Assessment of the interaction between ciprofloxacin and teicoplanin in vitro and in neutropenic patients

Methicillin-resistant Staphylococcus aureus: impact on dermatology practice

Methicillin (meticillin)-resistant Staphylococcus aureus (MRSA) emerged in the 1960s and is now commonly seen in hospitals, clinics and, since the mid-1990s, the community. Risk factors for the acquisition of MRSA include chronic dermatoses, underlying medical illnesses, attending healthcare facilities, use of prescription antibacterials, surgery, intravenous lines, hospitalization in an intensive care unit, and proximity to patients colonized with MRSA. Recent community-associated strains often occur in patients without these risk factors. Staphylococci are readily spread from person to person and readily contaminate the environment. Infection control measures thus involve identifying the infected patients, separating them from other non-infected patients, cleaning of the environment and, most important of all, scrupulous attention to hand hygiene. Alcoholic antiseptic hand rubs offer an alternative to antiseptic hand washes and increase compliance. Treatment of MRSA skin infections is challenging. Topical agents such as mupirocin or fusidic acid can be used, but the organisms often become resistant. Systemic therapy involves non-beta-lactams. Parenteral treatment is generally with glycopeptides such as vancomycin; oral therapy is more complex. Monotherapy with quinolones, rifampin (rifampicin), and fusidic acid often results in the development of resistance and so, if any of these agents are chosen it should be in combination. There are no data on combination therapy, although rifampin-containing combinations are often chosen. Fourth-generation quinolones and linezolid are expensive but promising alternatives.

Non-inpatient parenteral antibiotic therapy in febrile adults

Non-inpatient care is becoming an increasingly attractive option in many therapeutic areas, including the treatment of infections in patients with haematological malignancies. The choice of antibiotics for this care is governed by infection patterns and experience within particular institutions. There is an increase in infections caused by Gram-positive pathogens due to the long-term use of tunnelled catheters and intensive, punishing chemotherapy regimens. Patients suitable for non-inpatient care include both long- and short-term patients who fulfil specific clinical and social criteria. Haematological malignancy patients are often suitable for this type of care. Benefits for patients include improved quality of life, while benefits for the clinician include effective, safe care as well as reduced costs and greater bed availability. The glycopeptide teicoplanin has been assessed for use in non-inpatient care, and is particularly suitable due to its long half-life, no need for monitoring and its activity against Gram-positive pathogens. A comparative study of a teicoplanin-ciprofloxacin combination was conducted in inpatients, followed by a cohort study in non-inpatients. This combination was found to be clinically and microbiologically effective, suitable for non-inpatient administration and generated cost savings due to early discharge. The organization of a non-inpatient service demands dedicated team members, with well-defined roles and a designated treatment area. The day ward is the focus of care, which can then take place in the day ward or in the patient's home. Good communication between immediate and wider team members, and patient education are cornerstones of a successful service.

Non-inpatient Treatment of Febrile Episodes in Patients with Hematological Malignancy

Infection related to indwelling central venous catheters is associated with considerable morbidity and inconvenience to patients, and has traditionally required admission for intravenous antibiotics in an attempt to salvage the line. We report the successful usage of an outpatient regimen consisting of alternate day teicoplanin with oral ciprofloxacin, which resulted in line salvage in 74% of cases, achieved satisfactory serum levels of teicoplanin and avoided the need for admission to hospital, with concomitant cost savings.

Teicoplanin and oral ciprofloxacin as outpatient treatment of infective episodes in patients with indwelling central venous catheters and haematological malignancy

Central venous catheters are often the focus of microbial colonization which may cause bacteraemia (or fungal septicaemia) in both neutropenic and non-neutropenic patients. Such episodes are associated with considerable morbidity and may require admission to hospital or replacement of the central line. We have used the combination of intravenous teicoplanin and oral ciprofloxacin to treat such episodes as outpatients, achieving a salvage rate of 74%. Seven of thirty-five episodes resulted in removal of the line. The treatment was well tolerated and well-suited to the day ward setting.

Teicoplanin plus ciprofloxacin versus gentamicin plus piperacillin in the treatment of febrile neutropenic patients

Teicoplanin plus ciprofloxacin was compared with gentamicin plus piperacillin for the empirical treatment of fever in 80 neutropenic patients. A favourable response was seen in 78% of patients receiving teicoplanin plus ciprofloxacin and in 49% receiving gentamicin plus piperacillin (p less than 0.05). When microbiologically documented episodes were analysed separately, the response to teicoplanin plus ciprofloxacin was favourable in 81% of patients whereas only 35% responded favourably to gentamicin plus piperacillin (p = 0.034). Gram-positive organisms accounted for 76% of bacterial isolates, Staphylococcus epidermidis being the most common pathogen. Ten of 12 (83%) Staphylococcus epidermidis infections resolved when treated with teicoplanin plus ciprofloxacin as compared with 2 of 8 (25%) treated with gentamicin plus piperacillin. Teicoplanin is at least as effective as gentamicin plus piperacillin in the empirical treatment of febrile neutropenic patients and may be more effective in situations where gram-positive organisms are prevalent. The high incidence of gram-positive infections in our unit justifies the use of an agent with specific activity against gram-positive organisms in the first-line antibiotic regimen.