In this episode, I’ll discuss the antibiotics that inhibit bacterial toxin production.
Some bacteria produce microbial toxins that significantly contribute to infection severity. Notable examples include Clostridioides difficile, Staphylococcus aureus, and Streptococcus pyogenes.
During infection with these organisms, it is possible that therapies that suppress toxin production may lessen the severity of disease.
Because toxins are proteins, antibiotics that inhibit protein synthesis are good candidates for therapies that inhibit bacterial toxin production.
The antibiotics that are most widely used for this purpose are clindamycin, linezolid, and tetracyclines.
In most cases, an antibiotic given for the purpose of reducing toxin production is added to other antibiotics that are intended to cure the infection.
A recent review article published in AJHP detailed the role of toxin inhibition to treat C. diff, Staph aureus, and Strep infections.
Some guidelines include recommendations for adjunctive antibiotic use for the purpose of inhibiting toxin production:
Tigecycline has a weak recommendation in European C Diff guidelines when a patient is deteriorating or progressing to severe, complicated CDI. These guidelines specifically note tigecycline is in addition to anti-CDI antibiotic therapy.
Clindamycin is given a strong recommendation by the IDSA to be added to penicillin for treatment of documented group A streptococcal necrotizing fasciitis.
UK guidelines for MRSA pneumonia give a weak recommendation to consider the addition of toxin-inhibiting agent, such as clindamycin or rifampicin.
While not specifically mentioned in guidelines, linezolid also has evidence that suggests it is beneficial as adjunctive antitoxin therapy for strep bloodstream and skin infections.
The AJHP review gives the following dosing recommendations for antitoxin therapy:
Clindamycin when used for Staph/strep toxic shock syndrome given at a dose of 600 to 900 mg IV every 8 hours for 2-4 days
Linezolid when used for Staph/strep toxic shock syndrome given at a dose of 600 mg IV or PO every 12 hours for 2-4 days
Tigecycline when used for Severe C. difficile infection given at a dose of 100 mg IV × 1 followed by 50 mg IV every 12 hours for the duration of C. difficile treatment
The biggest conclusion from the AJHP review is that the authors feel based on available evidence that clinicians can consider linezolid an appropriate alternative to clindamycin for necrotizing infections due to S. aureus and S. pyogenes.
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