[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.

A prospective, randomized trial of two antibiotic regimens in the treatment of peritonitis in CAPD patients: teicoplanin plus tobramycin versus cephalothin plus tobramycin

A multicentre, comparative, randomized study was performed to compare the efficacy and tolerability of two antibiotic regimens in the treatment of peritonitis in continuous ambulatory peritoneal dialysis (CAPD) patients: teicoplanin plus tobramycin versus cephalothin plus tobramycin. After informed consent had been obtained, 68 patients were randomized prospectively to receive either teicoplanin plus tobramycin or cephalothin plus tobramycin. Patients were followed throughout the study and for up to 4 weeks after the end of treatment, when clinical and microbiological parameters were assessed again. The incidence of clinical failure was 4.6 times higher in the cephalothin plus tobramycin group than in the teicoplanin plus tobramycin group (7/28 versus 2/37; P < 0.05). There was no significant difference in bacterial eradication between the two groups. Local and systemic tolerability were good for both regimens. The study shows that teicoplanin plus tobramycin is more effective than cephalothin plus tobramycin and might become a 'first-line' treatment for peritonitis in CAPD patients.

A closer look at vancomycin, teicoplanin, and antimicrobial resistance

The worldwide increase in the incidence of resistant Gram-positive infections has renewed interest in the glycopeptide class of antimicrobial agents. Two glycopeptides are available in many parts of the world--vancomycin and teicoplanin. These two agents appear to differ in several respects, including: potential for selecting microbial resistance, dosing convenience, safety, and efficacy in severe infection. Teicoplanin appears to have lower toxicity and greater convenience; however, its widespread acceptance has been plagued by concerns over antimicrobial resistance, efficacy, and appropriate dosing. A review of available studies suggests that teicoplanin, when dosed at 6 mg/kg/day, is better tolerated than vancomycin 15 mg/kg/q12h; however, at these doses, it appears to be somewhat less effective than vancomycin in serious Staphylococcus aureus infection, such as endocarditis. Although higher doses of teicoplanin, 12 mg/kg/day to 30 mg/kg/day, have been associated with efficacy comparable to that of vancomycin in serious S. aureus infections, such doses may eliminate some of the safety advantages conferred by lower teicoplanin doses. Teicoplanin has been associated with resistance among coagulase-negative staphylococci and the selection of resistance in S. aureus. There is some evidence that widespread use of teicoplanin might accelerate the development of S. aureus resistance to both teicoplanin and vancomycin. The selection of an appropriate glycopeptide in an individual patient should be based not only on convenience, but also on a determination of optimal efficacy, safety at an efficacious dose, and the potential for resistance.

[Glycopeptides and the newborn infant's kidney]

The aim of this paper was to evaluate glycopeptide nephrotoxicity in the newborn. The exact mechanism of nephrotoxicity has not been defined. Basal mechanism of vancomycin nephrotoxicity seems related to the energy-dependent tubular transport of the drug from blood to tubular cell across the basolateral membrane. Moreover a tubular reabsorption is probably involved, but it is not relevant for nephrotoxicity. Considering the widespread use of this antibiotic, the question of nephrotoxic side effects in humans is of great importance. However, the results of studies published to date are controversial. Results differ considerably depending on the period considered and on the sensitivity of the methods used to indicate renal damage. In paediatric patients (including neonates) the nephrotoxicity of vancomycin appears to be less than that in adults, thus confirming a number of experimental observations. It is commonly suggested that pharmacokinetic monitoring of doses in children should minimize nephrotoxicity. The most important risk factors for the development of the nephrotoxic action of vancomycin are: pre-dose values > 10 mg/l, prolonged therapy (> 21 days), and concomitant treatment with aminoglycosides. In most cases nephrotoxicity associated with vancomycin is reversible, even after high doses. In conclusion it could be speculated that vancomycin nephrotoxicity relates to the combined effect of a large area under the concentration-time curve and duration of therapy. Teicoplanin is a new glycopeptide that is effective in the treatment of both children and neonates and offers the advantages of once daily administration, choice of administration route (intramuscular or rapid intravenous bolus) and lack of requirement for routine therapeutic drug monitoring. Finally it seems less nephrotoxic than vancomycin. In the neonatal age bracket, none of the 173 patients treated presented abnormalities of traditional kidney function parameters.

