title: A review of the current place of glycopeptides in turkish medical practice.
abstract: BACKGROUND
  Glycopeptide antibiotics are considered by many investigators to be the last resort in the treatment of gram-positive bacterial infections.
  
  
  OBJECTIVE
  The aim of this review was to assess the place of glycopeptides in the treatment of common gram-positive bacteria in accordance with the current epidemiologic data in Turkey.
  
  
  METHODS
  A search of both the English- and Turkish-language literature indexed on MEDLINE, Ulakbim (Turkey), and Pleksus (Turkey) was performed using the terms: vancomycin, teicoplanin, and glycopeptides, or their Turkish-language counterparts. The complete texts of the articles found in these databases were obtained from the electronic library of Gulhane Medical Academy, Ankara, Turkey. Articles from regional journals, without the support of an electronic format, were obtained by direct communication. Articles of interest were those based on studies occurring in Turkish populations, with special consideration given to publications in press after 2002.
  
  
  RESULTS
  Staphylococci were the most frequent gram-positive pathogens encountered in Turkish hospitals. Studies have found that ∼74% of strains were Staphylococcus aureus and the remaining strains were coagulase-negative staphylococci (CoNS). Overall methicillin resistance in staphylococci was reported as ∼60%. In Turkey, S aureus was one of the most common infectious agents found inside hospitals and is deemed a growing threat in the community. While the rate of methicillin resistance in community-acquired isolates is ∼4%, the data from hospitals suggest that reduced resistance comprises most of the isolates. In the studies reviewed, older quinolones like ciprofloxacin and ofloxacin seem to be ineffective in nearly half of the S aureus isolates. Alternatives like rifampicin, gentamicin, tetracycline, trimethoprim/sulfamethoxazole (TMP/SMX), clindamycin, and erythromycin have had substantial resistance profiles in >50% of the strains. In recent Turkish studies, in vitro profiles of linezolid, quinupristin/dalfopristin (QD), and daptomycin have had positive results. As in the S aureus isolates, resistance trends have been observed in the CoNS group of pathogens. The possible use of β-lactams seems restricted, and alternative approaches have become necessary. Quinolones, gentamicin, tetracycline, TMP/SMX, clindamycin, and erythromycin have resistance profiles of >50%. Although glycopeptide resistance was not detected, the frequency of heterogenous vancomycin-intermediate S aureus, a precursor to future resistance, was 13% in 1 study. Current studies in Turkey have found that Enterococcus faecalis comprises three quarters of enterococci while the rest are comprised of Enterococcus faecium. Initial studies performed with linezolid, QD, and daptomycin suggest that these drugs might be effective alternatives for future enterococcal infections that may have high glycopeptide resistance. Approximately 8% of the Streptococcus pneumoniae strains had high-level resistance in Turkey. However, 10 million units of crystallized penicillin or 3 g of oral amoxicillin maintains the optimum treatment of pneumococcal infections outside the central nervous system (CNS). Resistance profiles in third-generation cephalosporins in Turkey range between 2% and 2.5%.
  
  
  CONCLUSIONS
  In Turkey, a review of the existing literature found that the current use of glycopeptides in pneumococcal infections is restricted to CNS infections facing therapeutic failure in due course. However, the belief that these drugs are the last resort, either in staphylococcal or enterococcal infections, is no longer valid. If a patient has a critical status due to probable gram-positive microorganisms, clinicians should consider the empiric use of glycopeptides. However, new molecules such as linezolid, QD, and daptomycin, offered for use in the treatment of gram-positive bacterial diseases, should be reserved for the future, when glycopeptides eventually become obsolete.
authors.affiliation: Department of Infectious Diseases and Clinical Microbiology, Gulhane Medical Academy, Ankara, Turkey.
authors.forename: Hakan
authors.initials: H
authors.lastname: Erdem
authors.affiliation: Department of Infectious Diseases and Clinical Microbiology, Gulhane Haydarpasa Training Hospital, Ankara, Turkey.
authors.forename: Oral
authors.initials: O
authors.lastname: Oncul
keywords: Turkey; glycopeptides