Vancomycin staphylococcal

Broad-spectrum antibiotic cefotaxime or ceftriaxone (clindamycin for cephalosporin allergy) vancomycin for staphylococcal and resistant pneumococcal organisms... 

Broad intravenous antibiotic coverage for the encapsulated organisms can include ceftriaxone or cefotaxime. For patients with true cephalosporin allergy, clindamycin may be used. If staphylococcal infection is suspected owing to previous history or the patient appears acutely ill, vancomycin should be initiated. Macrolide antibiotics, such as erythromycin and azithromycin, may be initiated if Mycoplasma pneumonia is suspected. While the patient is receiving broad-spectrum antibiotics, their regular use of penicillin for prophylaxis can be suspended. Fever should be controlled with acetaminophen or ibuprofen. Because of the risk of dehydration during infection with fever, increased fluid may be needed.6,27... 

For staphylococcal PVE, treatment length increases significantly, typically requiring a minimum of 6 weeks (see Table 71-5). For MSSA, a penicillinase-resistant penicillin is still employed, as well as vancomycin for MRSA. However, with either regimen, the addition of both gentamicin for first 2 weeks and rifampin for the entire length of treatment is recommended. 

Vancomycin is used frequently in severe infections with gram-positive pathogens. With increasing staphylococcal resistance, linezolid, quinupris-tin/dalfopristin, daptomycin, and tigecycline are alternatives. 

Pseudomembranous colitis/staphylococcal enterocolitis caused by Clostridium difficile-The parenteral form may be administered orally parenteral use alone is unproven. The oral use of parenteral vancomycin is not effective for other infections. 

Oral Staphylococcal enterocolitis and antibiotic-associated pseudomembranous colitis produced by C. difficile. The parenteral product may also be given orally for these infections. Oral vancomycin is not effective for other types of infection. 

The glycopeptides include vancomycin and teico-planin. They are bactericidal antibiotics. Their mechanism of action is based on inhibition of bacterial cell-wall synthesis by blocking the polymerization of glycopeptides. They do not act from within the peptidoglycan layer, as the beta-lactam antibiotics do, but intracellularly. The indications are mainly restricted to the management of severe or resistant staphylococcal infections, especially those caused by coagulase negative staphylococcal species such as S. epidermidis. 

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 synergisticaUy against enterococci and is used effectively for the treatment or... 

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. 

The use of an antagonistic antimicrobial combination does not preclude other potential beneficial interactions. For example, rifampin may antagonize the action of anti-staphylococcal penicillins or vancomycin against staphylococci. However, the aforementioned antimicrobials may prevent the emergence of resistance to rifampin. 

Rifampin is used in a variety of other clinical situations. An oral dosage of 600 mg twice daily for 2 days can eliminate meningococcal carriage. Rifampin, 20 mg/kg/d for 4 days, is used as prophylaxis in contacts of children with Haemophilus influenzae type b disease. Rifampin combined with a second agent is used to eradicate staphylococcal carriage. Rifampin combination therapy is also indicated for treatment of serious staphylococcal infections such as osteomyelitis and prosthetic valve endocarditis. Rifampin has been recommended also for use in combination with ceftriaxone or vancomycin in treatment of meningitis caused by highly penicillin-resistant strains of pneumococci. 

Staphylococcal septicaemia may be suspected where there is an abscess, e.g. of bone or lung, or with acute infective endocarditis or infection of intravenous catheters high dose flucloxacillin is indicated (vancomycin). 

It acts by inhibiting RNA synthesis, bacteria being sensitive to this effect at much lower concentrations than mammalian cells it is particularly effective against mycobacteria that lie semidormant within cells. Rifampicin has a wide range of antimicrobial activity. Other uses include leprosy, severe Legionnaires disease (with erythromycin or ciprofloxacin), the chemoprophylaxis of meningococcal meningitis, and severe staphylococcal infection (with flucloxacillin or vancomycin). 

In a small, open, phase II pilot study, low-dose quinupristin-b dalfopristin (5 mg/kg intravenously every 8 hours n = 11) and high-dose quinupristin + dalfopristin (7.5 mg/kg intravenously every 8 hours n 15) were compared with vancomycin (1 g intravenously every 12 hours n = 13) in the treatment of catheter-related staphylococcal bacteremia (21). In patients with a baseline pathogen, the outcome was comparable in aU groups. Adverse clinical events in the quinupristin + dalfopristin group consisted of arm and chest pain, chills, fever, arthritis, and phlebitis or pain at the injection site quinupristin -I-dalfopristin was withdrawn in 12% of patients (compared with 15% of vancomycin-treated patients). 

Raad I, Bompart F, Hachem R. Prospective, randomized dose-ranging open phase II pilot study of quinupristin/dalfo-pristin versus vancomycin in the treatment of catheter-related staphylococcal bacteremia. Eur J Clin Microbiol Infect Dis 1999 18(3) 199-202. 

