Vre

• Community-acquired MRSA Minocycline

• Community-acquired/hospital-associated MRSA

Staphylococcal infections Osteomyelitis

Acute bacterial endocarditis

Central nervous system shunt infections

• Stenotrophomonas (Xanthomonas) maltophilia

• Burkholderia (Pseudomonas) cepacia

• MDR Acinetobacter baumannii

• Neuroborreliosis

* In adults with normal hepatic/renal function, not intolerant/allergic to the drug. Adapted from Cunha BA, editor. Antibiotic essentials. 5th edition. Royal Oak (MI): Physicians' Press; 2006.

100 mg (IV/PO) every 12 hours. Alternatively, in keeping with its pharma-cokinetic and pharmacodynamic characteristics, doxycycline may be administered as a single daily 400-mg IV/PO dose for 3 days, then decreased to the usual 100 mg (IV/PO) dose to complete the course of therapy [15,88-90].

Doxycycline is approximately five times more lipid soluble than conventional tetracycline, permitting good central nervous system penetration. Doxycycline is as effective as ceftriaxone in neuroborreliosis [91].

Minocycline

Minocycline has essentially the same spectrum of activity against microorganisms as doxycycline, with a few important exceptions. In contrast to doxycycline, minocycline has both excellent anti-MSSA and MRSA activity [1,81,92]. Aside from linezolid, minocycline is the only orally available antibiotic with a high degree of activity against MRSA [93-98]. Minocycline is also active against nonaeruginosa pseudomonads (ie, S [Pseudomonas] mal-tophilia, Burkholderia [Pseudomonas/Xanthomonas] cepacia). S maltophilia and B cepacia are low virulent organisms that commonly colonize secretions (eg, respiratory secretions in intubated patients), draining wounds, pleural fluid, and urine. These organisms rarely cause infections; when they do occur, it is usually in the setting of impaired host defenses or chronic lung diseases such as cystic fibrosis and bronchiectasis. These organisms rarely, if ever, cause ventilator-associated pneumonia in normal or compromised hosts. When treatment against S maltophilia/B cepacia is required, therapeutic options are limited to TMP-SMX, meropenem, cefepime, and minocycline. TMP-SMX and minocycline are the only orally administered antibiotics with activity against these organisms [99-102].

Although minocycline's spectrum of in vitro activity closely resembles that of doxycycline, because of its vestibular side effects, it has not been used extensively in all the infections where doxycycline has been used. Compared with doxycycline, minocycline has better central nervous system penetration [1,15,103]. On the basis of pharmacokinetic considerations, minocycline is the preferred tetracycline to use for central nervous system infections, namely shunt infections due to susceptible organisms (MSSA/ MRSA or coagulase-negative staphylococci, central nervous system infections, or neuroborreliosis). Minocycline has also been used for the oral treatment of MSSA/MRSA acute bacterial endocarditis in intravenous drug abusers. It has been employed in IV-to-PO switch programs in the treatment of staphylococcal infections, when a potent, inexpensive oral anti-MSSA/MRSA agent is required (Box 4) [15,93,98,104].

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