Clindamycin and Teicoplanin (Targocid): Clinical Overview
Clindamycin
Mechanism of Action
Clindamycin inhibits bacterial protein synthesis by binding to the 50S ribosomal subunit of susceptible bacteria, suppressing both bacterial growth and toxin production. 1 This dual mechanism makes it particularly valuable for toxin-producing organisms like Group A Streptococcus. 2, 3
Antimicrobial Coverage
- Gram-positive aerobes: Excellent activity against Staphylococcus aureus (including community-acquired MRSA), streptococci, and group B streptococci 1, 2, 4
- Anaerobes: Outstanding coverage against anaerobic bacteria, particularly beta-lactamase-producing Bacteroides species 4, 5
- Notable gaps: No activity against Haemophilus influenzae, Moraxella catarrhalis, aerobic gram-negative rods (e.g., E. coli), or enterococci 1, 4
Clinical Uses
Clindamycin is indicated for purulent cellulitis and skin/soft tissue infections at 300-450 mg orally three times daily in adults. 2 It provides effective empirical coverage for community-acquired MRSA in outpatient settings. 2
- Pediatric dosing: 10-13 mg/kg/dose IV every 6-8 hours (maximum 40 mg/kg/day) for complicated skin infections when local resistance rates are <10% 2
- Severe anaerobic infections: 900-1800 mg total daily dose divided into 3-4 doses 2
- Pelvic infections: Combined with aminoglycosides (typically gentamicin or tobramycin), clindamycin represents the standard regimen for serious obstetric/gynecologic infections, post-cesarean endometritis, and tubo-ovarian abscesses 4, 5
- Diabetic foot infections: Appropriate for mild infections with gram-positive coverage needs 1
- Topical formulation: Once-daily application for inflammatory acne vulgaris 2
Complications and Adverse Effects
- Pseudomembranous colitis: The most significant concern, caused by Clostridium difficile, though uncommon in practice and responsive to drug discontinuation plus vancomycin or metronidazole treatment 4
- Contraindications: History of hypersensitivity to clindamycin/lincomycin, regional enteritis, or ulcerative colitis 2
- Drug interactions: Neuromuscular blocking properties may enhance other neuromuscular blockers; avoid combination with erythromycin-containing products 2
- Gastrointestinal effects: Most common side effects involve the GI system 5
Clinical Pearls
- Resistance monitoring: Check macrolide sensitivity and consider D-test before using for MRSA, as clindamycin resistance can occur in some strains 1, 3
- Combination therapy: When treating mixed infections with gram-negative organisms, combine with agents effective against gram-negatives (e.g., aminoglycosides, fluoroquinolones) 2, 4
- IV to oral transition: Switch when patient shows clinical improvement and has been afebrile for 48-72 hours 2
Teicoplanin (Targocid)
Mechanism of Action
Teicoplanin is a glycopeptide antibiotic structurally related to vancomycin that inhibits bacterial cell wall synthesis by binding to D-alanyl-D-alanine terminals of peptidoglycan precursors. 6, 7
Antimicrobial Coverage
- Gram-positive bacteria: Highly active against staphylococci (including methicillin-resistant strains), streptococci, enterococci, and many anaerobic gram-positive bacteria 6, 7
- Equivalent spectrum to vancomycin: Provides comparable coverage for serious gram-positive infections 1, 7
Clinical Uses
Teicoplanin is indicated for severe gram-positive infections including septicemia, endocarditis, skin/soft tissue infections, and catheter-associated infections, with equal efficacy against methicillin-resistant and -susceptible staphylococci. 6, 7
- Standard maintenance dosing: 6 mg/kg/day (typically 400 mg/day) for most serious infections 1, 7
- High-dose situations requiring 12 mg/kg/day:
- Loading dose requirement: Teicoplanin requires loading doses (6 or 12 mg/kg three times) on the first day of administration 1
Dosing in Special Populations
- Renal impairment:
- GFR >90: 24-hour intervals
- GFR 50-90: 24-hour intervals
- GFR 10-50: 48-hour intervals
- GFR <10: 72-hour intervals 1
- Hemodialysis: 12 mg/kg loading dose, then 6 mg/kg at days 2 and 3, followed by 6 mg/kg weekly 1
- CAPD peritonitis: Intraperitoneal administration with specific weekly dosing schedules 1
- Pediatrics: 40 mg/kg/24 hours with loading doses of 10 mg/kg every 12 hours 1
Complications and Adverse Effects
Teicoplanin has a superior toxicity profile compared to vancomycin, with lower incidence of nephrotoxicity and ototoxicity when recommended serum concentrations are maintained. 6, 7
- Adverse effects: Generally limited to local reactions or hypersensitivity responses 6
- Monitoring: Unlike vancomycin, routine blood level monitoring is not recommended by the manufacturer, except for S. aureus endocarditis or septic arthritis (target trough ≥20 mg/L vs. standard 10 mg/L) 1
- Special monitoring situations: Major burns, IV drug abusers, or rapidly changing renal function 1
Pharmacokinetic Advantages
- Exceptionally long half-life: Terminal phase half-life of 87 hours allows once-daily dosing 8
- Administration routes: Intramuscular or intravenous, with rapid and extensive absorption from muscle and peritoneal cavity 8
- Tissue penetration: High concentrations in lung and bone; penetrates slowly into CSF but effectively into synovial/pleural fluids and soft tissue 8
- Protein binding: Highly bound to albumin (90%) 8
Clinical Context and Resistance Concerns
Restrictive use of glycopeptides including teicoplanin must be a priority to limit emergence of vancomycin-resistant enterococci and glycopeptide-resistant staphylococci. 1 The Belgian guidelines emphasize that glycopeptides should be reserved for documented MRSA infections, severe infections in settings with high MRSA prevalence (>10%), or documented glycopeptide-susceptible gram-positive infections when beta-lactams are contraindicated. 1