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Teicoplanin therapeutic drug monitoring (TDM) – excessive or essential?

Background: Teicoplanin is a glycopeptide antibiotic which is frequently used in preference to vancomycin because it does not require such regular TDM as the association between concentration and toxicity has not been fully established. TDM is however, recommended to help optimise therapy in some patients. In our hospital there was an observation of frequent sub-therapeutic levels which prompted an audit of TDM results. Methods: Retrospective review of TDM results August 2015- March 2017 at Homerton Hospital with analysis of dose, renal function, patients’ weight and type of infection. Results: We analysed 54 samples from 33 patients. The most common dose was 600 mg OD which equated to a mean dose of 8.68 mg/Kg with under-dosing in all weight groups but with lowest levels in the group between 110-120 Kg. A 24hr dosing regimen was the most common and other dosing regimens (48hrly or 72hrly) more frequently associated with sub-therapeutic levels. Overall, the mean level was 27.8 +/- 11.9 mg/L but 41% (n=22) of levels were sub-therapeutic for the type of infection treated including 4 patients with bacteraemia, 7 patients with bone and joint infections (n=10 samples) and 3 patients (n=6 samples) with prosthetic joint infections. There was only one patient with teicoplanin levels >60 mg/L who was on treatment for a streptococcal endocarditis. She did not report any side effects. Conclusion: The current dosing regimen recommended by the BNF frequently results in sub-therapeutic levels. TDM is essential in managing complex infections to ensure therapeutic levels are achieved.