Assessment of Therapeutic Approaches: Necrotizing Soft Tissue Infections and the Choice Between Vancomycin + Clindamycin and Linezolid

<b><i>Background:</i></b> Necrotizing skin and soft tissue infections (NSTIs) are life threatening, requiring antibiotic agents and surgical intervention. Clindamycin or linezolid is recommended as an adjunct therapy for toxin mediation; however, limited data are comparing clindamycin-based to linezolid-based regimens in NSTI. <b><i>Methods:</i></b> This single-center retrospective study included adults with NSTI admitted to the intensive care unit (ICU) at the University of Kentucky HealthCare for surgical debridement between January 2017 and June 2023. Patients were excluded if they received antibiotic agents for <24 hours, underwent surgical debridement at an outside hospital, or were readmitted within the study period. The primary outcome was the number of debridements before source control. Secondary outcomes included time to source control, acute kidney injury (AKI) rates, ICU length of stay, and antibiotic duration. <b><i>Results:</i></b> A total of 242 patients were included with 199 receiving clindamycin and 43 receiving linezolid. There was no difference observed in the number of surgical debridements between the clindamycin and linezolid cohorts ([2.0 (2, 4) vs. 3.0 (2, 4)]; p = 0.219). The multi-variable regression identified independent parameters that predicted a significant increase in number of debridements included sequential organ failure assessment score (1.03 [1.003, 1.047]; p = 0.028), culture(s) positive for <i>Streptococcus anginosus, Streptococcus constellatus</i>, or <i>Streptococcus intermedius</i> (1.309 [1.042, 1.629]; p = 0.018), and <i>Bacteroides</i> spp. (1.301 [1.048, 1.602]; p = 0.015). No differences were observed in AKI ([53.8% vs. 60.8%], p = 0.424), ICU stay ([5.3 vs. 6.1 d]; p = 0.399), or antibiotic duration between vancomycin, clindamycin, and linezolid ([5.6 vs. 5.6 vs. 6.7 d]; p = 0.683), respectively. <b><i>Conclusions:</i></b> Linezolid resulted in a similar number of surgical debridements compared with clindamycin in NSTI patients.