Discharge Criteria for CAP with MRSA
Discharge a patient with community-acquired MRSA pneumonia when they are clinically stable with hemodynamic stability, afebrile for 48-72 hours, oxygen saturation >90% on room air for 12-24 hours, able to tolerate oral antibiotics, and have a safe discharge environment—without waiting for complete radiographic resolution. 1
Core Clinical Stability Requirements
Your patient must meet ALL of the following criteria before discharge:
- Temperature ≤37.8°C for 48-72 hours 1
- Heart rate ≤100 beats/min 1
- Respiratory rate ≤24 breaths/min 1
- Systolic blood pressure ≥90 mmHg without vasopressor support 1
- Oxygen saturation ≥90% on room air for at least 12-24 hours 1
- Normal or baseline mental status 1
- Able to tolerate oral medications with functioning GI tract 1
MRSA-Specific Considerations
CA-MRSA pneumonia presents unique challenges that may prolong hospitalization, including necrotizing pneumonia, cavitary lesions, and severe sepsis that require extended monitoring even after initial clinical improvement. 2, 3
- Patients with necrotizing pneumonia or cavitary disease should demonstrate sustained clinical improvement for at least 48-72 hours before discharge, as these complications can deteriorate rapidly. 3, 4
- Hemoptysis, if present initially, must have completely resolved before discharge consideration. 2, 3
- Ensure adequate source control if empyema or complicated parapneumonic effusion was present—chest tube should be removed for 12-24 hours without clinical deterioration. 1
Transition to Oral Therapy
Switch from IV to oral antibiotics once the patient meets clinical stability criteria—you do NOT need to wait for complete defervescence or radiographic improvement. 1
- Linezolid is the preferred oral agent for CA-MRSA pneumonia due to superior outcomes compared to vancomycin in pneumonia. 5, 4
- Alternative oral options include doxycycline or a respiratory fluoroquinolone if the isolate is susceptible. 1
- Conversion to oral therapy is preferred over outpatient parenteral therapy when possible. 1
Common Pitfalls to Avoid
Do NOT delay discharge waiting for chest radiograph normalization—radiographic improvement lags behind clinical recovery by weeks, and repeating CXR before discharge in a clinically improving patient is unnecessary. 1, 6
Do NOT continue IV antibiotics unnecessarily once oral tolerance is established—this increases line-related complications, costs, and length of stay without improving outcomes. 1, 6
Do NOT discharge if any instability criteria persist—mortality increases dramatically with each unresolved instability marker (10.5% with zero instabilities vs 46.2% with two or more). 7
Do NOT assume the patient needs extended hospitalization just because MRSA is involved—if clinical stability criteria are met and oral therapy is tolerated, discharge is appropriate. 1
Duration of Antibiotic Therapy
- Minimum 5 days of total antibiotic therapy is required, but most CA-MRSA pneumonia cases require 7-14 days depending on severity and complications. 1, 6
- Longer courses (2-4 weeks) are needed for necrotizing pneumonia, empyema, or bacteremia. 1, 4
- Patients should be afebrile for 48-72 hours and have no more than 1 CAP-associated sign of clinical instability before stopping antibiotics. 1
Discharge Planning and Follow-Up
Arrange clinical follow-up at 6 weeks with either primary care or pulmonary clinic to assess for complete resolution and exclude underlying malignancy, especially in smokers over 50. 1, 6
- Obtain follow-up chest radiograph at 4-6 weeks to establish new baseline and exclude underlying pathology—NOT before discharge. 6
- Ensure the patient can tolerate and comply with the home antibiotic regimen before discharge. 1
- Address any barriers to care including home observation capability, medication compliance, and follow-up availability. 1
- Provide patient education about warning signs requiring return to emergency department (worsening dyspnea, fever recurrence, hemoptysis). 1