Telavancin in the Recent Hospital Acquired and Ventilator Associated Pneumonia (HAP/VAP) 2016 Guidelines

To the Editor—We read with interest the new HAP/VAP guideline published by Infectious Diseases Society of America/American Thoracic Society; the guideline tried their best to include most up-to-date information and incorporate strong evidence when possible, but we were surprised by the exclusion of telavancin from the recommended agents for methicillin- resistant Staphylococcus aureus (MRSA) infection [1]. Telavancin is a lipoglycopeptide approved by the Food and Drug Administration (FDA) as an alternative for gram-positive organisms including MRSA HAP/VAP. Two randomized multinational center studies demonstrated televancin was comparable to vancomycin [2]. The evidenced-based data in this largest trial to date in the MRSA HAP/VAP space revealed a higher non–statistically significant rate of cure in patients with bacteremia, VAP, elderly above 65, higher APACHE score, and CPIS SCORE, as well as in patients with MRSA with a vancomycin minimum inhibitory concentration (MIC) greater than or equal to 1. In both studies, 5.8% had MRSA VAP and 13.5% had MRSA HAP. The authors noted a concern about a non–statistically significant higher all-cause mortality in those patients with creatinine clearance less than or equal to 30 in the telavancin group. However, after further analysis it was demonstrated that this adverse event was related to inadequate gram-negative coverage [3]. In fact, if only gram- positive organisms were included, there was a statistical trend toward less all cause 28-day mortality in the telavancin group in comparison to vancomycin. Furthermore, we strongly believe that there is a critical need for alternative effective therapies for the treatment of MRSA HAP/VAP as there are definitely issues with the overutilization of vancomycin including MIC creep throughout the United States, known nephrotoxicity with increasing the dose, and maintaining trough levels near 20 and in combination therapies with common antiinfectives such as piperacillin-tazobactam as well as evidenced-based data consistently showing higher failure rate and mortality when higher MICs for vancomycin are encountered [4–6]. We believe, as stated in the gram-negative organisms section of the guidelines, where much of the included data had significantly low evidenced based support and yet marked toxicities is contradictory to the gram-positive section. These highly circulated guidelines should be inclusive of all available anti-MRSA agents. Televancin has very strong evidence available in large clinical trials and is one of only 3 drugs (linezolid and vancomycin as the others) approved by the FDA for the treatment of MRSA HAP/VAP and one of only 2 agents approved for MRSA HAP/VAP with concurrent bacteremia. Based on this well-documented data and in the spirit of a fair and balanced guideline using the most recent scientific evidence, we would strongly recommend reformatting the guidelines to include televancin as a primary as well as rescue therapy for MRSA HAP/VAP.

http://ift.tt/2pK7rRR