Linezolid versus teicoplanin in the treatment of Gram-positive infections in the critically ill: a randomized, double-blind, multicentre study

OBJECTIVES

Linezolid, the only commercially available oxazolidinone, is indicated for the treatment of Gram-positive infections, although little has been published specifically on its use in the critically ill. A randomized, prospective study was therefore performed to compare linezolid with the glycopeptide antibiotic, teicoplanin, for the treatment of suspected or proven Gram-positive infections in an intensive care population.

METHODS

Using a double-blind, double-dummy, prospective design, patients were randomized to (i) intravenous linezolid (600 mg/12 h) plus teicoplanin dummy [one dose/12 h for three doses then every 24 h intravenously (iv)] or (ii) teicoplanin (400 mg/12 h for three doses then 400 mg/24 h iv) plus linezolid dummy (one dose/12 h iv). Other antibiotics were used in combination with the trial agents in empirical treatment. Clinical and microbiological assessments were made daily in the first week, and at 8 and 21 days after treatment.

RESULTS

One hundred patients received linezolid plus placebo-teicoplanin, whereas 102 received teicoplanin plus placebo-linezolid. Population baseline characteristics were similar in both groups. At end of treatment, clinical success [71 (78.9%) linezolid versus 67 (72.8%) teicoplanin] and microbiological success [49 (70.0%) versus 45 (66.2%)] rates were similar, as were adverse effects, intensive care unit mortality, and success rates at short- and long-term follow-up. Linezolid was superior at initial clearance of methicillin-resistant Staphylococcus aureus (MRSA) colonization (end of treatment, 51.1% versus 18.6%, P = 0.002). Two MRSA isolates showed reduced susceptibility to teicoplanin.

CONCLUSIONS

Linezolid has similar safety and efficacy to teicoplanin in treating Gram-positive infections in the critically ill. Short-term MRSA clearance achieved with linezolid suggests better skin and mucosal penetration.

Fatal hemorrhagic pneumonia caused by infection due to Kytococcus sedentarius--a pathogen or passenger?

A 55-year old man developed a hemorrhagic pneumonia, likely due to infection with Kytococcus sedentarius during neutropenia following induction chemotherapy for acute myeloid leukemia. Severe mucosal barrier injury and the selective pressure of broad-spectrum antibiotics probably made it possible for this normally harmless commensal to penetrate the gut, spread through the blood stream, and invade the lungs.

Clinafloxacin monotherapy (CI-960) versus ceftazidime plus amikacin for empirical treatment of febrile neutropenic cancer patients

OBJECTIVE

To assess the efficacy and safety of clinafloxacin as a single agent for the empirical treatment of febrile episodes and bacterial infections in neutropenic cancer patients.

METHODS

An open label, active-controlled, randomized, parallel treatment, multicenter study was conducted where clinafloxacin monotherapy was compared to the combination of ceftazidime plus amikacin (plus optional vancomycin or teicoplanin). Four hundred and nineteen patients were randomized to receive either intravenous clinafloxacin 200 mg every 12 h or intravenous ceftazidime (2 g) iv every 8 h plus intravenous amikacin (15 mg/kg) per day in divided doses. All randomized patients were to receive a minimum of 48 h of primary study drug treatment, after which the primary treatment could be modified. Clinical and microbiological responses were evaluated at 7-21 days post-treatment after study treatment and long term (maximum 28 days), in intent-to-treat and modified intent-to-treat populations.

RESULTS

Clinafloxacin and ceftazidime-amikacin were statistically equivalent for the 72-h defervescence rate, overall defervescence rate, time to defervescence, clinical success rate, by-pathogen microbiological eradication rate, and survival rate. Clinical cure was achieved in 84% (59/70) of patients who received clinafloxacin monotherapy. There were no significant differences between treatments in rates of adverse events or treatment discontinuation rates due to adverse events.

CONCLUSIONS

Clinafloxacin appears to be an appropriate agent for empirical treatment in febrile neutropenic cancer patients.

