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Methicillin-resistant Staphylococcus aureus in Cystic Fibrosis
Table 1: Drugs and Dosages for the Most Frequently Used Anti-MRSA Therapy in Cystic Fibrosis Patients
(Assuming Normal Renal Function)
5,6,9,50,51
Antibiotic Administration Route Dosage Number of Daily Administrations
Sodium fusidate Oral <5 years 250mg/day 3
5–12 years 500mg/day
>12 years 750mg/day
Rifampin Oral, IV 15mg/kg/day 2
Vancomycin IV 40mg/kg/day 3
Teicoplanin IV 10mg/kg/day 1
Linezolid Oral, IV (<5 years) 30mg/kg/day 3
Linezolid Oral, IV (>5 years) 20mg/kg/day 2
Ciprofloxacin Oral 20–30mg/kg/day 2
Ciprofloxacin IV 15–30mg/kg/day 2
Tobramycin IV 10mg/kg/day 3
TMP-SMX Oral Trimethoprim 8–10mg/kg/day 2
TMP-SMX IV Trimethoprim 10–20mg/kg/day 4
Minocycline Oral, IV 4mg/kg/day 2
Doxycycline Oral 4.4mg/kg/day 2
Clindamycin oral 20–30mg/kg/day 3–4
IV = intravenous; TMP-SMX = trimethoprim–sulfamethoxazole.
the airways in five of seven CF adults in one study.
44
Treatment treated for a long time has been reported.
10
Unlike what has been
schedules with the same drugs, in combination with topical 2% verified for chronic infections due to other pathogens, the utility of
mupirocin to the anterior nostrils for five days and, possibly, repeated chronic suppressive antibiotic treatment has not yet been studied in
administrations, have been demonstrated to be effective.
47
Nebulised CF patients who chronically harbour MRSA in their airways.
and topical vancomycin has been shown to be efficacious in clearing
MRSA.
39
The use of nebulised vancomycin has nevertheless been Infection Control
criticised because of the possibility of the selection of strains Current medical opinion underlines that CF patients with MRSA infection
resistant to the drug, so this mode of administration is not included in should be segregated from each other and all other people with
the guidelines regarding vancomycin.
48
Recently, the possibility of CF
.6,10,52–54
The transmission of MRSA between patients with CF has been
eradicating MRSA with oral linezolid, a bacteriostatic agent of the documented both in hospital environments and in outpatients. The
oxazolidinone family, has been reported.
10
A European consensus percentage of MRSA isolates is higher in hospitalised CF patients than in
report suggests that it is important to try to eradicate MRSA, but the non-hospitalised CF patients. Even though MRSA is usually a bacterium
evidence on which the recommendations are based is not derived colonising the patient’s nostrils, it can also contaminate the surfaces of
from randomised clinical studies.
2
Other authoritative publications furniture in hospital rooms, and spreading in this way has been
reinforce suggestions regarding MRSA eradication.
24
described. Every CF clinic should have a microbiological surveillance
policy that considers the cross-infection risk of MRSA.
6
Recently
CF patients who are experiencing acute pulmonary exacerbations published guidelines on infection control in CF recommend the adoption
require parenteral antibiotic treatment (see Table 1), and vancomycin of proper isolation measures for CF patients infected with MRSA.
52–54
CF
is considered a first-choice drug for MRSA infections.
5,6,24
In patients patients infected or colonised with MRSA should be listed as requiring
with respiratory exacerbations, as with therapy for other types of contact precautions by healthcare personnel, in addition to the standard
infections, it is suggested to use vancomycin in combination with precautions that have an essential role in preventing multidrug-resistant
another antibiotics such as gentamicin or rifampin.
2,5,6
Other drugs organism transmission in the healthcare setting.
6,10,52–54
that could be used as alternatives to vancomycin have less activity
against the responsible bacteria and should be used only after Hand hygiene (washing or disinfection with alcohol rubs) is an
susceptibility testing.
5
Quinolone resistance seems to develop easily important component of standard precautions, and many studies
during treatment. The use of quinolones can be considered a risk demonstrate a temporal relationship between improved adherence to
factor for acquiring MRSA.
49
Their empirical use should be avoided, recommended hand hygiene practices and control of multidrug-
limiting their use to patients who are in well-defined protocols for resistant organism transmission.
5,6,52–54
In several reports, cohorting of
early eradication of Pseudomonas aeruginosa and patients patients, cohorting of staff, use of designated beds or units and even
chronically infected by P. aeruginosa with mild respiratory unit closure were reported as necessary to control transmission. The
exacerbations. Other antibiotics active against MRSA, such as CDC guidelines on the management of multidrug-resistant organism
trimethoprim–sulfamethoxazole and minocycline, can be used for transmission in healthcare settings suggest that donning gown and
patients who do not tolerate well or who experience adverse effects gloves upon room entry and discarding before exiting the patient
from vancomycin or when exacerbations are mild.
5
Linezolid has room is useful in containing pathogens.
15,52–54
However, there are
comparable bioavailability after both oral and parenteral limited data regarding the impact of contact precautions on CF
administration. Although experience with this drug in CF patients is patients, and evidence of effectiveness is scarce. One study found
limited, the possibility of using a drug either orally or parenterally that patients placed on contact precautions for MRSA expressed
is important. The use of linezolid among CF patients with MRSA greater dissatisfaction with their treatment and had significantly more
infection requires further investigation, particularly with regard to preventable adverse events and less documented care than control
safety.
10
Recently, the emergence of resistance to linezolid in a child patients who were not in isolation.
55
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EUROPEAN RESPIRATORY DISEASE 57
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