Teicoplanin Inpatient Guidelines for Adults (16 years and over)

Vancomycin is NHS Borders’ glycopeptide of choice. Please see NHS Borders Antimicrobial Companion app and Antimicrobials Microsite for vancomycin information and dosing calculator. Teicoplanin should only be used under advice from microbiology consultants or according to agreed local infection management guidelines.

Teicoplanin is a bacteriostatic agent which may be used against most Gram positive organisms (including Staph. aureus and Staph. epidermidis). Indications may include¹:

• Bone and joint infections
• Infective endocarditis
• Complicated skin and soft tissue infections
• Community and hospital acquired pneumonias (CAP/HAP)

NOTE: There are other Teicoplanin regimens in use in NHS Borders. This guidance does NOT apply to the use of teicoplanin as a three times a week regimen² or for Hospital at Home patients. Contact Consultant Microbiologist or Antimicrobial Pharmacist for advice on other regimens.

• Doses will vary depending on the indication – take care to ensure the correct dosing regime is used
• Loading and maintenance dose is based on actual weight and renal function
• Calculate creatinine clearance (CrCl) using Cockroft and Gault equation – do not use eGFR
• If CrCl>80 ml/min use tables below⁶ (Tables 1 and 2 for loading and maintenance doses)
• If CrCl <80ml/min, load as normal renal function then see Dosing in Renal Impairment (Table 3) for dose adjustments
• Doses should be prescribed on the regular section of the drug kardex (as per Fig)

Table 1 – dose banding for bone and joint infections and infective endocarditis ^3,6

^*Dose increases beyond this should be in response to teicoplanin levels only and on advice from Consultant Microbiologist

Table 2 – dose banding for complicated skin and soft tissue infections and severe CAP/HAP⁷

Figure 1 – example including loading and maintenance doses for a patient with a bone infection weighing 75kg with CrCl>80ml/min (black boxes indicate loading doses).

After day four of treatment, review doses as per table 3 below¹. See figure 2 for illustrated example of dosing adjustment.

Table 3 – Dose adjustments for patients with renal impairment

Figure 2 – example illustrating potential dosing for a patient weighing 75kg with a creatinine clearance of 25ml/min, dosing 72 hourly. (an alternative option would be 1/3 dosing every 24 hours)

Adverse Reactions^{1, 9}

Common adverse effects include: fever, skin reactions and pain at injection site

Uncommon adverse effects include: bronchospasm, diarrhoea, dizziness, eosinophilia, headache, hearing impairment, hypersensitivity, leucopenia, nausea, ototoxicity, thrombocytopenia, vomiting, deranged LFTs

Frequency not known: agranulocytosis, angioedema, chills, neutropenia, overgrowth of non-susceptible organisms, renal impairment, seizure, severe cutaneous adverse reactions (SCARs), thrombophlebitis

• Teicoplanin level monitoring is indicated when using high doses, in renal insufficiency, extremes of body weight, deep seated/complex infections, in patients not responding to treatment, or as advised by the Consultant microbiologist. This is to ensure it is within the recommended therapeutic range for efficacy.
• Teicoplanin levels are not required for treatment courses ≤7
• Pre dose (trough) to be taken on day 5 (avoid weekend sampling if possible). If levels are in range, monitoring is to be carried out weekly thereafter.
• If the dose is to be reduced due to renal impairment, take the level before the first dose of this
• Teicoplanin samples are sent to Bristol for analysis, therefore levels may take 3 – 5 working days to be reported on Trak.
• 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.
• Continue with the same teicoplanin dosing until the result is available unless creatinine is unstable (e.g. a change of > 15-20 %) – in this case, seek advice from Pharmacist or Consultant
• For dosing guidance, where creatinine is unstable or trough levels are out of range, contact Pharmacist or Consultant Microbiologist.
• Routine monitoring of U&Es, LFTs, FBC and CRP should continue at least

Table 4 - target trough levels1 ^4,8:

*round to nearest 100mg. Maximum of 2g per single dose