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Teicoplanin (Targocid, Hoechst Marion Roussel): a new glycopeptide antibiotic
DRUG T H E R A P Y R E V I E W
Teicoplanin (Targocid, Hoechst Marion
Roussel): anew glycopeptide antibiotic The glycopeptides are important antibiotics in the management of Staphylococcal infections. Teicoplanin, the latest member of the group, may offer some advantages over vancomycin, the workhorse drug, which has retained its importance in the presence of increasing major resistance to other antistaphylococcal agents.
A C T I O N A N D USES Teicoplanin is one of two glycopeptide antibiotics (the other is vancomycin) in clinical use over the past 10 years. Glycopeptides are narrow spectrum agents with activity primarlily against gram-positive organisms, most notably Staphylococcus aureus and coagulase negative staphylococci including methicillin (or multiple)-resistant strains (MRSA). They have no useful activity against gram-negative organisms. Although teicoplanin and vancomycin have broadly similar activity against Staphylococcus aureus, teicoplanin is reported to be more active against some methicillin-resistant strains. Uses for the group include known or suspected gram-positive bacteraemia, intravascular and intraperitoneal catheter sepsis, streptococcal and staphylococcal endocarditis, osteomyelitis, septic arthritis and skin and soft tissue infection. They are also used in antibiotic combinations in the treatment of febrile illness in neutropenic (immunocompromised) patients. Glycopeptides bind strongly to important components of the bacterial cell wall so inhibiting cell wall synthesis and are thus rapidly bactericidal to dividing cells. Resistance which is plasmid-mediated does occur. The emergence of vancomycin-resistant enterococci in hospital wards and departments has been a major concern in the past and Intensiveand Crmcal Care Nursing (I 997) 13 308-309
© 1997Harcourt Brace & Company Ltd
is a timely reminder of the consequence of overuse of antibiotics which are important in the treatment of severe infections.
ADMINISTRATION
AND DOSAGE
Teicoplanin may be given by the intramuscular route but administration by intravenous bolus injection (or rapid infusion if preferred) is more likely in serious infection. Dosage is based on 6 mg/kg body weight but most adults will receive 400 mg once daily. An initial (loading) regimen is used in which the first 3 doses are administered at 12-hourly intervals. Note the use of much higher doses (e.g. 12 mg/kg) in some instances (e.g. infected burns patients and Staphylococcus aureus endocarditis). Up to 30 mg/kg/day has been reported in severely infected mainlining drug abusers, apparently to compensate for the much higher rate of clearance of the drug in this group. Children normally require 10 mg/kg 12hourly for the first 3 doses then once dally thereafter and neonates 16 mg/kg stat then 8 mg/kg/day. Note also the use of doses up to 25 mg/kg/day in some cases (e.g. cystic fibrosis). Specifically, in the treatment of peritonitis associated with continuous ambulatory peritoneal dialysis (CAPD), teicoplanin is administered via the dialysis fluid in a concentration of 20 mg/]. It is clear that further revision of teicoplanin dosage regimen may take place in the future.
S U M M A R Y OF N U R S I N G CONSIDERATIONS Teicoplanin is not absorbed orally and must be administered by injection. It is extensively bound to albumin and has a notably long serum half-fife, hence it need be administered only once a day. Most teicoplanin is excreted unchanged in the urine and suitable dosage reduction is required for patients with kidney impairment. As a guide, give half the dose (or the same dose administered every 48 h) to patients with moderate renal impairment or one-third of the dose (or administer the same dose every 3 days) if kidney function is severely impaired. Renal function can be estimated from the patient's age, body weight and serum creatinine: Pharmacy can advise. Note that the dosage reduction does not apply until after the third treatment day. Since it is highly protein bound, teicoplanin is not effectively removed by dialysis.
