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Is Linezolid Really Superior to Vancomycin for Ventilator-Associated MRSA Pneumonia?

Linezolid for MRSA pneumonia: beyond the hype.

Methicillin-resistant Staphylococcus aureus (MRSA) is an increasingly common cause of nosocomial pneumonia. In an industry-supported study, researchers in the U.S. and Spain analyzed data on patients with MRSA ventilator-associated pneumonia (VAP) from two randomized, double-blind trials in which vancomycin was compared with linezolid (both plus aztreonam) in patients with nosocomial pneumonia. These studies, designed to forward the approval of linezolid, involved 1019 patients. Among the 544 with VAP, S. aureus was isolated from 221, including 91 with MRSA.

Survival rates for linezolid and vancomycin recipients were 79.1% and 73.7%, respectively, for all VAP patients (P=0.15); 78.2% and 70.3% for S. aureus VAP patients (P=0.19); and 84.1% and 61.7% for MRSA VAP patients (P=0.02). Logistic regression analysis showed linezolid therapy to be an independent predictor of survival in MRSA VAP and of clinical cure in S. aureus and MRSA VAP. The authors concluded that linezolid yielded higher survival and clinical cure rates than did vancomycin in MRSA VAP patients. Similar results from the same data were published previously for all forms of MRSA-associated nosocomial pneumonia (see Chest 2003; 124:1789).

Comment: Vancomycin has poor penetration into lung tissue and limited antibiotic activity overall. Alternatives are urgently needed. Nonetheless, the results of this analysis must be interpreted cautiously because of unbalanced comorbidities in the MRSA VAP subgroup (diabetes and cardiac disease were significantly more prevalent in vancomycin recipients than in linezolid recipients) and lack of a significant survival difference in all S. aureus VAP cases. An adequately powered prospective trial to compare vancomycin with linezolid for treatment of MRSA pneumonia is warranted.

— Thomas Glück, MD

Published in Journal Watch Infectious Diseases March 12, 2004

Citation(s):

Kollef MH et al. Clinical cure and survival in gram-positive ventilator-associated pneumonia: Retrospective analysis of two double-blind studies comparing linezolid with vancomycin. Intensive Care Med 2004 Mar; 30:388-94.

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