Vancomycin-induced immune thrombocytopenia

Assessment of the 4Ts pretest clinical scoring system as a predictor of heparin-induced thrombocytopenia

STUDY OBJECTIVE

To evaluate the utility of the 4Ts clinical scoring system as a pretest probability method for the detection of heparin-induced thrombocytopenia (HIT).

DESIGN

Prospective observational study.

SETTING

Medical and surgical inpatients at a tertiary care medical center.

PATIENTS

Eighty consecutive patients with suspicion of HIT who had a polyspecific enzyme-linked immunosorbent assay (ELISA) performed between December 1, 2008, and April 1, 2009, for detection of platelet factor 4 (PF4)-heparin antibodies.

MEASUREMENTS AND MAIN RESULTS

The predictive value of the 4Ts scoring system as determined by using a standard laboratory marker of HIT--the ELISA--and the interrater reliability of the scoring system were assessed. Sixty-seven (84%) of the 80 patients had low clinical probability of HIT based on the calculated 4Ts score. The ELISA result was negative for PF4-heparin antibodies in 74 patients (93%). Based on the results of the ELISA, the negative predictive value of the 4Ts score was 91%. Each 4Ts score was calculated by two independent investigators and adjudicated by a third investigator when necessary. The interrater reliability of the scoring system was fair (Cohen κ coefficient 0.362, 95% confidence interval [CI] 0.222-0.502; weighted κ coefficient 0.554 (95% CI 0.441-0.667). Determination of the timing of HIT was associated with the largest number of discrepancies (16) between evaluators, followed by other causes of thrombocytopenia (15), degree of decline in platelet count (14), and the presence of thrombosis or other sequelae (2).

CONCLUSION

A low 4Ts score supports a low probability of HIT based on the results of the polyspecific ELISA. Overall, the interrater reliability of the scoring system was fair. Components of the 4Ts scoring system need to be further clarified or modified in order to improve interrater reliability and thereby increase the clinical utility of this pretest probability model.

Oral infections and antibiotic therapy

Oral infections commonly originate from an odontogenic source in adults and from tonsil and lymphatic sources in children. Odontogenic infections arise from advanced dental caries or periodontal disease. Oral trauma, radiation injury, chemotherapy mucositis, salivary gland infection, lymph node abscess, and postoperative infection are potential nonodontogenic sources of infections that could potentially be life threatening. This article reviews the serious nature and potential danger that exists from oral infection and the antibiotics available to treat them are reviewed. Successful treatment requires an understanding of the microflora, the regional anatomy, the disease process, the treatment methods available, and interdisciplinary team collaboration.

Drug allergy: an updated practice parameter

Adverse drug reactions (ADRs) result in major health problems in the United States in both the inpatient and outpatient setting. ADRs are broadly categorized into predictable (type A and unpredictable (type B) reactions. Predictable reactions are usually dose dependent, are related to the known pharmacologic actions of the drug, and occur in otherwise healthy individuals, They are estimated to comprise approximately 80% of all ADRs. Unpredictable are generally dose independent, are unrelated to the pharmacologic actions of the drug, and occur only in susceptible individuals. Unpredictable reactions are subdivided into drug intolerance, drug idiosyncrasy, drug allergy, and pseudoallergic reactions. Both type A and B reactions may be influenced by genetic predisposition of the patient

Piperacillin and vancomycin induced severe thrombocytopenia in a hospitalized patient

In hospitalized patients with complex medical problems on numerous drugs, thrombocytopenia may have a multiple confounding etiology. Keeping this in mind, it is of utmost importance to monitor the platelet count regularly during hospitalization and on subsequent follow-up visits, even after the most probable etiology has been identified/most likely causative drug has been withdrawn. Isolated thrombocytopenia with no evidence of microangiopathic hemolysis on the peripheral blood smear in an acutely ill hospitalized patient implicated sepsis, disseminated intravascular coagulation and drugs as the most probable causes. Our patient represents an uncommon case of antibiotic-induced severe immune thrombocytopenia, as he developed both vancomycin-dependent and piperacillin-dependent antibodies, while being treated for cellulitis (vancomycin-specific antibodies of the IgG isotype, and both IgG and IgM antibodies specific for piperacillin were identified in laboratory testing). Vancomycin was stopped before the reports were available. Following this, the patient's platelet count showed a transient upward trend, but then the thrombocytopenia worsened drastically reaching a nadir of 10,000/µL. The platelet count returned to normal only after piperacillin/tazobactam was stopped after a week, thus establishing it as the cause of the more severe thrombocytopenia, which occurred later on; this was subsequently confirmed by the laboratory results. Vancomycin is an established cause of drug-induced immune thrombocytopenias, especially in acutely ill, hospitalized or elderly patients, whereas incidents of piperacillin/tazobactam-induced immune thrombocytopenia are uncommon. In case clinical suspicion is high, workup should include immunoprecipitation and flow cytometry studies to confirm antiplatelet antibodies.