Randomized placebo-controlled trial of teicoplanin in the antibiotic prophylaxis of infection following manipulation of burn wounds

BACKGROUND

Burn wound surgery or change of dressings commonly causes bacteraemia. The use of antibiotic prophylaxis has not been tested adequately in a controlled trial.

METHODS

A randomized double-blind placebo-controlled study was performed to determine the effect on Gram-positive bacteraemia and clinical outcome of a single dose of teicoplanin (12 mg/kg intravenously) given at burns surgery or change of dressings.

RESULTS

A total of 134 patients were entered into the study, representing 220 episodes of dressing or debridement (110 episodes in each group). There was a significant difference between the groups with respect to perioperative Gram-positive bacteraemia: eight episodes (7 per cent) in the teicoplanin group versus 51 (46 per cent) in the placebo group (P < 0.001). However, good clinical outcome was similar in both groups (80 of 110 versus 77 of 110 respectively, P = 0.7). Only eleven patients had bacteraemia caused by Gram-negative species alone. Bacteriological response in terms of wound culture showed no significant difference between the groups: 63 (57 per cent) of 110 episodes versus 58 (53 per cent) of 110 respectively respectively.

CONCLUSION

Prevention of Gram-positive bacteraemia did not affect postoperative recovery.

Treatment of endocarditis with teicoplanin: a retrospective analysis of 104 cases

Infective endocarditis is an uncommon disease but retains a high mortality. Glycopeptides are used for patients with resistant pathogens, those allergic to penicillins or for those outside the hospital. The once daily administration of teicoplanin and its low toxicity suggest that it would be suitable for use in the long courses required for endocarditis. However, the dosage and combinations to be used require further study. A retrospective review has been made of 104 episodes of endocarditis treated with teicoplanin in 101 patients seen over 7 years. Most patients had been referred to major London hospitals following failure of medical treatment. After three loading doses of 400 mg, teicoplanin was given at a dose of 400 mg/day in combination with other antibiotics such as gentamicin. Follow up was for one year. The most common pathogens were Streptococcus sanguis (15 cases), Staphylococcus aureus (13 cases) and Staphylococcus epidermidis (10 cases). Of 80 patients febrile at the start of treatment with teicoplanin, 63 (79%) lost their fever within a median of 2 days (1-35 days). Cure without surgery was effected in 50 (48%) and 75% of patients survived. Other antibiotics, usually gentamicin or rifampicin, were used in 92 (90%) of patients. Two strains of Streptococcus spp. were said to be resistant but there was no relationship between MIC of teicoplanin and outcome. Pathogens with a high MBC tended to be more likely to resist treatment. Adverse effects resulted in the withdrawal of teicoplanin in 20 cases (19%) but most events were mild and renal deterioration occurred in only five patients. Teicoplanin was effective in the treatment of endocarditis and appeared to be safe given the severity of disease in the patients treated.

Concentration of teicoplanin in the serum of adults with end stage chronic renal failure undergoing treatment for infection

We examined the adequacy of the following schedule for the administration of i.v. teicoplanin to patients with chronic renal failure: three doses of 6 mg/kg at 12 h intervals, a fourth dose 24 h later and then subsequent doses every 72 h. Eight infected patients undergoing dialysis were investigated, with serum antibiotic concentrations measured ten minutes before and one hour after administration. Mean trough concentrations were 6.9 +/- 3.1 mg/L on day two, 9.8 +/- 4.4 mg/L (day three), 9.2 +/- 4.8 mg/L (day six), 10.9 +/- 5.5 mg/L (day nine), 12.1 +/- 6.1 mg/L (day 12) and 14.8 +/- 8.0 mg/L (day 15). The proposed schedule achieved adequate trough serum teicoplanin concentrations by 48 h in six out of eight patients examined. The dosage regimen was well tolerated.

