Teicoplanin Dosing for Enterococcus faecium Bacteremia
For Enterococcus faecium bloodstream infections in patients with normal renal function, administer teicoplanin with three loading doses of 6 mg/kg (or 400 mg) every 12 hours, followed by 6 mg/kg (or 400 mg) every 24 hours, with therapeutic drug monitoring targeting trough concentrations of 20-30 mg/L. 1, 2
Loading Dose Strategy
The critical first step is aggressive loading to achieve rapid therapeutic levels:
- Administer 6 mg/kg (minimum 400 mg) every 12 hours for three doses 2
- This loading phase is essential because teicoplanin is highly protein-bound (≥98%) and penetrates slowly into infected tissues 3
- Without adequate loading, therapeutic levels may not be achieved for days, risking treatment failure 3
Maintenance Dosing
After loading, continue with:
- 6 mg/kg (or 400 mg) once daily for patients with creatinine clearance 80-120 mL/min 4, 2
- Reduce to 400 mg every 24 hours if creatinine clearance is <75 mL/min 4
- Treatment duration should be 4-6 weeks for endocarditis and 7-14 days for uncomplicated bacteremia with effective source control 1, 5
Therapeutic Drug Monitoring Requirements
Target trough concentrations (Cmin) of 20-30 mg/L based on international guidelines for serious enterococcal infections: 1
- Obtain first trough level before the 4th or 5th maintenance dose 1
- Recheck levels weekly or after dose adjustments 1
- In a recent study, only 62.7% of patients achieved target levels initially, but TDM-guided adjustments increased this to 85.1% 1
- Microbiological eradication occurred in 95% of cases when target levels were achieved with effective source control 1
Critical Source Control Requirement
Failure to achieve source control was the only variable associated with microbiological failure (75% failure rate without source control vs. 12.7% with source control): 1
- Remove infected catheters immediately for catheter-related bacteremia 1
- Drain abscesses or biliary tract obstructions 1
- Consider valve replacement for prosthetic valve endocarditis 4
Important Clinical Caveats
Teicoplanin should NOT be used as monotherapy for serious E. faecium infections without considering combination therapy: 3
- Major guidelines recommend beta-lactam plus aminoglycoside combinations as first-line for enterococcal endocarditis 3
- However, teicoplanin monotherapy achieved 95% microbiological eradication in recent TDM-guided studies for bacteremia 1
- For endocarditis specifically, consider adding gentamicin for synergy if the isolate is aminoglycoside-susceptible 3
Advantages Over Vancomycin
Teicoplanin offers several practical benefits:
- Once-daily dosing after loading (vs. twice-daily vancomycin) 2
- Lower nephrotoxicity risk 2, 6
- Can be administered intramuscularly for outpatient therapy 2, 6
- Comparable efficacy to vancomycin (no significant mortality difference: 18.2% vs 26.6%, p=0.358) 5