Infectious Disease

Linezolid safe, effective for treating necrotizing soft tissue infections

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Disclosures:
The authors report no relevant financial disclosures.

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Key takeaways:

  • There was no difference in rates of 30-day mortality for patients treated with clindamycin plus vancomycin vs. linezolid.
  • More acute kidney injury occurred in patients treated with clindamycin plus vancomycin.

Treating patients with necrotizing soft tissue infections with either clindamycin plus vancomycin or linezolid resulted in similar clinical outcomes, according to a study published in Open Forum Infectious Diseases.

“Our antimicrobial stewardship team evaluated all clindamycin usage in an effort to eliminate this antibiotic in our adult populations, if possible, due to its strong association with Clostridioides difficile infection,” Erin K McCreary, PharmD, clinical assistant professor of medicine at the University of Pittsburgh, told Healio.

IDN0523Dorazio_Graphic_01_WEB

Dorazio J, et al. Open Forum InfectDis. 2023;doi:10.1093/ofid/ofad258.

“We also were in the middle of a multifaceted effort to decrease vancomycin utilization. This led us to explore necrotizing soft tissue infections (NSTI), which are associated with high morbidity and mortality and all patients presenting get at least two, often three to four, empiric antibiotics including clindamycin and vancomycin,” she said.

According to McCreary, data supporting clindamycin use in this indication is “not robust.” She added that it has been hypothesized that another protein synthesis inhibitor, linezolid, would have similar ability to inhibit toxin production in these serious infections as clindamycin does.

Erin K McCreary

“Linezolid has the benefit of also eliminating the need for the addition of vancomycin (which we hypothesized would reduce acute kidney injury in this population), greater empirical susceptibility rates for gram-positive pathogens that may cause these infections and less incidence of C. difficile infection,” McCreary said. “Therefore, we updated an order set to use linezolid for this indication and evaluated safety and efficacy before and after this change.”

McCreary and colleagues performed a retrospective, single-center, quasi-experimental study of patients admitted during a preintervention period — June 1, 2018, to June 30, 2019 —and a postintervention period — May 1, 2020, to October 15, 2021 — who received surgical management within 24 hours of NSTI diagnosis and at least one dose of linezolid or clindamycin. The primary endpoint of the study was death at 30 days, although researchers also assessed rates of acute kidney injury or C. difficile infection.

In total, 274 patients were identified using an admission diagnosis code for NSTI or Fournier’s gangrene, 164 of whom met the study inclusion criteria, yielding 62 matched pairs for evaluation.

Overall, the researchers found that there was no difference in rates of 30-day mortality between the study periods (8.06% vs. 6.45%; HR = 1.67; 95% CI, 0.32-10.73), or in C. difficile infections (6.45 % vs. 1.61%). Researchers found, however, that there were more instances of acute kidney injury in the preintervention group (9.68% vs 1.61%, HR=6; 95% CI, 0.73-276).

Based on these results, McCreary concluded that “Linezolid is safe for use in NSTI with similar clinical outcomes as clindamycin plus vancomycin.”

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