Counterpoint: Vancomycin and S. aureus • CID 2007:44 (15 June) • 1543
I D S A L E C T U R E
Counterpoint: Vancomycin and Staphylococcus
aureus—An Antibiotic Enters Obsolescence
Division of Infectious Disease and Geographic Medicine, Department of Medicine, Stanford University, Stanford, and Division of Infectious
Disease, Santa Clara Valley Medical Center, San Jose, California
(See the point by Mohr and Murray on pages 1536–42)
The efficacy of vancomycin for the treatment of patients with infections due to Staphylococcus aureus is
impaired by its poor tissue penetration and by its relatively weak antibacterial activity—an activity that is
declining as S. aureus evolves. Neither dose escalation nor use of vancomycin in combination with other
antibiotics that have antistaphylcoccal activity has been demonstrated to safely enhance its therapeuticefficacy.
of its inferiority. Strong consideration should be given to the use of alternative agents in the treatment of
serious S. aureus infections.
The efficacy of vancomycin in the treatment of in-
fection due to Staphylococcus aureus has, in recent
years, come under increasing scrutiny. As a result, the
role of vancomycin in modern therapeutics has be-
come controversial, and the Infectious Diseases So-
ciety of America, in its infinite wisdom, decided that
fighting the battle over vancomycin in Toronto, On-
tario, at its 2006 annual meeting would save us from
having to fight it in the streets of the United States.
As a consequence of that decision, a debate took place
in which I was assigned the task of taking the position
that vancomycin has outlived its usefulness. Thisessay
is based on my arguments presented at that meeting,
where I restricted my focus to the treatment of in-
fection due to S. aureus.
Received 8 January 2007; accepted 24 March 2007; electronically published 4
This is a modified version of a paper presented at the 44th Annual Meeting
of the Infectious Diseases Society of America, Toronto, Ontario, Canada, 12–15
October 2006 (session 12L).
Reprints or correspondence: Dr. Stan Deresinski, 2900 Whipple Ave., Ste. 115,
Redwood City, CA 94062 (firstname.lastname@example.org).
Clinical Infectious Diseases2007;44:1543–8
? 2007 by the Infectious Diseases Society of America. All rights reserved.
S. AUREUS (MSSA)
Vancomycin is often used as initial empirical therapy
in patients with suspected infections due to gram-
positive organisms, as well as in the specific treatment
of known MSSA infection, either because of the pres-
ence of b-lactam allergy or for convenience (such as
when impaired renal function allows infrequent dos-
ing). The evidence is quite clear, however, that van-
comycin is inferior to at least some b-lactams for the
treatment of bacteremia and endocarditisdue toMSSA.
For instance, a retrospective study of 123 patients un-
dergoing long-term hemodialysis who developed bac-
teremia due to MSSA found that vancomycintreatment
was associated with a significantly greater risk of failure
than was treatment with cefazolin (31.2% vs. 13%;
), and use of this glycopepetide was an inde-P p .02
pendent risk factor for failure . In a prospective,
multicenter, observational study, vancomycin therapy
was associated with a significantly greaterriskoffailure,
with persistence of bacteremia for 17 days and/or re-
lapsed bacteremia occurring in 13 (19%) of 70 of pa-
tients receiving this antibiotic, compared with no fail-
ures among 18 persons treated with nafcillin . Thus,
the evidence is strong that vancomycin is not an ac-
ceptable alternative therapy for patients with MSSA
by guest on February 2, 2016
1548 • CID 2007:44 (15 June) • Deresinski
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