Glycopeptides

Vancomycin and teicoplanin are active only against Gram-positive bacteria but methicillin-resistant staphylococci are susceptible. The range of susceptibility of coagulase-negative staphylococci to teicoplanin is wider than to vancomycin. Teicoplanin is more active than vancomycin against enterococci and some vancomycin-resistant enterococci (vanB type). Streptococci, including those resistant to penicillin, are susceptible. Both agents are excreted by the kidneys and dosage reduction is necessary. Oral vancomycin (125 mg every 6 h for 10 days) is used to treat antibiotic-associated colitis. Teicoplanin can be given intravenously as a bolus dose, but vancomycin requires a slow infusion over 1 h to avoid flushing and hypotension. Teicoplanin has a longer half-life, allowing once-daily doses. Neither reliably penetrate the cerebrospinal fluid.

The glycopeptides are used to treat infections caused by MRSA (and other staphylococcal infections in penicillin-allergic patients) and catheter- or prosthesis-related infections caused by coagulase-negative staphylococci. Fever in neutropenic patients is treated with glycopeptides when there is evidence of catheter infection or failure of empirical treatment. Vancomycin concentrations in serum can be monitored to maintain troughs of 5 to 10 mg/l and peaks of 20 to 50 mg/l in order to avoid nephrotoxicity, particularly when used in combination with aminoglycosides. Teicoplanin does not require monitoring for toxicity but to ensure therapeutic levels, for example in staphylococcal endocarditis, when the trough should be over 20 mg/l, in renal failure, and in drug abusers. Ototoxicity and nephrotoxicity are rare using vancomycin alone, but there is a synergistic effect when it is combined with an aminoglycoside. Both glycopeptides can cause rash.

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