More on pneumonia: Treatment of MRSA in community acquired pneumonia

BMJ 2006; 332 doi: https://doi.org/10.1136/bmj.332.7553.1334 (Published 01 June 2006) Cite this as: BMJ 2006;332:1334
  1. James Greig (James.Greig{at}PHNT.swest.nhs.uk), consultant microbiologist,
  2. Peter Jenks, consultant microbiologist
  1. Department of Microbiology, Derriford Hospital, Plymouth PL6 8DH
  2. Department of Microbiology, Derriford Hospital, Plymouth PL6 8DH

    EDITOR—Hoare and Lim's update on the diagnosis and management of community acquired pneumonia does not mention methicillin resistant Staphylococcus aureus (MRSA),1 which is becoming more common in the community as a true community associated organism, in patients in residential care, and in those discharged from hospital. Patients who have newly acquired MRSA often develop further infections unless carriage is cleared. One study showed that in the 18 months after first colonisation, over one quarter of individuals developed further MRSA infections, many of which were pneumonias.2 All MRSA strains are resistant to penicillins and cephalosporins; over 90% of hospital associated strains are resistant to quinolones, and over 70% are resistant to erythromycin and clarithromycin.3 Treatment regimens advised in the article are inappropriate when MRSA is a likely pathogen.

    At Plymouth Hospitals NHS Trust in the past year 39% of all MRSA bacteraemias presented in the community, nearly half of all serious MRSA infections were in patients not previously known to be colonised, and nearly 20% of residents of nursing homes admitted to the orthopaedic service were colonised. With such high levels of unidentified carriage in the community, empirical treatment for MRSA pneumonia in many groups at risk seems prudent.

    Recent UK MRSA treatment guidelines advise the use of vancomycin or linezolid for proved MRSA pneumonia.3 Doxycyline is well tolerated and over 95% of MRSA strains are sensitive to it, as well as most of the atypical pathogens that Hoare and Lim suggest should be treated with the poorly tolerated antibiotic erythromycin or its more expensive relative clarithromycin.

    Although not mentioned in the British Thoracic Society's guidelines, in Plymouth doxycyline is used in addition to a penicillin to treat atypical pathogens. This has the additional benefit of providing some activity against unidentified MRSA infections. When conventional antibiotic treatment has failed or in patients who are intolerant of penicillins, an oral respiratory quinolone (levofloxacin) is used. In such patients who are at increased risk of MRSA infection—for example, elderly people or patients with a history of carriage, etc—we suggest intravenous vancomycin or linezolid be added as it should be for patients with severe pneumonia who are at risk. When MRSA pneumonia is subsequently confirmed, conversion to a regimen as recommended in the UK guidelines would be appropriate in most patients.

    With rising rates of MRSA infections in the community we urge other providers to consider the use of empirical treatment with a tetracycline or vancomycin in community acquired pneumonia in high risk patients when MRSA cannot be ruled out.


    • Competing interests None declared


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