Department of Medical Microbiology, Aberdeen Royal Infirmary, Foresterhill, Aberdeen, UK.
Curr Opin Infect Dis. 2014 Apr;27(2):146-54. doi: 10.1097/QCO.0000000000000048.
Despite concerns regarding efficacy and tolerability, vancomycin continues to be the standard treatment for skin and soft tissue infections (SSTIs) when β-lactam antimicrobials cannot be used. This review sought to establish the role of both old and new alternatives to vancomycin. Methods for achieving optimization of vancomycin therapy are also explored.
Several meta-analyses have demonstrated poorer clinical outcomes when the vancomycin minimum inhibitory concentration approaches the breakpoint of 2 μg/ml. Higher doses should be utilized to optimize pharmacokinetics and pharmacodynamics when higher volumes of distribution occur (e.g. sepsis). Newer agents with established noninferiority to vancomycin include the oxazolidinones linezolid and tedizolid, the lipopeptide daptomycin, the anti-meticillin-resistant Staphylococcus aureus cephalosporin ceftaroline and the glycylcycline tigecycline. Linezolid is thus far the only agent that has been shown to be associated with better clinical and microbiological cure rates. Ceftaroline and tigecycline are broad-spectrum agents best reserved for polymicrobial infections (e.g. diabetic foot infections).
When vancomycin is used for the treatment of SSTIs, maximizing the dose should be performed to improve efficacy. Cost is often the main limiting factor with regard to the newer agents, but their suitability for outpatient antimicrobial therapy may counteract this.
尽管存在疗效和耐受性方面的担忧，但当不能使用β-内酰胺类抗菌药物时，万古霉素仍然是治疗皮肤和软组织感染（SSTIs）的标准治疗药物。本综述旨在确定万古霉素的新旧替代药物的作用。还探讨了优化万古霉素治疗的方法。
几项荟萃分析表明，当万古霉素最小抑菌浓度接近 2μg/ml 的折点时，临床结局较差。当分布容积较高时（例如脓毒症），应使用更高的剂量以优化药代动力学和药效学。与万古霉素具有明确非劣效性的新型药物包括唑烷酮类药物利奈唑胺和替加环素、脂肽类药物达托霉素、抗耐甲氧西林金黄色葡萄球菌头孢菌素头孢洛林和甘氨酰环素替格环素。迄今为止，利奈唑胺是唯一显示与更好的临床和微生物学治愈率相关的药物。头孢洛林和替格环素是广谱药物，最好保留用于治疗混合感染（例如糖尿病足感染）。
当使用万古霉素治疗 SSTIs 时，应最大限度地提高剂量以提高疗效。新型药物的主要限制因素通常是成本，但它们适合门诊抗菌治疗可能会抵消这一点。
