Evaluation of treatment options for methicillin-resistant Staphylococcus aureus infections in the obese patient

Figures & data

Table 1 Summary of antibiotic characteristics for agents used to treat methicillin-resistant Staphylococcus aureus infections

Drug class	Drug	Pharmacodynamic target	Typical adult dosage	Dosage in obesity	Evidence to support altered dosing strategy*
Cephalosporin	Ceftaroline	T>MIC	600 mg IV every 12 hours	Consider 600 mg every 8 hours dosing if there is concern of inadequate exposure in severe MRSA infections	+
Lincosamide	Clindamycin	T>MIC	300–900 IV every 6–8 hours (maximum; 2,700 mg/day) 150–600 mg PO every 6 hours	Consider 900 mg every 8 hours or at least 10 mg/kg/day depending on infection severity	+
Glycopeptide	Vancomycin	AUC:MIC; T>MIC	Maintenance dose: 15–20 mg/kg IV every 8–12 hours	Consider 20–25 mg/kg loading dose, then 10–15 mg/kg IV every 12 hours (maximum single dose of 2 g and maximum total daily dose of 4.5 g); adjusted by TDM for AUC targets Consider empiric dosing nomogram by Crass et al followed by TDM for AUC targets^Citation48	+++
Lipoglycopeptide	Dalbavancin	AUC:MIC	1,000 mg IV followed by 500 mg IV one week later OR 1,500 mg IV once	No dosage adjustment	+
	Oritavancin	AUC:MIC	1,200 mg IV once	No dosage adjustment	++
	Telavancin	AUC:MIC, Cmax:MIC	10 mg/kg IV every 24 hours	No dosage adjustment; consider dose cap of 750–1,000 mg	++
Cyclic lipopeptides	Daptomycin	AUC:MIC, Cmax:MIC	4–10 mg/kg IV every 24 hours	Consider dosing based on adjusted body weight or capping at 1 g Clinicians should weigh the risk/benefit of potential underdosage when using adjusted body weight or dose capping	++
Tetracycline	Doxycycline	AUC:MIC	100–200 mg IV/PO twice daily	No dosage adjustment	ND
Glycylcycline	Tigecycline	AUC:MIC	100 mg IV loading dose followed by 50 mg IV twice daily	Consider higher dose; 200 mg IV loading dose followed by 100 mg twice daily; however, may have increased nausea and vomiting or other toxicities	+
Oxazolidinone	Linezolid	AUC:MIC, T>MIC	600 mg IV/PO every 12 hours	No dosage adjustment	+
	Tedezolid	AUC:MIC	200 mg IV/PO every 24 hours	No dosage adjustment	+
Sulfonamide	Trimethoprim-sulfamethoxazole	AUC:MIC	1–2 double strength tablets twice daily	Consider higher end of the typical dosing; aim for at least 5 mg/kg/day for skin and skin structure infections^a	+

Notes: *+Pharmacokinetic studies OR observational studies. ++Pharmacokinetic studies PLUS observational studies. +++Pharmacokinetic studies plus several observational/outcome studies. ^aMore serious MRSA infections such as bacteremia should not be treated with trimethoprim/sulfamethoxazole. Limit use to skin and skin structure infections.

Abbreviations: AUC, area under the curve; AUC:MIC, area under the curve to minimum inhibitory concentration ratio; C_max:MIC, maximum drug concentration to minimum inhibitory concentration ratio; TDM, therapeutic drug monitoring; IV, intravenous; PO, by mouth; ND, no data; T>MIC, time above the minimum inhibitory concentration.

Crass RL, Dunn R, Hong J, Krop LC, Pai MP. Dosing vancomycin in the super obese: less is more. J Antimicrob Chemother. 2018;73(11):3081–3086.30203073

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