Cloxacillin plus fosfomycin versus cloxacillin alone for methicillin-susceptible Staphylococcus aureus bacteremia: a randomized trial

Treatment failure occurs in about 25% of patients with methicillin-susceptible Staphylococcus aureus (MSSA) bacteremia. We assessed whether cloxacillin plus fosfomycin achieves better treatment success than cloxacillin alone in hospitalized adults with MSSA bacteremia. We conducted a multicenter, op...

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Authors: Grillo, S., Pujol, M., Miró, J.M., López-Contreras, J., Euba, G., Gasch, O., Boix-Palop, L., García Pais, María José, Perez Rodriguez, Maria Teresa, Gomez-Zorrilla, S., Oriol, I., López-Cortés, L.E., Pedro-Botet, M.L., San-Juan, R., Aguado, J.M., Gioia, F., Iftimie, S., Morata, L., Jover-Sáenz, A., García-Pardo, G., Loeches, B., Izquierdo-Cárdenas, Á., Goikoetxea, A.J., Gomila-Grange, A., Dietl, B., Berbel, D., Videla, S., Hereu, P., Padullés, A., Pallarès, N., Tebé, C., Cuervo, G., Carratalà, J., Rivera, M.A., Aguirregabiria, M., Rodríguez-Álvarez, R., Blanco Vidal, Maria, Alguacil-Guillen, M., Xercavins, M., Pomar, V., Siverio-Parés, A., de Cueto, M., Moreno-Mellado, E., Sousa Dominguez, Adrián, Vasallo Vidal, Francisco José, Borjabad, B., Coloma-Conde, A., Clivillé-Abad, R., González-di Lauro, S.X., Tiago-Silva, J., Orellana, M.A., Ruíz-Bastián, M., Vizcarra, P., Garcia, C., Ballester, F., Ramírez-Hidalgo, M.F., Bellés-Bellés, A., Meije, Y., Ribera, A., LLaberia, J., Domínguez, M.Á., Rigo-Bonnin, R.F., Horna, G., Mediavilla, D., Sanllorente, M., Picó-Plana, E., Soriano, A., Pitart, C., Sanchez-Diaz, A.M.
Format: article
Publication Date:2023
Country:España
Institution:Servizo Galego de Saúde (SERGAS)
Repository:RUNA. Repositorio da Consellería de Sanidade e Sergas
OAI Identifier:oai:runa.sergas.gal:20.500.11940/21235
Online Access:https://portalcientifico.sergas.gal//documentos/652b2923ebee473633a36bf3
http://hdl.handle.net/20.500.11940/21235
Access Level:Open access
Keyword:Adult
Humans
Anti-Bacterial Agents
Bacteremia
Cloxacillin
Fosfomycin
Methicillin
Staphylococcal Infections
Staphylococcus aureus
Treatment Outcome
Drug Therapy, Combination
AS Lugo
CHULA
AS Vigo
CHUVI
Description
Summary:Treatment failure occurs in about 25% of patients with methicillin-susceptible Staphylococcus aureus (MSSA) bacteremia. We assessed whether cloxacillin plus fosfomycin achieves better treatment success than cloxacillin alone in hospitalized adults with MSSA bacteremia. We conducted a multicenter, open-label, phase III-IV superiority randomized clinical trial. We randomly assigned patients (1:1) to receive 2 g of intravenous cloxacillin alone every 4 h or with 3 g of intravenous fosfomycin every 6 h for the initial 7 days. The primary endpoint was treatment success at day 7, a composite endpoint with the following criteria: patient alive, stable or with improved quick Sequential Organ Failure Assessment score, afebrile and with negative blood cultures for MSSA, adjudicated by an independent committee blinded to treatment allocation. We randomized 215 patients, of whom 105 received cloxacillin plus fosfomycin and 110 received cloxacillin alone. We analyzed the primary endpoint with the intention-to-treat approach in 214 patients who received at least 1 day of treatment. Treatment success at day 7 after randomization was achieved in 83 (79.8%) of 104 patients receiving combination treatment versus 82 (74.5%) of 110 patients receiving monotherapy (risk difference 5.3%; 95% confidence interval (CI), -5.95-16.48). Secondary endpoints, including mortality and adverse events, were similar in the two groups except for persistent bacteremia at day 3, which was less common in the combination arm. In a prespecified interim analysis, the independent committee recommended stopping recruitment for futility prior to meeting the planned randomization of 366 patients. Cloxacillin plus fosfomycin did not achieve better treatment success at day 7 of therapy than cloxacillin alone in MSSA bacteremia. Further trials should consider the intrinsic heterogeneity of the infection by using a more personalized approach. ClinicalTrials.gov registration: NCT03959345 .

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