From the Guidelines
For coagulase-negative staphylococcal (CoNS) infections, the first-line antibiotic treatment is typically vancomycin combined with rifampin and gentamicin, as recommended for a minimum of 6 weeks, with gentamicin limited to the first 2 weeks of therapy 1. When treating CoNS infections, it is crucial to consider the potential for methicillin resistance, particularly in cases where the infection develops within 1 year after surgery.
- Vancomycin and rifampin are the cornerstone of treatment, with gentamicin added for the initial 2 weeks to enhance bacterial clearance.
- The dosing of rifampin is conventional, and vancomycin should be administered with careful monitoring of renal function and therapeutic drug levels.
- For cases where the organism is resistant to gentamicin, an alternative aminoglycoside to which the organism is susceptible should be used, or a fluoroquinolone if the organism is susceptible to it 1.
- In patients with true penicillin allergy or methicillin-sensitive strains, alternatives such as nafcillin or oxacillin plus rifampin and gentamicin can be considered. Key considerations in the management of CoNS infections include the potential for biofilm formation on medical devices, which may necessitate device removal, and the high prevalence of antimicrobial resistance, which underscores the importance of susceptibility testing and tailored antibiotic therapy 1.
From the FDA Drug Label
- Comparator: vancomycin (1 g IV q12h) or an anti-staphylococcal semi-synthetic penicillin (i.e., nafcillin, oxacillin, cloxacillin, or flucloxacillin; 4 to 12 g/day IV in divided doses). *Comparators included intravenous therapy with either vancomycin, clindamycin, or an anti-staphylococcal semi-synthetic penicillin (nafcillin, oxacillin or cloxacillin) *Comparators included intravenous therapy with either vancomycin, cefazolin, or an anti-staphylococcal semi-synthetic penicillin (nafcillin, oxacillin or cloxacillin)
The antibiotics of choice for coagulase-negative Staphylococcal (CoNS) infections are not directly stated in the provided text. However, based on the comparators used in the clinical trials, the following antibiotics may be considered:
- Vancomycin
- Anti-staphylococcal semi-synthetic penicillins (e.g., nafcillin, oxacillin, cloxacillin, or flucloxacillin)
- Clindamycin
- Cefazolin 2
From the Research
Antibiotics of Choice for Coagulase-Negative Staphylococcal (CoNS) Infections
- The choice of antibiotic for CoNS infections depends on various factors, including the species of Staphylococcus, its resistance pattern, and the type of infected valve 3.
- For native valve endocarditis, penicillin G or a penicillinase-resistant penicillin (oxacillin) plus an aminoglycoside (gentamicin) may be recommended for penicillin-susceptible and penicillin-resistant, methicillin-susceptible strains, respectively 3.
- For methicillin-resistant strains, vancomycin may be used, with or without rifampin 3.
- Newer antibiotics, such as telavancin, daptomycin, linezolid, and tigecycline, have shown activity against CoNS, with daptomycin being effective against all isolates tested 4.
- Vancomycin remains a suitable option for empiric therapy in CoNS bloodstream infections, despite concerns about increasing MICs 5, 6.
- Other antibiotics, such as ciprofloxacin and linezolid, may also be effective against CoNS, but resistance has been reported 7.
Specific Antibiotic Options
- Vancomycin: remains appropriate empiric therapy for CoNS bloodstream infections, with MICs ≤4 µg/mL considered susceptible 5, 6.
- Daptomycin: shows high efficacy against CoNS, with no resistance observed in some studies 4, 7.
- Linezolid: may be effective against CoNS, but resistance has been reported, particularly with prolonged use 7.
- Telavancin: has shown activity against CoNS, with MICs 1-2 dilutions lower than vancomycin 4.
- Tigecycline: has shown activity against CoNS, with restricted within-species MIC variation 4.