Aim Teicoplanin is an alternative treatment option for serious Gram-positive infections where vancomycin is not appropriate. Teicoplanin is also used in surgical prophylaxis and line insertions in penicillin allergy. Prescribing of teicoplanin for treatment of infection was audited in 2020 and shown to have variability in loading and maintenance dose regimen and Therapeutic Drug Monitoring (TDM). The audit findings prompted the development of a teicoplanin prescribing panel which includes loading and maintenance doses appropriate to age and weight and automated ordering of TDM at day 3.

Method The teicoplanin prescribing audit resulted from anecdotal reporting of poor practice, Datix reports of missed loading or maintenance doses and medicines information enquiries on dosing due to multiple options in the British National Formulary for Children (BNFc). The audit showed that 70% of 62 teicoplanin prescriptions in one month were prescribed for appropriate indications with doses in line with BNFc. Accuracy of dosing and completion of an appropriate loading and maintenance regimen was variable in the other 30%. 44% of prescriptions had a duration of more than 3 days, only two out of 27 patients had TDM carried out. Teicoplanin was prescribed due to a documented vancomycin allergy in eight patients, half of these recorded allergies were ‘Red Man Syndrome’ or vancomycin infusion reaction. This is a histamine-mediated reaction caused by infusing vancomycin too quickly and is not a true allergy.¹

It is recognised that teicoplanin posology is complex with different loading and maintenance regimens and administration instructions depending on age, indication and route. Non-weight-based dosing of teicoplanin in adults has been shown to result in sub-optimal levels² and the Summary of Product Characteristics (SmPC) and BNFc now recommends weight-based dosing and TDM for all indications. TDM has not been widely implemented at the Trust due to poor turnaround time and misconceptions about the lack of clinical need. Sub-optimal antimicrobial prescribing and TDM contributes to antimicrobial resistance. It is imperative that antimicrobials are prescribed only when necessary and optimised in terms of dosing and duration. It was identified that prescribing of teicoplanin could be improved in two main ways, education of pharmacists and prescribers on guidelines and appropriate choice of antibiotic for patients, i.e., reviewing allergies and secondly, through improving and standardising electronic prescribing.

Results The antimicrobial stewardship pharmacist and pharmacists with EPR expertise developed a teicoplanin prescribing panel for treatment of infection. This includes loading and maintenance doses automated for age and weight and TDM on day 3, infusions are automated for neonates and injections for all other ages, in line with the SmPC and Medusa. Lower doses for skin and urinary tract infections are not included as this is for treatment of serious Gram-positive infections. SmPC and Medusa links and latest creatinine and teicoplanin levels are available within the panel. Microbiology, pharmacy and the antibiotic policy group reviewed and approved the panel.

Conclusion We hope that this teicoplanin prescribing panel will standardise prescribing and TDM, thus improving care for our patients by ensuring safe, optimal dosing. Teicoplanin prescribing will be reaudited in one year.

References

1. Sivagnanam S, Deleu D. Red man syndrome. Crit Care 2003;7:119–20. doi: 10.1186/cc1871. Epub 2002 Dec 23. PMID: 12720556; PMCID: PMC270616.

2. Ramos-Martín V, Paulus S, Siner S, et al. Population pharmacokinetics of teicoplanin in children. Antimicrob Agents Chemother 2014;58:6920–6927. doi: 10.1128/AAC.03685–14. Epub 2014 Sep 15. PMID: 25224001; PMCID: PMC4249354.