Three-times weekly teicoplanin in the outpatient treatment of acute methicillin-resistant staphylococcal osteomyelitis: a pilot study

Evaluation of a thrice weekly administration of teicoplanin in the outpatient setting: a retrospective observational multicentre study

Introduction

The glycopeptide teicoplanin is commonly utilized to facilitate outpatient parenteral antimicrobial therapy (OPAT). Licensed for once daily maintenance dosing, teicoplanin’s long half-life allows for less frequent dosing (e.g. thrice weekly) following successful loading. This service evaluation reviews the safety and effectiveness of a novel thrice weekly teicoplanin dosing regimen.

Methods

A retrospective, observational study was conducted at Chelsea and Westminster Hospital (March 2018 to July 2020), evaluating trough serum teicoplanin concentrations for patients receiving >5 days of teicoplanin in the OPAT setting. Teicoplanin dosing and administration (once daily versus thrice weekly), clinical outcomes and therapeutic levels were analysed for all patients. The project was registered with clinical governance locally.

Results

A total of 82 patients treated with teicoplanin in the OPAT service were included; 53/82 receiving thrice weekly and 29/82 receiving once daily dosing. Mean teicoplanin trough levels were similar in both groups (26.2 mg/L and 25.8 mg/L in once daily and thrice weekly groups, P = 0.8895). High clinical success rates were recorded in both groups (25/29 [86.2%] versus 50/53 [94.3%]). No correlation with clinical outcomes and initial teicoplanin serum levels was identified. Normal renal function (>90 mL/min) was associated with lower teicoplanin serum concentrations (mean [±SD] 21.4 mg/L [±10.1] versus 29.7 mg/L [±14], P = 0.0178) in the thrice weekly dosed group but not with the once daily dosed group (mean [±SD] 28.2 mg/L [±9.4] versus 23.7 mg/L [±9.9], P = 0.2201).

Conclusions

This study supports thrice weekly teicoplanin as a convenient and effective OPAT for administration in the OPAT setting. Therapeutic drug monitoring is advised to adjust for intra-patient variability.

Palliative outpatient parenteral antibiotic therapy: a review of 5 years of patient data

OBJECTIVES

A review of patients requiring lifelong antibiotics to control, rather than cure, infection was performed ['palliative outpatient parenteral antibiotic therapy (OPAT)']. This was to evaluate emerging themes and complications. The aim was to aid in the management of such patients.

METHODS

A retrospective review of the OPAT database over 5 years (2013-17) was performed. Of the 1438 patients, 9 were deemed to have received palliative OPAT.

RESULTS

The palliative cohort represented 0.6% of the total number of patients on OPAT and 8.6% of the bed days saved. Patients fell into two main groups: those with multiple comorbidities that precluded surgical management and those with a terminal condition. Both groups received IV antibiotics with no clear endpoint. The themes to emerge were: patients often had multiple comorbidities with a high operative risk to control the source of infection; a trial of no or oral antibiotics led to resurgence of the infection; vascular patients appeared to tolerate long-term antibiotics well; and conversely, antibiotic side effects were a significant issue in others. Patients with incurable cancer and a coincident infection can be given additional quality of life with the judicious use of appropriate therapy.

CONCLUSIONS

There are significant issues surrounding antimicrobial stewardship in the palliative OPAT group that should be considered. Excellent communication is required to deal with these often very complicated patients. There are considerable gains to be made both for patients and the number of bed days saved. The small number of patients accounted for a disproportionate number of bed days saved.

Teicoplanin-based antimicrobial therapy in Staphylococcus aureus bone and joint infection: tolerance, efficacy and experience with subcutaneous administration

Background

Staphylococci represent the first etiologic agents of bone and joint infection (BJI), leading glycopeptides use, especially in case of methicillin-resistance or betalactam intolerance. Teicoplanin may represent an alternative to vancomycin because of its acceptable bone penetration and possible subcutaneous administration.

Methods

Adults receiving teicoplanin for S. aureus BJI were included in a retrospective cohort study investigating intravenous or subcutaneous teicoplanin safety and pharmacokinetics.