[The comparative costs of vancomycin treatment versus teicoplanin in osteoarticular infection caused by methicillin-resistant staphylococci]

This clinical and economical study compared two glycopeptides regimen i.e., vancomycin and teicoplanin in the treatment of osteoarticular infection involving methicillin-resistant staphylococcus. After randomization, 15 patients (group 1) received vancomycin (23 F per gram) in continuous infusion through a central venous catheter and 15 others (group 2) intramuscular teicoplanin (311-357 F a 400 mg vial). The clinical study focused on treatment tolerance in an in-patient setting as well as in a non in-patient one. The cost analysis focused on total expenses including those of antibiotics, those of medical devices for antibiotic administration and those of the complications caused by the antibiotics use. Total expenses per patient averaged 8744 F with vancomycin and 8555 F with teicoplanin (NS). The apparent money saving by using a cheap antibiotic (i.e. vancomycin) was illusionary as one took in account the expenses for medical devices e.g., central venous catheters required to administer vancomycin and the complications due to the use of these devices.

Teicoplanin-induced neutropenia in a paediatric patient with vertebral osteomyelitis

Teicoplanin is a glycopeptide antibiotic that has been used extensively in adults but less so in children for the treatment of bone and joint infections. It has a good safety profile with low incidences of blood dyscrasias. We report a case of teicoplanin-induced neutropenia in a child.

The role of teicoplanin in the treatment of febrile neutropenia

The clinical and microbiological efficacy, cost-per-patient and tolerability of teicoplanin were compared with those of vancomycin as empirical or second-line treatment of febrile neutropenic episodes in patients with hematologic malignancy or solid tumors. In terms of efficacy and cost teicoplanin and vancomycin were found equivalent, while teicoplanin is better tolerated and may be used effectively for treatment of out-patients.

Comparative safety of teicoplanin and vancomycin

Although modern preparations of vancomycin are associated with a lower incidence of adverse events than the early preparations, a number of clinically significant problems remain. Consequently monitoring of serum concentrations is required. In a meta-analysis of comparative trials adverse events were significantly less likely to occur with teicoplanin (13.9%) than with vancomycin (21.9%) (P = 0.0003). This was particularly significant when nephrotoxicity was considered: 4.8% vs. 10.7%, for teicoplanin and vancomycin, respectively (P = 0.0005). Red man syndrome, which may be due to histamine release, occurs after rapid infusion of vancomycin but is very rare following teicoplanin administration. In USA trials, thrombocytopenia was more commonly seen with teicoplanin administration but this was almost exclusively in patients receiving much larger doses than are now recommended. The lower rate of adverse events supports the choice of teicoplanin over vancomycin in treating infections where the two antibiotics have similar efficacy.

Comparative pharmacokinetics of teicoplanin and vancomycin

Teicoplanin has unique properties that should be used to the advantage of patients. Due to its pharmacokinetic profile, teicoplanin is more effectively administered once daily than vancomycin and offers a choice of administration routes (i.v./i.m.). At the recommended dosing regimen (6 mg/kg/day, with an additional loading dose of 12 mg/kg in the first 24 hours) efficacious serum levels of teicoplanin are almost guaranteed. Unlike vancomycin, routine drug monitoring is not required for safety reasons, but is, in certain clinical situations, useful for predicting teicoplanin's therapeutic effect.

Use of teicoplanin in preterm neonates with staphylococcal late-onset neonatal sepsis

OBJECTIVE

To study the clinical pharmacology of teicoplanin in babies admitted to a newborn intensive care unit, by monitoring serum levels, efficacy and potential side effects.

METHODS

An open, nonrandomized descriptive study was performed in the neonatal intensive and high care unit of the University Hospital Maastricht, The Netherlands. Twenty-three preterm neonates, gestational age ranging from 26 to 32 weeks (median 28.4 weeks), postnatal age from 5 to 47 days, and birth weight from 570 to 1,740 g, presenting with (suspected) late onset septicemia, were studied. Of 21 culture-proven septicemias, 20 were caused by staphylococci. The teicoplanin loading dose was 15 mg/kg i.v., followed by a maintenance dose of 8 mg/kg every 24 h. Intravenous gentamicin was also administered pending blood culture. Serum teicoplanin concentrations were measured by fluorescence polarization immunoassay. Clinical and microbiological cure/failure rates were determined and possible side effects were monitored.

