Contemporary pharmacologic treatments of MRSA for hospitalized adults: rationale for vancomycin versus non-vancomycin therapies as first line agents

ABSTRACT

Introduction

Methicillin-resistant Staphylococcus aureus (MRSA) remains an important pathogen in the hospital setting and causes significant morbidity and mortality each year. Since the initial discovery over 60 years ago, vancomycin has remained a first-line treatment for many different types of MRSA infections. However, significant concerns related to target attainment and nephrotoxicity have spurred efforts to develop more effective agents in the last two decades.

Areas covered

Newer anti-MRSA antibiotics that have been approved since 2000 include linezolid, daptomycin, and ceftaroline. As clinical evidence has accumulated, these newer agents have become more frequently used, and some are now recommended as co-first-line options (along with vancomycin) in clinical practice guidelines. For this review, a scoping review of the literature was conducted to support our findings and recommendations.

Expert opinion

Vancomycin remains an important standard of care for MRSA infections but is limited with respect to nephrotoxicity and rapid target attainment. Newer agents such as linezolid, daptomycin, and ceftaroline have specific indications for treating different types of MRSA infections; however, newer agents also have unique attributes which require consideration during therapy.

KEYWORDS:

• Staphylococcus aureus
• methicillin-resistant Staphylococcus aureus (MRSA)
• treatment
• vancomycin
• comparative studies

Article highlights

• Methicillin-resistant Staphylococcus aureus (MRSA) remains a formidable and contemporary pathogen with over 100,000 attributable annual deaths per year worldwide.

• Vancomycin therapy has been a standard of care for MRSA since the 1980s, and vancomycin therapy is well known to be associated with kidney injury.

• Attributable vancomycin-induced kidney injury occurs with rates that exceed 10% even in the setting of drug monitoring and dose adjustment to reach therapeutic concentrations.

• Linezolid is an alternative option for MRSA, particularly for patients with pneumonia.

• Daptomycin remains a guideline-suggested therapy for non-lung infections (most notably bloodstream infections).

• Ceftaroline is a beta-lactam with activity against MRSA; however, clinical trials demonstrating efficacy against standards of care are lacking.

• Ceftobiprole is a beta-lactam with MRSA activity that was recently found to be non-inferior to daptomycin-based therapy for treatment of complicated S. aureus bacteremia in a clinical trial.

Declaration of interest

MS has previous research contracts with Nevakar and SuperTrans Medical; has filed patent US10688195B2; has served as a consultant for the following companies for GSK, Entasis, Cidara, Third Pole Therapeutics, F2G, AbbVie, Spero, Merck, and Takeda; and consulted in legal cases for Chambless, Higdon, Richardson, Katz & Griggs, LLP; Hall, Booth, Smith, P.C; and Reminger Co., L.P.A in the previous 24 months. All other authors have no other related conflicts of interest to declare.

The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed.

Reviewer disclosures

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

Additional information

Funding

This paper was not funded.