From the Guidelines
The next best step for this 48-year-old male with persistent MRSA infection of the bilateral hands would be to initiate intravenous vancomycin therapy, typically dosed at 15-20 mg/kg every 12 hours, with subsequent dose adjustments based on trough levels (aim for 15-20 μg/mL for serious infections). This recommendation is based on the patient's failure to respond to multiple oral antibiotics including Bactrim, Keflex, and Clindamycin, suggesting a more resistant infection requiring parenteral therapy 1. Before starting vancomycin, wound cultures with susceptibility testing should be obtained to confirm the continued presence of MRSA and rule out other pathogens or development of additional resistance.
Some key points to consider in the management of this patient include:
- The importance of surgical consultation for possible debridement of infected tissue, as persistent hand infections may harbor purulent collections requiring drainage 1.
- The need for close monitoring of renal function and vancomycin levels to prevent toxicity, as vancomycin can cause nephrotoxicity 1.
- The potential for transition to oral therapy once improvement is demonstrated, with options including linezolid, clindamycin, or doxycycline/minocycline, depending on the patient's clinical response and susceptibility testing results 1.
- The consideration of other treatment options, such as daptomycin or ceftaroline, in cases where vancomycin is not suitable or effective 1.
Overall, the management of this patient requires a comprehensive approach, including antimicrobial therapy, surgical intervention, and close monitoring to ensure optimal outcomes and prevent complications.
From the FDA Drug Label
The FDA drug label does not answer the question.
From the Research
Treatment of Persistent MRSA Infection
The patient has a persistent Methicillin-resistant Staphylococcus aureus (MRSA) infection of the bilateral hands, despite initial treatment with Trimethoprim/Sulfamethoxazole (Bactrim), Cephalexin (Keflex), and Clindamycin. The next best step is to prescribe Linezolid 600 mg BID for 10 days and follow-up in 14 days.
Rationale for Linezolid Treatment
- Linezolid has been shown to be effective in treating MRSA infections, including complicated skin and soft-tissue infections (cSSTI) 2, 3, 4, 5.
- A study published in 2009 found that linezolid-based salvage therapy was effective in eradicating S. aureus from the blood in patients with persistent MRSA bacteremia 6.
- Another study published in 2010 found that linezolid was more likely to achieve microbiologic eradication in MRSA evaluable patients compared to vancomycin 4.
- Linezolid has been shown to be well-tolerated, with common adverse events including gastrointestinal tract-related symptoms, such as nausea, vomiting, and diarrhea 3, 4, 5.
Key Considerations
- The patient's infection has persisted despite initial treatment with other antibiotics, making linezolid a suitable alternative 6, 2, 3, 4, 5.
- The patient will require close follow-up to monitor the effectiveness of the treatment and potential adverse events 3, 4, 5.
- Linezolid may be associated with a higher risk of thrombocytopenia, nausea, diarrhea, and possibly anemia, which should be monitored during treatment 4.