Teicoplanin Dosing for Post-Operative Prophylaxis in Cardiac Surgery
For post-operative prophylaxis in cardiac surgery, teicoplanin should be administered as a loading dose of 12 mg/kg given three times on the first day, followed by maintenance doses of 6 mg/kg every 24 hours based on renal function. 1
Recommended Dosing Regimen
Initial Loading Dose
- Dose: 12 mg/kg intravenously 1, 2
- Timing: First dose should be administered within 30-60 minutes before surgical incision 1
- Frequency: Three loading doses on the first day 1
Maintenance Dosing
- Standard dose: 6 mg/kg every 24 hours 1
- Duration: Single day dosing is generally sufficient for most procedures 1
- Dose adjustment based on renal function: 1
- GFR > 90 mL/min: Every 24 hours
- GFR 50-90 mL/min: Every 24 hours
- GFR 10-50 mL/min: Every 48 hours
- GFR < 10 mL/min: Every 72 hours
Rationale for Dosing Recommendation
The 12 mg/kg loading dose is specifically recommended for cardiac surgery based on pharmacokinetic studies showing that this higher dose achieves significantly better tissue penetration in cardiac and mediastinal tissues compared to the 6 mg/kg dose 2. Research has demonstrated that with the 12 mg/kg regimen:
- Teicoplanin concentrations in heart and mediastinal tissues exceed the MIC90 for potential pathogens in almost all patients 2
- The 6 mg/kg regimen resulted in subtherapeutic tissue concentrations in over 50% of patients 2
Monitoring Recommendations
- Unlike vancomycin, routine monitoring of teicoplanin levels is not generally required 1, 3
- Monitoring should be considered in specific situations: 1
- Treatment of Staphylococcus aureus endocarditis or septic arthritis (target trough ≥20 mg/L)
- Patients with major burns
- Intravenous drug users
- Rapidly changing renal function
Important Considerations
- Teicoplanin requires a loading dose on the first day of administration due to its long half-life (157 ± 93 hours) 1, 4
- A single preoperative dose is generally sufficient for prophylaxis in most procedures, with no evidence supporting prolonged post-operative prophylaxis 1
- For cardiac surgery specifically, the European Society of Clinical Microbiology and Infectious Diseases suggests that glycopeptide prophylaxis should be targeted to MRSA carriers rather than used universally 1
- When used for prophylaxis in cardiac surgery, teicoplanin should be administered with a β-lactam to avoid an increase in postoperative MSSA infections 1
Potential Pitfalls
- Using the standard 6 mg/kg dose (without the higher loading dose) may result in inadequate tissue concentrations in cardiac and mediastinal tissues 2
- Failure to administer teicoplanin within the optimal 30-60 minute window before incision reduces effectiveness 1, 5
- Some studies have shown that teicoplanin alone may be less effective than cefazolin for cardiac surgery prophylaxis, with one large study (n=3027) showing more deep sternotomy wound infections with teicoplanin by 6 months 6
- Teicoplanin has poor penetration into sternal bone, which may be a limitation for preventing sternal wound infections 2
By following these dosing recommendations, adequate tissue concentrations can be achieved to minimize the risk of surgical site infections while maintaining patient safety.