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Discuss.
Vancomycin vs Zyvox in complicated MRSA infection in hospitalized patients
- Thread starter ZpackSux
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Dr. Record (KY) says Vanco first all others later, maybe.
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I am not going to look up any studies but I will say vanco first. Less DDI's and cheaper. At my hospital, we saved Zyvox for VRE or for people who couldnt take it. I have only seen it used less than 5 times.
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I do believe my prof told us that zyvox has never been proven SUPERIOR to vanco for MRSA, only that it works just as well. It (zyvox) has some advantages for treating MRSA in the community since it can be given po. And of course it does cover VRE which is what it is reserved for at UKHospital.
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Vanc. When generic linezolid comes out, then we can talk. That **** is expensive as a damn BMW M3. WITH LESS HORSEPOWER.
I agree, Vanc first then Zyvox for vanc resistant organisms such a VRE. Zyvox may be used on an outpatient basis to simply route of administration if patient refuses home IV. However, you must balance that with the possibility of resistance.
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http://www.medscape.com/viewprogram/5995
decent CE.
from what I know, zyvox advantage - can be given PO (tablet and oral suspension), better tissue penetration, don't need to renally dose or draw levels
That being said, use vanco first-line, all zyvox orders must have an approved indication or positve VRE cultures.
by complicated, I think they mean drug resistant strains, diabetes,etc.
cost wise - I have read some "studies" saying the cost issue is not that great, since the hospital length of stay is decreased with zyvox, oral is 100% bioavailable, getting patients off IV therapy as soon as possible may prevent other complications, no kinetics monitoring charges or lab peak/trough charges.
anyone have any info on how much home infusion care costs?
here is WAY too much information (I HATE medchem):
http://www.chm.bris.ac.uk/motm/linezolid/linezolid.htm
decent CE.
from what I know, zyvox advantage - can be given PO (tablet and oral suspension), better tissue penetration, don't need to renally dose or draw levels
That being said, use vanco first-line, all zyvox orders must have an approved indication or positve VRE cultures.
by complicated, I think they mean drug resistant strains, diabetes,etc.
cost wise - I have read some "studies" saying the cost issue is not that great, since the hospital length of stay is decreased with zyvox, oral is 100% bioavailable, getting patients off IV therapy as soon as possible may prevent other complications, no kinetics monitoring charges or lab peak/trough charges.
anyone have any info on how much home infusion care costs?
here is WAY too much information (I HATE medchem):
http://www.chm.bris.ac.uk/motm/linezolid/linezolid.htm
OK....I don't think you're looking for the "textbook" answer since you specifically mentioned "complicated" hospitalized pt.
So...without further info...I'm going to jump in with some thoughts:
Altho MRSA is associated with morbidity, the association with mortality rises significantly with certain comorbid states. Some reports (the state of PA in 2004, specifically) noted that 32% of pts with MRSA with respiratory failure on ventilators died, while only 1.9% of pts with kidney or uti's with MRSA died. Likewise, if that same pt went into renal failure...the percentage of death rose to 12.8% CHF with MRSA had a 12.7% death rate. Since more than 50% of all hospitalizations with MRSA were among pts with respiratory diseases, circulatory disorders & a variety of infectious sources...the death rates of each climb.
However....MRSA is a much easier disease to treat when community acquired than hospital acquired....so the timing of the infection is vital to know as well.
So...what do we do? Most of us are taught to use Vanc first. However, as pharmacists, we've been taught to be VERY afraid of nephrotoxicities & ototoxicities due to resulting elevated serum concentrations. Evidence of this occuring is lacking however & it is now suspected that these toxicities are a result of older impure formulations. It is still suspected that serum concentrations between 80-100 mcg/ml may be linked to toxicity.
Now...how to determine the appropriate target for efficacy? Historically, a trough concentration of 5-10mcg/ml was desired since it would acheive the goal of 2-4 times the MIC. But..the target is being reevaluated due to failures. Perhaps we have been underdosing for years & that is the reason for our treatment failures - particularly when treating more deep-seated infections like meningitis, endocarditis & osteomylitis where penetration is an issue.
The most recent guidelines from the American Thoracic Society & the Infectious Disease Society of America advocate a target vanc of 15-20mcg/ml. Two recent studies which compare Zyvox with Vanc for nosocomial pneumonia were not able to find a difference in outcomes. However, on further analysis of the combined results of 2 trials, the Zyvox arm was associcated with better survival & clinical cure rates with confirmed MRSA pneumonia. But, there are suggestions that the vanc dosing followed more traditional models than the newer models suggest which throws the results of these studies into a spin.
Likewise, the American Heart Assoc. in conjunction with IDSA revised their guidelines in June 2005 for endocarditis. The recommendation used to be a target tough of 15-20mcg/ml due to the suspicion that the vegetation was difficult to penetrate. However, now they suggest a lower tough - 10-15mcg/ml, but for 2-6 weeks.
The interesting note is the new mention of a peak concentration monitoring. Most of us have used trough solely, since the predictable kinetics & lack of strong association for efficacy or toxicity with peaks. However, more & more evidence suggests that the peak might be important in infections located in the CNS, bone & joints & pneumonia. No specific guidelines have been put forth, but it does indeed bring up the question - do we really know the kinetics with regard to the therapeutics of this drug as well as we thought?
