REVIEW
SA JOURNAL OF DIABETES & VASCULAR DISEASE
38
VOLUME 11 NUMBER 1 • MARCH 2014
Table 1.
Management of invasive S. aureus infections.
Types of infection
Antibiotics used
Duration
Other comments
Skin and soft tissue infections
MSSA
MRSA
Spondylodiscitis
MSSA
MRSA
Osteomyelitis
MSSA
MRSA
Prosthetic joint infection
(PJI)
51,45
MSSA
MRSA
Flucloxacillin 1–2 g 6 h iv
Vancomycin iv aiming for trough levels
of 15–20 mg/l OR
Teicoplanin iv after loading aiming for a
trough levels of 20-40 mg/l
Flucloxacillin 2g 6 h iv
Vancomycin iv aiming for trough levels
of 15–20 mg/l OR
Teicoplanin iv after loading aiming for a
trough levels of 20–40 mg/l
Flucloxacillin 2g 6 h iv
Vancomycin iv aiming for trough levels
of 15–20 mg/l OR
Teicoplanin iv after loading aiming for a
trough levels of 20–40 mg/l
PJI following debridement and
retention of the prosthesis
Flucloxacillin 2 g 6 h iv and rifampin
300–450 mg 12 h
Vancomycin iv aiming for trough levels
of 15–20 mg/l OR
Teicoplanin daily iv after loading aiming
for a trough level of 20–40 mg/l and
oral rifampin 300–450mg 12 h
The above regime is followed by
rifampin plus a companion oral drug
(quinolone, doxycycline, co-trimoxa-
zole).
PJI following 1-stage exchange as
above
PJI following resection arthroplasty
with or without planned staged
reimplantation as above
Duration variable
10–21 days
Duration variable both
between and within
centres. Minimum length
ranging from 6 to 12
weeks
The optimal duration
of antibiotic therapy is
not certain.
Generally 4-12 weeks
Duration variable.
2–6 weeks of iv followed
by oral regime.
2–6 weeks of iv followed
by oral regime
4–6 weeks
Duration may be longer in severe infections. Linezolid
and daptomycin could be considered for severe infections
where risk of MRSA bacteraemia is high.
54
Once daily anti-staphylococcal agents such as ceftriaxone,
teicoplanin and daptomycin may be particularly suited for
OPAT.
Debridement of necrotic tissue and vascular surgical review
may be required for severe diabetic foot infections. If the
infection is deemed polymicrobial and where MRSA is con-
sidered to be an important pathogen, monotherapy with
tigecycline may be considered as an alternative.
54
Consider PVL
S aureus
infections if patients present with
hypotension, leucopenia, raised CK, a history of recurrent
boils and have features of pyomyositis, necrotising fasciitis
and TSS. Refer to text for treatment.
6 weeks of iv followed by 6 weeks of oral antibiotics is the
commonly chosen course.
49
Drugs such as clindamycin,
rifampicin, cotrimoxazole, fusidic acid and fluoroquinolones
have good intra-osseous penetration and oral bioavailability
and when used in combination may provide effective oral
therapy.
49
OPAT options as above.
Immobilisation is advocated when pain is significant or
there is a risk of spinal instability.
49
See text for indications for surgical interventions.
Oral and OPAT options as above.
Surgical review may be required for bone debridement ±
amputation.
Most experts favour continuing parenteral antimicrobial
therapy at least until debrided bone has been covered by
vascularised soft tissue, which is usually at least six weeks
from the last debridement.
89
In diabetic foot infections with osteomyelitis when a
radical resection leaves no remaining infected tissue, only
2–5 days of antibiotics may be required. When there is
persistent infected or necrotic bone, ≥ 4 weeks antibiotic
treatment may be required.
81
Total duration of antibiotics used in general: THA 3 months
and TKA 6 months recommended. Elbow, ankle, shoulder
infections treated similar to THA.
45
Daptomycin 6 mg/kg iv 24 h or linezolid 600 mg po/iv 12 h
could be used as alternative treatment.
45
Rifampicin is an agent with excellent oral bioavailability that
achieves high concentrations in biofilms. Should never be
used alone due to rapid emergence of resistance.
51
Total of 3 months antibiotics recommended.
45
Highly bioavailable oral regime could be used to complete
course of antibiotics.
45
