US Government Case Study: Vancomycin

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US Government Case Study: Vancomycin

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Therapeutic Drug Monitoring: Aminoglycosides and Vancomycin - Amanda Mercurio, PharmD.

In , the use of vancomycin monotherapy was clearly documented in only three of 82 available cases in the literature. To put this into context, similar rates of kidney dysfunction have been reported for cefamandole and benzylpenicillin , two reputedly non-nephrotoxic antibiotics. In addition, evidence to relate nephrotoxicity to vancomycin serum levels is inconsistent. Nephrotoxicity has also been observed with concentrations within the "therapeutic" range, as well. In essence, the reputation of vancomycin as a nephrotoxin is overstated, and it has not been demonstrated that maintaining vancomycin serum levels within certain ranges will prevent its nephrotoxic effects, when they do occur.

Attempts to establish rates of vancomycin-induced ototoxicity are even more difficult due to the scarcity of quality evidence. The current consensus is that clearly related cases of vancomycin ototoxicity are rare. The association between vancomycin serum levels and ototoxicity is also uncertain. Thus, whether therapeutic drug monitoring of vancomycin for the purpose of maintaining "therapeutic" levels will prevent ototoxicity also remains unproven. Another area of controversy and uncertainty concerns the question of whether, and if so, to what extent, vancomycin increases the toxicity of other nephrotoxins. Clinical studies have yielded variable results, but animal models indicate some increased nephrotoxic effect probably occurs when vancomycin is added to nephrotoxins such as aminoglycosides.

However, a dose- or serum level-effect relationship has not been established. The recommended parenteral dosage in adults is mg iv every 6 hours or mg every 12 hours, with modification to achieve a therapeutic range as needed. The recommended oral dosage in the treatment of antibiotic induced pseudomembranous enterocolitis is to mg every 6 hours for 7 to 10 days. Vancomycin must be given intravenously IV for systemic therapy, since it is not absorbed from the intestine.

It is a large hydrophilic molecule that partitions poorly across the gastrointestinal mucosa. Due to short half-life, it is often injected twice daily. The only approved indication for oral vancomycin therapy is in the treatment of pseudomembranous colitis, where it must be given orally to reach the site of infection in the colon. Inhaled vancomycin has also been used off-label , via nebulizer , for treatment of various infections of the upper and lower respiratory tract.

There is an ongoing debate as to whether vancomycin should be given through a central or peripheral line. According to a review, midline catheters are a safe option for administration. Symptoms may be treated or prevented with antihistamines , including diphenhydramine , and are less likely to occur with slow infusion. Vancomycin activity is considered to be time-dependent; that is, antimicrobial activity depends on the duration that the serum drug concentration exceeds the minimum inhibitory concentration of the target organism. Thus, peak serum levels have not been shown to correlate with efficacy or toxicity; indeed, concentration monitoring is unnecessary in most cases. Circumstances in which therapeutic drug monitoring is warranted include: patients receiving concomitant aminoglycoside therapy, patients with potentially altered pharmacokinetic parameters, patients on haemodialysis , patients administered high-dose or prolonged treatment, and patients with impaired renal function.

In such cases, trough concentrations are measured. Target ranges for serum vancomycin concentrations have changed over the years. Vancomycin is made by the soil bacterium Amycolatopsis orientalis. Before vancomycin is assembled through NRPS, the non-proteinogenic amino acids are first synthesized. Nonribosomal peptide synthesis occurs through distinct modules that can load and extend the protein by one amino acid per module through the amide bond formation at the contact sites of the activating domains. In the A domain, the specific amino acid is activated by converting into an aminoacyl adenylate enzyme complex attached to a 4'phosphopantetheine cofactor by thioesterification [43] [44] The complex is then transferred to the PCP domain with the expulsion of AMP.

The PCP domain uses the attached 4'-phosphopantethein prosthetic group to load the growing peptide chain and their precursors. In the biosynthesis of Vancomycin, additional modification domains are present, such as the epimerization E domain, which isomerizes the amino acid from one stereochemistry to another, and a thioesterase domain TE is used as a catalyst for cyclization and releases of the molecule via a thioesterase scission.

Figure 2. VpsB codes for modules 4, 5, and 6, and VpsC codes for module 7. The vancomycin aglycone contains 4 D-amino acids, although the NRPSs only contain 3 epimerization domains. The origin of D-Leu at residue 1 is not known. The three peptide syntheses are located at the start of the region of the bacterial genome linked with antibiotic biosynthesis, and span 27 kb. After the linear heptapeptide molecule is synthesized, vancomycin has to undergo further modifications, such as oxidative cross-linking and glycosylation , in trans [ clarification needed ] by distinct enzymes, referred to as tailoring enzymes, to become biologically active Figure 3.

To convert the linear heptapeptide to cross-linked, glycosylated vancomycin, six enzymes, are required. OxyB catalyzes oxidative cross-linking between residues 4 and 6, OxyA between residues 2 and 4, and OxyC between residues 5 and 7. These Ps are recruited by the X domain present in the 7th NRPS module, which is unique to glycopeptide antibiotic biosynthesis. GtfE then joins D-glucose to the phenolic oxygen of residue 4, followed by the addition of vancosamine catalyzed by GtfD. Some of the glycosyltransferases capable of glycosylating vancomycin and related nonribosomal peptides display notable permissivity and have been employed for generating libraries of differentially glycosylated analogs through a process known as glycorandomization.

Both the vancomycin aglycone [52] [53] and the complete vancomycin molecule [54] have been targets successfully reached by total synthesis. Vancomycin is a branched tricyclic glycosylated nonribosomal peptide produced by the Actinobacteria species Amycolatopsis orientalis formerly designated Nocardia orientalis. Vancomycin exhibits atropisomerism — it has multiple chemically distinct rotamers owing to the rotational restriction of some of the bonds. The form present in the drug is the thermodynamically more stable conformer. Vancomycin acts by inhibiting proper cell wall synthesis in Gram-positive bacteria. Due to the different mechanism by which Gram-negative bacteria produce their cell walls and the various factors related to entering the outer membrane of Gram-negative organisms, vancomycin is not active against them except some nongonococcal species of Neisseria.

Under normal circumstances, this is a five-point interaction. This binding of vancomycin to the D -Ala- D -Ala prevents cell wall synthesis of the long polymers of N -acetylmuramic acid NAM and N -acetylglucosamine NAG that form the backbone strands of the bacterial cell wall, and it prevents the backbone polymers that do manage to form from cross-linking with each other. Vancomycin is one of the few antibiotics used in plant tissue culture to eliminate Gram-positive bacterial infection. It has relatively low toxicity to plants. A few Gram-positive bacteria are intrinsically resistant to vancomycin: Leuconostoc and Pediococcus species, but these organisms rarely cause diseases in humans. Most Gram-negative bacteria are intrinsically resistant to vancomycin because their outer membranes are impermeable to large glycopeptide molecules [64] with the exception of some non- gonococcal Neisseria species.

Evolution of microbial resistance to vancomycin is a growing problem, in particular, within healthcare facilities such as hospitals. While newer alternatives to vancomycin exist, such as linezolid and daptomycin , the widespread use of vancomycin makes resistance to the drug a significant worry, especially for individual patients if resistant infections are not quickly identified and the patient continues the ineffective treatment. Vancomycin-resistant Enterococcus emerged in Vancomycin resistance evolved in more common pathogenic organisms during the s and s, including vancomycin-intermediate S.

The D -alanyl- D -lactate variation results in the loss of one hydrogen-bonding interaction 4, as opposed to 5 for D -alanyl- D -alanine possible between vancomycin and the peptide. This loss of just one point of interaction results in a fold decrease in affinity. The D -alanyl- D -serine variation causes a six-fold loss of affinity between vancomycin and the peptide, likely due to steric hindrance. In enterococci, this modification appears to be due to the expression of an enzyme that alters the terminal residue.

Three main resistance variants have been characterised to date among resistant Enterococcus faecium and E. Variant of vancomycin has been tested that binds to the resistant D-lactic acid variation in vancomycin-resistant bacterial cell walls, and also binds well to the original target vancomycin-susceptible bacteria. In a team at the University Hospital Heidelberg Germany re-gained the antibacterial power of vancomycin by modifying the molecule with a cationic oligopeptide.

The oligopeptide consists of six arginin units in Position V N. In comparison to the unmodified vancomycin the activity against vancomycin-resistant bacteria could be enhanced by a factor of 1 Therefore a potential approval will take several more years. Vancomycin was first isolated in by Edmund Kornfeld working at Eli Lilly from a soil sample collected from the interior jungles of Borneo by a missionary, Rev. William M. Bouw The compound was initially called compound , but was eventually given the generic name vancomycin, derived from the term "vanquish". The rapid development of penicillin resistance by staphylococci led to its being fast-tracked for approval by the Food and Drug Administration in Eli Lilly first marketed vancomycin hydrochloride under the trade name Vancocin [22].

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Download references. You can also search for this author in PubMed Google Scholar. Correspondence to Cornelius J. Clancy or Deanna J. There was no funding for the study. Buehrle has served on an advisory board for Shionogi. Smith and Dr. Aspinall have no conflicts of interest to declare. The study was performed in accordance with the ethical standards as laid down in the Declaration of Helsinki and its later amendments or comparable ethical standards.

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