Do meropenem or teicoplanin cause transaminitis?

Hepatotoxicity Risk with Meropenem and Teicoplanin

Both meropenem and teicoplanin can cause transaminitis, though meropenem carries a more clearly documented risk of hepatocellular injury, while teicoplanin's hepatotoxic potential appears minimal based on available evidence.

Meropenem and Transaminitis

FDA-Documented Hepatotoxicity

• Meropenem causes elevated liver enzymes (ALT, AST, alkaline phosphatase, LDH, and bilirubin) in clinical practice, as documented in the FDA prescribing information 1
• The FDA label specifically lists increased alanine transaminase (ALT), aspartate aminotransferase (AST), alkaline phosphatase, and bilirubin as adverse laboratory changes occurring in greater than 0.2% of patients 1
• Cholestatic jaundice/jaundice and hepatic failure are listed as post-marketing adverse events in the digestive system category 1

Clinical Evidence of Meropenem-Induced Liver Injury

• A documented case report demonstrates meropenem can cause severe, rapidly developing hepatocellular injury with ALT reaching 1160 U/L, AST 787 U/L, alkaline phosphatase 297 U/L, and GGT 252 U/L within 48 hours of administration 2
• The injury pattern was mixed hepatocellular/cholestatic, and rechallenge with meropenem reproduced the liver enzyme elevation, confirming causality 2
• Liver enzymes normalized after meropenem discontinuation in both instances, supporting a direct drug-related mechanism 2

Safety Profile Data

• In a large safety analysis of nearly 5,000 patients, increased hepatic enzymes occurred in 1.5-4.3% of meropenem-treated patients 3
• The overall safety profile showed meropenem was generally well tolerated, but hepatic enzyme elevation remains a recognized adverse effect 3, 4

Teicoplanin and Transaminitis

Limited Evidence of Hepatotoxicity

• Teicoplanin does not appear in guidelines or FDA documentation as a significant cause of transaminitis, and no specific hepatotoxicity warnings are present in the dosing guidelines 5
• One guideline reference notes teicoplanin was used successfully in combination with meropenem for brain abscess treatment without adverse effects, though this doesn't specifically address hepatotoxicity 6
• The absence of hepatotoxicity warnings in comprehensive dosing guidelines suggests transaminitis is not a clinically significant concern with teicoplanin 5

Clinical Context

• When teicoplanin is considered as an alternative in patients with elevated bilirubin, guidelines recommend switching to linezolid or daptomycin instead, suggesting awareness of potential hepatic considerations, though this may reflect redundancy concerns rather than direct hepatotoxicity 7

Clinical Implications

Monitoring Recommendations

• For patients receiving meropenem, baseline and periodic liver function tests should be obtained, particularly in those with pre-existing liver disease or receiving prolonged therapy 1, 2
• Early recognition of drug-induced liver injury is critical, as enzyme elevations can occur rapidly (within 48 hours) and reach severe levels 2
• If transaminitis develops on meropenem, consider alternative antibiotics based on infection type and susceptibility patterns 1

Risk Stratification

• Patients with renal impairment receiving meropenem may have increased risk of adverse events overall, though specific hepatotoxicity risk in this population is not well-defined 1
• The mixed hepatocellular/cholestatic pattern seen with meropenem suggests both direct hepatocyte injury and biliary involvement 2