Considering Alternatives to Vancomycin for MRSA

Rachel Britt, PharmD, BCIDP, clinical practice specialist, Infectious Diseases, University Health System, says vancomycin has a storied history with a long track record that demonstrates it noninferiority against other, newer antibiotics for treatment of MRSA. However, the antibiotic does have its limitations.

“I would argue it's one of our most durable agents for MRSA infections over the years, but it's a more narrow therapeutic index drug,” Britt said. “There are some toxicities associated with it, and a pretty heavy lift when it comes to therapeutic drug monitoring.”

These toxicity concerns combined with a limited understanding of vancomycin dosing especially in an era AUC (Area Under the Curve) and MIC (Minimum Inhibitory Concentration) makes it less attractive as a therapeutic option, she stated.

In terms of finding the right agent for patients, Britt reminds clinicians that there are other options and that diagnostics and making therapeutic adjustments are key.

“Vancomycin monotherapy has not really been the standard,” Britt said. “And fortunately, we have some other options, like combination therapy, daptomycin and ceftaroline, and other agents that are used in those cases...Vancomycin has not been the only first line recommended agent for MRSA bacteremia in the guidelines since 2011 so I know some people think that vancomycin, you have to start there, and that's the way to go, but that's not necessarily what the guidelines currently say. There are some concerns with other newer agents, specifically daptomycin with treatment emergent resistance. So, I still see a lot of providers starting with vancomycin.”

“I would advise to choose your therapy based on the clinical progression of the patient. If their cultures are clearing or not, how ill they are and how well they're doing, to really decide what therapy you're going to switch to or continue on…A lot of times, vancomycin alternatives are a really great when you're transitioning out of the hospital. So vancomycin logistically is very difficult and has increased risk of harms when you're doing it in an OPAT setting. So daptomycin is a great agent for that when it's a once-a-day dosing.”

Reference
Britt R. Should Vancomycin Be Replaced in the MRSA Guidelines? Presented at IDWeek 2025. October 19-22, 2025. Atlanta, GA.