The role of glycopeptide antibiotics in the treatment of infective endocarditis

Surgical debridement with muscle flap transposition and systemic teicoplanin therapy for infected hip arthroplasty

The use of muscle flaps is now accepted as a method for coverage of infected wounds. To obtain complete eradication of infection following hip arthroplasty surgery is combined with antibiotic treatment. Aggressive debridment to remove devitalized tissue followed by vastus lateralis muscle flap transposition may improve the likelihood of success in certain challenging cases. We report two cases of prosthetic joint infection treated by aggressive debridment and vastus lateralis transposition with associated appropriate antibiotic therapy. Complete recovery of functional status was observed.

Teicoplanin levels in bone and joint infections: Are standard doses subtherapeutic?

OBJECTIVES

Previously published data suggest that a trough serum teicoplanin level of > or = 20 mg/l is predictive of improved outcomes in serious staphylococcal infection. We investigated how dose regimen and patient characteristics impact on trough teicoplanin levels in patients with musculoskeletal infection, in order to help standardise teicoplanin use.

METHODS

We prospectively collected data for 141 clinically stable adults with bone and joint infection treated as outpatients with teicoplanin. Patients with end stage renal failure were excluded.

RESULTS

The most frequently used teicoplanin dose regimens were 400 mg or 600 mg i.v. once daily. Trough levels were available for 78% of episodes, of which 51% were > or = 20 mg/l. Unsurprisingly, a level of > or = 20 mg/l occurred more often with a dose of 600 mg than with lower doses (p=0.005). There was no significant relationship between teicoplanin level and age, body weight or creatinine clearance, but male gender was associated with lower trough levels than female gender (p=0.03).

CONCLUSIONS

These data suggest that teicoplanin levels of > or = 20 mg/l for bone and joint infection in stable adult patients are best achieved with a daily dose of at least 600 mg.

Differential binding specificities of oral streptococcal antigen I/II family adhesins for human or bacterial ligands

The antigen I/II (AgI/II) family polypeptides, ranging from 1310 to 1653 amino acid (aa) residues, are cell wall anchored adhesins expressed by most indigenous species of oral streptococci. The polypeptides interact with a wide range of host molecules, in particular salivary agglutinin glycoprotein (SAG or gp340), and with ligands on other oral bacteria. To determine the receptor recognition properties of six different AgI/II family polypeptides from strains of Streptococcus gordonii, Streptococcus intermedius and Streptococcus mutans, the genes were cloned and expressed on the surface of the surrogate host Lactococcus lactis. The S. gordonii SspA and SspB polypeptides mediated higher binding levels of L. lactis cells to surface immobilized gp340 than did S. intermedius Pas protein, or S. mutans SpaP or PAc proteins. However, the AgI/II proteins were all similar in their abilities to mediate aggregation of lactococci by fluid phase gp340. The SpaP(I) polypeptide from S. mutans Ingbritt, which was C-terminally truncated by approximately 400 aa residues, did not bind gp340. Lactococci expressing AgI/II proteins, including SpaP(I), were aggregated by a synthetic 16 aa residue peptide SRCRP2 derived from the aa repeat block sequences within gp340. In coaggregation assays, SspB from S. gordonii was unique in mediating coaggregation with only group A and group E strains of Actinomyces naeslundii. All the other AgI/II polypeptides mediated coaggregation with group C and group D strains of A. naeslundii. Analysis of chimeric protein constructs revealed that coaggregation specificity was determined by sequences within the N-terminal half of AgI/II protein. A synthetic peptide (20 aa residues), which defines a putative adhesion epitope within the C-terminal region of polypeptide, inhibited AgI/II-mediated aggregation by gp340 but did not affect coaggregation with A. naeslundii. These results suggest that different mechanisms operate in interactions of AgI/II family polypeptides with native gp340, gp340 SRCR domain peptide, and A. naeslundii. Specificity of these interactions appears to be determined by discontinuous but interacting regions of the polypeptides, thus providing flexibility in receptor recognition for streptococcal colonization of the human host.

The use and therapeutic drug monitoring of teicoplanin in the UK

Teicoplanin dosage recommendations for specific infections have been modified in recent years. However, there was no significant increase in the proportion of pre-dose concentrations > 20 mg/L between 1994 and 1998 in samples sent for teicoplanin assay at the Regional Antimicrobial Reference Laboratory, Bristol, UK. A questionnaire on the use of teicoplanin and therapeutic drug monitoring (TDM) was sent to all UK National External Quality Assurance Scheme antibiotic assay users. Teicoplanin was widely used in the UK, although vancomycin was more popular as a choice of glycopeptide. Fewer than 25% recommended teicoplanin TDM during routine use, the main reasons being perceived lack of toxicity and lack of evidence for the use of teicoplanin TDM. Pre-dose concentrations < 20 mg/L were considered appropriate for treatment of bacteraemia caused by methicillin-resistant Staphylococcus aureus by 53% of those responding. Data sheet advice was relied upon more than TDM as an indication of therapeutic dosing. Microbiologists who mainly used vancomycin tended to perform more TDM and seek higher serum concentrations when using teicoplanin than those who preferentially used teicoplanin.

Glycopeptide Antibiotics

Vancomycin and teicoplanin are still the only glycopeptide antibiotics available for use in humans. Emergence of resistance in enterococci and staphylococci has led to restriction of their use to severe infections caused by Gram-positive bacteria for which no other alternative is acceptable (because of resistance or allergy). In parallel, considerable efforts have been made to produce semisynthetic glycopeptides with improved pharmacokinetic and pharmacodynamic properties, and with activity towards resistant strains. Several molecules have now been obtained, helping to better delineate structure-activity relationships. Two are being currently evaluated for skin and soft tissue infections and are in phases II/III. The first, oritavancin (LY333328), is the 4'-chlorobiphenylmethyl derivative of chloroeremomycin, an analogue to vancomycin. It is characterised by: i) a spectrum covering vancomycin-resistant enterococci (VRE), methicillin-resistant Staphylococcus aureus (MRSA) and to some extent glycopeptide-intermediate S. aureus (GISA); ii) rapid bactericidal activity including against the intracellular forms of enterococci and staphylococci; and iii) a prolonged half-life, allowing for daily administration. The second molecule is dalbavancin (BI397), a derivative of the teicoplanin analogue A40926. Dalbavancin has a spectrum of activity similar to that of oritavancin against vancomycin-sensitive strains, but is not active against VRE. It can be administered once a week, based on its prolonged retention in the organism. Despite these remarkable properties, the use of these potent agents should be restricted to severe infections, as should the older glycopeptides, with an extension towards resistant or poorly sensitive bacteria, to limit the risk of potential selection of resistance.