Teico 400 mg is indicated in adults and in children from birth for the parenteral treatment of
the following infections (see sections 4.2, 4.4 and 5.1):
• Complicated skin and soft tissue infections,
• Bone and joint infections,
• Hospital acquired pneumonia,
• Community acquired pneumonia,
• Complicated urinary tract infections,
• Infective endocarditis,
• Peritonitis associated with continuous ambulatory peritoneal dialysis (CAPD),
• Bacteraemia that occurs in association with any of the indications listed above.
Where appropriate, Teicoplanin should be administered in combination with other
antibacterial agents.
Consideration should be given to official guidance on the appropriate use of antibacterial
agents.

Posology

The dose and duration of treatment should be adjusted according to the underlying type and severity of infection and clinical response of the patient, and patient factors such as age and renal function.

Measurement of serum concentrations

Teicoplanin trough serum concentrations should be monitored at steady state after completion of the loading doseregimen in order to ensure that a minimum trough serum concentration has been reached: • For most Gram-positive infections, teicoplanin trough levels of at least 10 mg/L when measured by High PerformanceLiquid Chromatography (HPLC), or at least 15 mg/L when measured by Fluorescence Polarization Immunoassay (FPIA)method. • For endocarditis and other severe infections, teicoplanin trough levels of 15-30 mg/L when measured by HPLC, or30-40 mg/L when measured by FPIA method. During maintenance treatment, teicoplanin trough serum concentrations monitoring may be performed at least once aweek to ensure that these concentrations are stable.

Adults and elderly patients with normal renal function

¹ Measured by FPIA

Duration of treatment

The duration of treatment should be decided based on the clinical response. For infective endocarditis a minimum of 21days is usually considered appropriate. Treatment should not exceed 4 months.

Combination therapy

Teicoplanin has a limited spectrum of antibacterial activity (Gram positive). It is not suitable for use as a single agent for the treatment of some types of infections unless the pathogen is already documented and known to be susceptible or there is a high suspicion that the most likely pathogen(s) would be suitable for treatment with Teicoplanin.

Elderly population

No dose adjustment is required, unless there is renal impairment (see below).

Adults and elderly patients with impaired renal function

Dose adjustment is not required until the fourth day of treatment, at which time dosing should be adjusted to maintain a serum trough concentration of at least 10 mg/L. After the fourth day of treatment:

• In mild and moderate renal insufficiency (creatinine clearance 30-80 mL/min): maintenance dose should be halved,either by administering the dose every two days or by administering half of this dose once a day.
• In severe renal insufficiency (creatinine clearance less than 30 mL/min) and in haemodialysed patients: dose should beone-third the usual dose, either by administering the initial unit dose every third day or by administering one-third of thisdose once a day. Teicoplanin is not removed by haemodialysis.

Patients in continuous ambulatory peritoneal dialysis (CAPD) 
After a single intravenous loading dose of 6 mg/kg bodyweight, 20 mg/L is administered in the bag of the dialysis solutionin the first week, 20 mg/L in different bags the second week and then 20 mg/L in the overnight bag in the third week.

Paediatric population:

The dose recommendations are the same in adults and children above 12 years of age.

Neonates and infants up to the age of 2 months:

Loading dose

One single dose of 16 mg/kg body weight, administered intravenously by infusion on the first day.

Maintenance dose One

single dose of 8 mg/kg body weight administered intravenously by infusion once a day.

Children (2 months to 12 years):

Loading dose

One single dose of 10 mg/kg body weight administered intravenously every 12 hours, repeated 3 times.

Maintenance dose

One single dose of 6-10 mg/kg body weight administered intravenously once a day.

Method of administration

Teicoplanin should be administered by the intravenous or intramuscular route. The intravenous injection may be administered either as a bolus over 3 to 5 minutes or as a 30-minutes infusion.

Only the infusion method should be used in neonates. For instructions on reconstitution and dilution of the medicinal product before administration, see section 6.6.

 

Hypersensitivity to Teicoplanin or to any of the excipients listed in section 6.

Hypersensitivity reactions

Serious, life-threatening hypersensitivity reactions, sometimes fatal, have been reported with Teicoplanin (e.g.anaphylactic shock). If an allergic reaction to Teicoplanin occurs, treatment should be discontinued immediately and appropriate emergency measures should be initiated. Teicoplanin must be administered with caution in patients with known hypersensitivity to vancomycin, as crossed hypersensitivity reactions, including fatal anaphylactic shock, may occur.

