Teicoplanin guidelines for Adult Patients - Department of Microbiology Antimicrobial Prescribing Guidelines

Publication: 11/09/2017  --
Last review: 30/08/2018  
Next review: 11/09/2020  
Clinical Guideline
CURRENT 
ID: 5154 
Approved By: Improving Antimicrobial Prescribing Group 
Copyright© Leeds Teaching Hospitals NHS Trust 2018  

 

This Clinical Guideline is intended for use by healthcare professionals within Leeds unless otherwise stated.
For healthcare professionals in other trusts, please ensure that you consult relevant local and national guidance.

Department of Microbiology Antimicrobial Prescribing Guidelines

Teicoplanin guidelines for Adult Patients

This document provides guidelines for prescribers in Leeds Teaching Hospitals regarding the situations in which it would be appropriate to consider the use of teicoplanin. This document is supplementary to, and should be used in conjunction with, the summary of product characteristics.

The use of teicoplanin can be considered within its currently approved LTHT Drugs and Therapeutics Committee [DTC] application; other indications will require chairman’s action.

DRUG INFORMATION
Introduction

Teicoplanin is a glycopeptide with bacteriostatic and bactericidal activity against most Gram positive organisms, depending on the dose and sensitivity of the organism. It also usually has activity against staphylococci that are resistant to β-lactam antibiotics. Teicoplanin interferes with cell-wall biosynthesis by blocking synthesis of peptidoglycan to inhibit the growth of susceptible organisms.

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Antimicrobial activity

Teicoplanin is active against a range of aerobic and anaerobic Gram positive bacteria, but does not have any activity against Gram negative bacteria.
Teicoplanin should be co-administered with appropriate antibacterial agents or other agents should be considered in cases of mixed infections where Gram negative and/or certain types of anaerobic bacteria are suspected.
Teicoplanin has in vitro activity against:
Staphylococcus aureus [methicillin resistant and methicillin susceptible strains]
Coagulase negative staphylococci
Streptococci
Corynebacterium spp
Teicoplanin does not have in vitro activity against:
Gram negative bacteria

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Dose/Routes of administration

Teicoplanin requires a loading dose and the daily dose varies between 6mg/kg and 12mg/kg depending on the indication as described below. The dose should always be rounded up to the nearest 100mg for ease of administration. The dose is based on actual body weight and is capped at 2grams as a single dose.

LOADING DOSE FOR ADULTS

Infection

Loading dose

Maintenance dose

Infective endocarditis

12mg/kg every 12 hours for three to five doses, then 12mg/kg once daily until day 5

12mg/kg- frequency according to renal function as stated in table below

Bone and joint including osteomyelitis and septic arthritis
Bacteraemias
Diabetic Foot Infections
Infected central venous catheters (CVCs)
Infected long term intravascular access devices
Spontaneous bacterial peritonitis
Infected parapneumonic effusions and empyemas
Intra-abdominal sepsis
Neutropenic sepsis

12mg/kg every 12 hours for three doses, then 12mg/kg once daily until day 5

12mg/kg- frequency according to renal function as stated in table below

Skin and soft tissue including cellulitis, breast abscesses and mastitis
Community acquired, hospital acquired and ventilator acquired pneumonia
Aspiration pneumonia
Exacerbations of cystic fibrosis
Parotitis
Sinusitis
Otitis externa
Otitis media and mastoiditis
Tonsillar pharyngitis and epiglottitis

6mg/kg every 12 hours for three doses, then 6mg/kg once daily until day 5

6mg/kg- frequency according to renal function as stated in table below

 

MAINTENANCE DOSING AND DOSE ADJUSTMENT IN RENAL IMPAIRMENT

Dosage adjustments are made according to degree of renal impairment. Dose adjustments described should only be made on the FIFTH DAY of treatment with teicoplanin. Consider rechecking renal function on day 4 if you think it is likely to have changed and will impact the dosing regimen. Creatinine clearance (CrCl) using the Cockcroft and Gault calculation should be calculated and eGFR should not be used. Calculators 

Ideal body weight (IBW) should be used to calculate CrCl if a patient is overweight. If a patient’s actual body weight is more than 25% greater than their IBW, adjusted body weight should be used to calculate CrCl.

Creatinine Clearance (mL/minute)

Dose adjustment from FIFTH DAY

Example with 12mg/kg dosing based on a 70kg adult

Example with 6mg/kg dosing based on a 70kg adult

>80

No dose adjustment required

800mg once daily

400mg once daily

30-80

Dose should be administered on alternate days (i.e. from day 6)

800mg alternate days

400mg alternate days

<30 or Peritoneal Dialysis

Dose should be administered every 72 hours (i.e. from day 7)

800mg every 72 hours

400mg every 72 hours

Intermittent Haemodialysis

1/3rd of the dose administered daily

300mg once daily

150mg once daily

Haemodialysis
Patients receiving dialysis at Leeds are not suitable for fixed 72 hour dosing of teicoplanin. The increased clearance of teicoplanin during HDF / Hi-Flux dialysis means that patients may have periods of subtherapeutic drug levels when dialysis and teicoplanin dosing times do not coincide.

