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Trimethoprim-Sulfamethoxazole Compared with Vancomycin for the Treatment of Staphylococcus aureus Infection

Norman Markowitz, MD; Edward L. Quinn, MD; and Louis D. Saravolatz, MD
[+] Article and Author Information

Grant Support: In part by a grant from Hoffman-La Roche Inc.

Requests for Reprints: Norman Markowitz, MD, Division of Infectious Diseases, Henry Ford Hospital, 2799 West Grand Boulevard, Detroit, MI 48202.

Current Author Addresses: Drs. Markowitz, Quinn, and Saravolatz: Division of Infectious Diseases, Henry Ford Hospital, 2799 West Grand Boulevard, Detroit, MI 48202.


©1992 American College of PhysiciansAmerican College of Physicians


Ann Intern Med. 1992;117(5):390-398. doi:10.7326/0003-4819-117-5-390
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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 < 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 > 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.

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