Background: Anti-staphylococcal penicillins (ASPs) have been regarded as first-line in the treatment of serious MSSA bloodstream infections (BSI) with cefazolin considered an alternative. Recent studies have suggested that infection outcomes between cefazolin and ASPs may be similar. The objective of this study was to compare the clinical efficacy and tolerability of cefazolin to ASPs for MSSA BSI.
Methods: A systematic review and meta-analysis was conducted. Articles were identified via PubMed, Web of Science, and the Cochrane Library. Studies written in English comparing cefazolin to ASPs for MSSA BSI in adult patients were included. Study quality was assessed using the Cochrane Risk of Bias Assessment Tool and the Newcastle-Ottawa Scale for prospective and retrospective studies, respectively. All review stages were independently conducted by two reviewers, with a third reviewer adjudicating any discrepancies. The fixed- or random-effects model was utilized, as appropriate. A planned subgroup analysis was conducted between high (>15%) vs. low (<14.9%) mortality probability as defined by logit functions applied at the study level.
Results: Nine studies were identified. Pooled data extracted from 1,726 cefazolin- and 2,716 ASP-patients indicated that cefazolin was associated with a significant reduction in treatment failure (OR: 0.70; 95% CI: 0.61-0.82; P<0.001; I2=14%) and crude, all-cause mortality (OR: 0.69; 95% CI: 0.59-0.81; P<0.001; I2=18%) compared to ASPs. Within a subset of studies (n=6) demonstrating low mortality probability (<14.9%), cefazolin therapy remained protective against failure (OR: 0.70; P<0.001; I2=39%) and mortality (OR: 0.70; P<0.001; I2=35%). Within the high mortality probability (>15%) subset, no significant differences for failure or mortality were noted. The risk of adverse events was higher with ASPs (OR: 2.58; 95% CI: 1.00-6.64; P=0.05).
Conclusion: Cefazolin was associated with significantly lower rates of failure, mortality, and treatment-related adverse events when compared to ASPs among less severely ill patients. Prospective, randomized controlled trials are needed to establish the role of these agents in serious MSSA BSI.
Figure 1. Forest plot for treatment failure
Figure 2. Forest plot for all-cause mortality
B. J. Lee,
K. Apolinario, None
S. K. Wang, None
B. Nadler, None
M. H. Scheetz, None
N. J. Rhodes, None