Results

Sixty-five S. aureus BJIs (orthopedic device-related infections, 69 %; methicillin-resistance, 17 %) were treated by teicoplanin at the initial dose of 5.7 mg/kg/day (IQR, 4.7–6.5) after a loading dose of 5 injections 12 h apart. The first trough teicoplanin level (C_min) reached the therapeutic target (15 mg/L) in 26 % of patients, only. An overdose (C_min >25 mg/L) was observed in 16 % patients, 50 % of which had chronic renal failure (p = 0.049). Seven adverse events occurred in 6 patients (10 %); no predictive factor could be highlighted. After a 91-week follow-up (IQR, 51–183), 27 treatment failures were observed (42 %), associated with diabetes (OR, 5.1; p = 0.057), systemic inflammatory disease (OR, 5.6; p = 0.043), and abscess (OR, 4.1; p < 10⁻³). A normal CRP-value at 1 month was protective (OR, 0.2; p = 0.029). Subcutaneous administration (n = 14) showed no difference in pharmacokinetics and tolerance compared to the intravenous route.

Conclusions

Teicoplanin constitutes a well-tolerated therapeutic alternative in S. aureus BJI, with a possible subcutaneous administration in outpatients. The loading dose might be increase to 9–12 mg/kg to quickly reach the therapeutic target, but tolerance of such higher doses remains to be evaluated, especially if using the subcutaneous route.

Electronic supplementary material

The online version of this article (doi:10.1186/s12879-016-1955-7) contains supplementary material, which is available to authorized users.

Antibiotic prophylaxis with teicoplanin on alternate days reduces rate of viridans sepsis and febrile neutropenia in pediatric patients with acute myeloid leukemia

Intensive chemotherapy directed against acute myeloid leukemia of childhood is followed by profound neutropenia and high risk for bacterial and fungal infections, including viridans group streptococci as a common cause for gram-positive septicemia. Few retrospective studies have shown the efficacy of various antibiotic prophylactic regimens in children. We retrospectively studied 50 pediatric patients treated on the AML-BFM 2004 protocol between 2005 and 2015 at St. Anna Children's Hospital and assessed the effect of antibiotic prophylaxis on the frequency of febrile neutropenia and bacterial sepsis. Fifty pediatric patients underwent 199 evaluable chemotherapy cycles. Viridans sepsis occurred after none of 98 cycles with prophylactic administration of teicoplanin/vancomycin in comparison to 12 cases of viridans sepsis among 79 cycles without systemic antibacterial prophylaxis (0 vs. 15 %, p < 0.0001). In addition, there were significantly fewer episodes of febrile neutropenia in the teicoplanin/vancomycin group (44 % vs. no prophylaxis 82 %, p < 0.0001). Severity of infection seemed to be worse when no antibiotic prophylaxis had been administered with a higher rate of intensive care unit treatment (0/98, 0 %, vs. 4/79, 5 %, p = 0.038). So far, no increase of vancomycin-resistant enterococcus isolates in surveillance cultures was noticed. Antibiotic prophylaxis with teicoplanin (or vancomycin) appears safe and feasible and resulted in eradication of viridans sepsis and decreased incidence of febrile neutropenia in pediatric AML patients. The possibility to administer teicoplanin on alternate days on an outpatient basis or at home could contribute to patient's quality of life and decrease health care costs.

Spinal Infection Multidisciplinary Management Project (SIMP): From Diagnosis to Treatment Guideline

Spine infections require a multidisciplinary approach to be treated and solved. A guide line to drive physicians in the deep complexity of such a disease is extremely helpful. SIMP suggests a flow-chart built up on clear concepts such as right and well managed antibiotic therapy, sound stability of the spine, correct and smart use of the standard and functional imaging techniques, such as f18 FDG PET/CT. In 16 months a total of 41 patients have been treated for spondylodiscitis, discitis and vertebral osteomyelitis by our team of physicians and 25 patients have been enrolled in a prospective study whose target is the assessment of the SIMP flow-chart and of every single aspect that characterize it.

Pharmacodynamics of antibiotics to treat multidrug-resistant Gram-positive hospital infections

Hospital infection due to multidrug-resistant Gram-positive bacteria may often represent a life-threatening challenge; thus, to appropriately combat them, clinicians should be confident and systematically apply several important pharmacodynamic concepts. The concept of 'correct antibiotic treatment' should include, in addition to an appropriate choice in terms of antimicrobial susceptibility, an appropriate dosage and administration schedule consistent with the pharmacodynamic principles. In the next few years, it is expected that some of the anti-Gram-positive antimicrobial agents that are currently under investigation will be added to the therapeutic armamentarium. However, optimization of the usage of old drugs still remains a clinical priority and a scientific challenge, whose dignity may be considered of similar importance to that of the assessment of the possible therapeutic role of the new compounds.