To avoid this it is advised that the maintenance dose of teicoplanin from day 5 onwards is reduced to 1/3rd and given ONCE daily (rounded to the nearest 50mg).  On dialysis days the dose should be administered post dialysis.

DOSE IN OBESITY
There is no dose adjustment required for the dosing of teicoplanin in obese patients.
Ideal body weight should always be used to calculate creatinine clearance using the Cockroft & Gault method for patients who are obese.
Note dose should be capped at a maximum of 2gram as a single dose.

DOSE IN LIVER FAILURE
There is no dose adjustment required

PAEDIATRIC DOSES
This guideline is not for use in paediatrics. See information in the BNFc for information related to teicoplanin use in paediatric patients.

ADMINISTRATION INFORMATION
Doses up to 800mg can be administered as a slow bolus.
Doses over 800mg should be administered as an intravenous infusion over 60 minutes.

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Therapeutic Drug Monitoring (checking levels)

Levels only need to be monitored in patients who are being treated for more than seven days. Levels should be taken as a trough level just before the dose is administered. The initial level should be taken before the dose on the fifth day. If the dose has been reduced to alternate days, or every 72 hours, take the level before the first dose of this change. Levels that are in range should be monitored weekly. When dose adjustments have been made due to plasma concentration levels being out of range, take the level on the fifth day after this change.

Infection

Target Level

Infective endocarditis

30-40mg/L

Bone and joint including osteomyelitis and septic arthritis
Bacteraemias
Diabetic Foot Infections
Infected central venous catheters (CVCs)
Infected long term intravascular access devices
Spontaneous bacterial peritonitis
Infected parapneumonic effusions and empyemas
Intra-abdominal sepsis
Neutropenic sepsis

20-30mg/L

Skin and soft tissue including cellulitis, breast abscesses and mastitis
Community acquired, hospital acquired and ventilator acquired pneumonia
Aspiration pneumonia
Exacerbations of cystic fibrosis
Parotitis
Sinusitis
Otitis externa
Tonsillar pharyngitis and epiglottitis
Otitis media and mastoiditis

15-30mg/L

 

RECOMMENDATIONS ON DOSE ADJUSTMENTS

Type of Infection

Dosing

Target Levels (mg/L)

Level above target range

Level below target range

Infective endocarditis

12mg/kg OD

30-40

If 40-60mg/L reduce dose by 25%.
If above 60mg/L consider reducing dose by 50% or withholding doses and discussing with an antimicrobial pharmacist.

If below 20mg/L, increase dose by 50%.
If 20-30mg/L, increase dose by 25%

Bone and joint including osteomyelitis and septic arthritis
Bacteraemias
Diabetic Foot Infections
Infected central venous catheters (CVCs)
Infected long term intravascular access devices
Spontaneous bacterial peritonitis
Infected parapneumonic effusions and empyemas
Intra-abdominal sepsis
Neutropenic sepsis

12mg/kg OD

20-30

If 30-40mg/L take no action unless any adverse effects reported or renal function deteriorated.
If above 40mg/L reduce dose.
If 40-60mg/L reduce dose by 25%
If above 60mg/L consider reducing dose by 50% or withholding doses and discussing with an antimicrobial pharmacist.

If below 15mg/L, increase dose by 50%.
If 15-20mg/L increase dose by 25%

Skin and soft tissue including cellulitis, breast abscesses and mastitis
Community acquired, hospital acquired and ventilator acquired pneumonia
Aspiration pneumonia
Exacerbations of cystic fibrosis
Parotitis
Sinusitis
Otitis externa
Tonsillar pharyngitis and epiglottitis
Otitis media and mastoiditis

 

6mg/kg OD

15-30

If 30-40mg/L take no action unless any adverse effects reported or renal function deteriorated.
If above 40mg/L reduce dose.
If between 40-60mg/L reduce dose by 25%
If above 60mg/L consider reducing dose by 50% or withholding doses and discussing with an antimicrobial pharmacist.

If below 10mg/L, increase dose by 50%.
If 10-15mg/L, increase dose by 25%

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Pharmacokinetics

Absorption: Teicoplanin is administered as an intravenous injection, although the intravenous preparation can be administered orally for the treatment of Clostridium difficile infection where indicated

Distribution: Teicoplanin is highly bound to plasma proteins and is distributed in the lung, myocardium and bone tissues. It does not readily cross the blood brain barrier.

Metabolism/Elimination: Teicoplanin is mainly excreted unchanged through the urine and does not appear to be metabolised through the cytochrome P450 system, therefore has minimal drug-drug interactions. Teicoplanin has a long half life of 100-170 hours and mainly renally excreted. 

