In this episode, I’ll discuss linezolid vs clindamycin for toxin inhibition in patients with invasive group A streptococcus infections.
In episode 962 I discussed a review that concluded clinicians can consider linezolid an appropriate alternative to clindamycin for necrotizing infections due to group A strep. Since then, the Lancet has published a retrospective study that adds more evidence to support this opinion.
The study was a retrospective analysis of over 1000 patients who received clindamycin or linezolid in a 3:1 ratio as an adjunct to beta lactam therapy for a group A strep infection. In this population, the receipt of linezolid was not associated with a statistically significant different absolute risk reduction of in-hospital mortality compared with clindamycin. This met the pre-specified criteria for non-inferiority. When subgroup and sensitivity analyses were applied, the results remained consistent. Secondary endpoints including median length of stay and C diff infection were not different between groups.
The authors concluded that linezolid appeared non-inferior to clindamycin suggesting linezolid as an alternative for adjunctive antitoxin therapy.
While this study was done using pre-existing data, it was performed in the style of an emulated clinical trial. This type of trial is suggested to reduce immortal time bias, selection bias, and even some confounding bias that is normally present in a retrospective review. Whether or not these results are more reliable than a traditional retrospective analysis, they do confirm existing data and add to the evidence that suggests linezolid is an appropriate alternative to clindamycin for reducing toxin production in group A strep patients.
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Assuming use of linezolid would preclude the need for vancomycin, am I correct? Seems like this would be a nice way to simplify care (I’m in the ER and find myself oftentimes ordering a ridiculous cocktail of 4-5 empiric abx on these patients)