Daptomycin: a novel lipopeptide antibiotic against Gram-positive pathogens

The aim of this review is to summarize the historical background of drug resistance of Gram-positive pathogens as well as to describe in detail the novel lipopeptide antibiotic daptomycin. Pharmacological and pharmacokinetic aspects are reviewed and the current clinical use of daptomycin is presented. Daptomycin seems to be a reliable drug in the treatment of complicated skin and skin structure infections, infective right-sided endocarditis, and bacteremia caused by Gram-positive agents. Its unique mechanism of action and its low resistance profile, together with its rapid bactericidal action make it a favorable alternative to vancomycin in multi-drug resistant cocci. The role of daptomycin in the treatment of prosthetic material infections, osteomyelitis, and urogenital infections needs to be evaluated in randomized clinical trials.

Drug-induced thrombocytopenia in critically ill patients

Thrombocytopenia occurs in 15% to 58% of intensive care unit patients. The incidence varies based upon patient population, timing and frequency of platelet monitoring, and definition of thrombocytopenia. Up to 25% of acutely ill patients develop drug-induced thrombocytopenia. When drug-induced thrombocytopenia is suspected, nondrug related causes must be evaluated and excluded. Establishing the diagnosis of drug-induced thrombocytopenia is challenging, as hundreds of medications have been implicated. Medications commonly associated with drug-induced thrombocytopenia include glycoprotein IIb/IIIa inhibitors, cinchona alkaloids, antibiotics, anticonvulsants, and heparin. Once the diagnosis is suspected, clinicians should identify the start date of medications to assess the timeline of development. The likelihood of each medication causing thrombocytopenia must be evaluated. The risk vs. benefit of discontinuing the suspected medication and availability of alternative medications must be assessed. The role of corticosteroids, immune globulin, and plasmapheresis is uncertain. Once the offending agent has been discontinued, the overall prognosis is excellent. In the case of suspected or confirmed heparin-induced thrombocytopenia, an alternative anticoagulant should be initiated. Drug-induced thrombocytopenia should be documented in the medical record and reported according to institutional and national standards. This review focuses on immune-mediated drug-induced thrombocytopenia from medications commonly utilized in the critically ill patient.

Use of vancomycin pharmacokinetic-pharmacodynamic properties in the treatment of MRSA infections

Vancomycin is a commonly used antimicrobial in patients with methicillin-resistant Staphylococcus aureus (MRSA) infections. Increasing vancomycin MIC values in MRSA clinical isolates makes the optimization of vancomycin dosing pivotal to its continued use. Unfortunately, limited data exist regarding the optimal pharmacokinetic-pharmacodynamic (PK-PD) goal to improve bacterial killing and clinical outcomes with vancomycin. The hallmark study in this area suggests that achieving an AUC to MIC ratio of over 400 improves the likelihood of achieving these outcomes. Challenges in the implementation of PK-PD-based dosing for vancomycin include current methodologies utilized in microbiology laboratories, as well as intra- and interpatient pharmacokinetic variability. Individualized dosing based on MIC and specific patient factors is important to achieve optimal outcomes from vancomycin therapy.

Coagulopathy in critically ill patients: part 1: platelet disorders

Abnormalities of platelet number and function are the most common coagulation disorders seen among ICU patients. This article reviews the most frequent causes of thrombocytopenia by providing an overview of the following most common mechanisms: impaired production; sequestration; dilution; and destruction. Guidelines for treating thrombocytopenia and platelet dysfunction are also provided.

Studies of the anti-platelet factor 4/heparin immune response: adapting the enzyme-linked immunosorbent spot assay for detection of memory B cells against complex antigens

BACKGROUND

The anti-platelet factor 4 (PF4)/heparin immune response, which underlies heparin-induced thrombocytopenia (HIT), has several atypical features: relatively rapid onset even without previous heparin exposure, lack of immune anamnesis, and transience of antibody production.

