This protocol covers the management of adult inpatients hospitalised with community-acquired pneumonia (CAP) who have locally validated risk factors for MRSA — a scenario in which empiric coverage must extend beyond the standard CAP regimen.
Empiric MRSA coverage is indicated in adult CAP inpatients when specific locally validated risk factors are present. The evidence-supported risk factors are:
Empiric MRSA coverage is not recommended as routine practice for all CAP patients — only when these risk factors have been identified.
The regimen adds empiric MRSA-directed coverage on top of standard CAP therapy. Microbiological sampling — including cultures and nasal PCR — is obtained at the outset to allow for deescalation or confirmation of ongoing need at 48 hours.
Treatment targets clinical stability, defined as resolution of vital sign abnormalities (heart rate, respiratory rate, blood pressure, oxygen saturation, and temperature), ability to eat, and return to normal mentation. Most patients are expected to reach stability within 48 to 72 hours; therapy continues for a minimum of 5 days total.
DOI: 10.1164/rccm.201908-1581ST
We recommend clinicians only cover empirically for MRSA or P. aeruginosa in adults with CAP if locally validated risk factors for either pathogen are present (strong recommendation, moderate quality of evidence).
The most consistently strong individual risk factors for respiratory infection with MRSA or P. aeruginosa are prior isolation of these organisms, especially from the respiratory tract, and/or recent hospitalization and exposure to parenteral antibiotics.
Add MRSA coverage and obtain cultures/nasal PCR to allow deescalation or confirmation of need for continued therapy.
We recommend that the duration of antibiotic therapy should be guided by a validated measure of clinical stability (resolution of vital sign abnormalities [heart rate, respiratory rate, blood pressure, oxygen saturation, and temperature], ability to eat, and normal mentation), and antibiotic therapy should be continued until the patient achieves stability and for no less than a total of 5 days (strong recommendation, moderate quality of evidence).
As most patients will achieve clinical stability within the first 48 to 72 hours, a total duration of therapy of 5 days will be appropriate for most patients.
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