Experimental study of teicoplanin, alone and in combination, in the therapy of cephalosporin-resistant pneumococcal meningitis

OBJECTIVES

The aim of the study was to determine the efficacy of teicoplanin, alone and in combination with ceftriaxone, in a rabbit model of cephalosporin-resistant pneumococcal meningitis, and to assess the effect of concomitant therapy with dexamethasone.

METHODS

In vitro killing curves of teicoplanin, with and without ceftriaxone, were performed. Groups of eight animals per treatment were inoculated with a cephalosporin-resistant pneumococcal strain (penicillin MIC, 4 mg/L; ceftriaxone MIC, 2 mg/L; teicoplanin MIC, 0.03 mg/L) and treated over a 26 h period. Teicoplanin was administered at a dose of 15 mg/kg, alone and in combination with ceftriaxone at 100 mg/kg with or without dexamethasone at 0.25 mg/kg. CSF samples were collected at different time-points, and bacterial titres, white blood cell counts, lactate and protein concentrations and bacteriostatic/bactericidal titres were determined. Blood and CSF teicoplanin pharmacokinetic and pharmacodynamic parameters were determined.

RESULTS

Teicoplanin alone promoted a decrease in bacterial counts at 6 h of -2.66 log cfu/mL and was bactericidal at 24 h, without therapeutic failures. Similar good results were obtained when dexamethasone was used simultaneously, in spite of the penetration of teicoplanin into the CSF being significantly reduced, from 2.31% to 0.71%. Teicoplanin and ceftriaxone combinations were synergic in vitro, but not in the meningitis model.

CONCLUSIONS

Teicoplanin alone was very effective in this model of cephalosporin-resistant pneumococcal meningitis. The use of concomitant dexamethasone resulted in lower CSF teicoplanin levels, but not in therapeutic failures. The combination of teicoplanin plus ceftriaxone and dexamethasone might be a good alternative for the empirical therapy of pneumococcal meningitis. Additional data should confirm our experiments, in advance of clinical trials to assess efficacy in humans.

Outpatient parenteral antibiotic therapy (OPAT) in different countries: a comparison

In order to assess how outpatient parenteral antibiotic therapy (OPAT) is managed in different countries, we analyzed the data collected in the USA, UK and Italy by the International OPAT Registry using an ad hoc Access/Excel Microsoft program. The analysis of data concerned 9826 patients in the USA, 981 in the UK and 620 in Italy. Differences were observed in several aspects of OPAT management such as the infections treated and the antibiotics utilized. The duration of therapy also differed: it was much longer in Italy (56.0 average days), than in the USA (22.5 days) and UK (19.9 days). Delivery model, delivery route and infusion devices show substantial differences. The present analysis shows that OPAT is carried out with substantial differences in different countries probably according to different programmes and guidelines adopted.

Randomized comparison of serum teicoplanin concentrations following daily or alternate daily dosing in healthy adults

Trough serum teicoplanin concentrations were compared in healthy adults following intravenous administration of one of two regimens: (i) 12 mg/kg of body weight every 12 h for 3 doses and then 15 mg/kg every 48 h for 4 doses (n = 16 subjects) or (ii) 6 mg/kg every 12 h for 2 doses and then 6 mg/kg every 24 h for 9 doses (n = 8 subjects). The mean +/- standard deviation trough concentrations in serum on day 11 (24 and 48 h after administration of the last dose for the daily and alternate-day dosing schedules, respectively) were 16.0 +/- 2.1 and 17.9 +/- 3.5 mg/liter for subjects receiving the two regimens, respectively, by a fluorescence polarization immunoassay. The limits of the 95% confidence interval of the difference (-0.2, 3.6 mg/liter) determined by a nonparametric test were situated above the -1.3-mg/liter maximum set difference and indicated a noninferiority of the alternate-day dosing to the daily dosing. Throughout the study the individual trough concentrations in serum in the alternate-day dosing group constantly exceeded 10 mg/liter, the presently recommended target concentration for the treatment of severe infections. The trough concentrations in the sera of all subjects were bactericidal for six Staphylococcus aureus strains for which teicoplanin MICs are between 0.5 and 4 mg/liter. The bactericidal activity of serum was related to total teicoplanin (protein bound and unbound). In conclusion, an alternate-day dosing schedule (15 mg/kg on alternate days following administration of a 12-mg/kg loading dose three times every 12 h) could be considered for further efficacy and safety studies.