A prospective study comparing vancomycin and teicoplanin as second‐line empiric therapy for infection in neutropenic patients

Abstract

In recent years, the most common cause of infection in neutropenic patients has shifted from Gram-negative to Gram-positive bacteria. To compare the efficacy and toxicity of teicoplanin and vancomycin in neutropenic patients, we conducted a prospective study of 151 adult leukaemic patients hospitalized for intensive chemotherapy. After chemotherapy, the median duration of granulocytopenia (less than 500/mm3) was 25 d (range 13-49). When the patients became febrile, they received ceftazidime (CTZ) alone (2 g every 12 h, intravenously). If fever persisted more than 48-72 h after administration of CTZ, the patients were randomly assigned to receive CTZ combined with either vancomycin (vanco) (30 mg/kg/d) or teicoplanin (teico) (6 mg/kg every 12 h on day 1, then daily). When fever persisted further, an aminoglycoside antibiotic and/or amphotericin B were usually added to the previous combination. Of the 151 patients, 116 patients became febrile during the period of aplasia. Fifty-nine patients had persistent (or recurrent) fever despite administration of CTZ and received either vanco (n = 35) or teico (n = 24). Sixteen of these latter 59 patients had septicaemia (vanco n = 9; teico n = 7) due to Candida sp. (n = 2), Gram-negative (n = 2) or Gram-positive (n = 12) bacteria. The main characteristics of patients and infection were similar in both arms. The treatment was considered as a success (disappearance of fever within 48 h) in 21/35 patients of the vanco group (60%) compared to 13/24 patients of the teico group (54%; P not significant). The percentage of failures for infection due to Gram-positive bacteria was 2/11 for vanco versus 2/7 for teico (P not significant). Two patients in each group died from infection. The main cause of failure was retrospectively attributed to fungal pathogens. No major toxic effects were found in either group. These preliminary results do not show any difference between vanco and teico as second-line antibiotic therapy in leukaemic patients with severe and prolonged granulocytopenia.

Comparative Efficacy and Safety of Vancomycin versus Teicoplanin: Systematic Review and Meta-Analysis

“…1. The search yielded 269 publications, 61 of which were potentially eligible; and 24 individual randomized controlled trials comparing vancomycin versus teicoplanin fulfilled inclusion criteria (1,4,8,10,11,14,18,20,22,33,34,40,42,45,46,48,49,51,60,62,(71)(72)77).…”

“…Four trials were performed prior to Eli Lilly's launch of purified vancomycin in 1990 (8,11,62,72), and in one study the purified preparation was introduced during the trial (71). The standard dosing of teicoplanin for adults was 400 mg/day for adults and 10 to 12 mg/kg of body weight/day for children, following a loading dose (Table 1); lower doses (200 mg/day) were used for adults during the first part of the study in three trials (45,62,71).…”

Meta-analysis of Randomized Controlled Trials of Vancomycin for the Treatment of Patients With Gram-Positive Infections: Focus on the Study Design

“…77 In trials studying febrile neutropenic patients, vancomycin and comparator antibiotics were included in the first-line empirical regimen in 7 trials, 32,54,61,62,64,67,69 in 2 trials they were administered after treatment failure of the initial regimen (usually a ␤-lactam with or without an aminoglycoside) was encountered, 59,71 and in the remaining 3 randomization was performed after the VANCOMYCIN FOR GRAM-POSITIVE INFECTIONS: A META-ANALYSIS isolation of gram-positive cocci. 55,57,73 Finally, 1 trial did not report the time of randomization.…”

“…When patients with proven grampositive infections were analyzed alone, mortality rates were not different between linezolid and vancomycin. However, the mortality rate was higher in patients allocated to the linezolid arm with infec- 2007 Charbonneau et al, 68 1994 Cony-Makhoul et al, 71 1990 Fagon et al, 47 2000 Figuera et al, 64 1996 Itani et al, 29 2010 Kaplan et al, 35 2003 Kohno et al, 30 2007 Menichetti et al, 67 1994 Sanofi-Aventis, 54 2009 Neville et al, 65 1995 Nucci et al, 61 1998 Pfizer, 31 2007 Pertel et al, 74 2009 Pham Dang et al, 56 2001 Raad et al, 48 1999 Rehm et al, 76 2008 Sidi et al, 57 2000 Stevens et al, 37 2002 Talbot et al, 41 2007 Van Laethem et al, 60 1988 Vásquez et al, 59 1999 Weigelt et al, 34 2005 Wilcox et al, 25 2009 Wunderink et al, 26 …”

2002 Guidelines for the Use of Antimicrobial Agents in Neutropenic Patients With Cancer

“…Several studies have evaluated vancomycin drug combinations for the treatment of neutropenic patients with fever; these combinations have included vancomycin plus any of the following antibiotics: imipenem [72,96], cefepime [60], amikacin and ticarcillin [94], meropenem [74], ciprofloxacin [97], aztreonam [98,99], ceftazidime [100][101][102][103][104], ceftazidime and amikacin [30,103], tobramycin and piperacillin [105,106], ticarcillin [93], and ceftazidime and ticarcillin [38]. Although the combination of ceftazidime and vancomycin has been used most extensively in the past, in some medical centers, the possible risk of emergence of resistance to ceftazidime may justify the recommendation that vancomycin be preferentially used in combination with cefepime or a carbapenem (imipenem-cilastatin or meropenem).…”