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

Antimicrobial resistance in the chronically critically ill patient

Infection caused by organisms resistant to conventional antimicrobial therapy is an emerging problem of global proportions. This article describes the epidemiology of infections caused by resistant organisms in chronically critically ill patients and explores factors and mechanisms that lead to the development of resistance. Specific organisms and strategies for the treatment and control of these resistance organisms are discussed.

A survey of the use of teicoplanin in patients with haematological malignancies and solid tumours

A significant number of open and comparative studies have now addressed the use of teicoplanin in the treatment of documented or presumed infection in patients with haematological and non-haematological malignancy. Available evidence suggests that teicoplanin is an effective agent against such infections, with an excellent safety profile. The use of teicoplanin and vancomycin may be justified as part of the initial management of clinically infected right atrial catheters in patients with malignancy. The first-line use of glycopeptides may also be appropriate in units where streptococcal and methicillin resistant staphylococcal infections are prevalent. However, such a policy should be reviewed regularly. Except in the above situations, a delay in the introduction of either teicoplanin or vancomycin in cancer patients does not appear to produce any excess mortality, but there may be some additional morbidity in terms of fever and malaise. The introduction of glycopeptides as second-line agents is indicated for sensitive, microbiologically documented infections and for patients who have not responded to empirical, first-line therapy. Non-inpatient treatment with teicoplanin is an area of ongoing interest and may be justified on both humanitarian and pharmacoeconomic grounds. The use of glycopeptides in the prophylactic setting remains controversial and should be avoided while the emergence of resistance, particularly in enterococci, should be monitored closely.

A review of the use of teicoplanin in haematological malignancy

Factors determining the change in patterns of antibiotic use in patients with haematological malignancies include the growing numbers of infections caused by Gram-positive pathogens, the increasing reliance on indwelling catheters, and strategic movement away from inpatient therapy towards day-case and non-inpatient therapy. The suitability of teicoplanin in this context is examined. The indications for teicoplanin use are now established as: early use in clinically infected patients; as a second-line agent for sensitive pathogens; and in primary antibiotic failures. Teicoplanin should not be used as empirical therapy in fevers of unknown origin; neither should teicoplanin be used as prophylaxis (the situations of infection in chemotherapy patients or for Hickman catheter insertion in particular are discussed). Comparative studies versus vancomycin have shown teicoplanin to be equally effective and to be well tolerated. Teicoplanin's good safety profile and ease of use make it particularly useful for non-inpatient therapy. Problems are posed for both glycopeptides by specific resistant pathogens, although these pathogens are currently not common. Haematologists must be aware of, and guard against, abuse of the glycopeptides in their own and other fields, including oral gut decontamination, the treatment of Clostridium difficile and veterinary use.