However, a prior history of "red man syndrome" with vancomycin is not a contraindication to the use of Teicoplanin.

Infusion related reactions

In rare cases (even at the first dose), red man syndrome (a complex of symptoms including pruritus, urticaria, erythema, angioneuroticoedema, tachycardia, hypotension, dyspnoea) has been observed. Stopping or slowing the infusion may result in cessation of these reactions. Infusion related reactions can be limited if the daily dose is not given via bolus injection but infused over a 30-minute period.

Severe bullous reactions

Life-threatening or even fatal cutaneous reactions Stevens-Johnson syndrome (SJS) and Toxic Epidermal Necrolysis (TEN) have been reported with the use of Teicoplanin. If symptoms or signs of SJS or TEN (e.g. progressive skin rash often with blisters or mucosal lesions) are present Teicoplanin treatment should be discontinued immediately.

Spectrum of antibacterial activity

Teicoplanin has a limited spectrum of antibacterial activity (Gram-positive). It is not suitable for use as a single agent for the treatment of some types of infections unless the pathogen is already documented and known to be susceptible or there is a high suspicion that the most likely pathogen(s) would be suitable for treatment with teicoplanin.

The rational use of teicoplanin should take into account the bacterial spectrum of activity, the safety profile and the suitability of standard antibacterial therapy to treat the individual patient. On this basis it is expected that in most instances teicoplanin will be used to treat severe infections in patients for whom standard antibacterial activity is considered to be unsuitable.

Loading dose regimen

Since data on safety are limited, patients should be carefully monitored for adverse reactions when teicoplanin doses of 12mg/kg body weight twice a day are administered. Under this regimen blood creatinine values should be monitored in addition to the recommended periodic haematological examination.
Teicoplanin should not be administered by intraventricular use.

Thrombocytopenia

Thrombocytopenia has been reported with Teicoplanin. Periodic haematological examinations are recommended duringtreatment, including complete cell blood count.

Nephrotoxicity
Renal failure has been reported in patients treated with Teicoplanin (see section 4.8). Patients with renal insufficiency,and/or in those receiving Teicoplanin in conjunction with or sequentially with other medicinal products with known nephrotoxic potential (aminoglycosides, colistin, amphotericin B, ciclosporin, and cisplatin) should be carefully monitored, and should include auditory tests. Since Teicoplanin is mainly excreted by the kidney, the dose of Teicoplanin must be adapted in patients with renal impairment (see section 4.2).
 

Ototoxicity

As with other glycopeptides, ototoxicity (deafness and tinnitus) has been reported in patients treated with Teicoplanin(see section 4.8). Patients who develop signs and symptoms of impaired hearing or disorders of the inner ear during treatment with Teicoplanin should be carefully evaluated and monitored, especially in case of prolonged treatment and in patients with renal insufficiency. Patients receiving teicoplanin in conjunction with or sequentially with other medicinalproducts with known neurotoxic/ototoxic potential (aminoglycosides, ciclosporin, cisplatin, furosemide and ethacrynic acid) should be carefully monitored and the benefit of Teicoplanin evaluated if hearing deteriorates.

Special precautions must be taken when administering Teicoplanin in patients who require concomitant treatment with ototoxic and/or nephrotoxic medicinal products for which it is recommended that regular haematology, liver and kidney function tests are carried out.

Superinfection

As with other antibiotics, the use of Teicoplanin, especially if prolonged, may result in overgrowth of non-susceptible organisms. If superinfection occurs during therapy, appropriate measures should be taken.

No specific interaction studies have been performed.

Teicoplanin and aminoglycoside solutions are incompatible and must not be mixed for injection; however, they arecompatible in dialysis fluid and may be freely used in the treatment of CAPD-related peritonitis. Teicoplanin should beused with care in conjunction with or sequentially with other medicinal products with known nephrotoxic or ototoxicpotential. These include aminoglycosides,colistin, amphotericin B, ciclosporin, cisplatin, furosemide, and ethacrynic acid(see section 4.4). However, there is no evidence of synergistic toxicity in combinations with Teicoplanin.

In clinical studies, teicoplanin has been administered to many patients already receiving various medications includingother antibiotics, antihypertensives, anaesthetic agents, cardiac medicinal products and antidiabetic agents withoutevidence of adverse interaction.

This medicine contains sodium. To be taken into consideration by patients on a controlled sodium diet.