Now...what place does Zyvox play? Altho it shouldn't be the first choice for a community acquired MRSA or even for the complicated hospitalized pt, you have referred to Zpak. I would put forth....it might indeed the the first choice in SOME complicated hospitalized pts - those who have a greater chance of dying due to a comorbid condition. So...each case might need to be individualized.
If, say, I were to see a pt in the ICU who was 10 weeks s/p CABG with community acquired pneumonia & is now in ICU on a ventilator & has developed a CHF with decreasing renal failure. If that pt after 2 wks develops MRSA....I'm not sure I'd fool around with Vanc - high troughs or otherwise. That guy is at high risk of dying. I might go straight to Zyvox.
Now...I'll put forth a real concern about Zyvox. It is being used in Europe & in some areas of the US for resistant TB......that throws its use into a whole new scary area.
Sorry for the length......I ramble...
So...without further info...I'm going to jump in with some thoughts:
Altho MRSA is associated with morbidity, the association with mortality rises significantly with certain comorbid states. Some reports (the state of PA in 2004, specifically) noted that 32% of pts with MRSA with respiratory failure on ventilators died, while only 1.9% of pts with kidney or uti's with MRSA died. Likewise, if that same pt went into renal failure...the percentage of death rose to 12.8% CHF with MRSA had a 12.7% death rate. Since more than 50% of all hospitalizations with MRSA were among pts with respiratory diseases, circulatory disorders & a variety of infectious sources...the death rates of each climb.
However....MRSA is a much easier disease to treat when community acquired than hospital acquired....so the timing of the infection is vital to know as well.
So...what do we do? Most of us are taught to use Vanc first. However, as pharmacists, we've been taught to be VERY afraid of nephrotoxicities & ototoxicities due to resulting elevated serum concentrations. Evidence of this occuring is lacking however & it is now suspected that these toxicities are a result of older impure formulations. It is still suspected that serum concentrations between 80-100 mcg/ml may be linked to toxicity.
Now...how to determine the appropriate target for efficacy? Historically, a trough concentration of 5-10mcg/ml was desired since it would acheive the goal of 2-4 times the MIC. But..the target is being reevaluated due to failures. Perhaps we have been underdosing for years & that is the reason for our treatment failures - particularly when treating more deep-seated infections like meningitis, endocarditis & osteomylitis where penetration is an issue.
The most recent guidelines from the American Thoracic Society & the Infectious Disease Society of America advocate a target vanc of 15-20mcg/ml. Two recent studies which compare Zyvox with Vanc for nosocomial pneumonia were not able to find a difference in outcomes. However, on further analysis of the combined results of 2 trials, the Zyvox arm was associcated with better survival & clinical cure rates with confirmed MRSA pneumonia. But, there are suggestions that the vanc dosing followed more traditional models than the newer models suggest which throws the results of these studies into a spin.
Likewise, the American Heart Assoc. in conjunction with IDSA revised their guidelines in June 2005 for endocarditis. The recommendation used to be a target tough of 15-20mcg/ml due to the suspicion that the vegetation was difficult to penetrate. However, now they suggest a lower tough - 10-15mcg/ml, but for 2-6 weeks.
The interesting note is the new mention of a peak concentration monitoring. Most of us have used trough solely, since the predictable kinetics & lack of strong association for efficacy or toxicity with peaks. However, more & more evidence suggests that the peak might be important in infections located in the CNS, bone & joints & pneumonia. No specific guidelines have been put forth, but it does indeed bring up the question - do we really know the kinetics with regard to the therapeutics of this drug as well as we thought?
Now...what place does Zyvox play? Altho it shouldn't be the first choice for a community acquired MRSA or even for the complicated hospitalized pt, you have referred to Zpak. I would put forth....it might indeed the the first choice in SOME complicated hospitalized pts - those who have a greater chance of dying due to a comorbid condition. So...each case might need to be individualized.
If, say, I were to see a pt in the ICU who was 10 weeks s/p CABG with community acquired pneumonia & is now in ICU on a ventilator & has developed a CHF with decreasing renal failure. If that pt after 2 wks develops MRSA....I'm not sure I'd fool around with Vanc - high troughs or otherwise. That guy is at high risk of dying. I might go straight to Zyvox.
Now...I'll put forth a real concern about Zyvox. It is being used in Europe & in some areas of the US for resistant TB......that throws its use into a whole new scary area.
Sorry for the length......I ramble...
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Sorry for the late reply.
Here are the articles of interest.
http://www.chestjournal.org/cgi/content/full/130/4/947
http://aac.asm.org/cgi/content/full/49/6/2260
http://www.sciencedirect.com/scienc...=1494338&md5=de7f3f4eb7dc2b02730009b7a9ade2d7
Here are the articles of interest.
http://www.chestjournal.org/cgi/content/full/130/4/947
http://aac.asm.org/cgi/content/full/49/6/2260
http://www.sciencedirect.com/scienc...=1494338&md5=de7f3f4eb7dc2b02730009b7a9ade2d7
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