The comparative efficacy and safety of teicoplanin and vancomycin

Glycopeptide antibiotics, such as teicoplanin and vancomycin, are active against staphylococci (including methicillin resistant strains), streptococci, enterococci and Clostridium spp. Vancomycin and teicoplanin are both widely used in the treatment of infections caused by Gram-positive organisms. Vancomycin can, however, provoke a number of side-effects, and serum concentrations should be monitored during treatment. Teicoplanin has a longer half-life than vancomycin, it can be given as an intravenous bolus or by intramuscular injection, and nephrotoxicity and ototoxicity are relatively uncommon. Treatment with teicoplanin might, therefore, offer advantages over treatment with vancomycin-provided that similar clinical efficacy can be shown. At least 11 clinical trials comparing the efficacy and safety of teicoplanin and vancomycin have been carried out worldwide. Meta-analysis of the combined results from these studies indicates that more than three-quarters of the patients in each of the treatment groups had a clinical response to therapy. Meta-analysis of the numbers of adverse events occurring in each treatment group shows significantly fewer reports of adverse events in patients receiving teicoplanin (13.9%) than in those receiving vancomycin (21.9%). Direct comparisons are difficult because of inherent differences between studies, but available data suggest that teicoplanin is as effective as vancomycin and that its superior tolerability together with advantages such as once-daily bolus administration, intramuscular use and lack of requirement for routine serum monitoring, give it considerable potential for use in clinical practice.

A risk-benefit assessment of teicoplanin in the treatment of infections

Teicoplanin is a glycopeptide antibiotic whose activity is selectively oriented against Gram-positive aerobic and anaerobic bacteria, including Staphylococcus aureus, coagulase-negative staphylococci, Clostridium difficile, Peptostreptococcus spp. and Corynebacterium jeikeium; such activity is affected by neither methicillin resistance nor beta-lactamase production. Teicoplanin is not significantly absorbed from the gastrointestinal tract; consequently, it has to be administered intravenously (either by infusion or by rapid injection) or intramuscularly. Its long half-life allows regimens based upon once daily administration. The adverse effects most frequently associated with teicoplanin treatment are local and hypersensitivity reactions, such as itching and drug fever; anaphylactoid reactions (the 'red man syndrome') are seldom observed. Teicoplanin also has less potential than vancomycin to cause nephrotoxicity, especially when administered in combination with an aminoglycoside. Teicoplanin has been proven to be effective in the treatment of microbiologically documented Gram-positive infections, including 'difficult to treat infections' such as endocarditis and prosthetic infections. Furthermore, recent trials in patients with haematological malignancies or other cancers have clearly demonstrated that teicoplanin is at least as efficacious as vancomycin in the empirical initial antibiotic regimen for febrile neutropenic patients, and is associated with fewer adverse effects. Finally, owing to its good tolerability profile and the advantage of once daily administration by both intravenous and intramuscular routes, teicoplanin has proven to be very useful for the outpatient treatment of serious Gram-positive infections. In conclusion, teicoplanin is potentially an effective alternative to vancomycin both in immunocompetent and immunocompromised patients, with the advantage over vancomycin of single daily dose administration and lower toxicity. Further comparative studies with vancomycin are, however, required to better define the therapeutic role of teicoplanin for particular infections (i.e. infective endocarditis).

Teicoplanin

Teicoplanin, a new glycopeptide antibiotic similar to vancomycin, has proved effective in the treatment of various gram-positive infections in both the normal and the immunocompromised host. In vitro activity against most gram-positive organisms is equal to or greater than that of vancomycin. In both open and comparative clinical trials, teicoplanin has been well tolerated, rarely prompting discontinuation of treatment. Nephrotoxicity caused by teicoplanin is uncommon, even when used concomitantly with aminoglycosides or cyclosporin A. Favorable pharmacokinetics allow for intramuscular administration as well as intravenous bolus dosing, and, after appropriate loading doses, maintenance therapy may be given on a once-daily basis. The combination of all of these factors makes teicoplanin an effective, safe alternative to vancomycin in the treatment of gram-positive infections.

Teicoplanin or vancomycin in the treatment of gram-positive infections?