Paediatric population

Interaction studies have only been performed in adults.

Pregnancy

There are a limited amount of data from the use of Teicoplanin in pregnant women. Studies in animals have shownreproductive toxicity at high doses (see section 5.3): in rats there was an increased incidence of stillbirths and neonatal mortality. The potential risk for humans is unknown.

Therefore, Teicoplanin should not be used during pregnancy unless clearly necessary. A potential risk of inner ear and renal damage to the foetus cannot be excluded (see section 4.4).

Breast-feeding

It is unknown whether teicoplanin is excreted in human milk. There is no information on the excretion of teicoplanin in animal milk. A decision on whether to continue/discontinue breast-feeding or to continue/discontinue therapy with teicoplanin should be made taking into account the benefit of breast-feeding to the child and the benefit of teicoplanin therapy to the mother.

Fertility

Animal reproduction studies have not shown evidence of impairment of fertility.

Teico 400 mg has minor influence on the ability to drive and use machines. Teicoplanin can cause dizziness and headache.

The ability to drive or use machines may be affected. Patients experiencing these undesirable effects should not drive or use machines.

Tabulated list of adverse reactions

In the table below all the adverse reactions, which occurred at an incidence greater than placebo and more than one patient are listed using the following convention:

Very common (≥1/10); common (≥1/100 to <1/10); uncommon (≥1/1,000 to <1/100); rare (≥1/10,000 to <1/1,000); very rare (<1/10,000); not known (cannot be estimated from the available data).
Within each frequency grouping, undesirable effects are presented in order of decreasing seriousness.
Adverse reactions should be monitored when teicoplanin doses of 12 mg/kg body weight twice a day are administered (see section 4.4).

Symptoms

Cases of accidental administration of excessive doses to paediatric patients have been reported. In one case agitation occurred in a 29-day-old newborn who had been administered 400 mg intravenously (95 mg/kg).

Management
Treatment of Teicoplanin overdose should be symptomatic.
Teicoplanin is not removed by haemodialysis and only slowly by peritoneal dialysis.

Pharmacotherapeutic group: GlycopeptideAntibacterials

ATC code: J01XA02

Mechanism of action

Teicoplanin inhibits the growth of susceptible organisms by interfering with cell-wall biosynthesis at a site different from that affected by beta-lactams. Peptidoglycan synthesis is blocked by specific binding to D-alanyl-D-alanine residues.

Mechanism of resistance

Resistance to teicoplanin can be based on the following mechanisms:

• Modified target structure: this form of resistance has occurred particularly in Enterococcus faecium. The modification is based on exchange of the terminal D-alanine-D-alanine function of the amino-acid chain in a murein precursor with D-Ala-D-lactate, thus reducing the affinity to vancomycin. The responsible enzymes are a newly synthesised D-lactate dehydrogenase or ligase.

• The reduced sensitivity or resistance of staphylococci to teicoplanin is based on the overproduction of murein precursors to which teicoplanin is bound. Cross-resistance between teicoplanin and the glycoprotein vancomycin may occur. A number of vancomycin-resistant enterococci are sensitive to teicoplanin (Van-B phenotype).

Susceptibility testing breakpoints

The MICs breakpoints according to the European Committee on Antimicrobial Susceptibility Testing (EUCAST), version 3.1, February 11, 2013 are displayed in the following table:

^aGlycopeptide MICs are method dependent and should be determined by broth microdilution (reference ISO 20776). S.aureus with vancomycin MIC values of 2 mg/L are on the border of the wild type MIC distribution and there may be an impaired clinical response. The resistance breakpoint for S.aureus has been reduced to 2 mg/L to avoid reporting of GISA isolates intermediate as serious infections with GISA isolates are not treatable with increased doses of vancomycin or teicoplanin.

^b Isolates with MIC values above the susceptible breakpoint are very rare or not yet reported. The identification and antimicrobial susceptibility tests on any such isolate must be repeated and if the result is confirmed the isolate must be sent to a reference laboratory. Until there is evidence regarding clinical response for confirmed isolates with MIC above the current resistant breakpoint they should be reported resistant.

^c IE indicates that there is insufficient evidence that the species in question is a good target for therapy with the drug.

^d A MIC with a comment but without an accompanying S, I or R categorisation may be reported.

Pharmacokinetic/Pharmacodynamic relationship

Teicoplanin antimicrobial activity depends essentially on the duration of time during which the substance level is higher than the minimum inhibitory concentration (MIC) of the pathogen.

