Methicillin-resistant Staphylococcus aureus necrotising skin and soft tissue infection
Methicillin-resistant Staphylococcus aureus (MRSA) is an uncommon cause of necrotising skin and soft tissue infection – seek expert advice.
In adults and children with MRSA necrotising skin and soft tissue infection, as a 2-drug regimen in combination with surgical debridement, use:
vancomycin intravenously; see below for duration of therapy vancomycin vancomycin vancomycin
adult: 25 mg/kg (actual body weight) rounded up to nearest 125 mg, up to 3 g intravenously, as a loading dose. See Calculated vancomycin loading dosage in critically ill adults for calculated weight-based loading doses. Subsequent doses are dependent on weight and kidney function; see Intermittent vancomycin dosing in critically ill adults
child: for initial dosing, see Intermittent vancomycin dosing in young infants and children
PLUS
clindamycin 600 mg (child: 15 mg/kg up to 600 mg) intravenously, 8-hourly1. Switch to oral clindamycin as tolerated (see dosage below). clindamycin clindamycin clindamycin
Clindamycin is recommended for MRSA necrotising skin and soft tissue infection because of a theoretical reduction in bacterial toxin production; however, clinical evidence is limited. When oral clindamycin is tolerated, replace intravenous clindamycin with:
clindamycin 450 mg (child: 10 mg/kg up to 450 mg) orally, 6-hourly until intravenous therapy is stopped. clindamycin clindamycin clindamycin
Duration of therapy: if infection was associated with Staphylococcus aureus bacteraemia, including sepsis and septic shock, continue intravenous vancomycin for at least 4 weeks.
If infection was not associated with S. aureus bacteraemia, continue intravenous vancomycin until further debridement is no longer necessary, there has been clinical improvement, and the patient has been afebrile for 48 to 72 hours. Once these criteria are met, switch to oral antibiotic therapy guided by susceptibility results. Continue oral therapy until the infection has resolved, but not necessarily until the wound has healed.