STUDY DESIGN AND METHODS

We modified the enzyme-linked immunosorbent spot (ELISPOT) assay to investigate for PF4/heparin-specific memory B cells in cardiac surgery patients, in whom the high anti-PF4/heparin immunization rate made a prospective study feasible. The PF4-containing antigen complexes were attached to microtiter plates via a spacer, rather than using nitrocellulose, and the final reaction enzyme substrate was added in melted agarose which, after rapid hardening, localized color development of enzyme-tagged anti-immunoglobulin G (IgG) probes to single PF4/heparin-specific B cells. This modified ELISPOT assay was applied to 58 consecutive patients (testing blood from preoperative baseline and Postoperative Days 6 and 10), in which we compared detectability of PF4/heparin-specific B cells to tetanus toxin-specific B cells (comparator group with presumed vaccination).

RESULTS

No patient had detectable PF4/heparin-specific memory B cells at baseline. In 2 of 30 patients (6.7%) who formed anti-PF4/heparin IgG, PF4/heparin-specific memory B cells (three to four spots/well) were detected by Postoperative Day 10, whereas tetanus toxin-specific memory B cells were found in 12 of 24 (50.0%) patients tested (3-25 spots/well; p < 0.001).

CONCLUSIONS

HIT lacks a strong memory B-cell response, perhaps explaining transience and lack of anamnesis of the anti-PF4/heparin immune response. The technical modifications we describe for the ELISPOT assay, which permit detection of B-cell reactions to complex antigens, could be useful for studying other immunohematologic disorders, for example, drug-dependent thrombocytopenia and acquired hemophilia.

Influence of antidrug antibodies on plectasin efficacy and pharmacokinetics

Plectasin is a 4.4-kDa antimicrobial peptide with the potential to be a treatment of infections caused by gram-positive bacteria. Since plectasin is a large molecule compared to conventional antibiotics, the development of antidrug antibodies (ADAs) could be anticipated. The immunogenic properties of plectasin were assessed through immunization studies. In mice treated for 5 days with one to two daily subcutaneous doses of plectasin, no antibody response was observed. If the animals were immunized again, after a rest period, low levels of antibodies developed in approximately half the animals. Additionally, mice were immunized with plectasin in Freund's incomplete adjuvant (FIA). Ninety-two percent of these mice developed ADAs after repeated immunizations, with two-thirds having high levels of antibodies. An agar diffusion bioassay showed that sera from animals immunized with plectasin did not inhibit the efficacy of the drug, while hyperimmune sera from animals in which an immune response was provoked by immunization with plectasin in FIA reduced the efficacy of plectasin at the lowest concentration tested. Studies in the murine peritonitis model showed an excellent efficacy of plectasin for the treatment of Streptococcus pneumoniae infections both in naïve animals and in animals with ADAs. No difference in bacterial counts was seen when the animals were treated with plectasin at 2.5 mg/kg of body weight, a dose below the expected therapeutic level. When animals were treated with plectasin at 0.625 mg/kg, the effect was reduced but not neutralized in animals with high levels of ADAs. No animals showed signs of hypersensitivity or injection site reactions toward plectasin, and the half-life of the compound did not vary between animals with and without antibodies.

Drug-induced hematologic syndromes

Objective. Drugs can induce almost the entire spectrum of hematologic disorders, affecting white cells, red cells, platelets, and the coagulation system. This paper aims to emphasize the broad range of drug-induced hematological syndromes and to highlight some of the newer drugs and syndromes. Methods. Medline literature on drug-induced hematologic syndromes was reviewed. Most reports and reviews focus on individual drugs or cytopenias. Results. Drug-induced syndromes include hemolytic anemias, methemoglobinemia, red cell aplasia, sideroblastic anemia, megaloblastic anemia, polycythemia, aplastic anemia, leukocytosis, neutropenia, eosinophilia, immune thrombocytopenia, microangiopathic syndromes, hypercoagulability, hypoprothrombinemia, circulating anticoagulants, myelodysplasia, and acute leukemia. Some of the classic drugs known to cause hematologic abnormalities have been replaced by newer drugs, including biologics, accompanied by their own syndromes and unintended side effects. Conclusions. Drugs can induce toxicities spanning many hematologic syndromes, mediated by a variety of mechanisms. Physicians need to be alert to the potential for iatrogenic drug-induced hematologic complications.

