Empirical therapy for high-severity Staphylococcus aureus (staphylococcal) pneumonia
Aliberti, 2016Charles, 2008Kalil, 2016
These recommendations are for patients with high-severity pneumonia or clinical features suggesting aggressive staphylococcal infection when Staphylococcus aureus has been identified by culture of blood or sputum. While awaiting results of susceptibility testing, use combination therapy. When the results of susceptibility testing are available, use directed therapy for methicillin- or penicillin-susceptible S. aureus or methicillin-resistant S. aureus.
When treating patients with S. aureus bacteraemia and staphylococcal pneumonia, consider both the recommendations in this topic and the recommendations in Staphylococcus aureus bacteraemia, including sepsis and septic shock.
For empirical therapy of high-severity pneumonia or clinical features suggesting aggressive staphylococcal infection in adults and children, as a 2-drug regimen, use:
1cefazolin 2 g (child: 50 mg/kg up to 2 g) intravenously, 6-hourly. For dosage adjustment in adults with kidney impairment, see cefazolin dosage adjustment cefazolin cefazolin cefazolin
OR
1flucloxacillin 2 g (child: 50 mg/kg up to 2 g) intravenously, 4-hourly. For dosage adjustment in adults with kidney impairment, see flucloxacillin intravenous dosage adjustment flucloxacillin flucloxacillin flucloxacillin
PLUS, with either of the above drugs, one of the following
1vancomycin intravenously vancomycin vancomycin vancomycin
adult: 25 mg/kg (actual body weight) rounded up to nearest 125 mg, up to 3 g, 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 for critically ill adults
child: for initial dosing, see Intermittent vancomycin dosing for young infants and children
OR
2linezolid intravenously linezolid linezolid linezolid
adult: 600 mg, 12-hourly. For dosage adjustment in adults with kidney impairment, see linezolid dosage adjustment
child younger than 12 years: 10 mg/kg up to 600 mg intravenously, 8-hourly.
Accumulating evidence suggests that cefazolin is as effective as flucloxacillin for the treatment of methicillin-susceptible S. aureus pneumonia and may have lower risk of acute kidney injury. However, there are no published randomised controlled trials comparing cefazolin with flucloxacillin for this indication.
Use linezolid if vancomycin is not suitable (eg use of vancomycin is precluded due to vancomycin toxicity, therapeutic drug monitoring is not feasible).
For patients who have had a nonsevere (immediate or delayed) or a severe immediate1 hypersensitivity reaction to a penicillin, use a cefazolin-based regimen (see dosage above).
For patients who have had a severe delayed2 hypersensitivity reaction to a penicillin, use vancomycin as monotherapy (see dosage above). Alternatively, if vancomycin is not suitable (eg use of vancomycin is precluded due to vancomycin toxicity, therapeutic drug monitoring is not feasible), use linezolid (see dosage above).