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Microbiology and ID > Glycopeptides > Flashcards

Glycopeptides Flashcards

1
Q

What is the general action of glycopeptides?

A

Bactericidal activity against aerobic and anaerobic Gram +ve bacteria including multi-resistant staphylococci

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2
Q

What are the common glycopeptides that you should know?

A

Vancomycin

Teicoplanin

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3
Q

How is teicoplanin different to vancomycin?

A

It has a significantly longer duration of action

Allows for OD administration after the loading dose

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4
Q

What are the indications for teicoplanin?

A

C. diff infection

Moderate to severe diabetic foot infection

Leg ulcer infection

Cellulitis/erysipelas

Serious infection caused by Gram +ve bacteria (e.g., complicated SSTIs, pneumonia, complicated UTIs)

Streptococcal or enterococcal endocarditis (in combo with another antibacterial)

Bone and joint infections

Surgical prophylaxis

Surgical prophylaxis in open fractures

Peritonitis associated with peritoneal dialysis (added to dialysis fluid)

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5
Q

What are the indications for vancomycin?

A

C. diff infection

Moderate to severe diabetic foot infection

Leg ulcer infection

Cellulitis/erysipelas

Serious infection caused by Gram +ve bacteria (e.g., complicated SSTIs, pneumonia, complicated UTIs)

HAP (inc. ventilator associated pneumonia) and CAP

Acute bacterial meningitis

Bacteraemia

Streptococcal or enterococcal endocarditis (in combo with another antibacterial)

Bone and joint infections

Perioperative prophylaxis of bacterial endocarditis (in patients with high risk of developing bacterial endocarditis when undergoing major surgical procedures)

Surgical prophylaxis (when high risk of MRSA)

Peritonitis associated with peritoneal dialysis (added to dialysis fluid)

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6
Q

What are the pharmacokinetics of vancomycin?

A

Bioavailability = poorly absorbed from GI tract so not given orally, systemic absorption = up to 60%

Protein binding = 50% serum protein bound

Half-life = 6 hours (range = 4-11 hours)

Metabolism = 75-80% of drug not metabolised - seemingly no apparent metabolism of the drug. [vancomycin] in liver and bile has been reported at or below detection limits

Excretion = kidney via urine (undergoes glomerular filtration)

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7
Q

What are the pharmacokinetics of teicoplanin?

A

Bioavailability = 90% via IM

Protein binding = 90-95%

Half-life = 70-100 hours

Metabolism = ?

Excretion = not available

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8
Q

What are the contraindications of IV vancomycin?

A

Previous hearing loss

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9
Q

What are the cautions of PO vancomycin?

A

Systemic absorption may be enhanced in patients with inflammatory disorders of the intestinal mucosa or with C. diff pseudomembranous colitis (increased risk of adverse reaction)

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10
Q

What do manufacturers advise about using glycopeptides in pregnancy?

A

Only use if potential benefit outweighs the risk

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11
Q

What are the general side effects with frequency not known of vancomycin?

A

Agranulocytosis

Dizziness

Drug fever

Eosinophilia

Hypersensitivity

N+V

Nephritis tubulointerstitial

Neutropenia (more common after 1 week or cumulative dose of 25g)

Renal failure

SCARs

Skin reaction

Thrombocytopenia

Tinnitus (discontinue)

Vasculitis

Vertigo

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12
Q

What are common/very common side effects associated with IV vancomycin use?

A

Vancomycin infusion reaction

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13
Q

What are frequency not known side effects associated with IV vancomycin use?

A

Back pain

Bradycardia

Cardiac arrest (on rapid IV injection)

Cardiogenic shock (on rapid IV injection)

Chest pain

Dyspnoea

Hearing loss

Muscle complaints

Pseudomembranous enterocolitis

Wheezing

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14
Q

Which of the glycopeptide is associated with a higher incidence of nephrotoxicity?

A

Vancomycin

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15
Q

What are common/very common side effects associated with teicoplanin?

A

Fever

Pain

Skin reactions

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16
Q

What are uncommon side effects associated with teicoplanin?

A

Bronchospasm

Diarrhoea

Dizziness

Eosinophilia

Headache

Hearing impairment

Hypersensitivity

Leucopenia

N + V

Ototoxicity

Thrombocytopenia

Vomiting

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17
Q

What are rare/very rare side effects associated with teicoplanin?

A

Abscess

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18
Q

What are frequency not known side effects associated with teicoplanin?

A

Agranulocytosis

Angioedema

Chills

Neutropenia

Overgrowth of non-susceptible organisms

Renal impairment

Seizure

SCARs

Thrombophlebitis

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19
Q

What is the severe drug interaction for vancomycin?

A

Vancomycin + colistimethate = increased risk of nephrotoxicity

20
Q

What is the severe drug interaction for teicoplanin?

A

No specific interactions information available

21
Q

What are the 3 steps to take to ensure safe dosing of vancomycin according to ESHT?

A
  1. Calculate loading dose - based on actual body weight
  2. Select maintenance dose & dose interval - based on creatine clearance (i.e., renal function)
  3. Monitor levels & interpret accordingly
22
Q

What loading dose of vancomycin should be given to an individual that weighs between 40 to <60 kg? How would you give it?

A

1g

Dilute in 250mL of either 0.9%NaCl or 5% glucose and give over 2 hours

23
Q

What loading dose of vancomycin should be given to an individual that weighs between 60 to 90 kg? How would you give it?

