Vancomycin skin infections

Vancomycin-resistant infections (VRE) PO, IV 600 mg q 12h for 14-28 days. Pneumonia, complicated skin and skin-structure infections PO, IV 600 mg q 12h for... 

Currently the most important hospital-acquired pathogen is methicillin-resistant Staph, aureus, which is responsible for a range of serious infections such as pneumonia, postoperative wound infection and skin infections which may in turn be complicated by bloodstream spread. The use of vancomycin and teicoplanin has escalated as a consequence, and in turn has been linked to the emergence of vancomycin-resistant enterococci. 

Barriere SL. ATLAS trials efficacy and safety of telavancin compared with vancomycin for the treatment of skin infections. Future Microbiol 2010 5(12) 1765-73. 

Skin and soft tissue Catheter-related Unknown source of infection Nafcillin or cefazolin Ceftriaxone +/- vancomycin Vancomycin Antipseudomonal penicillin OR Antipseudomonal cephalosporin OR Antipseudomonal carbapenem plus Aminoglycoside plus Vancomycin... 

Even newer is the natural product daptomycin (Cubicin), a complex cyclic lipopeptide structure, approved for use in the United States in 2003. Daptomycin has a spectrum similar to that of linezolid and specifically includes MRSA and VRE. In contrast to linezolid, daptomycin is bactericidal for these Gram-positive organisms. It is, like vancomycin, a parenteral antibiotic and is given intravenously. It is indicated for treatment of complicated skin and skin structure infections and for some cases of bacteremia, including endocarditis. Daptomycin may be thought of as an alternative to vancomycin. 

Dhawan B, Gadepalli R, Kapil A. (2009) In vitro activity of daptomycin against Staphylococcus Aureus and vancomycin-resistant Enterococcus Faecium isolates associated with skin and soft tissue infections First results from India. Diagn Microbiol Infect Dis 65 196-198. 

Breed J, Teras J, Gardovskis J, Maritz FJ, Vaasna T, Ross DP, Gioud-Paquet M, Dartois N, Ellis-Grosse EJ, Loh E. (2005) Safety and efficacy of tigecycline in treatment of skin and skin structure infections Results of a double-blind phase 3 comparison study with vancomycin-aztreonam. Antimicrob Agents Chemother 49 4658 666. 

Noel GJ, Bush K, Bagchi P, lanus J, Strauss RS. (2008) A randomized, double-blind trial comparing ceftobiprole medocaril with vancomycin plus ceftazidime for the treatment of patients with complicated skin and skin-structure infections. Clin Infect Dis 46 647-655. 

Local treatment of skin and soft tissue infections with antibiotic-containing ointments or solutions should not be used because it leads to allergic reactions and rapid development of bacterial resistance. In settings where MRSA or resistant Enterobacte-riaceae (like ESBL s gram negative bacteria with extended spectrum beta lactames) or Pseudomonas spp. occur, the empiric use of vancomycin and a carbapenem can be necessary. The risk of transmission of these organisms should be minimalised by hygienic and isolation measures. 

Infections due to vancomycin-resistant Enterococcus faecium IV 7 5 mg/kg/dose q8h Skin and skin-structure infections IV 7 5 mg/kg/dose q 12h. 

Nichols RL, Graham DR, Barriere SL, Rodgers A, Wilson SE, Zervos M, Dunn DL, Kreter B. Treatment of hospitalized patients with complicated Gram-positive skin and skin structure infections two randomized, multicentre studies of quinupristin/dalfopristin versus cefazolin, oxacillin or vancomycin. Synercid Skin and Skin Structure Infection Group. J Antimicrob Chemother 1999 44(2) 263-73. 

A 53-year-old white woman with liver cirrhosis took vancomycin (1 g bd) for sepsis due to methicillin-resistant S. aureus and a catheter-associated infection due to Enterococcus faecalis, developed oral and vaginal mucositis and conjunctivitis followed by a macu-lopapular rash (69). The diagnosis was confirmed by skin biopsy. Vancomycin was replaced by teicoplanin and corticosteroids the symptoms disappeared within 7 days. 

A bUstering eruption developed in the skin and buccal mucosa of a 79-year-old man after 8 days of vancomycin therapy for an infected leg ulcer (82). Biopsy showed linear IgA deposition along the basement membrane. The lesions cleared spontaneously within two days of withdrawal. 