RESULTS

The study of individual pharmacokinetics during multiple-dose intravenous infusions was rendered impossible by apparently inaccurate dosing. Peak (30 min after end of the infusion) and trough teicoplanin levels were stable throughout the study and averaged 27.8 (interquartile range 23.7-32.9) and 12.3 (interquartile range 9.1-16.8) mg/l, respectively. The microbiological and clinical cure rates were 90% in gram-positive septicemia. There was no apparent toxicity.

CONCLUSIONS

Inaccurate drug administration was a problem in this study, making a multidose pharmacokinetic study impossible. It is possible that inaccurate drug administration and not current dosage guidelines yielded trough levels below 10 mg/l in 57 (32%) of 176 instances. This pharmaceutical aspect clearly warrants further study. However, microbiological and clinical cure rates were high in gram-positive septicemias. No side effects attributable to teicoplanin therapy were encountered.

Long-term intramuscular teicoplanin treatment of chronic osteomyelitis due to oxacillin-resistant Staphylococcus aureus in outpatients

Oxacillin-resistant staphylococci are the most serious pathogens in chronic osteomyelitis and only glycopeptides have been shown to be efficacious against them. We assessed the safety and efficacy of a regimen of teicoplanin 400 mg/day i.m. as long-term treatment in outpatients with osteomyelitis. A total of 76 patients received teicoplanin. Twenty-five patients had chronic prosthetic osteomyelitis (20 hip) and 51 patients had osteomyelitis caused by osteo-synthesis devices. Oxacillin-resistant Staphylococcus aureus was isolated in pure culture in 55 patients (72%). A total of 21 patients had polymicrobial infection with a total of 48 isolated strains. All patients were treated with teicoplanin 400 mg i.m. once-a-day alone or with other drugs for a minimum of 4 months. Only one patient had side effects requiring discontinuation of treatment. The teicoplanin dose was reduced to 200 mg/day i.m. in 2 patients to decrease creatinine clearance values. Seventy out of 76 patients were cured.

Comparison of efficacy and safety of teicoplanin and vancomycin in children with antineoplastic therapy-associated febrile neutropenia and gram-positive bacteremia

To compare their efficacy and safety, teicoplanin and vancomycin were randomly administered to 32 children for 52 gram-positive bacteremias during malignancy-associated neutropenia (<1000/microl). Patients mainly suffered from hematological malignancies. Twenty-five episodes were treated with teicoplanin (10 mg x kg(-1) x d(-1)) and 21 with vancomycin (40 mg x kg(-1) x d(-1)) plus ceftazidime and netilmicin. Six episodes were treated with teicoplanin because of previous "red man" reaction to vancomycin. Staphylococci (12% Staphylococcus aureus) were isolated from 50 episodes and viridans streptococci from 2. Defervescence on 3rd-4th day occurred in 29/31 (93.5%) teicoplanin-treated and 18/21 (85.7%) vancomycin-treated episodes. All 12 teicoplanin-treated and 13/13 vancomycin-treated episodes with repeat blood cultures on 3rd-4th day showed microbiological response. Two teicoplanin-treated and 3 vancomycin-treated patients required antifungals. Mild renal insufficiency appeared in 5 vancomycin-treated patients that was corrected without drug discontinuation. While both glycopeptides exhibit equal clinical and microbiological efficacy, teicoplanin is less likely to induce allergic reactions or nephrotoxicity in children.

