What is the recommended dosage of teicoplanin and how is it modified in patients with impaired renal (kidney) function or hepatic (liver) impairment?

Teicoplanin Dosing and Renal/Hepatic Modifications

Standard Dosing Regimen

For standard infections, administer a loading dose of 6 mg/kg every 12 hours for three doses, followed by maintenance dosing of 6 mg/kg once daily; for severe infections (endocarditis, septic arthritis, osteomyelitis), use 12 mg/kg every 12 hours for three doses, followed by 12 mg/kg once daily, with maintenance intervals extended based on renal function but loading doses remaining unchanged regardless of kidney function. 1, 2, 3

Loading Dose Strategy

• The loading dose is NOT modified by renal impairment and must be given at full dose to rapidly achieve therapeutic levels 1, 2
• Standard loading: 6 mg/kg every 12 hours for three doses 2, 3
• Severe infections loading: 12 mg/kg every 12 hours for three doses 2, 3
• The rationale is that loading doses depend on volume of distribution, not clearance, and critically ill patients often have expanded extracellular volume requiring aggressive loading 1

Renal Function-Based Maintenance Dosing

Maintenance dose intervals must be extended based on GFR to prevent drug accumulation, while the dose per kilogram remains the same (6-12 mg/kg depending on infection severity). 1, 2, 3

Dosing Algorithm by GFR:

• GFR >90 mL/min: 6-12 mg/kg every 24 hours 1, 2, 3
• GFR 50-90 mL/min: 6-12 mg/kg every 24 hours 1, 2, 3
• GFR 10-50 mL/min: 6-12 mg/kg every 48 hours 1, 2, 3
• GFR <10 mL/min: 6-12 mg/kg every 72 hours 1, 2, 3

Special Renal Replacement Situations:

• Hemodialysis: Loading dose 12 mg/kg, then 6 mg/kg on days 2 and 3, followed by maintenance of 6 mg/kg once weekly 1, 2, 3
• CAPD peritonitis (IV route): Follow GFR <10 mL/min dosing (every 72 hours) 2, 3
• 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, 2
• CAVH(D)-CVVH(D): Follow GFR 10-50 mL/min dosing (every 48 hours) 1, 2

Hepatic Impairment

No dose adjustment is required for hepatic impairment, as teicoplanin is not hepatically metabolized and is eliminated primarily by renal excretion. 1, 2, 3

• Teicoplanin clearance is directly related to creatinine clearance, not hepatic function 4
• Monitor renal function closely in patients with hepatic disease, as they may have concurrent renal impairment requiring dose adjustment 1

Target Trough Concentrations

Therapeutic drug monitoring is not routinely required but is strongly indicated for severe infections and high-risk patients to ensure adequate dosing. 1, 2, 3

Target Levels:

• Standard infections: Trough ≥10 mg/L 1, 2
• Severe infections (endocarditis, septic arthritis, osteomyelitis): Trough ≥20 mg/L 1, 2, 3

Indications for Therapeutic Drug Monitoring:

• S. aureus endocarditis or septic arthritis 1, 2
• Major burns 1, 2
• Intravenous drug users 1, 2
• Rapidly changing renal function 1, 2
• Immunocompromised patients 1, 2
• 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, 2

• Do not reduce loading doses in renal impairment – this delays achievement of therapeutic levels and compromises outcomes 1, 2
• Do not fail to extend maintenance intervals in renal impairment – this leads to drug accumulation 2
• In critically ill patients with increased volume of distribution (fluid resuscitation, hypoalbuminemia), higher loading doses (12 mg/kg) are essential even for standard infections 1, 5
• Research demonstrates that achieving initial trough concentrations ≥15 μg/mL significantly improves clinical success rates in patients with renal dysfunction (75.0% vs 50.0%, p=0.008) 1

Pharmacokinetic Considerations

• Teicoplanin has high protein binding (≥98%) and slow penetration into tissues, necessitating aggressive loading 1
• Total and renal clearance significantly decrease with decreasing creatinine clearance 4
• The relationship between teicoplanin clearance and creatinine clearance is consistent across the dose range of 3-30 mg/kg 4
• Standard 400 mg daily dosing frequently results in subtherapeutic levels; weight-based dosing (6-12 mg/kg) is superior 6