The glycopeptide antibiotics vancomycin and teicoplanin have similar mechanisms of action on bacterial cell wall synthesis. Their spectra of activity are limited to Gram-positive bacteria, with the degree of bactericidal activity depending on the species of micro-organism. Staphylococcus aureus, Staphylococcus epidermis, enterococci and Clostridium difficile are generally sensitive, including methicillin-resistant strains of S. aureus and S. epidermidis. Glycopeptide resistance has recently emerged in staphylococci and enterococci. Vancomycin has a shorter half-life than teicoplanin and requires multiple dosing to maintain adequate serum levels. It can only be given by prolonged intravenous infusion over 1 h. In contrast, the pharmacokinetics of teicoplanin allow for once-daily dosing, either by rapid intravenous infusion or by the intramuscular route. The latter offers reliable absorption for patients with limited venous access and is also of benefit for out-patient therapy. Teicoplanin is a safer drug than vancomycin. It is associated with a lower incidence of nephrotoxicity or ototoxicity. Compared to vancomycin, the availability of the intramuscular route and the absence of a requirement for routine serum monitoring, together with the reduced need to treat drug-related side-effects make teicoplanin more cost-effective. It is as effective as vancomycin for most indications, is safe, easy to administer and an important agent for treating Gram-positive infections. Its role in hospitals is likely to increase if the price of drug acquisition is kept low.

Right-sided endocarditis caused by Staphylococcus aureus in drug abusers

A prospective, open, and randomized study of right-sided endocarditis caused by Staphylococcus aureus in drug abuse patients is reported. The following parenteral treatments were compared. Group A patients were treated with 2 g of cloxacillin every 4 h and 1.5 mg of gentamicin per kg of body weight every 8 h for 2 weeks. Group B patients were treated with teicoplanin at 10 mg/kg/12 h on the 1st to 3rd days, 6 mg/kg/12 h on the 4th to 7th days, and 7 mg/kg/24 h on the 8th days. Drug abusers with bacteremia caused by S. aureus and suggestive signs of endocarditis were included. Clinical failures were observed in one patient in group A and in four of six patients in group B. Three patients in group B developed breakthrough bacteremia with teicoplanin-susceptible strains on days +6, +14, and +19. Serum teicoplanin levels and serum bactericidal titers showed a decrease in the 2nd week, when dosages received were 7 mg/kg/day. In conclusion, in treatment of right-sided endocarditis caused by S. aureus in drug abusers with teicoplanin, the use of dosages of 7 mg/kg/day is not recommended even if patients have received dosages of 12 mg/kg/day during the 1st week.

Glycopeptides and nephrotoxicity

Infections due to Gram-positive bacteria have become an increasing problem in the ICU. Furthermore, multidrug resistance among Gram-positive pathogens is increasingly recognized. Empirical therapy with antibiotic regimens that are effective against Gram-positive pathogens is often required in the ICU. Many critically ill patients in the ICU have multiorgan system failure, including acute renal failure, which further impedes optimal antimicrobial therapy. In this communication, the use of glycopeptides in the ICU is briefly reviewed, and the occurrence of associated nephrotoxicity during therapy with vancomycin or teicoplanin, alone or in combination with an aminoglycoside, is examined. Finally, existing recommendations regarding the dose regimens of these agents in patients with renal impairment are evaluated, and guide-lines for optimizing glycopeptide therapy through improved pharmacokinetic monitoring are presented.

Effects of teicoplanin and those of vancomycin in initial empirical antibiotic regimen for febrile, neutropenic patients with hematologic malignancies. Gimema Infection Program

The efficacy and toxicity of teicoplanin and vancomycin in the initial empirical antibiotic regimen in febrile, neutropenic patients with hematologic malignancies were compared in a prospective, randomized, unblinded, multicenter trial in the setting of 29 hematologic units in tertiary-care or university hospitals. A total of 635 consecutive febrile patients with hematologic malignancies and chemotherapy-induced neutropenia were randomly assigned to receive intravenously amikacin plus ceftazidime plus either teicoplanin at 6 mg/kg of body weight once daily or vancomycin at 1 g twice daily. An efficacy analysis was done for 527 evaluable patients: 275 treated with teicoplanin and 252 treated with vancomycin. Overall, successful outcomes were recorded for 78% of patients who received teicoplanin and 75% of those who were randomized to vancomycin (difference, 3%; 95% confidence interval [CI], -10 to 4%; P = 0.33). A total of 102 patients presented with primary, single-agent, gram-positive bacteremia. Coagulase-negative staphylococci accounted for 42%, Staphylococcus aureus accounted for 27%, and streptococci accounted for 21% of all gram-positive blood isolates. The overall responses to therapy of gram-positive bacteremias were 92 and 87% for teicoplanin and vancomycin, respectively (difference, 5%; CI, -17 to 6%; P = 0.22). Side effects, mainly represented by skin rash, occurred in 3.2 and 8% of teicoplanin- and vancomycin-treated patients, respectively (difference, -4.8%; CI, 0.7 to 8%; P = 0.03); the rate of nephrotoxicity was 1.4 and 0.8% for the teicoplanin and vancomycin groups, respectively (difference, 0.6%; CI, -2 to 1%; P = 0.68). Further infections were caused by gram-positive organisms in two patients (0.7%) treated with teicoplanin and one patient (0.4%) who received vancomycin (difference, 0.3%; CI, -0.9 to 1.0%; P = 0.53). Overall mortalities were 8.5 and 11% for teicoplanin- and vancomycin-treated patients, respectively (difference, -2.5%; CI, - 2 to 7%; P = 0.43); death was caused by primary gram-positive infections in three patients (1%) in each treatment group. When used for initial empirical antibiotic therapy in febrile, neutropenic patients, teicoplanin was at least as efficacious as vancomycin, but it was associated with fewer side effects.

