Linezolid versus vancomycin for skin and soft tissue infections

  • Review
  • Intervention

Authors


Abstract

Background

The morbidity and treatment costs associated with skin and soft tissue infections (SSTIs) are high. Linezolid and vancomycin are antibiotics that are commonly used in treating skin and soft-tissue infections, specifically those infections due to methicillin-resistant Staphylococcus aureus (MRSA).

Objectives

To compare the effects and safety of linezolid and vancomycin for treating people with SSTIs.

Search methods

In May 2013 we conducted searches of the following databases: Cochrane Wounds Group Specialised Register; The Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library); Ovid MEDLINE; Ovid MEDLINE (In-Process & Other Non-Indexed Citations); Ovid EMBASE; and EBSCO CINAHL. We also contacted manufacturers for details of unpublished and ongoing trials. We scrutinised citations within all obtained trials and major review articles to identify any additional trials.

Selection criteria

We included all randomised controlled trials (RCTs) comparing linezolid with vancomycin in the treatment of SSTIs.

Data collection and analysis

Two review authors independently selected trials, assessed risk of bias and extracted data. The primary outcomes were clinical cure, microbiological cure, and SSTI-related and treatment-related mortality. We performed subgroup analyses according to age, and whether the infection was due to MRSA.

Main results

We included nine RCTs (3144 participants). Linezolid was associated with a significantly better clinical (RR 1.09, 95% CI 1.03 to 1.16) and microbiological cure rate in adults (RR 1.08, 95% CI 1.01 to 1.16). For those infections due to MRSA, linezolid was significantly more effective than vancomycin in clinical (RR 1.09, 95% CI 1.03 to 1.17) and microbiological cure rates (RR 1.17, 95% CI 1.04 to 1.32). No RCT reported SSTI-related and treatment-related mortality. There was no significant difference in all-cause mortality between linezolid and vancomycin (RR 1.44, 95% CI 0.75 to 2.80). There were fewer incidents of red man syndrome (RR 0.04, 95% CI 0.01 to 0.29), pruritus (RR 0.36, 95% CI 0.17 to 0.75) and rash (RR 0.27, 95% CI 0.12 to 0.58) in the linezolid group compared with vancomycin, however, more people reported thrombocytopenia (RR 13.06, 95% CI 1.72 to 99.22), and nausea (RR 2.45, 95% CI 1.52 to 3.94) when treated with linezolid. It seems, from the available data, that length of stay in hospital was shorter for those in the linezolid group than the vancomycin group. The daily cost of outpatient therapy was less with oral linezolid than with intravenous vancomycin. Although inpatient treatment with linezolid cost more than inpatient treatment with vancomycin per day, the median length of hospital stay was three days shorter with linezolid. Thus, total hospital charges per patient were less with linezolid treatment than with vancomycin treatment.

Authors' conclusions

Linezolid seems to be more effective than vancomycin for treating people with SSTIs, including SSTIs caused by MRSA. The available evidence is at high risk of bias and is based on studies that were supported by the pharmaceutical company that makes linezolid. Further well-designed, independently-funded, RCTs are needed to confirm the available evidence.

Plain language summary

Antibiotic drugs for treating skin and soft tissue infections

Skin and soft tissue infections such as impetigo, abscesses, ulcers, and surgical site infections are common infections of the skin. For serious skin and soft tissue infections involving the deeper tissues, the death rate and treatment costs are high. Linezolid and vancomycin are antibiotics that are effective in treating skin and soft tissue infections, particularly infections caused by bacteria that have developed resistance to some antibiotics. This review identified nine RCTs, with a total of 3144 participants, and compared treatment with linezolid against treatment with vancomycin for skin and soft tissue infections. Linezolid was found to be more effective than vancomycin for treating these infections. There were fewer skin complications in the group that were treated with linezolid. There were no differences between the two groups in the number of reported deaths, and those treated with linezolid had shorter lengths of hospital stay than those treated with vancomycin. The daily cost of outpatient therapy was less with oral linezolid than with intravenous vancomycin, although for inpatient treatment, linezolid was more expensive than vancomycin. Well-designed trials will be required in future to confirm these results, as the trials from which these conclusions were drawn were of poor methodological quality, at high risk of bias, and were funded by the pharmaceutical company that makes linezolid.

Laički sažetak

Antibiotici za liječenje infekcija kože i mekih tkiva

Česte infekcije koje se javljaju na području kože i mekih tkiva su impetigo, apsces, ulkusi te infekcija na mjestu kirurškog zahvata. Stopa smrtnosti i cijena liječenja visoki su kod ozbiljnijih infekcija u kojima su zahvaćena dublja tkiva. Linezolid i vankomicin su se pokazali kao učinkoviti antibiotici za liječenje infekcija kože i mekih tkiva, posebno onih stanja uzrokovanih bakterijama koje su razvile rezistenciju na neke od drugih antibiotika. U ovom je Cochrane sustavnom pregledu uključeno devet randomiziranih kontroliranih ispitivanja s ukupno 3144 ispitanika u kojima je uspoređivana terapija linezolidom u odnosu na vankomicin za liječenja infekcija kože i mekih tkiva. Linezolid je učinkovitiji od vankomicina za liječenje takvih infekcija. U grupi ispitanika liječenih linezolidom utvrđeno je manje komplikacija vezanih uz kožu. Između dvije grupe ispitanika nije bilo razlike u broju prijavljenih smrtnih slučajeva, no kod ispitanika liječenih linezolidom period hospitalizacije je bio kraći. Dnevni trošak ambulantnog liječenja je manji uz primjenu oralnog linezolida nego intravenskog vankomicina; no za bolničko liječenje, linezolid je skuplji u odnosu na vankomicin. Za potvrdu ovakvih rezultata bit će potrebno provesti dodatna, dobro osmišljena ispitivanja, budući da su trenutno dostupni podaci istraživanja loše metodološke kvalitete, te visokog rizika pristranosti jer su financirani od strane farmaceutske tvrtke koja proizvodi linezolid.

Bilješke prijevoda

Hrvatski Cochrane
Prevela: Maja Kišan
Ovaj sažetak preveden je u okviru volonterskog projekta prevođenja Cochrane sažetaka. Uključite se u projekt i pomozite nam u prevođenju brojnih preostalih Cochrane sažetaka koji su još uvijek dostupni samo na engleskom jeziku. Kontakt: cochrane_croatia@mefst.hr

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