Teicoplanin (Targocid, Hoechst Marion Roussel): a new glycopeptide antibiotic
• Teicoplanin injection is generally well tolerated. Local problems (irritation, redness, thrombophlebitis) and generalized hypersensitivity reactions (chills, fever, rashes, etc) are encountered rarely. In particular, the ototoxicity and nephrotoxicity which is widely reported with vancomycin is rarely, if ever, seen. Nevertheless, liver and kidney function should be monitored during prolonged therapy. • Teicoplanin vials are prepared with water for injections using the diluent provided. Do not shake (but rather gently roll) the vial during reconstitution since foaming will result. Reconstituted solution in the vial may be stored under refrigeration and used within 24 h. • If required to be given by intravenous infusion, further dilute in 50-100 ml glucose 5% or sodium chloride 0.9% and administer over 30 rain.
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SUMMARY
The glycopeptides play an important role in the treatment of serious infections which may arise in the intensive care setting including coagulase negative staphylococcal and M1LSA (e.g. bacteraemia, osteomyelitis) and penicillin-resistant enterococcal infections. Antibiotic therapy regimen which include a glycopeptide are frequently used for empiric treatment in febrile
309
neutropenic patients, in prosthetic valve endocarditis, CNS shunt infections (ventriculitis), and CAPD-associated peritonitis in which teicoplanin/vancomycin-sensitive organisms are implicated. Teicoplanin has the significant advantage over vancomycin of once daily administration, administration by bolus injection and no requirement for routine plasma level monitoring and a relative lack of hypersensitivity reactions. The latter includes the somewhat disturbing 'red man syndrome' sometimes seen in patients who receive vancomycin, especially if administered too rapidly or in high concentration. Teicoplanin may also be indicated in rare cases of vancomycin resistance when sensitivity to teicoplanin is reported by the microbiology laboratory. Inevitably almost, teicoplanin is more expensive than vancomycin in terms of unit cost but it can be argued that this is largely offset by savings on the cost of monitoring, as well as the cost of disposables and nursing time. It is especially suitable for home administration in the treatment of chronic infections (e.g. osteomyelitis, endocarditis) and recurring chest infections in patients with cystic fibrosis, so obviating the need for inconvenient and costly prolonged or repeated hospitalizations. FURTHER READING
Brogden 1KN, Peters D H. Teicoplanin. A reappraasal of its antimicrobial activity, pharmacokinetlc propemes and therapeutic efficacy. Drugs 1994; 47:823-854
A. M. MacConnachie
Teicoplanin (Targocid, Hoechst Marion
Roussel): anew glycopeptide antibiotic The glycopeptides are important antibiotics in the management of Staphylococcal infections. Teicoplanin, the latest member of the group, may offer some advantages over vancomycin, the workhorse drug, which has retained its importance in the presence of increasing major resistance to other antistaphylococcal agents.
A C T I O N A N D USES Teicoplanin is one of two glycopeptide antibiotics (the other is vancomycin) in clinical use over the past 10 years. Glycopeptides are narrow spectrum agents with activity primarlily against gram-positive organisms, most notably Staphylococcus aureus and coagulase negative staphylococci including methicillin (or multiple)-resistant strains (MRSA). They have no useful activity against gram-negative organisms. Although teicoplanin and vancomycin have broadly similar activity against Staphylococcus aureus, teicoplanin is reported to be more active against some methicillin-resistant strains. Uses for the group include known or suspected gram-positive bacteraemia, intravascular and intraperitoneal catheter sepsis, streptococcal and staphylococcal endocarditis, osteomyelitis, septic arthritis and skin and soft tissue infection. They are also used in antibiotic combinations in the treatment of febrile illness in neutropenic (immunocompromised) patients. Glycopeptides bind strongly to important components of the bacterial cell wall so inhibiting cell wall synthesis and are thus rapidly bactericidal to dividing cells. Resistance which is plasmid-mediated does occur. The emergence of vancomycin-resistant enterococci in hospital wards and departments has been a major concern in the past and Intensiveand Crmcal Care Nursing (I 997) 13 308-309
© 1997Harcourt Brace & Company Ltd
is a timely reminder of the consequence of overuse of antibiotics which are important in the treatment of severe infections.
