Evidence map›Paper›PMID 39396526›Full record

ArticleThe Lancet. Infectious diseases2025

Adjunctive linezolid versus clindamycin for toxin inhibition in β-lactam-treated patients with invasive group A streptococcal infections in 195 US hospitals from 2016 to 2021: a retrospective cohort study with target trial emulation.

Ahmed Babiker, Sarah Warner, Xiaobai Li, Emad A Chishti, Eltaib Saad, Bruce J Swihart, John P Dekker, Morgan Walker, Alexander Lawandi, Sameer S Kadri and 1 more

Erratum issuedAbstract readMulticenter StudyComparative Study
PubMed Full text at PMC Publisher
In one paragraph

Article in The Lancet. Infectious diseases, 2025. The graph could read no effect estimate from its abstract, so it casts no vote on the map. An erratum has been issued. Cited by 16 papers.

0numbers the graph read from it
0cells of the map it votes in
16citing papers in PubMed
–field-weighted citation impact
1 · What the graph read from it

What it found

Each row is one number read from the abstract, on the scale the paper reported it, with its interval. Left of the dashed line favours the treatment, right favours the comparator. Under each row is the sentence it came from. New to these charts? A ten-minute tutorial.

The abstract states no effect estimate the extractor could read, or names no intervention and outcome on the map, so this paper lights no cell and moves no belief. It is still indexed, cited and linked below.

2 · The registry

The trial behind it

Trials whose registry record cites this paper, or whose number appears in the abstract. A trial that started after this paper was published is citing it as background, not reporting it.

Neither the registry nor the abstract names a trial number. If this is a trial report, that itself is worth knowing.

3 · Its place in the literature

Who cites it

16 citing papers in PubMed.

  1. Article
  2. Article
  3. Article
  4. Article
  5. Review
  6. Article
  7. [Research progress on toxic shock syndrome due to group AZhongguo dang dai er ke za zhi = Chinese journal of contemporary pediatrics · 2026
    Review
  8. Top unanswered questions in antimicrobial management of necrotizing soft tissue infections.Antimicrobial stewardship & healthcare epidemiology : ASHE · 2026
    Review
  9. Can emulated trials in antimicrobial therapy replace randomized trials?Journal of the Association of Medical Microbiology and Infectious Disease Canada = Journal officiel de l'Association pour la microbiologie medicale et l'infectiologie Canada · 2025
    Article
  10. Article
  11. Article
  12. Review
  13. Molecular Characterization ofMicroorganisms · 2025
    Article
  14. Review
  15. Review
  16. Article
4 · The record

Corrections and comments

5 · Who and what money

Authors and funding

11 authors.

Ahmed BabikerDivision of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA; Department of Pathology and Laboratory Medicine, Emory University School of Medicine, Atlanta, GA, USA. Electronic address: ahmed.babiker@emory.edu.
Sarah WarnerClinical Epidemiology Section, Critical Care Medicine Department, National Institutes of Health Clinical Center, Bethesda, MD, USA; Critical Care Medicine Branch, National Heart Lung and Blood Institute, Bethesda, MD, USA.
Xiaobai LiDepartment of Biostatistics, National Institutes of Health Clinical Center, Bethesda, MD, USA.
Emad A ChishtiClinical Epidemiology Section, Critical Care Medicine Department, National Institutes of Health Clinical Center, Bethesda, MD, USA; Critical Care Medicine Branch, National Heart Lung and Blood Institute, Bethesda, MD, USA.
Eltaib SaadDepartment of Medicine, Ascension Saint Francis Hospital, Evanston, IL, USA.
Bruce J SwihartClinical Epidemiology Section, Critical Care Medicine Department, National Institutes of Health Clinical Center, Bethesda, MD, USA; Critical Care Medicine Branch, National Heart Lung and Blood Institute, Bethesda, MD, USA.
John P DekkerDepartment of Laboratory Medicine, National Institutes of Health Clinical Center, Bethesda, MD, USA; Laboratory of Clinical Immunology and Microbiology, National Institute of Allergy and Infectious Diseases, Bethesda, MD, USA.
Morgan WalkerClinical Epidemiology Section, Critical Care Medicine Department, National Institutes of Health Clinical Center, Bethesda, MD, USA; Critical Care Medicine Branch, National Heart Lung and Blood Institute, Bethesda, MD, USA.
Alexander LawandiClinical Epidemiology Section, Critical Care Medicine Department, National Institutes of Health Clinical Center, Bethesda, MD, USA; Laboratory of Clinical Immunology and Microbiology, National Institute of Allergy and Infectious Diseases, Bethesda, MD, USA; Division of Infectious Diseases, Department of Medicine, McGill University Health Centre, Montréal, QC, Canada.
Sameer S KadriClinical Epidemiology Section, Critical Care Medicine Department, National Institutes of Health Clinical Center, Bethesda, MD, USA; Critical Care Medicine Branch, National Heart Lung and Blood Institute, Bethesda, MD, USA. Electronic address: Sameer.kadri@nih.gov.
NIH-Antimicrobial Resistance Outcomes Research Initiative

