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Severe Community Acquired Pneumonia (SCAP) is broadly defined as CAP that requires ICU admission. Although MRSA pneumonia is overall quite rare (1), it is associated with a high mortality rate. Therefore, empiric MRSA coverage is commonly used for patients with SCAP. Common empiric agents include vancomycin and linezolid. Linezolid has both pharmacologic and clinical data that suggest it may be a preferred option for many patients.
When approaching a patient with SCAP, a key consideration is whether empiric MRSA coverage is needed. Risk factors for MRSA pneumonia include prior MRSA infection or colonization, recurrent skin infections, post-influenza pneumonia, recent hospitalization or antibiotic use (1).
If empiric MRSA coverage is determined to be needed, Linezolid offers several advantages for the treatment of SCAP. Highlights below:
- Linezolid has 100% oral bioavailability which can be especially useful for those patients with difficult IV access
- Linezolid has better lung epithelial lining penetration compared to vancomycin (6)
- In direct comparison between linezolid and vancomycin for confirmed MRSA pneumonia, linezolid was shown to have improved microbiologic cure rates without an improvement in mortality (2, 7)
- Linezolid was shown to have less nephrotoxicity than vancomycin (2, 7)
Side effects to consider with linezolid include:
- Serotonin syndrome, although extremely rare (5). May consider discussion with your pharmacist if taking additional serotonergic agents.
- Myelosuppression (typically thrombocytopenia), although usually with longer treatment courses. This study shows no significant difference in rates of thrombocytopenia compared to vancomycin (4).
If providing linezolid for treatment of SCAP:
- Dose: Linezolid 600mg IV or PO q12 hours
- Ideally should obtain blood cultures, sputum culture, MRSA nares prior to (or closely following) antibiotic administration