Vancomycin-induced thrombocytopenia in a 60-year-old man: a case report

Introduction

Vancomycin, a glycopeptide antibiotic, is used to treat resistant gram-positive infections. There has been a 10- to 20-fold increase in its use over the past 25 years. Although ototoxicity and nephrotoxicity are well known side effects of vancomycin, it can also induce platelet reactive antibodies leading to life-threatening thrombocytopenia. Vancomycin is often clinically overlooked as a cause of thrombocytopenia, especially in a scenario of sepsis or when there is use of heparin. We report a proven case of vancomycin-induced thrombocytopenia and its reversal after discontinuation of vancomycin.

Case presentation

A 60-year-old man with a history of hypertension, congestive heart failure and dyslipidemia was admitted for a right shoulder rotator cuff tear. He underwent right-shoulder arthroscopy and rotator cuff repair. About three weeks later, he developed pain, swelling and purulent drainage from his right shoulder. Arthroscopic irrigation and drainage was then performed. Intraoperative fluid revealed the presence of Methicillin susceptible Staphylococcus aureus, vancomycin-sensitive Enterococcus spp. and Serratia marcescens. The patient had no known allergies. After reviewing his antimicrobial susceptibility, he was started on vancomycin 1500 mgs intravenously every 12 hours (to treat both Staphylococcus aureus and Enterococcus spp) and ciprofloxacin 750 mgs by oral induction every 12 hours. The patient's condition improved following antibiotic treatment. He was discharged and allowed to go home on IV vancomycin and oral ciprofloxacin. The patient's platelet count on the day of starting vancomycin therapy was 253 × 10³/mm³. At weeks one, two and three, the counts were 231 × 10³/mm³, 272 × 10³/mm and 6 × 103/mm³, respectively. The patient was admitted for further work-up of the thrombocytopenia. He was later shown to have vancomycin-induced platelet-reactive antibodies, causing significant thrombocytopenia, and then reversal after his vancomycin medication was discontinued.

Conclusion

Thrombocytopenia is a potentially life-threatening condition. Vancomycin is often clinically overlooked as a cause of thrombocytopenia, especially in a scenario of sepsis or when there is use of heparin. Simple laboratory testing with drug-dependent antibodies can be helpful in identifying vancomycin as a cause of thrombocytopenia.

Drug-induced immune thrombocytopenia: pathogenesis, diagnosis, and management

Drug-induced immune thrombocytopenia (DITP) can be triggered by a wide range of medications. Although many cases of DITP are mild, some are characterized by life-threatening bleeding symptoms. The pathogenesis of DITP is complex, in that at least six different mechanisms have been proposed by which drug-induced antibodies can promote platelet destruction. It is possible in many cases to identify antibodies that react with platelets in the presence of the sensitizing drug, but the required testing is technically demanding and not widely available. Therefore, a decision on whether to discontinue an implicated medication in a patient suspected of having DITP must be made on clinical grounds. An algorithm is available that can be helpful in assessing the likelihood that a particular drug caused thrombocytopenia, but the most important aspects of patient management are a high index of suspicion and a careful history of drug exposure in an individual who presents with acute, often severe thrombocytopenia of unknown etiology. How drugs induce platelet-reactive antibodies and how, once formed, the antibodies cause platelet destruction following exposure to the drug is poorly understood. Further studies to address these issues and characterize more completely the range of drugs and drug metabolites that can cause DITP are needed.

The temporal profile of the anti-PF4/heparin immune response

The immune response in heparin-induced thrombocytopenia (HIT) is puzzling: heparin-naive patients can develop IgG antibodies and clinical HIT as early as day 5, and evidence for an anamnestic response on heparin reexposure is lacking. We assessed daily serum samples by anti-PF4/heparin enzyme-immunoassay (EIA) in patients receiving heparin thromboprophylaxis. Of 435 patients, 56.1% showed an increase in EIA optical density (OD) of more than or equal to 15%, with more than 90% starting between days 4 and 14. After reaching maximum reactivity by days 10 to 12, ODs declined despite heparin continuation, including in 2 patients with clinical HIT. Individual IgG/A/M classes showed identical time of onset (median, day 6). Most (58.7%) antibody-positive patients developed all 3 Ig classes; only 11.3% lacked IgG response. IgG/A/M increase usually occurred simultaneously (± 1 day) with no general tendency for IgM precedence. Consistent with the transient immune response, none of the IgG-EIA–positive (OD > 0.5) patients at discharge developed clinically evident thrombosis during extended low-molecular-weight heparin thromboprophylaxis. The rapid onset of the anti-PF4/heparin immune response, its transience, and the simultaneous appearance of antibodies of different classes with no IgM precedence suggest short-term activation of B cells that have previously undergone Ig-class switching even without previous pharmacologic heparin exposure.