Randomized comparison trial of teicoplanin i.v., teicoplanin i.m., and cefazolin therapy for skin and soft tissue infections caused by gram-positive bacteria

Teicoplanin, a glycopeptide antibiotic chemically related to the vancomycin-ristocetin group of antibiotics, has potent activity against aerobic and anaerobic gram-positive bacteria. In this study, we examined the efficacy and safety of teicoplanin for parenteral treatment of skin and soft tissue infections caused by gram-positive bacteria. Ninety-six hospitalized adults with moderate to severe skin and soft tissue infections were randomized to receive either teicoplanin intravenously (i.v.) once a day, teicoplanin intramuscularly (i.m.) once a day, or cefazolin i.v. every 8 hours. We evaluated patients' clinical and microbiologic status and assessed clinical and laboratory adverse events. Of 76 clinically assessable patients, 26 of 26 (100%) given teicoplanin i.v., 21 of 22 (95%) given teicoplanin i.m., and 26 of 28 (93%) given cefazolin showed improvement or cure. Of 60 microbiologically assessable patients, 22 of 22 (100%) given teicoplanin i.v., 16 of 18 (89%) given teicoplanin i.m, and 18 of 20 (90%) given cefazolin were cured. Of 96 patients assessable for adverse events, 7 of 34 (21%) given teicoplanin i.v., 4 of 31 (13%) give teicoplanin i.m., and 1 of 31 (3%) given cefazolin had adverse events. In this study, once daily teicoplanin appeared to be safe and effective therapy for skin and soft tissue infections.

A prospective, randomized study of pefloxacin versus teicoplanin in the treatment of gram-positive coccal infections in cancer patients: early termination due to emergence of resistance to fluoroquinolones

A randomized prospective study comparing pefloxacin to teicoplanin in the treatment of gram-positive infections in cancer patients was prematurely terminated because of the emergence of pefloxacin resistance associated with oxacillin resistance in Staphylococcus aureus and coagulase-negative staphylococci. Among 56 patients evaluated for efficacy (26 pefloxacin and 30 teicoplanin) and infected with bacteria susceptible to both antibiotics, the clinical cure and eradication rates were similar for pefloxacin (80.5% and 77.3% respectively) and teicoplanin (66.6% and 52.2% respectively). The relapse rates (15% and 10% for pefloxacin and teicoplanin respectively) and the overall mortalities within 1 month (42% and 31%) were similar.

A randomized double-blind trial of vancomycin versus teicoplanin for the treatment of gram-positive bacteremia in patients with cancer

In a prospective, randomized, double-blind study comparing teicoplanin and vancomycin for the treatment of gram-positive bacteremias in neutropenic patients, teicoplanin was given at 6 mg/kg of body weight every 24 h intravenously (i.v.) after initial loading every 12 h for three doses, while vancomycin was administered at 15 mg/kg every 12 h i.v. At enrollment, both groups were comparable in age, sex, underlying hematologic or neoplastic disorder, baseline renal functions, and incidence of neutropenia. Treatment was successful in 19 (90%) of 21 patients who received teicoplanin and 24 (96%) of 25 who received vancomycin (P = .58). Adverse reactions occurred more often in the vancomycin group (31%) than in the teicoplanin group (9%; P = .06) and were primarily cutaneous or gastrointestinal. In conclusion, teicoplanin was better tolerated than vancomycin, and no statistically significant difference in efficacy was detected with the sample size in this study.