Ceftazidime in combination with glycopeptide antibiotic is an effective first-line therapy for patients undergoing high-dose therapy with autologous peripheral blood stem cell support

It was the objective of this study to evaluate the efficacy and toxicity of an empirical antibiotic therapy consisting in ceftazidime and a glycopeptide antibiotic. All patients enrolled in the study had hematological malignancies and underwent high-dose therapy with peripheral blood stem cell (PBSC) support. In this retrospective study, 183 of 207 patients who had received a PBSC-supported high-dose therapy were evaluable. Any patients who had fever higher than 38.5 degrees C received ceftazidime in combination with vancomycin (105 patients) or teicoplanin (69 patients). In 80 of 174 patients with fever (45%) the fever resolved within 72 h as a result of the treatment with ceftazidime and the glycopeptide antibiotic. In nonresponding patients, the changes included the replacement of ceftazidime by imipenem/cilastin (94 patients) and the addition of erythromycin (12 patients) or metronidazole (3 patients). Amphotericin B was administered in 29 patients. Following hematological reconstitution, the fever and clinical signs, including radiographic findings, resolved in 20 primarily nonresponding patients. In blood cultures, a significantly higher incidence of gram-positive than of gram-negative bacteria was observed (26 vs 7). The toxicity of the first-line antibiotic therapy was limited to allergic skin reactions in 12 patients. Ceftazidime in combination with a glycopeptide antibiotic provides an effective and safe first-line therapy for patients with neutropenic fever following PBSC-supported high-dose therapy.

Randomized prospective study comparing cost-effectiveness of teicoplanin and vancomycin as second-line empiric therapy for infection in neutropenic patients

BACKGROUND AND OBJECTIVE

The current health-care philosophy dictates that new therapies should always be evaluated for their economic impact. Along with acquisition cost, the cost of delivery, monitoring, adverse effects and treatment failure must also be considered when determining the total cost of therapy. These auxiliary costs can be significant and greatly alter the overall cost of a drug treatment. We conducted a prospective randomized study to evaluate the efficacy, safety and cost of vancomycin and teicoplanin therapy in patients with neutropenia, after the failure of empirical treatment with a combination of piperacillin/tazobactam and amikacin.

DESIGN AND METHODS

Seventy-six febrile episodes from 66 patients with hematologic malignancies under treatment, neutropenia (neutrophils <500/mm3) and fever (38 degrees C twice or 38.5 degrees C once) resistant to the combination piperacillin/tazobactam and amikacin were included in the study.

RESULTS

Primary success of second-line therapy was obtained in 35 cases (46%) with no significant difference between vancomycin (17/38) and teicoplanin arms (18/38). No difference in renal or hepatic toxicity related to the antibiotic therapy was observed. The average cost per patient according to glycopeptide used was $450+/-180 for the teicoplanin group and $473+/-347 for the vancomycin group. Interestingly, in the teicoplanin arm, drug acquisition accounted for 97% of the total cost, while in the vancomycin arm administration and monitoring play an important role in overall costs.

INTERPRETATION AND CONCLUSIONS

In conclusion, our pharmacoeconomic analysis demonstrates that teicoplanin and vancomycin can be administered in neutropenic hematologic patients with similar efficacy and direct costs.

Red-man syndrome after vancomycin: potential cross-reactivity with teicoplanin

We report a patient with infective endocarditis who developed a severe form of Red-man syndrome after vancomycin. On substituting the antibiotic to teicoplanin, the patient went on to develop a dramatic pyrexia which settled only after the teicoplanin was discontinued. This suggested that there may be an element of cross-reactivity between teicoplanin and vancomycin in such patients and that teicoplanin may not be the most appropriate substitute in all cases of vancomycin-induced Red-man syndrome.

Efficacy and safety of teicoplanin plus rifampicin in the treatment of bacteraemic infections caused by Staphylococcus aureus