In a patient with a positive skin test or a history of immediate hypersensitivity to penicillin, vancomycin is the agent of choice. Vancomycin, however, kills S. aureus slowly and is regarded as inferior to penicillinase-resistant penicillins for MSSA. Rifampin as an adjunctive therapy is controversial however, this agent, added to vancomycin in refractory or complicated infections in patients with left-sided IE may result in dramatic patient improvement. Generally, antibiotic therapy should be continued for 4 to 6 weeks. Unfortunately, left-sided IE caused by S. aureus continues to have a poor prognosis, with a mortality rate of 25% to 47%. Eor reasons discussed in the following section, those with IE associated with TVDA have a more favorable response to therapy. 

Pathogens from the Staphylococcus genus are found in both the hospital and the community, and the most prevalent species, aureus,. causes illnesses that range from minor skin abscesses to severe pneumonia, meningitis, and infections of the heart, bloodstream, bone, and joint. Multiple strains of S. aureus are now antibiotic resistant, including a few strains that are partially resistant to vancomycin (18), the last effective antibiotic against... 

Daptomycin is indicated in treatment of complicated skin and skin-structure infections caused by methicillin-susceptible and methicillin-resistant strains of S. aureus, hemolytic stteptococci, and vancomycin-susceptible E. faecalis. Its efficacy is comparable to that of vancomycin. Efficacy in more serious infections, such as endocarditis or complicated bacteremia, has not been demonsttated, although clinical ttials are under way. Daptomycin was inferior to comparators for treatment of community-acquired pneumonia and is not indicated for this infection. 

Linezolid is FDA approved for treatment of infections caused by vancomycin-resistant E. faecium nosocomial pneumonia caused by methicillin-susceptible and methicillin-resistant strains of S. aureus community-acquired pneumonia caused by penicillin-susceptible strains of S. pneumoniae complicated skin and skin-structure infections caused by streptococci and methicillin-susceptible and -resistant strains of S. aureus and uncomplicated skin and skin-structure infections. In noncomparative studies, linezolid (600 mg twice daily) has had clinical and miaobiological cure rates in the range of 85 to 90% in treatment of a variety of infections (soft tissue, urinary tract, and bacteremia) caused by vancomycin-resistant E. faecium. A 200-mg, twice-daily dose was less effective, with clinical and microbiological cure rates of approximately 75 and 59%, respectively. The 600-mg, twice-daily dose, therefore, should be used for treatment of infections caused by enterococci. A 400-mg, twice-daily dosage regimen is recommended only for treatment of uncomplicated skin and skin-structure infections. 

THERAPEUTIC USES Qumupristrn/dalfopristin is approved in the U.S. for treatment of infections caused by vancomycin-resistant strains of E. faecium and comphcated skin and skin-structure infections caused by methicilUn-susceptible strains of S. aureus or S. pyogenes. In Europe, it also is approved for treatment of nosocomial pneumonia and infections caused by methiciUin-resistant strains of S. aureus. Cure rates for a variety of infections caused by vancomycin-resistant E. faecium were -70% with quinupiistin/dalfopiistin at a dose of 7.5 mg/kg every 8-12 hours. Quinupiistin/dal-fopiistin should be reserved for treatment of serious infections caused by multiple-drug-resistant gram-positive organisms such as vancomycin-resistant E. faecium. 

Cure rates with linezolid ( 60%) were similar to those with vancomycin for nosocomial pneumonia caused by methicillin-resistant or -susceptible S. aureus. Linezolid efficacy also was similar to that of either oxacillin or vancomycin for skin arul skin-structure infections, the majority of cases due to by 8. aureus. Linezolid appears comparable in efficacy to varwomycin for methicillin-resistant strains. Linezolid may be effective for patients with methicillin-resistant S. aureus infections who are failing varwomycin therapy or whose isolates have reduced susceptibility to vancomycin. Linezolid is bacteriostatic for staphylococci arul enterococci arul probably should not be used to treat suspected erulocarditis. 

Daptomycin is indicated for treatment of complicated skin and skin-structure infections caused by methicillin-susceptible and methicillin-resistant strains ofS. aureus, hemolytic streptococci, and vancomycin-susceptible E. faecalis. Its efficacy is comparable to that of vancomycin. 

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