What is the recommended dosing regimen of teicoplanin for adults with serious Gram‑positive infections, including loading and maintenance doses, and how should it be adjusted for renal impairment and in children?

Teicoplanin Dosing for Serious Gram-Positive Infections

Loading Dose Regimen

For serious Gram-positive infections in adults, administer teicoplanin 12 mg/kg IV every 12 hours for three doses, followed by 12 mg/kg once daily maintenance dosing, with mandatory therapeutic drug monitoring targeting trough levels ≥20 mg/L for severe infections such as endocarditis and septic arthritis. 1

Standard vs. Severe Infections

• Standard infections: Loading dose of 6 mg/kg IV every 12 hours for three doses 2, 1
• Severe infections (endocarditis, septic arthritis, complicated bacteremia): Loading dose of 12 mg/kg IV every 12 hours for three doses 2, 1
• The higher loading dose (12 mg/kg) achieves therapeutic trough concentrations (≥10 mg/L) in 90-100% of patients by days 2-3, compared to only 16-18% with the 6 mg/kg regimen 3
• Critical pitfall: Failure to use adequate loading doses results in subtherapeutic levels for 7-15 days, delaying optimal therapy 4

Maintenance Dose Regimen

Normal to Moderate Renal Function

• Standard infections: 6 mg/kg IV once daily 2, 1
• Severe infections: 12 mg/kg IV once daily 2, 1
• For stable adults with normal renal function, 600 mg daily (approximately 8-10 mg/kg for a 70 kg patient) achieves therapeutic levels in 68% of patients versus only 37% with 400 mg daily 5

Renal Impairment Adjustments

The loading dose remains unchanged regardless of renal function, but maintenance dosing intervals must be extended: 2, 1

• GFR >50 mL/min: Administer every 24 hours 2, 1
• GFR 10-50 mL/min: Administer every 48 hours 2, 1
• GFR <10 mL/min: Administer every 72 hours 2, 1

Special Clinical Situations

Hemodialysis

• Loading dose: 12 mg/kg 2, 1
• Follow-up doses: 6 mg/kg on days 2 and 3 2, 1
• Maintenance: 6 mg/kg once weekly 2, 1
• Negligible drug removal occurs during hemodialysis 6

Continuous Renal Replacement Therapy (CAVH/CVVH)

• Follow the GFR 10-50 mL/min schedule (dose every 48 hours) 2, 1

CAPD Peritonitis

• Intravenous route: Follow GFR <10 mL/min schedule (every 72 hours) 2, 1
• Intraperitoneal route: 2, 1
  • Week 1: 20 mg/L in each dialysis bag
  • Week 2: 20 mg/kg every other bag
  • Week 3: 20 mg/kg in night bag only

Pediatric Dosing

Loading Dose

• Standard regimen: 10 mg/kg IV every 12 hours for three doses 7
• Severe infections (endocarditis, septic arthritis, osteomyelitis): 12 mg/kg IV every 12 hours for three doses 7

Maintenance Dose

• Normal renal function: 6-10 mg/kg IV every 24 hours 7
• Severe infections: 10-12 mg/kg IV every 24 hours 7

Pediatric Renal Impairment

• Mild impairment: 6-10 mg/kg every 24 hours 7
• Moderate impairment: 6-10 mg/kg every 48 hours 7
• Severe impairment: 6-10 mg/kg every 72 hours 7
• Loading dose does not change with renal impairment 7

Therapeutic Drug Monitoring

Target Concentrations

• Standard infections: Trough ≥10 mg/L 1, 7
• Severe infections (endocarditis, septic arthritis): Trough ≥20 mg/L 2, 1, 7
• Achieving trough levels ≥20 mg/L is associated with 75% clinical success versus 50% with lower levels (p=0.008) in endocarditis and septic arthritis 1

Mandatory Monitoring Situations

Routine monitoring is not recommended by manufacturers for standard infections, but is mandatory in: 2, 1

• S. aureus endocarditis or septic arthritis 2, 1
• Patients with major burns 2, 1
• Intravenous drug users 2, 1
• Rapidly changing renal function 2, 1
• Combination therapy with aminoglycosides 2
• All pediatric patients due to highly variable pharmacokinetics 7

Monitoring Timing

• Check trough levels on day 4 after loading doses 4
• Repeat monitoring at steady-state (approximately day 7-11) 1, 4
• Continue monitoring twice weekly during treatment 2

Treatment Duration by Infection Type

• Uncomplicated skin infections: 5-10 days 1
• Complicated skin/soft tissue infections: 7-14 days 1
• Uncomplicated bacteremia: 2 weeks 1
• Complicated bacteremia: 4-6 weeks 1
• Native valve endocarditis: 4-6 weeks 1
• Prosthetic valve endocarditis: 6 weeks (with rifampin 300 mg IV/PO q8h and gentamicin 1 mg/kg IV q8h) 1
• Osteomyelitis: >6 weeks 1
• Septic arthritis: 3-4 weeks 1

Critical Pitfalls to Avoid

• Never omit loading doses regardless of renal function—this is the most common cause of treatment failure in the first week 4
• Do not use standard 400 mg daily dosing in adults with normal renal function; 600 mg daily is required for therapeutic levels 5
• Do not rely on clinical improvement alone—verify therapeutic levels with TDM, especially in severe infections 1
• Do not reduce loading doses in renal impairment—only adjust maintenance dosing intervals 2, 1, 7
• For AUC0-24/MIC targets of ≥610, consider prolonging dosing intervals rather than reducing unit doses in renal insufficient patients 8