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Review Article

Vancomycin: Understanding Its Past and Preserving Its Future

Donald P. Levine, MD
Volume: 101 Issue: 3 March, 2008

Abstract:

The increase in vancomycin use in the 1980s to treat antibiotic-associated colitis and methicillin-resistant Staphylococcus aureus (MRSA) is largely responsible for the appearance of vancomycin-resistant enterococcus, which in turn spawned isolated cases of vancomycin-resistant S. aureus. Perhaps most worrisome to clinicians are strains of MRSA that are heteroresistant to vancomycin; these isolates are difficult to detect. Appropriate use of vancomycin coupled with awareness of infection control measures is paramount to abrogating the emergence of new vancomycin-resistant MRSA organisms and preserving its future efficacy. The continued reliance on vancomycin for the treatment of MRSA infections will depend on whether vancomycin resistance can be minimized. Newer antibacterial agents, particularly those with activity toward MRSA and vancomycin-resistant enterococcus, such as linezolid, quinupristin/dalfopristin, daptomycin, and tigecycline, may take a more prominent clinical role when Gram-positive bacteria resistance to vancomycin further escalate.


Key Points


* Vancomycin-intermediate and -resistant Staphylococcus aureus have recently been isolated but remain uncommon.


* Methicillin-resistant S. aureus (MRSA) strains that are heteroresistant to vancomycin are more prevalent than vancomycin-resistant S. aureus and maybe difficult to detect with common testing methods.


* Frequent inappropriate use of vancomycin (Table 1) and failure to follow infection control measures (Table 3) may contribute to growing resistance to vancomycin. This drug should be reserved for high-risk patients, such as those suspected of having MRSA, and monitored to ensure therapeutic dosing. Empiric use should be discontinued when cultures do not reveal MRSA or other vancomycin-susceptible Gram-positive bacteria, and use as surgical prophylaxis is not recommended.

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