Comparative efficacy and safety of vancomycin versus teicoplanin: systematic review and meta-analysis

Abstract

Vancomycin and teicoplanin are the glycopeptides currently in use for the treatment of infections caused by invasive beta-lactam-resistant gram-positive organisms. We conducted a systematic review and meta-analysis of randomized controlled trials that have compared vancomycin and teicoplanin administered systemically for the treatment of suspected or proven infections. A comprehensive search of trials without year, language, or publication status restrictions was performed. The primary outcome was all-cause mortality. Two reviewers independently extracted the data. Risk ratios (RRs) with 95% confidence intervals (CIs) were pooled by using the fixed-effect model (RRs of >1 favor vancomycin). Twenty-four trials were included. All-cause mortality was similar overall (RR, 0.95; 95% CI, 0.74 to 1.21), and there was no significant heterogeneity. In trials that used adequate allocation concealment, the results favored teicoplanin (RR, 0.82; 95% CI, 0.63 to 1.06), while in trials with unknown methods or inadequate concealment, the results favored vancomycin (RR, 3.61; 95% CI, 1.27 to 10.30). The latter trials might have recruited more severely ill patients. No other variable affected the RRs for mortality, including the assessment of glycopeptides administered empirically or for proven infections, neutropenia, the participant's age, and drug dosing. There were no significant differences between teicoplanin and vancomycin with regard to clinical failure (RR, 0.92; 95% CI, 0.81 to 1.05), microbiological failure (RR, 1.24; 95% CI, 0.93 to 1.65), and other efficacy outcomes. Lower RRs (in favor of teicoplanin) for clinical failure were observed with a lower risk of bias and when treatment was initiated for infections caused by gram-positive organisms rather than empirically. Total adverse events (RR, 0.61; 95% CI, 0.50 to 0.74), nephrotoxicity (RR, 0.44; 95% CI, 0.32 to 0.61), and red man syndrome were significantly less frequent with teicoplanin. Teicoplanin is not inferior to vancomycin with regard to efficacy and is associated with a lower adverse event rate than vancomycin.

FIG. 1.

Trial flow. RCTs, randomized controlled trials; CR, catheter related; IVDU, intravenous drug abuse. Three publications described two trials each (22, 55, 66).

FIG. 2.

All-cause mortality for trials. Trials are subgrouped by the methods of allocation concealment used in the trial. M-H, Mantel-Haenszel.

FIG. 3.

Funnel plots. (A) All-cause mortality; (B) nephrotoxicity. RRs are plotted against standard errors, as a measure of the study's precision.

FIG. 4.

Nephrotoxicity. Trials are subgrouped by the type of vancomycin preparation used in the trial: trials that used purified vancomycin and those reporting on the use of unpurified vancomycin for part or all of the trial. Similar results were obtained when the results for one trial published in 1991 were removed from the unpurified subgroup. M-H, Mantel-Haenszel.