Methicillin-Resistant Staphylococci and Their Treatment in the Intensive Care Unit

Abstract

Methicillin resistance in Staphylococcus aureus (MRSA) and the coagulase-negative staphylococci (MRCNS) is widespread and continues to increase in prevalence, particularly in the health care setting. The clinical significance of methicillin resistance for patients with staphylococcal infections is not clear: studies in patients with bacteremia, pneumonia, and mediastinitis show a higher mortality with MRSA infection compared to methicillin-sensitive Staphylococcus aureus (MSSA) infection, though this may be due to underlying patient, pharmacodynamic, or microbiological differences. For serious methicillin-resistant staphylococcal infections, vancomycin-based regimens are preferred. Treatment alternatives for patients with severe methicillin-resistant infections who are unable to tolerate vancomycin include linezolid and quinupristin/dalfopristin; these agents should be considered second-line options, given the relative lack of clinical experience and the nonsignificant but consistent trends toward worse outcomes in bacteremia and pneumonia with these agents compared to vancomycin. For less severe infections, treatment options also include trimethoprim-sulfamethoxazole, or fluoroquinolones in combination with rifampin.

Vacuum-Assisted Closure for Mediastinitis after Pediatric Cardiac Surgery

“…Despite the established treatments for deep sternal wound infection, including antibiotic therapy, surgical debridement, closed irrigation, delayed closure, and plastic reconstruction with muscle and omental flaps, MRSA mediastinitis after open-heart surgery is still associated with a high mortality rate. 2,3 Since the introduction of VAC by Argenta and Morykwas 1 in 1997, it has become widely accepted in the management of difficult wounds. 4,5 The principle of this treatment is based on uniform negative pressure applied to the wound, resulting in arteriolar dilatation, thus promoting granulation tissue proliferation.…”

Role of Folate Antagonists in the Treatment of Methicillin-Resistant Staphylococcus aureus Infection

“…Notably absent in this series of patients were patients with a large collection of pus and left-sided endocarditis, which is more severe and difficult to treat. There was a high failure rate in treatment of lung abscesses, which is of concern because most lung abscesses clear with appropriate therapy [91], and the comparitor drug was vancomycin, which is less effective than cloxacillin in treatment of patients with MSSA pneumonia and bacteremia (8 of 17 deaths with vancomycin vs. 0 of 10 deaths with cloxacillin) [29,92]. Similarly, when examining vancomycin efficacy for staphylococcal endocarditis in patients and experimental models [, 83, 93-96], vancomycin is consistently and significantly less effective than b-lactam antibiotics.…”

Gram-Positive Cocci Infections in Intensive Care

“…Therapeutic Problems Related to cover infections caused by S. epidermidis or meticil-Gram-Positive Cocci Infections in lin-resistant CoNS. [15] These changes in the empiri-Critically Ill Patients Admitted to the cal strategies have been associated with an impor-Intensive Care Unit (ICU) tant increase in the use of cephalosporins and glycopeptides, which have contributed to the ap-The management of Gram-positive cocci infecpearance of cephalosporin-resistant S. pneumoniae tions in critically ill patients presents some limitastrains and the selection of Staphylococcus spp. tions.…”