Clindamycin Plus Vancomycin Has Similar Mortality Rate vs Linezolid for NSTIs

There is a growing need for new therapeutic options that are both safe and effective in treatment of necrotizing soft tissue infections.

Patients who receive clindamycin plus vancomycin vs linezolid in combination with standard gram-negative, anaerobic therapy and surgical debridement for the treatment of necrotizing soft tissue infections (NSTI) show no difference in 30-day mortality, according to study findings published in Open Forum Infectious Diseases.

Researchers conducted a retrospective, single-center, quasi-experimental study compared the 2 therapies in patients with NSTI at an academic tertiary referral center from June 2018 to June 2019 (preintervention) and May 2020 to October 2021 (postintervention). All participants received surgical management within 24 hours of NSTI diagnosis and at least 1 dose of linezolid or clindamycin.

The primary endpoint was 30-day mortality at any time as an inpatient or following discharge. The participants in the preintervention period were matched with a participant in the postintervention period.

A total of 164 participants were included — 62 participants received treatment in the preintervention period and 102 received treatment in the postintervention period. Before matching, the median age was similar between those in the 2 groups (58.5 years [32% women] preintervention vs 56 years [50% women] postintervention).

It builds upon previous work demonstrating that linezolid was a safe and effective alternative to clindamycin plus vancomycin for a surgical population and for patients with documented u003cemu003eS pyogenesu003c/emu003e infections.

No difference in 30-day mortality rate was observed in the matched cohort (8.06% vs 6.45%; hazard ratio [HR], 1.67; 95% CI, 0.32-10.73; P =.65). No difference was found in Clostridioides difficile infection (CDI) (6.45% vs 1.61%; HR, Inf; 95% CI, 0.66-Inf; P =.07), although acute kidney injury (AKI) was more common in the preintervention group (9.68% vs 1.61%; HR, 6; 95% CI, 0.73-276; P =.05).

The preintervention group had a higher rate of the composite outcome of death, AKI, or CDI within 30 days (14 [22.58%] vs 6 [9.68%]; HR, 4.67; 95% CI, 1.30-25.33; P =.02).

No differences were observed in the matched cohort regarding total duration of antibiotic exposure, time to leukocytosis resolution and discontinuation of vasopressors, and intensive care unit or hospital length of stay. An increased number of patients in the preintervention group had inpatient mortality within 60 days of surgery (7 [11.29%] vs 3 [4.84%]; HR 5.00; 95% CI, 0.56-236; P =.22).

A culture positive for group A Streptococcus was found in 5 participants in the preintervention group and 3 participants in the postintervention group. No participants died in the preintervention group, and 1 participant died in the postintervention group.

Limitations include that the study design was not adequately powered to conduct a multivariable regression to determine factors associated with 30-day mortality; the postintervention group occurred during the COVID-19 pandemic when hospital care paradigms changed; and 46% of postintervention group participants received 1 day of clindamycin before switching to linezolid.

The study authors concluded, “To our knowledge, this is the largest published clinical study comparing clindamycin and vancomycin vs linezolid for the treatment of NSTI.” They continued, “The population was high acuity and received early surgical intervention. It builds upon previous work demonstrating that linezolid was a safe and effective alternative to clindamycin plus vancomycin for a surgical population and for patients with documented S pyogenes infections.”

This article originally appeared on Dermatology Advisor


Dorazio J, Chiappelli AL, Shields RK, et al. Clindamycin plus vancomycin versus linezolid for treatment of necrotizing soft tissue infection. Open Forum Infect Dis. Published online May 11, 2023. doi:10.1093/ofid/ofad258