Funding

Antibacterial Resistance Leadership Group (ARLG)UM1AI104681 · NIAID · DUKE UNIVERSITY · PI Vance G. Fowler, Henry F HENRY CHAMBERS · 2013 to 2026
$180.8M
Big Data - Epidemiology of Critical Illness and SepsisZIACL090045 · CLC · CLINICAL CENTER · PI KADRI, SAMEER · 2017 to 2025
$0k
Intramural NIH HHS ZIA CL090045NIAID NIH HHS UM1 AI104681
6 · The paper itself

Abstract

backgroundAdjunctive clindamycin use is associated with survival in invasive group A streptococcus (GAS) infections but increasing clindamycin resistance in GAS has called into question its durability for this indication. Linezolid also inhibits GAS toxin and virulence factor production, but clinical efficacy data remain sparse.

methodsWe retrospectively emulated a target multicentre, non-blinded, non-inferiority trial to assess the efficacy of adjunctive linezolid compared with clindamycin in adult inpatients with invasive GAS infection treated with a β-lactam using the PINC AI database between 2016 and 2021. Patients were eligible if they had a monomicrobial GAS culture and received adjunctive therapy within 3 days of culture either concurrently or after β-lactam initiation and completed at least 3 days of β-lactam therapy. The primary outcome was adjusted risk ratio (aRR) of in-hospital mortality assessed by overlap-weighting using propensity scores. Secondary outcomes were length of stay among survivors and Clostridium difficile infection.

findingsOf 1095 β-lactam-treated patients with GAS, 829 (76%) received clindamycin and 266 (24%) received linezolid. In the overlap weighted cohort, the receipt of linezolid was not associated with a statistically significant different aRR of in-hospital mortality compared with clindamycin (linezolid: 9·8% [26/266] vs clindamycin: 7·0% [58/829]; aRR: 0·92 [95% CI 0·42 to 1·43]; p=0·76). The risk difference was -0·005 (95% CI -0·05 to 0·04; p=0·81) and fell within the non-inferiority margin of 0·05. The primary analysis results were consistent across important subgroups and sensitivity analyses. Among survivors, median length of stay (adjusted ratio 0·96 [95% CI 0·16 to 0·08]; p=0·47) and C difficile infection risk (aRR 1·76 [95% CI 0·37 to 1·75]; p=0·29) were not statistically significantly different between the two groups.

interpretationIn this emulated trial of adult patients with invasive GAS infections treated with β-lactam, linezolid appeared non-inferior to clindamycin suggesting linezolid as an alternative for adjunctive antitoxin therapy.

fundingThe Intramural Research Program of the US National Institutes of Health Clinical Center and the National Institute of Allergy and Infectious Disease.

Indexed as

Anti-Bacterial Agentsbeta-LactamsClindamycinLinezolidStreptococcal InfectionsStreptococcus pyogenesAdultAgedFemaleHospital MortalityHospitalsHumansLength of StayMaleMiddle AgedRetrospective StudiesAnti-Bacterial Agentsbeta-LactamsClindamycinLinezolid

Identifiers

PMID39396526
PMCPMC11871996

What OpenQuestion holds

Textmetadata
LicenceTDM
Read underepoch 390

Registered trials

None linked

Read under generation 80e0d062 · epoch 390. Bibliography from PubMed, PubMed Central and OpenAlex; grants from NIH RePORTER; trial links from ClinicalTrials.gov; estimates, votes and beliefs from the OpenQuestion graph.