Linezolid use in post-neurosurgical central nervous system infections: A systematic review

Post-neurosurgical central nervous system (CNS) infections are associated with prolonged hospital stays and poor neurological outcomes. Given the predominance of Gram-positive bacteria as causative pathogens, vancomycin is the first-line treatment. However, its use is limited by nephrotoxicity, the global emergence of resistant strains, and unfavorable pharmacokinetics with poor cerebrospinal fluid penetration. Therefore, linezolid may be a promising alternative. This systematic review assesses the current evidence regarding its efficacy and safety in the treatment of post-neurosurgical CNS infections. This review was registered in PROSPERO (CRD42024496278) and adhered to PRISMA guidelines. A literature search was conducted across five databases (PubMed, Web of Science, CINAHL Complete, Dimensions, and the Cochrane Library). A risk of bias and quality assessment procedure (MINORS scale) was conducted for non-case-reports studies. We extracted epidemiological, microbiological, and pharmacological data, along with clinical outcomes and safety issues. Out of 611 records screened, 36 studies were included-27 of which were case reports. According to MINORS scores, most non-case-report studies exhibited poor (7/9) or moderate (2/9) methodological quality. Linezolid was primarily employed as a second-line therapy due to treatment failure (46.3%) or culture of glycopeptide-resistant strains (20.6%). Methicillin-resistant Staphylococci (67%) and Vancomycin-Resistant Enterococci (8.2%) were most commonly identified. The oral route was used in 41.4% of cases. Low mortality (10.6%) and high but variable microbiological cure rates (65%) were reported. Adverse events occurred in 10 to 27.3% of patients, with hematological toxicity being the most common. Although linezolid shows promise in treating post-neurosurgical CNS infections, current evidence relies heavily on case reports and methodologically limited retrospective studies. Further rigorous research, including prospective trials, is needed to establish its role in these infections.