A

1.5g

Dilute in 500mL of 0.9%NaCl or 5% glucose and give over 2.5 hours

24
Q

What loading dose of vancomycin should be given to an individual that weighs between >90 kg? How would you give it?

A

2g

Dilute in 500mL 0.9%NaCl or 5% glucose and give over 3.5 hours

25
Q

How do you calculate creatine clearance?

A

Use Cockcroft-Gault formula :

(((140 - age in years) x (wt in kg)) x 1.23(male) or 1.04 (female)) / (serum creatinine in micromol/l)

26
Q

If someone has a CrCl of <20 :

a) what initial dose level of vancomycin would you give?
b) how would you give it?
c) when would you take the 1st trough level?

A

a) 500mg every 48 hours

b) give in 100mL over 1 hour

c) before 2nd maintenance dose

27
Q

If someone has a CrCl between 20-29 :

a) what initial dose level of vancomycin would you give?
b) how would you give it?
c) when would you take the 1st trough level?

A

a) 500mg OD

b) give in 100mL over 1 hour

c) before 2nd maintenance dose

28
Q

If someone has a CrCl between 30-39 :

a) what initial dose level of vancomycin would you give?
b) how would you give it?
c) when would you take the 1st trough level?

A

a) 750mg OD

b) in 250mL over 1.5 hours

c) before 2nd maintenance dose

29
Q

If someone has a CrCl between 40-54 :

a) what initial dose level of vancomycin would you give?
b) how would you give it?
c) when would you take the 1st trough level?

A

a) 500mg BD

b) give in 100mL over 1 hour

c) before 4th maintenance dose

30
Q

If someone has a CrCl between 55-74 :

a) what initial dose level of vancomycin would you give?
b) how would you give it?
c) when would you take the 1st trough level?

A

a) 750mg BD

b) give in 250mL over 1.5 hour

c) before 4th maintenance dose

31
Q

If someone has a CrCl between 75-89 :

a) what initial dose level of vancomycin would you give?
b) how would you give it?
c) when would you take the 1st trough level?

A

a) 1g BD

b) give in 250mL over 2 hours

c) before 4th maintenance dose

32
Q

If someone has a CrCl between 90-110 :

a) what initial dose level of vancomycin would you give?
b) how would you give it?
c) when would you take the 1st trough level?

A

a) 1.25g BD

b) give in 250mL over 2 hours

c) before 4th maintenance dose

33
Q

If someone has a CrCl between >110 :

a) what initial dose level of vancomycin would you give?
b) how would you give it?
c) when would you take the 1st trough level?

A

a) 1.5g BD

b) give in 500mL over 2.5 hours

c) before 4th maintenance dose

34
Q

What is the target trough level for vancomycin?

A

15-20mg/L

35
Q

For someone who is haemodynamically unstable/critically ill or has unstable renal function (either deteriorating or significantly improving) how frequently should you take trough level readings and U&Es?

A

Trough level = daily

U&Es = daily

36
Q

For someone who has had a dose change how frequently should you take trough level readings and U&Es post dose change?

A

Trough level = at 48 h (repeat again after a further 48 h if renal impairment)

U&Es = daily

37
Q

For someone with stable haemodynamics and stable renal function with no dose change how frequently should you take trough level readings and U&Es?

A

Trough = 2ce weekly

U&Es = every 48 h

38
Q

If someone on vancomycin with target trough level of 15-20mg/L, has a trough level reading of <5mg/L what should you do?

A

Checked for missed doses

Reload and increase maintenance dose by 2 dose levels

39
Q

If someone on vancomycin with target trough level of 15-20mg/L, has a trough level reading between 5-10mg/L what should you do?

A

Increase maintenance dose by 2 dose levels

40
Q

If someone on vancomycin with target trough level of 15-20mg/L, has a trough level reading between 10-15mg/L what should you do?

A

Increase maintenance dose by 1 dose level

41
Q

If someone on vancomycin with target trough level of 15-20mg/L, has a trough level reading between 15-20mg/L what should you do?

A

Continue current maintenance dose

42
Q

If someone on vancomycin with target trough level of 15-20mg/L, has a trough level reading between 20-25mg/L what should you do?

A

Reduce maintenance dose by 1 dose level

43
Q

If someone on vancomycin with target trough level of 15-20mg/L, has a trough level reading of >25mg/L what should you do?

A

Discuss wit Pharmacy

Omit a dose and reduce maintenance dose by 2 dose levels

44
Q

Sources

A

https://go.drugbank.com/drugs/DB00512

https://go.drugbank.com/drugs/DB06149

https://bnf.nice.org.uk/drugs/teicoplanin/

https://bnf.nice.org.uk/drugs/vancomycin/

BSUH Antimicrobial Microguide (this provides all the info about vancomycin dosage and monitoring)

ESHT Antimicrobial Microguide (provides the 3-step action to take to ensure safe dosage of vancomycin)

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC270616/#:~:text=If%20red%20man%20syndrome%20appears,or%20at%20a%20lesser%20dosage.

45
Q

What are the features of vancomycin infusion reaction?

A

Red man syndrome - appears 4-10 min after an infusion started or may begin soon after its finished.

Consists of:
- pruritus
- erythematous rash that involves face, neck, and upper torso

Less frequently:
- hypotension
- angioedema

46
Q

How would you treat vancomycin infusion reactions?

A

50mg diphenhydramine hydrochloride IV/PO

Microbiology and ID (5 decks)

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