycin6mg/kg/doseIVoncedaily(AI) for at least 2 weeks. Forcomplicated bacteremia (defined as patients with positive bloodculture results who do not meet criteria for uncomplicatedbacteremia), 46 weeks of therapy is recommended, dependingon the extent of infect
46、ion. Some experts recommend higherdosagesofdaptomycinat810mg/kg/doseIVoncedaily(B-III).20. For adults with infective endocarditis, IV vancomycin(A-II) or daptomycin 6 mg/kg/dose IV once daily (A-I) for 6weeks is recommended. Some experts recommend higherdosages of daptomycin at 810 mg/kg/dose IV onc
47、e daily(B-III).21. Addition of gentamicin to vancomycin is not recom-mended for bacteremia or native valve infective endocarditis(A-II).22. Addition of rifampin to vancomycin is not recommen-ded for bacteremia or native valve infective endocarditis (A-I).23. A clinical assessment to identify the sou
48、rce and extent ofthe infection with elimination and/or debridement of othersites of infection should be conducted (A-II).24. Additional blood cultures 24 days after initial positivecultures and as needed thereafter are recommended todocument clearance of bacteremia (A-II).25. Echocardiography is rec
49、ommended for all adultpatients with bacteremia. Transesophageal echocardiography(TEE) is preferred over transthoracic echocardiography (TTE)(A-II).26. Evaluation for valve replacement surgery is recommen-ded if large vegetation (.10 mm in diameter), occurrence of1 embolic event during the first 2 weeks of therapy, severevalvular insufficiency, valvular perforation or dehiscence,e20dCID 2011:52 (1 February)dLiu et alby guest on March 3, 2016http:/cid.oxfordjournals.org/Downloaded from decompensated heart failure, perivalvular or myocardi