Drug-induced thrombocytopenia

Drug-induced thrombocytopenia was first described in the 19th century, yet our understanding of its pathogenesis continues to evolve. The list of drugs implicated in drug-induced thrombocytopenia is extensive and growing. Many, if not most, of these medications induce thrombocytopenia by immune mechanisms. Because the degree of thrombocytopenia can put patients at risk for serious bleeding, a prompt diagnosis is key to clinical management. The laboratory approach to diagnosing drug-induced thrombocytopenia is 2-pronged. First, nondrug causes of thrombocytopenia must be ruled out. Second, testing for drug-dependent platelet antibodies, available at specialized reference laboratories, often can identify the offending medication, although usually not in time for initial clinical management. Once a medication is suspected of causing thrombocytopenia, it must be discontinued promptly, and the patient should be monitored closely. Thrombocytopenia generally resolves quickly after offending medication withdrawal, and the prognosis of drug-induced thrombocytopenia is then excellent.

Acute vancomycin-dependent immune thrombocytopenia as an anamnestic response

Drug-related thrombocytopenia is a well-described but relatively rare complication of antibiotic therapy. In this entity, platelet destruction is immune-mediated, often resulting in a precipitous drop in platelet count over a short period of time. Most of these cases of thrombocytopenia are drug-dependent, as discontinuation of the offending agent frequently results in a timely return to baseline, pre-exposure platelet levels. We report the case of a 61-year-old male patient receiving vancomycin and ceftazidime for lower extremity wet gangrene who experienced a marked, acute reduction in platelet count 12 to 15 hours after starting antibiotic therapy. There was no readily apparent clinical or laboratory explanation for his thrombocytopenia. Pre- and post- antibiotic serum samples were preserved and sent for drug-dependent platelet antibody analysis. The pre-exposure specimen revealed the presence of IgG vancomycin-dependent platelet antibodies, while the post-exposure specimen demonstrated both IgG and IgM vancomycin-dependent platelet antibodies. Ceftazidime-dependent platelet antibodies were not identified in either sample. These findings indicate prior sensitization to vancomycin, with subsequent acute production of IgM anti-platelet antibodies after re-exposure to the antibiotic. The patient's antibiotics were held after the acute-onset of thrombocytopenia with subsequent restoration of normal platelet counts within 4 days of drug withdrawal, and the patient at no time experienced significant adverse bleeding events. Antibiotic therapy with vancomycin is a rare and perhaps overlooked cause for new-onset thrombocytopenia in hospitalized patients. This case illustrates that the development of severe thrombocytopenia within hours of vancomycin administration does not rule out drug-related immune clearance, as the rapid platelet destruction may indicate an anamnestic antibody response to the drug after previous exposure. In such a scenario, immediate discontinuation of vancomycin is recommended to improve platelet counts. From a laboratory perspective, retrieval of serum both pre- and post-administration of vancomycin is most helpful in determining a patient's drug-immunization status and can help guide safe drug use during future infections.

Vancomycin revisited: a reappraisal of clinical use

Vancomycin has been used for decades to treat serious systemic gram positive infections. Extensive use over time has demonstrated vancomycin is not nephrotoxic even when used in high dosage, i.e., twice the usual dose. Since vancomycin is not nephrotoxic, there is no rationale for dosing vancomycin based on serum vancomycin levels. Since vancomycin is eliminated by GFR, vancomycin dosing should be based on creatinine clearance. Vancomycin obeys "concentration dependent" kinetics and higher than usual doses may be useful in some infections (eg, osteomyelitis). Widespread vancomycin use has resulted in increased VRE prevalence worldwide. Among staphylococci, vancomycin induced cell wall thickening results in "permeability mediated" resistance to vancomycin, as well as other anti-staphylococcal antibiotics. "Permeability mediated" resistance accounts for the common clinical observation that MRSA infections treated with vancomycin often resolve slowly or not at all. Other effective MRSA antibiotics are available (eg, linezolid, daptomycin, minocycline, or tigecycline) and are more reliably effective, do not increase staphylococcal resistance or increase VRE prevalence.

