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Vancomycin and teicoplanin display excellent activity against staphylococci and streptococci, but because of the wide availability of equally effective and less toxic drugs, they are second-line drugs in the treatment of most infections. As antistaphylococcal agents they are less effective than (3-lactam cephalosporin antibiotics, such as nafcillin and cefazolin. They have attained much wider use in recent years as a consequence of the emergence of methicillin-resistant S. aureus (MRSA) infections, in particular the growing importance of Staph-ylococcus epidermidis infections associated with the use of intravascular catheters and in patients with peritonitis who are on continuous ambulatory peritoneal dialysis.

Vancomycin is also an effective alternative therapy for the treatment of staphylococcal enterocolitis and endocarditis. The combination of vancomycin and either streptomycin or gentamicin acts synergistically against enterococci and is used effectively for the treatment or prevention of enterococcal endocarditis. Teicoplanin demonstrates similar synergy.

Staphylococcal vascular shunt infections in persons undergoing renal dialysis have been successfully treated with vancomycin. Vancomycin in oral form can also be used in patients in whom C. difficile colitis is not responding to metronidazole.

Teicoplanin, although not available in the United States, has been used to treat a wide range of gram-positive infections, including endocarditis and peritonitis. It is not as effective as the (3-lactams,but its actions are similar to those of vancomycin against staphylococcal infections.

An increased prevalence of MRSA has resulted in a greater use of vancomycin for this disorder. High-grade resistance of pneumococci to penicillin may also necessitate vancomycin therapy. Enterococci that are resistant to vancomycin are emerging as major nosocomial pathogens. These strains are generally resistant to a number of other antibiotics, such as penicillin, ampi-cillin, and gentamicin, which limits treatment options. The possibility of transferring these resistance determinants to other gram-positive organisms, like S. aureus, is a valid concern. It is therefore necessary to limit the use of vancomycin to treatment of serious infections caused by methicillin-resistant staphylococci and situations in which allergies preclude the use of other antibiotics.

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