Merck Manual

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Lipoglycopeptides

By

Brian J. Werth

, PharmD, University of Washington School of Pharmacy

Last full review/revision May 2020| Content last modified May 2020
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Telavancin, dalbavancin, and oritavancin are lipoglycopeptides, which are semisynthetic antibacterials related to glycopeptides (eg, vancomycin). Lipoglycopeptides have bactericidal activity exclusively against gram-positive bacteria. Lipoglycopeptides inhibit bacterial cell wall synthesis and disrupt cell membrane integrity.

Pharmacokinetics

Lipoglycopeptides are not absorbed orally and are available only as IV formulations. Lipoglycopeptides penetrate well into pulmonary epithelial lining fluid and skin blisters.

Telavancin has a half-life of 7 to 9 hours and a postantibiotic effect of about 4 hours. Dalbavancin has a prolonged half life of 204 hours, and oritavancin has a prolonged half-life of 245 hours; thus, single-dose regimens with these drugs are possible.

Telavancin is excreted by the kidneys, so the dose must be adjusted in patients with renal insufficiency.

Indications

Lipoglycopeptides are broadly active against gram-positive bacteria including

Oritavancin is active against vancomycin-resistant enterococci (VRE) strains that harbor the vanA gene; dalbavancin and telavancin are not. Dalbavancin, oritavancin, and telavancin have activity against vanB VRE.

Telavancin is used for complicated skin and skin structure infections as well as for hospital-acquired and ventilator-acquired bacterial pneumonia caused by sensitive isolates of S. aureus.

The long-acting lipoglycopeptides dalbavancin and oritavancin are used to treat complicated skin and skin structure infections but are still being studied as treatment for more invasive infections.

Contraindications

Lipoglycopeptides are contraindicated in patients who are allergic to them. They should be used with care in patients who are allergic to vancomycin or other glycopeptides because cross-reactivity is possible.

Use During Pregnancy and Breastfeeding

Lipoglycopeptides have had some adverse effects on fetal development in animals; safety data in pregnant women are limited. Lipoglycopeptides should be used during pregnancy only if the potential benefit to the patient outweighs the potential risk to the fetus.

There are no data regarding excretion in breast milk in humans, but lipoglycopeptides are known to be excreted in the breast milk of rats.

Adverse Effects

Common adverse effects of lipoglycopeptides include

  • Nausea and vomiting

  • Taste disturbance

  • Foamy urine

Telavancin and oritavancin may falsely increase values on coagulation tests (prothrombin time/partial thromboplastin time [PT/PTT]) for a period of time. Therefore, blood for these tests should be drawn before these antibiotics are given. Telavancin interferes with urine protein assays.

Significant adverse effects include

  • Increased mortality in patients with pre-existing moderate/severe renal impairment (creatinine clearance ≤ 50 mL/minute) who were treated with telavancin for hospital-acquired bacterial pneumonia/ventilator-associated bacterial pneumonia versus vancomycin

  • A histamine-mediated pruritus and flushing of the face, neck, and shoulders, similar to the red-person syndrome that can occur with vancomycin

  • Nephrotoxicity, which may occur more often with telavancin than with vancomycin but has not been associated with dalbavancin or oritavancin

  • With telavancin, QTc prolongation

Nephrotoxicity with telavancin is more likely in patients with known kidney dysfunction, disorders that predispose to kidney dysfunction (eg, diabetes, hypertension, heart failure), or use of potentially nephrotoxic drugs. Renal function should be assessed before starting the drug and monitored at least every 48 to 72 hours.

Pruritus and flushing associated with rapid infusion of lipoglycopeptides can be prevented prolonging the infusions as follows:

  • Telavancin: Over ≥ 60 minutes

  • Oritavancin: Over ≥ 3 hours

  • Dalbavancin: Over ≥ 30 minutes

All infusions can be extended if the patient shows signs of infusion-associated flushing and pruritis.

QTc prolongation occurred in healthy subjects in the clinical trials of telavancin; thus, telavancin should be used with caution or not be used in patients taking drugs that prolong the QT interval. Telavancin should not be used in patients with congenital long QT syndrome, known QTc prolongation, uncompensated heart failure, or severe left ventricular hypertrophy (patients with these disorders were excluded from the clinical trials).

Dosing Considerations

Dalbavancin doses should be reduced in patients with creatinine clearance < 30 mL/minute; clinicians should use 1125 mg for single-dose regimens or 750 mg once followed by 375 mg 1 week later.

Oritavancin does not appear to require renal dose adjustment, but adequate studies to support a recommendation for patients with renal failure have not been done.

Telavancin dosing is based on creatinine clearance:

  • Creatinine clearance > 50 mL/minute: 10 mg/kg IV every 24 hours

  • Creatinine clearance 30 to 50 mL/minute: 7.5 mg/kg every 24 hours

  • Creatinine clearance 10 to < 30 mL/minute: 10 mg/kg every 48 hours

  • Creatinine clearance < 10 mL/minute: Data limited, no recommendations available

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