Principles of glycopeptide use for surgical antibiotic prophylaxis

The role of glycopeptides in surgical antibiotic prophylaxis

The glycopeptide antibiotics, vancomycin and teicoplanin, have a limited role in surgical antibiotic prophylaxis because they are less effective than cefazolin at preventing postoperative methicillin-susceptible Staphylococcus aureus (MSSA) skin and soft tissue infections. Vancomycin and teicoplanin are also associated with selection of glycopeptide-resistant organisms (eg vancomycin-resistant enterococci [VRE], vancomycin-intermediate S. aureus [VISA]).

In some centres, teicoplanin is used as an alternative to vancomycin because, unlike vancomycin, it does not require a long infusion.

Glycopeptides should not be used for surgical prophylaxis, except for patients:

• with severe hypersensitivity (immediate or delayed) to penicillins
• at increased risk of postoperative infection caused by methicillin-resistant S. aureus (MRSA).

Glycopeptide use for patients with severe hypersensitivity to penicillins

In patients with severe (immediate or delayed) hypersensitivity to penicillins, vancomycin or teicoplanin is used as a replacement for cefazolin. If there is a significant risk that the surgical site will be contaminated with Gram-negative organisms, vancomycin or teicoplanin is given in combination with gentamicin.

In general, vancomycin or teicoplanin is preferred to clindamycin because it has activity against a greater percentage of S. aureus isolates; however, clindamycin is an alternative for susceptible S. aureus strains, based on local epidemiology, or recent screening or culture results.

Glycopeptide use for patients at increased risk of postoperative infection caused by MRSA

Consider adding vancomycin or teicoplanin to the prophylactic regimen if there is an increased risk of postoperative infection with MRSA. This includes:

• patients with an increased risk of MRSA infection (see Risk factors for infection with methicillin-resistant Staphylococcus aureus)
• patients undergoing prosthetic cardiac valve, joint or vascular surgery if the procedure is a reoperation (return to theatre or early revision).

Glycopeptide dosing

Use actual body weight to calculate vancomycin doses, even in patients who are overweight or obese. A vancomycin dose of 15 mg/kg up to 2 g is recommended for prophylaxis in these guidelines because therapeutic concentrations only need to be maintained for the duration of the procedure.

If teicoplanin is used, an appropriate regimen is: