Should Linezolid Replace Clindamycin as the Adjunctive Antimicrobial of Choice in Group A Streptococcal Necrotizing Soft Tissue Infection and Toxic Shock Syndrome? A Focused Debate

Clin Infect Dis. 2023 Jan 13;76(2):346-350. doi: 10.1093/cid/ciac720.


Group A Streptococcus (GAS) necrotizing soft tissue infections and toxic shock syndrome remain high-mortality conditions. In vitro and animal model data, as well as multiple observational studies, suggest adjunctive clindamycin (ie, given with a beta-lactam) reduces invasive GAS infection mortality by inhibiting exotoxin production. Unfortunately, clindamycin resistance in GAS has been rapidly increasing in the United States since the mid-2010s, although the clinical significance of this remains unclear. Linezolid is a promising alternative adjunctive agent to which US GAS isolates remain near-universally susceptible, with a similar mechanism of action and similar in vitro evidence of GAS virulence factor attenuation. However, the clinical data supporting linezolid's value in severe GAS infections are far more limited. Here the authors review the data and reasoning behind a general preference for clindamycin or linezolid in a focused, pro-con debate format.

Keywords: clindamycin; group A Streptococcus; linezolid; necrotizing soft tissue infection; toxic shock syndrome.

MeSH terms

  • Animals
  • Anti-Bacterial Agents / pharmacology
  • Anti-Bacterial Agents / therapeutic use
  • Anti-Infective Agents*
  • Clindamycin / pharmacology
  • Clindamycin / therapeutic use
  • Fasciitis, Necrotizing*
  • Linezolid / pharmacology
  • Linezolid / therapeutic use
  • Shock, Septic* / drug therapy
  • Soft Tissue Infections* / drug therapy
  • Streptococcal Infections* / drug therapy
  • Streptococcus pyogenes


  • Clindamycin
  • Linezolid
  • Anti-Bacterial Agents
  • Anti-Infective Agents