Evidence for the treatment of methicillin-resistant Staphylococcus aureus (MRSA) pneumonia with trimethoprim-sulfamethoxazole (TMP-SMX), clindamycin, doxycycline, or minocycline was found to be based on limited data, according to a systematic review published in the Annals of Pharmacotherapy.

Currently, the Infectious Disease Society of America (IDSA) recommends vancomycin and linezolid for the treatment of MRSA pneumonia, although the former has been associated with low clinical success rates and the latter with significant toxicities. To investigate the effectiveness of alternative therapies, the authors conducted a literature search (1946 to May 20, 2019) for studies in which TMP-SMX, clindamycin, doxycycline or minocycline were used as part of a treatment regimen for MRSA pneumonia.

A total of 16 articles were included in the analysis (6 TMP-SMX, 8 clindamycin, 0 doxycycline, and 2 minocycline). For TMP-SMX, prospective randomized trials and retrospective studies showed inconsistent results with limitations including sample size and potential bias, however, the authors noted these studies were not designed to evaluate treatment outcomes for MRSA pneumonia specifically.

Although recommended as a second line agent for MRSA pneumonia, evidence for the use of clindamycin as monotherapy or in combination with other antibiotics was found to be limited. “If clindamycin is to be considered for MRSA pneumonia treatment, it is important to ensure that the isolate is susceptible and D-testing is used to rule out any inducible resistance because S aureus susceptibilities to clindamycin have decreased to 40% over the past few years in the United States,” the authors stated. As for the tetracyclines, support for the use of minocycline was based on data from limited retrospective studies.

“Even though TMP-SMX, clindamycin, doxycycline, and minocycline have good bioavailability and lung penetration, which are ideal characteristics, the evidence for their use in MRSA pneumonia remains indeterminate,” the study authors concluded. “Clinicians should base their preference to use these agents on susceptibility results and determine their utility on a case-by-case basis.” They added that further clinical studies are needed to validate the effectiveness of these agents.

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This article originally appeared on MPR