A typical case of vancomycin-induced neutropenia has been reported in a 39-year-old woman with sickle cell SS disease treated with vancomycin for methicillin-resistant coagulase-negative staphylococcal bacteremia (50). However, in addition to neutropenia, the clinical course was defined by a febrile period characteristic of drug fever, with delayed onset and resolution 48 hours after vancomycin was withdrawn. In this case, fluconazole and cefazoline were also administered, but their contribution to neutropenia was judged unlikely (negative rechallenge with fluconazole, withdrawal of cefazoline after less than 5 days of therapy). 

Thrombocytopenia also developed in a 72-year-old man who was treated with vancomycin for staphylococcal sepsis after treatment with gemcitabine for metastatic pancreatic cancer (53). On day 12 thrombocytopenia developed, reached a nadir on day 18 (13 x lO /l), and did not respond to platelet transfusions. Bone-marrow megakaryocjrtes were adequate. Platelet-associated IgG and IgM were increased. Vancomycin was withdrawn on day 28, with prompt recovery of the platelet count to 136 x lO /l in 10 days. 

Of 69 neonates (including 8 with peak vancomycin concentrations over 40 pg/ml) with culture-proven S. aureus or coagulase-negative staphylococcal septicemia who received vancomycin for more than 3 days, 6 had a doubling of serum creatinine concentration during vancomycin treatment, and all were in the group with peak serum vancomycin concentrations under 40 pg/ml (58). 

A 72-year-old woman developed a bullous eruption on her palms, soles, and conjunctivae a day after receiving vancomycin (intravenously and via a cecostomy tube) for staphylococcal sepsis (81). Immunofluorescence of the skin biopsy showed linear IgA deposition along the basement membrane. The lesions cleared over the next 2 weeks after withdrawal of vancomycin. 

Wysocki M, Delatour F, Faurisson F, Rauss A, Pean Y, Misset B, Thomas F, Timsit JF, Similowski T, Mentec H, Mier L, Dreyfuss D. Continuous versus intermittent infusion of vancomycin in severe staphylococcal infections prospective multicenter randomized study. Antimicrob Agents Chemother 2001 45(9) 2460-7. 

C Treatment for catheter-related infections is often initiated empirically, with definitive therapy based on culture results and susceptibility. Dialysis catheters are usually permanently inserted lines, and patients on chronic hemodialysis are at higher risk for developing catheter-related infections secondary to staphylococcal species, particularly coagulase-negative staphylococci. Oral vancomycin is not appropriate because it does not achieve adequate blood levels to treat systemic infections. 

The glycopcptide antibiotic vancomycin has been efta -tive in the treatment of clindamycin-induced pseudoiiKm branous colitis and in the control of the experimentally in duced bacterial condition in animals. Clindamycin shotiU be reserved for staphylococcal tissue infections, such asetf lulitis and osteomyelitis, in penicillin-allergic patients aid for severe anaerobic infections ouLside the central nemw.. system. Ordinarily, it should not be used to treat upper ie p ratory tract infections caused by bacteria sen.sitivc to oiiia safer antibiotics or in prophylaxis. 

Vancomycin hydrochloride is always administered intravenously (never intramuscularly), either by slow injection or hy continuous infusion, for the treatment of systemic infections. In shott-term therapy, the toxic side reactions arc usually slight, hut continued u.sc may lead to impaired auditory acuity, renal damage, phlebitis, and rashes. Bccau.se it is nut assorted or signilicantly degraded in the gastrointc.stinal tract, vancomycin may he administered orally fur the treatment of staphylococcal enterocolitis and for pseudomembranous colitis associated with clindamycin therapy. Some conversion to aglucovancomycin likely (Kcurs in the low pH of the stomach. The latter retains about three-fourths of the activity of vancomycin. 

Rifampicin possesses significant bactericidal activity at very low concentrations against staphylococci. Unfortunately, resistant mutants may arise very rapidly, both in vitro and in vivo. It has thus been recommended that rifampicin should be combined with another antibiotic, e.g. vancomycin, in the treatment of staphylococcal infections. 

Raymond et al. reported on a rotation study in a surgical intensive care unit with a different twist.Patients were stratified as either having sepsis/peritonitis or pneumonia, and empiric therapy was cycled every 3 months by syndrome. Fourteen hundred fifty-six admissions and 540 infections were treated over a 2-year period. With similar severity of illness during the before and after periods (mean APACHE II = 19), the authors demonstrated a reduction of length of stay from a mean of 62 days to 39 days, a reduction of vancomycin-resistant enterococcal and methicillin-resistant staphylococcal infection from 14 per 100 admissions to 8 per 100 admissions and death due to any cause dropped from 25 in the before period to 18 in the rotation period. Antimicrobial susceptibility and several other key parameters needed to evaluate the effectiveness of this program were not reported. 

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