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Allergy advice

Hypersensitivity reactions and anaphylaxis have been reported with teicoplanin. If such a reaction occurs, teicoplanin should be stopped immediately and appropriate emergency measures taken.

Caution should be taken if there has been previous hypersensitivity reported with vancomycin due to the risk of cross-sensitivity between the two agents. However, if “red-man syndrome” has previously been reported with vancomycin, teicoplanin can still be used with caution.

A case series of perioperative anaphylaxis associated with teicoplanin has recently been reported and any such reactions should be reported to the MHRA.

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Key interactions (include BNF black dot)

There are no key interactions to note with teicoplanin. Care should be taken when using with other nephrotoxic and ototoxic medicines therefore renal function and hearing should be monitored regularly.

[THIS LIST IS NOT EXHAUSTIVE]

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Side effects and monitoring required

Infusion-related reactions have rarely been reported with teicoplanin and “red-man syndrome” has been observed. Administering large doses slowly can reduce the risk of infusion-related reactions. Note that teicoplanin can commonly cause drug rashes. Whilst these rashes may be harmless, care must be taken to assess and monitor such rashes as there are reports of DRESS occurring with teicoplanin.

Teicoplanin can cause nephrotoxicity, although this is reported less frequently compared with vancomycin. Renal function should be monitored at least weekly and the frequency increased where there is existing renal impairment, or the patient is on concurrent nephrotoxic medicines.
Teicoplanin can cause haematological side effects, notably thrombocytopenia and full blood count should be monitored at least weekly and the frequency increased if there is an existing haematological disease or the patient is on concurrent medicines that can cause haematological side effects.

There have been very few reports of ototoxicity associated with teicoplanin but changes in hearing should be monitored for.

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DRUG INDICATIONS
Prophylaxis indications in LTHT

Teicoplanin is recommended as prophylaxis in the following guidelines:

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Treatment indications in LTHT

LTHT recommends teicoplanin to be used in the following indications:

Note that teicoplanin is licensed for the following indications:
Complicated skin and soft tissue infections
Bone and joint infections
Hospital acquired pneumonia
Community acquired pneumonia
Complicated urinary tract infections
Infective endocarditis
Peritonitis associated with continuous ambulatory peritoneal dialysis (CAPD)
Bacteraemia that occurs in association with any of the indications listed above

All other use is considered off-label. The evidence for teicoplanin in the indications listed within LTHT guidelines has been reviewed and deemed appropriate to use at LTHT. Patients should be informed that other than in the above indications that the medication is being used in for an off-label indication. The prescriber should be aware that they take full responsibility for any medicines that they prescribe.

Teicoplanin can be used to facilitate the Community Intravenous Antibiotic Service (CIVAS). Please see CIVAS homepage and CIVAS drug monographs on the formulary for more information.

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Prescribing restriction

Teicoplanin is a protected antimicrobial within LTHT. It should only be used in conjunction with the relevant antimicrobial guidelines and on recommendations from microbiology.

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Provenance

Record: 5154
Objective:
Clinical condition:
Target patient group: Adults
Target professional group(s): Pharmacists
Secondary Care Doctors
Adapted from:

Evidence base

References

  1. BNF
  2. Summary of Product Characteristics. Targocid® 400mg powder for solution for injection/infusion or oral solution. Date of revision of text 21st July 2016.
  3. Brauers, J et al. 2007. Bactericidal activity of daptomycin, vancomycin, teicoplanin and linezolid against Staphylococcus aureus, Enterococcus faecalis and Enterococcus faecium using human peak free serum drug concentrations. International Journal of Antimicrobial Agents.29:3 p322-325
  4. Savic, L. C et al. 2015. Teicoplanin allergy – an emerging problem in the anaesthetic allergy clinic. British Journal of Anaesthesia. 115: 4 p595-600
  5. Stockley’s Drug Interactions. 2017. MedicinesComplete.
  6. Cavalcanti, A. B. et al. 2010. Cochrane Review: Teicoplanin versus vancomycin for proven or suspected infection. Cochrane Library, Cochrane Database of Systematic Reviews. 6
  7. Bonnet, R. M. et al. 2004. Clinical Ototoxicity of Teicoplanin. Annals of Otology, Rhinology and Layrngology. 113: 4 p310-312
  8. Lamont, E. 2009. Development of teicoplanin dosage guidelines for patients treated within an outpatient parenteral antibiotic therapy (OPAT) programme. Journal of Antimicrobial Chemotherapy. 64:1 p181-187
  9. Chen-Hsiang Lee et al. 2014. Teicoplanin therapy for MRSA bacteraemia: a retrospective study emphasising the importance of maintenance dosing in improving clinical outcomes. Journal of Antimicrobial Chemotherapy.70:1 p257-263

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Approved By

Improving Antimicrobial Prescribing Group

Document history

LHP version 1.0

Related information

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