Susceptibility

The prevalence of resistance may vary geographically and over time for selected species and local information on resistance is desirable, particularly when treating severe infections. As necessary, expert advice should be sought when the local prevalence of resistance is such that the utility of the agent in at least some of types of infections is questionable.

Commonly susceptible species
Aerobic Gram-positive bacteria
Corynebacteriumjeikeium^a
Enterococcus faecalis
Staphylococcus aureus (including methicillin-resistant strains)
Streptococcus agalactiae
Streptococcus dysgalactiae subsp. equisimilis ^a
(Group C & G streptococci)
Streptococcus pneumoniae
Streptococcus pyogenes
Streptococci in the viridans group ^{a b}

Anaerobic Gram-positive bacteria
Clostridium difficile^a
Peptostreptococcus spp. ^a

Species for which acquired resistance may be a problem
Aerobic Gram-positive bacteria
Enterococcus faecium
 Staphylococcus epidermidis
Staphylococcus haemolyticus
Inherently resistant bacteria
All Gram-negative bacteria
Other bacteria
Chlamydia spp.
Chlamydophila spp.
Legionella pneumophila
Mycoplasma spp

^a No current data were available when the tables were published. The primary literature, standard volumes and treatment recommendations assume sensitivity

^b Collective term for a heterogeneous group of streptococcus species. Resistance rate can vary depending on the actual streptococcus species

Absorption

Teicoplanin is administered by parenteral route (intravenously or intramuscularly). After intramuscular administration, the bioavailability of teicoplanin (as compared to intravenous administration) is almost complete (90%). After six daily intramuscular administrations of 400 mg the mean (SD) maximum teicoplanin concentration (C_max) amounts to 12.1 (0.9) mg/L and occurs at 2 hours after administration.

After a loading dose of 6 mg/kg administered intravenously every 12 hours for 3 to 5 administrations, C_max values range from 60 to 70 mg/L and C_trough are usually above 10 mg/L. After an intravenous loading dose of 12 mg/kg administered every 12 hours for 3 administrations, mean values of C_max and C_trough are estimated to be around 100 mg/L and 20 mg/L, respectively.

After a maintenance dose of 6 mg/kg administered once daily C_max and C_trough values are approximately 70 mg/L and 15 mg/L, respectively. After a maintenance dose of 12 mg/kg once daily C_trough values range from 18 to 30 mg/L.

Distribution

The binding to human serum proteins ranges from 87.6 to 90.8% without any variation in function of the teicoplanin concentrations. Teicoplanin is mainly bound to human serum albumin. Teicoplanin is not distributed in red cells.

The volume of distribution at steady-state (Vss) varies from 0.7 to 1.4 mL/kg. The highest values of Vss are observed in the recent studies where the sampling period was superior to 8 days.

Teicoplanin distributed mainly in lung, myocardium and bone tissues with tissue/serum ratios superior to 1. In blister fluids, synovial fluid and peritoneal fluid the tissue/serum ratios ranged from 0.5 to 1. Elimination of teicoplanin from peritoneal fluid occurs at the same rate as from serum. In pleural fluid and subcutaneous fat tissue the tissue/serum ratios are comprised between 0.2 and 0.5. Teicoplanin does not readily penetrate into the cerebrospinal fluid (CSF).

Biotransformation

Unchanged form of Teicoplanin is the main compound identified in plasma and urine, indicating minimal metabolism. Two metabolites are formed probably by hydroxylation and represents 2 to 3% of the administered dose.

Elimination

Unchanged Teicoplanin is mainly excreted by urinary route (80% within 16 days) while 2.7% of the administered dose is recovered in feces (via bile excretion) within 8 days following administration.

Elimination half-life of Teicoplanin varies from 100 to 170 hours in the most recent studies where blood sampling duration is about 8 to 35 days.

Teicoplanin has a low total clearance in the range of 10 to 14 mL/h/kg and a renal clearance in the range of 8 to 12 mL/h/kg indicating that Teicoplanin is mainly excreted by renal mechanisms.

Linearity

Teicoplanin exhibited linear pharmacokinetics at dose range of 2 to 25 mg/kg.

Special populations

• Renal impairment:

As teicoplanin is eliminated by renal route, teicoplanin elimination decreases according to the degree of renal impairment. The total and renal clearances of teicoplanin depends on the creatinine clearance.

