Semin Respir Crit Care Med 2015; 36(01): 017-030
DOI: 10.1055/s-0034-1397040
Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.

Treatment of Methicillin-Resistant Staphylococcus aureus: Vancomycin and Beyond

Natasha E. Holmes
1  Department of Infectious Diseases, Austin Centre for Infection Research, Heidelberg, Victoria, Australia
Steven Y. C. Tong
2  Department of Global and Tropical Health, Menzies School of Health Research, Darwin, Northern Territory, Australia
Joshua S. Davis
2  Department of Global and Tropical Health, Menzies School of Health Research, Darwin, Northern Territory, Australia
3  Department of Infectious Diseases, John Hunter Hospital, Newcastle, New South Wales, Australia
Sebastiaan J. van Hal
4  Department of Microbiology and Infectious Diseases, Royal Prince Alfred Hospital, Sydney, Australia
5  University of Western Sydney, Sydney, Australia
› Author Affiliations
Further Information

Publication History

Publication Date:
02 February 2015 (online)


There has been a welcome increase in the number of agents available for the treatment of methicillin-resistant Staphylococcus aureus (MRSA). Vancomycin remains an acceptable treatment option, with moves toward individualized dosing to a pharmacokinetic/pharmacodynamic (PK/PD) target. Numerous practicalities, however, would need to be resolved before implementation. Lipoglycopeptides as a class show excellent in vitro potency. Their long half-lives and complex PKs may preclude these agents being used in critically ill patients. Anti-MRSA cephalosporins provide great promise in the treatment of MRSA. These agents, despite broad-spectrum activity, should be reserved for patients with MRSA infections as it is likely that usage will be associated with increased rates of resistance. Daptomycin is currently the only antibiotic to have shown noninferiority to vancomycin in the treatment of MRSA bacteremia. The results of an open-labeled trial to address the superiority of daptomycin compared with vancomycin in reduced vancomycin susceptibility infections are eagerly anticipated. No drug to date has shown superiority to vancomycin in the treatment of MRSA infections with the possible exception of linezolid in hospital-acquired pneumonia (HAP), making linezolid an important option in the treatment of MRSA-proven HAP. Whether these strengths and features are agent or class specific are unclear but will likely be answered with the marketing of tedizolid. There are insufficient data to recommend either quinupristin/dalfopristin or tigecycline, as first line in the treatment of severe MRSA infections. These agents however remain options in patients with no other alternatives.