Review of meta-analyses of vancomycin compared with new treatments for Gram-positive skin and soft-tissue infections: are we any clearer?

Vancomycin has been considered the standard of care for treatment of Gram-positive skin and soft-tissue infections (SSTIs). Its value has been questioned over the last decade owing to well acknowledged limitations in efficacy and tolerability and the emergence of newer meticillin-resistant Staphylococcus aureus (MRSA)-active antibacterial agents. However, no single agent has shown better results versus vancomycin in SSTI trials. The aim of this review was to identify and summarise data from meta-analyses (MAs) for the treatment of Gram-positive and MRSA SSTIs. A systematic search identified 21 published MAs examining the use of newer antibiotics and vancomycin in SSTIs. In terms of clinical and microbiological efficacy, linezolid (in Gram-positive and MRSA SSTIs) and telavancin (in MRSA SSTIs) were shown to be more effective than vancomycin. The safety of newer antimicrobials in general was comparable with vancomycin, except for telavancin, which was associated with more severe adverse events (AEs), and tigecycline owing to an all-cause mortality imbalance observed in all infections but not confirmed in SSTIs. Specific AEs were related to the use of newer agents, such as nephrotoxicity for telavancin, creatine phosphokinase elevations for daptomycin, and thrombocytopenia with linezolid. Some evidence suggests that daptomycin could be associated with reduced treatment duration, and linezolid with reduced length of intravenous treatment and hospital length of stay compared with vancomycin. Considering the limitations of this type of research and the comparative efficacy results demonstrated in head-to-head randomised controlled trials, data are still not sufficient to support the widespread use of new agents over vancomycin.