• Elderly patients:

In the elderly population the teicoplanin pharmacokinetics is not modified unless in case of renal impairment.

• Paediatric population:

A higher total clearance (15.8 mL/h/kg for neonates, 14.8 mL/h/kg for a mean age 8 years) and a shorter elimination half-life (40 hours neonates; 58 hours for 8 years) are observed compared to adult patients.

Following repeated parenteral administration to the rat and dog, effects on the kidney were observed and were shown to be dose-dependent and reversible. Studies to investigate the potential to cause ototoxicity in the guinea-pig indicate that a mild impairment of cochlear and vestibular function is possible, in the absence of morphological damage. Subcutaneous administration of teicoplanin at up to 40 mg/kg/day did not affect male and female fertility in the rat. In embryofetal development studies, no malformations were observed following subcutaneous administration of up to 200 mg/kg/day in the rat and intramuscular administration up to 15 mg/kg/day in the rabbit. However, in the rat, there was an increased incidence of stillbirths at doses of 100 mg/kg/day and above and neonatal mortality at 200 mg/kg/day. This effect was not reported at 50 mg/kg/day A peri and postnatal study in rats showed no effects on the fertility of the F1 generation or on the survival and development of the F2 generation following subcutaneous administration of up to 40 mg/kg/day.

Teicoplanin did not show any potential to cause antigenicity (in mice, guinea-pigs or rabbits), genotoxicity or local irritancy.

Sodium chloride

Sodium hydroxide (for pH adjustment)

Teicoplanin and aminoglycoside are incompatible when mixed directly and must not be mixed before injection.

If Teicoplanin is administered in combination therapy with other antibiotics, the preparation must be administered separately.

This medicinal product must not be mixed with other medicinal products except those mentioned in section 6.6.

Shelf life of powder as packaged for sale: 2 years Shelf life of reconstituted solution: Chemical and physical in-use stability of the reconstituted solution prepared as recommended has been demonstrated for 24 hours at 2 to 8°C. From a microbiological point of view, the medicinal product should be used immediately. If not used immediately, in-use storage times and conditions prior to use are the responsibility of the user and would normally not be longer than 24 hours at 2 to 8°C, unless reconstitution has taken place in controlled and validated aseptic conditions. Shelf life of diluted medicinal product: Chemical and physical in-use stability of the reconstituted solution prepared as recommended has been demonstrated for 24 hours at 2 to 8°C. From a microbiological point of view, the medicinal product should be used immediately. If not used immediately, in-use storage times and conditions prior to use are the responsibility of the user and would normally not be longer than 24 hours at 2 to 8°C, unless reconstitution/dilution has taken place in controlled and validated aseptic conditions.

.Powder as packaged for sale:

Store below 30°C.

For storage conditions of the reconstituted/diluted medicinal product, see section 6.3.

Primary packaging:

The freeze-dried medicinal product is packaged in:

Type I, colorless glass vial of useful volume of 15 ml for 400 mg closed with bromobutyl grey stopper and blue capsule flip-off.

The solvent solution is packaged in: Colorless glass ampoule of useful volume of 3.2mL

Pack sizes: - 1 powder vial + 1 solvent ampoule

This medicinal product is for single use only.

Preparation of reconstituted solution

The solution is reconstituted by adding the entire content of the supplied solvent into the 200 mg and 400 mg powder vial. The water is slowly added to the vial which should be rotated until all the powder is dissolved to avoid foaming. If foam is developed, allow the solution to stand for approximately 15 minutes so that the foam disappears. Only limpid and slightly yellowish particle free solutions should be used.

Nominal Teicoplanin content of vial	200 mg	400 mg
Volume of powder per vial	15 mL	15 mL
Volume containing nominal Teicoplanin dose (extracted by 5 mL syringe and 23 G needle)	3.0 mL	3.0 mL

The reconstituted solution may be injected directly or alternatively further diluted.

Preparation of the diluted solution before infusion

Teico 400 mg can be administered in the following infusion solutions:

- Sodium chloride 9 mg/mL (0.9%) solution
- Ringer solution
- Ringer-lactate solution
- Hartmann solution
- 5% glucose solution
- 0.18% sodium chloride and 4% dextrose solution
- Peritoneal dialysis solution containing 1.36% or 3.86% dextrose solution.
- 10% dextrose injection
- 0.45% sodium chloride and 5% glucose solution

Any unused product or waste material should be disposed of in accordance with local requirements.