Trimethoprim-sulfamethoxazole compared with vancomycin for the treatment of Staphylococcus aureus infection

Ann Intern Med. 1992 Sep 1;117(5):390-8. doi: 10.7326/0003-4819-117-5-390.

Abstract

Objective: To compare trimethoprim-sulfamethoxazole (TMP-SMZ) and vancomycin regarding efficacy and safety in the therapy of serious Staphylococcus aureus infections.

Design: Randomized, double-blind comparative trial.

Setting: A tertiary-care hospital.

Patients: One hundred and one intravenous drug users hospitalized with S. aureus infection.

Measurements: Cure and failure rates; blood and wound cultures; minimum inhibitory and bactericidal concentrations; serum inhibitory and bactericidal titers; temperature; leukocyte count; durations of treatment and hospitalization; and toxicity.

Results: Of 228 intravenous drug users, 101 had S. aureus infection and were included in the efficacy analysis (43 received TMP-SMZ and 58 received vancomycin). Methicillin-resistant S. aureus (MRSA) accounted for 47% of S. aureus isolates, and 65% of patients were bacteremic. Infections were cured in 57 of 58 vancomycin recipients and in 37 of 43 TMP-SMZ recipients (P less than 0.02). Failure occurred mostly in patients with tricuspid valve endocarditis and only in those with infection caused by methicillin-sensitive S. aureus (MSSA). The mean duration of bacteremia was 6.7 days in TMP-SMZ recipients and 4.3 days in vancomycin recipients. Among 222 subjects hospitalized for at least 24 hours, toxicity rates were similar for TMP-SMZ (23%) and vancomycin (20%) recipients; nausea and vomiting were associated with TMP-SMZ and inflammation at the intravenous site was associated with vancomycin. Forty-four percent of TMP-SMZ recipients and 29% of vancomycin recipients experienced side effects in the efficacy cohort (P greater than 0.05).

Conclusions: Vancomycin is superior to TMP-SMZ in efficacy and safety when treating intravenous drug users who have staphylococcal infections. However, all treatment failures occurred in patients with MSSA infection at any site. Therefore, TMP-SMZ may be considered as an alternative to vancomycin in selected cases of MRSA infection.

Publication types

  • Clinical Trial
  • Comparative Study
  • Randomized Controlled Trial
  • Research Support, Non-U.S. Gov't

MeSH terms

  • Adult
  • Bacteriophage Typing
  • Double-Blind Method
  • Female
  • Humans
  • Male
  • Methicillin Resistance
  • Microbial Sensitivity Tests
  • Prospective Studies
  • Staphylococcal Infections / drug therapy*
  • Staphylococcal Infections / etiology
  • Substance Abuse, Intravenous / complications
  • Treatment Outcome
  • Trimethoprim, Sulfamethoxazole Drug Combination / adverse effects
  • Trimethoprim, Sulfamethoxazole Drug Combination / therapeutic use*
  • Vancomycin / adverse effects
  • Vancomycin / therapeutic use*

Substances

  • Vancomycin
  • Trimethoprim, Sulfamethoxazole Drug Combination