What is the recommended dosage of Teicoplanin (glycopeptide antibiotic) for patients with normal and impaired renal function?

Teicoplanin Dosing Recommendations

Standard Dosing for Normal Renal Function

For patients with normal renal function, administer a loading dose of 6-12 mg/kg every 12 hours for three doses, followed by a maintenance dose of 6-12 mg/kg once daily, with the higher end of the dosing range (12 mg/kg) reserved for severe infections such as endocarditis, septic arthritis, and osteomyelitis. 1, 2

Loading Dose Regimen

• Loading doses are critical to rapidly achieve therapeutic levels and must be given regardless of renal function 1
• Standard loading: 6 mg/kg every 12 hours for three doses 1
• Severe infections: 12 mg/kg every 12 hours for three doses 2
• The loading dose remains unchanged even in renal impairment because rapid achievement of therapeutic levels is essential 1

Maintenance Dose Selection

• Standard infections: 6 mg/kg once daily targeting trough concentrations ≥10 mg/L 1
• Severe infections (endocarditis, septic arthritis, osteomyelitis, complicated bacteremia): 12 mg/kg once daily targeting trough concentrations ≥20 mg/L 2, 3
• Higher doses (600 mg daily in average-weight adults) achieve therapeutic levels more reliably than standard 400 mg dosing (68% vs 37% therapeutic levels achieved) without increased toxicity 4

Dosing Adjustments for Renal Impairment

The loading dose remains unchanged in renal impairment, but maintenance dosing intervals must be extended based on GFR to prevent drug accumulation. 1

Maintenance Dosing by GFR

• GFR >90 mL/min: 6-12 mg/kg every 24 hours 1, 2
• GFR 50-90 mL/min: 6-12 mg/kg every 24 hours 1, 2
• GFR 10-50 mL/min: 6-12 mg/kg every 48 hours 1, 2
• GFR <10 mL/min: 6-12 mg/kg every 72 hours 1, 2

Special Renal Replacement Situations

• Hemodialysis: Loading dose 12 mg/kg, then 6 mg/kg on days 2 and 3, followed by 6 mg/kg once weekly 1, 2
• CAPD peritonitis (intravenous): Follow GFR <10 mL/min dosing (every 72 hours) 1
• CAPD peritonitis (intraperitoneal): 20 mg/L in each bag for week 1,20 mg/kg every other bag for week 2,20 mg/kg in night bag only for week 3 1
• CAVH(D)-CVVH(D): Follow GFR 10-50 mL/min dosing (every 48 hours) 1

Target Trough Concentrations and Monitoring

Therapeutic drug monitoring is not routinely required but is strongly indicated for severe infections and high-risk patients to ensure adequate dosing and prevent treatment failure. 1, 2

Target Levels by Infection Severity

• Standard infections: Trough ≥10 mg/L 1
• Severe infections (endocarditis, septic arthritis, osteomyelitis): Trough ≥20 mg/L 1, 2, 3
• Optimal therapeutic range: 15-30 mg/L 5
• Potentially toxic levels: >60 mg/L 4

Indications for Therapeutic Drug Monitoring

• S. aureus endocarditis or septic arthritis 1
• Major burns 1
• Intravenous drug users 1
• Rapidly changing renal function 1
• Immunocompromised patients 1
• MRSA infections with high MIC values to glycopeptides 2

Critical Pitfalls to Avoid

Failure to provide adequate loading doses is the most common error, leading to subtherapeutic levels and treatment failure regardless of renal function. 1

Common Dosing Errors

• Inadequate loading: Using only 1-2 loading doses instead of 3 doses results in significantly lower trough levels (11.97 mg/L vs 18.11 mg/L) 6
• Insufficient maintenance dosing: Standard 400 mg daily achieves therapeutic levels in only 37% of patients versus 68% with 600 mg daily 4
• Not extending intervals in renal impairment: Failure to adjust dosing intervals leads to drug accumulation 1
• Undertreating severe infections: Using 6 mg/kg instead of 12 mg/kg for endocarditis or septic arthritis results in inadequate trough levels and treatment failure 3

Specific Clinical Scenarios

• Endocarditis monotherapy: Requires 12 mg/kg daily to achieve cure rates similar to vancomycin; lower doses are only acceptable when combined with aminoglycosides 3
• Critically ill patients with increased volume of distribution: Higher loading doses are essential due to altered pharmacokinetics 2
• Elderly patients: Clearance decreases with age; maintenance intervals may need extension even with normal creatinine 7

Alternative Route Considerations

• Intramuscular administration: Rapidly and extensively absorbed, suitable alternative to intravenous route 7
• Oral administration: Very poorly absorbed from gastrointestinal tract; only useful for C. difficile infection at 100-200 mg twice daily for at least 10 days 8