The use of daptomycin for Staphylococcus aureus infections in critical care medicine

The proliferation of methicillin-resistant Staphylococcus aureus (MRSA) and the severity of nosocomial critical care infections necessitate the development of viable alternative therapies. An increase in the tolerance of MRSA to the activity of vancomycin and to the associated suboptimal therapeutic measures is of particular concern. Daptomycin, the first of a new class of antimicrobials known as the lipopeptides, is indicated for the treatment of S aureus, including MRSA, in bacteremia, right-sided endocarditis, and complicated skin and skin structure infections. Daptomycin has a novel mechanism of action, rapid bactericidal activity, and a lack of cross resistance with other antibiotic classes. Daptomycin has also demonstrated efficacy in case studies involving the treatment of osteomyelitis and involving complicated persistent infections associated with indwelling medical devices. Because of its efficacy and safety in a variety of infectious conditions and because of its rapid bactericidal activity, daptomycin is well suited as a viable alternative for patients in the critical care setting.

Antibiotic adverse reactions and drug interactions

When contemplating antibiotic use, intensivists must consider possible beneficial and harmful drug interactions. After antibiotics are instituted, adverse reactions must be anticipated. Acute illness, comorbidities, and concurrent medications affect the presentation and management of antibiotic-related adverse events. Intensivists should use the fewest possible antibiotics, carefully choosing agents that maximize antimicrobial activity and minimize potential drug interactions and adverse reactions.

Flow cytometry in the diagnosis of drug-induced thrombocytopenia: two illustrative cases

Drug-induced thrombocytopenia is a challenging diagnosis in the clinical practice because of the many drugs or alternative causes that may be implicated. Exact identification of such drug(s) is required to guide future management and avoid re-exposure. We describe two cases of isolated thrombocytopenia in which cytometric analysis, a readily available technique, allowed the identification of the causative drug in the context of complex therapies (rifampicin and abciximab causing late onset thrombocytopenia).

New paradigms in the management of alloimmune refractoriness to platelet transfusions

PURPOSE OF REVIEW

Following transfusion or pregnancy, a significant number of patients develop antibodies to class I human leukocyte antigen. Some will exhibit platelet transfusion refractoriness, defined as inappropriately low platelet count increments after two or more consecutive transfusions. Unfortunately, failure of at least two products is required before an immunologic work-up is undertaken. Among those diagnosed with immune refractoriness, there is no standard method for identifying platelet products likely to be effective.

RECENT FINDINGS

Recent advances in detection and identification of human leukocyte antigen antibody may permit pretransfusion screening of selected patients and provide guidance in choosing the optimal product. An approach more like that for red cell alloimmunized patients, in which one provides products guided solely by the antibody profile, is preferable to selection based on educated guesswork when human leukocyte antigen identical units are unavailable, and offers some advantages over platelet crossmatching.

SUMMARY

This review presents a literature-based algorithm with which to approach the management of platelet refractory individuals, focusing on newer technology to maximize the post-transfusion yield of matched units. Strategies are presented that allow selection of more effective products for difficult, broadly alloimmunized individuals, including patients who have developed antibodies to human platelet antigens.

Vancomycin for treatment of invasive, multi-drug resistant Staphylococcus aureus infections

Staphylococcus aureus is a bacterial pathogen responsible for a variety of serious infections and is a frequent cause of nosocomial disease. During the last 60 years, S. aureus has developed increasing in vitro resistance to virtually all antimicrobials. In contrast, vancomycin has maintained a high degree of activity in vitro against this pathogen, although slight changes with in vitro activity could vastly change clinical activity. As a result, vancomycin has become the mainstay of therapy for invasive infections due to methicillin-resistant strains. However, clinical strains of S. aureus with intermediate resistance to vancomycin were reported in 1996, followed in 2002 with reports of isolates that were fully resistant. Although many authorities believe vancomycin remains the drug of choice for most staphylococcal-resistant infections, important issues surrounding its clinical application remain. These include the need for multiple daily dosing, intravenous administration, requirements for serum concentration monitoring, increasing resistance in vitro, modest efficacy rates and (less frequently) treatment-limiting adverse effects. This review addresses these important topics.

Recent Publications on Medications and Pharmacy

Hospital Pharmacy presents this feature to keep pharmacists abreast of new publications in the medical/pharmacy literature. Articles of interest will be abstracted monthly regarding a broad scope of topics. Suggestions or comments may be addressed to: Jacyntha Sterling, Drug Information Specialist at Saint Francis Hospital, 6161 S Yale Ave., Tulsa, OK 74136 or e-mail: jasterling@saintfrancis.com .