ADMINISTRATION
AND DOSAGE
Teicoplanin may be given by the intramuscular route but administration by intravenous bolus injection (or rapid infusion if preferred) is more likely in serious infection. Dosage is based on 6 mg/kg body weight but most adults will receive 400 mg once daily. An initial (loading) regimen is used in which the first 3 doses are administered at 12-hourly intervals. Note the use of much higher doses (e.g. 12 mg/kg) in some instances (e.g. infected burns patients and Staphylococcus aureus endocarditis). Up to 30 mg/kg/day has been reported in severely infected mainlining drug abusers, apparently to compensate for the much higher rate of clearance of the drug in this group. Children normally require 10 mg/kg 12hourly for the first 3 doses then once dally thereafter and neonates 16 mg/kg stat then 8 mg/kg/day. Note also the use of doses up to 25 mg/kg/day in some cases (e.g. cystic fibrosis). Specifically, in the treatment of peritonitis associated with continuous ambulatory peritoneal dialysis (CAPD), teicoplanin is administered via the dialysis fluid in a concentration of 20 mg/]. It is clear that further revision of teicoplanin dosage regimen may take place in the future.
S U M M A R Y OF N U R S I N G CONSIDERATIONS Teicoplanin is not absorbed orally and must be administered by injection. It is extensively bound to albumin and has a notably long serum half-fife, hence it need be administered only once a day. Most teicoplanin is excreted unchanged in the urine and suitable dosage reduction is required for patients with kidney impairment. As a guide, give half the dose (or the same dose administered every 48 h) to patients with moderate renal impairment or one-third of the dose (or administer the same dose every 3 days) if kidney function is severely impaired. Renal function can be estimated from the patient's age, body weight and serum creatinine: Pharmacy can advise. Note that the dosage reduction does not apply until after the third treatment day. Since it is highly protein bound, teicoplanin is not effectively removed by dialysis.
Teicoplanin (Targocid, Hoechst Marion Roussel): a new glycopeptide antibiotic
• Teicoplanin injection is generally well tolerated. Local problems (irritation, redness, thrombophlebitis) and generalized hypersensitivity reactions (chills, fever, rashes, etc) are encountered rarely. In particular, the ototoxicity and nephrotoxicity which is widely reported with vancomycin is rarely, if ever, seen. Nevertheless, liver and kidney function should be monitored during prolonged therapy. • Teicoplanin vials are prepared with water for injections using the diluent provided. Do not shake (but rather gently roll) the vial during reconstitution since foaming will result. Reconstituted solution in the vial may be stored under refrigeration and used within 24 h. • If required to be given by intravenous infusion, further dilute in 50-100 ml glucose 5% or sodium chloride 0.9% and administer over 30 rain.
IIIIIIlll[l'llI II i
IIIIIIIrl
SUMMARY
The glycopeptides play an important role in the treatment of serious infections which may arise in the intensive care setting including coagulase negative staphylococcal and M1LSA (e.g. bacteraemia, osteomyelitis) and penicillin-resistant enterococcal infections. Antibiotic therapy regimen which include a glycopeptide are frequently used for empiric treatment in febrile
309
neutropenic patients, in prosthetic valve endocarditis, CNS shunt infections (ventriculitis), and CAPD-associated peritonitis in which teicoplanin/vancomycin-sensitive organisms are implicated. Teicoplanin has the significant advantage over vancomycin of once daily administration, administration by bolus injection and no requirement for routine plasma level monitoring and a relative lack of hypersensitivity reactions. The latter includes the somewhat disturbing 'red man syndrome' sometimes seen in patients who receive vancomycin, especially if administered too rapidly or in high concentration. Teicoplanin may also be indicated in rare cases of vancomycin resistance when sensitivity to teicoplanin is reported by the microbiology laboratory. Inevitably almost, teicoplanin is more expensive than vancomycin in terms of unit cost but it can be argued that this is largely offset by savings on the cost of monitoring, as well as the cost of disposables and nursing time. It is especially suitable for home administration in the treatment of chronic infections (e.g. osteomyelitis, endocarditis) and recurring chest infections in patients with cystic fibrosis, so obviating the need for inconvenient and costly prolonged or repeated hospitalizations. FURTHER READING
Brogden 1KN, Peters D H. Teicoplanin. A reappraasal of its antimicrobial activity, pharmacokinetlc propemes and therapeutic efficacy. Drugs 1994; 47:823-854
A. M. MacConnachie