An open study was carried out on 16 patients with hospital-acquired, bacteraemic Staphylococcus aureus infections to evaluate the safety and efficacy of teicoplanin plus rifampicin. Patients received teicoplanin 400 mg bd for the first 24 h followed by 400 mg od thereafter, and rifampicin 600 mg bd. Both agents were given intravenously. Serum samples were collected to determine trough and peak antibiotic concentrations. The MIC of teicoplanin and rifampicin and the MBC of teicoplanin were determined for all S. aureus isolates. Time-kill curves were performed for the drugs individually and in combination. Clinical efficacy was assessed by the APACHE II scoring system. Bacteriological success was evaluated by elimination, persistence or recurrence of S. aureus. Safety was carefully monitored by regular biochemical and haematological testing and recording of adverse events. Fifteen patients were evaluable, of whom 13 (86.7%) were clinically cured with elimination of S. aureus. One patient died, but death was not attributed to the study drugs. Treatment failed in another patient who relapsed with a high fever. S. aureus was recovered from blood cultures from this patient, and resistance to rifampicin had developed. Time-kill curves all showed adequate killing of S. aureus at the drug concentrations measured in vivo. Neither synergy nor antagonism between teicoplanin and rifampicin was demonstrated. The combination of teicoplanin and rifampicin is an effective and well-tolerated treatment for bacteraemic S. aureus infections, but in deep-seated foci of infection resistance to rifampicin may develop.

[Glycopeptides (vancomycin, teicoplanin)--their place in the antibacterial therapy of patients in a high-risk group]

Today, when the number of high-risk patients is increasing, special attention should be paid to polyresistant gram-positive microorganisms staphylococci and enterococci, whose role in infective complications and septic states is increasing. The author analyzes published reports on the rate of isolation of methicillin-resistant staphylococci (MRS) and enterococci in different countries and relationship of this parameter with antibiotic policy. Special attention is paid to unjustified wide use of third-generation cephalosporines and their role in selection of polyresistant bacteria. The rate of MRS isolation vs. all other staphylococci at intensive care wards for newborns is as high as 63.9%. The incidence of coagulase-negative staphylococci (most often S. epidermidis) in clinical material (blood, cerebrospinal fluid, urine) from high-risk patients increased 2-3 times during two recent years. Glycopeptides vancomycin and teicoplanine are drugs of choice for the treatment of infections caused by such microorganisms (sepsis, endocarditis, osteomyelitis, pneumonia, etc.). These drugs should be listed among obligatory antibiotics for resuscitation and intensive care wards as life-saving drugs.

Glycopeptide-induced vasculitis--cross-reactivity between vancomycin and teicoplanin

Teicoplanin has been suggested for use in patients suffering complications from vancomycin. We describe two patients who developed a vasculitic rash whilst on vancomycin with recrudescence of the rash with subsequent teicoplanin therapy.

Comparative safety of teicoplanin and vancomycin

Teicoplanin have different safety profiles which can affect choice. Nephrotoxicity is significantly less likely to occur during treatment with teicoplanin than vancomycin when an aminoglycoside is being given concurrently. 'Red man' syndrome is a troublesome effect of vancomycin infusion which is extremely uncommon with teicoplanin use. Rash and fever can be dose-related phenomena but patients reacting to one glycopeptide may not react to both. Although thrombocytopenia is more frequent with teicoplanin, it is reversible and seldom seen at standard doses.

Antimicrobial prophylaxis in orthopaedic surgery: the role of teicoplanin

Orthopaedic joint replacement is generally considered 'clean' surgery characterized by a low incidence of infection. In recent years the use of a clean theatre environment, high local concentrations of antibiotic in the cement and systemic antibiotic prophylaxis have been recognized as important measures to reduce infection rates significantly, and this has been supported by clinical trials. Staphylococcus aureus and Staphylococcus epidermidis cause at least half of all orthopaedic surgical infections. Gram-negative bacilli are involved to a much lesser extent (10-30%). First- and second-generation cephalosporins are currently considered by most authors as standard prophylaxis in elective orthopaedic surgery. In the light of the increasing incidence of methicillin resistance in coagulase-positive and -negative staphylococci, it is becoming more important for antibiotics to act efficiently against such organisms if they are to be of value in prophylaxis in orthopaedic surgery. A combined, single-dose of vancomycin/gentamicin has been used successfully in an open, controlled study in patients undergoing total joint arthroplasty but, given the disadvantages associated with the use of vancomycin, teicoplanin may be an alternative choice in such procedures. This review analyses four comparative trials of the efficacy and safety of teicoplanin, two with cefamandole, one with cefuroxime and one with cephazolin, as prophylaxis in orthopaedic total joint replacement surgery.