Teicoplanin is a glycopeptide antibiotic with a spectrum of activity similar to vancomycin. Its mechanism of action is to inhibit bacterial cell wall peptidoglycan synthesis. It is used in the prophylaxis and treatment of serious infections caused by Gram-positive bacteria, including methicillin-resistant Staphylococcus aureus and Enterococcus faecalis. Teicoplanin is widely available in many European, Asian, and South American countries, however it is not currently approved by the US Food and Drug Administration and is not commercially available in the United States. Teicoplanin is marketed by Sanofi-Aventis under the trade name Targocid. Other trade names include Ticocin marketed by Cipla(India). Its strength is considered to be due to the length of the hydrocarbon chain.
History Teicoplanin was first isolated in 1978 from Actinoplanes teichomyceticus (ATCC 31121), a rare species of actinobacteria in the family Micromonosporaceae. The bacteria were obtained from a soil sample collected in Nimodi Village, Indore, India. The chemical structure of teicoplanin was determined and published in 1984. Teicoplanin was first introduced into clinical use in 1984. Following the publication of studies demonstrating its efficacy against infections such as bone and soft tissue infections, endocarditis, pneumonia, and sepsis in 1986, it received regulatory approval in Europe in 1988. The biosynthetic pathway leading to teicoplanin, as well as the regulatory circuit governing the biosynthesis, were studied intensively in recent years, allowing for the creation of an integrated model of its biosynthesis.
Indications Teicoplanin treats a wide range of infections with Gram-positive bacteria, including endocarditis, sepsis, soft tissue and skin infections, and venous catheter-associated infections. Studies have investigated the use of oral teicoplanin in the treatment of pseudomembranous colitis and Clostridioides difficile-associated diarrhea, finding it to demonstrate efficacy comparable to that of vancomycin.
Susceptible organisms Teicoplanin has demonstrated in vitro efficacy against Gram-positive bacteria including staphylococci (including MRSA), streptococci, enterococci, and against anaerobic Gram-positive bacteria including Clostridium spp. Teicoplanin is ineffective against Gram-negative bacteria as the large, polar molecules of the compound are unable to pass through the external membrane of these organisms. The following represents MIC susceptibility data for a few medically significant pathogens:
Clostridioides difficile: 0.06 μg/ml - 0.5 μg/ml Staphylococcus aureus: ≤0.06 μg/ml - ≥128 μg/ml Staphylococcus epidermidis: ≤0.06 μg/ml - 32 μg/ml
Pharmacology
Pharmacokinetics Due to poor oral absorption, teicoplanin requires intravenous or intramuscular administration for systemic effect. Intramuscular administration achieves approximately 90% bioavailability. The drug exhibits high protein binding (90-95%) and is primarily eliminated through the kidneys unchanged, with minimal liver metabolism (2-3%) via hydroxylation. Clearance is reduced in patients with kidney impairment and is not significantly removed by hemodialysis. Teicoplanin exhibits a long half-life of 45-70 hours, allowing for once-daily dosing after loading doses. Although teicoplanin is primarily approved for intravenous and intramuscular use, several clinical and pharmacokinetic studies have explored its administration via the subcutaneous route. Subcutaneous teicoplanin has been reported as a feasible alternative in selected patients, particularly in outpatient, frail, or palliative care settings. Available evidence suggests that subcutaneous administration achieves pharmacokinetic and pharmacodynamic exposures comparable to intravenous dosing after appropriate loading, with good local tolerability. However, this route of administration remains off-label.
Pharmacodynamics Teicoplanin is a glycopeptide antibiotic that inhibits bacterial cell wall synthesis. It binds to the D-alanyl-D-alanine (D-Ala-D-Ala) terminus of the peptidoglycan precursor, preventing the transpeptidation reaction necessary for cell wall cross-linking. This binding also interferes with the polymerization of peptidoglycan, ultimately leading to cell death. In addition to its binding to the D-Ala-D-Ala terminus, teicoplanin may also interact with the lipid II substrate in the bacterial cell membrane through its hydrophobic tail. This interaction could facilitate the antibiotic's proximity to the nascent peptidoglycan, enhancing its inhibitory effect. However, this mechanism has not been fully confirmed.
Adverse effects Adverse effects of teicoplanin are usually limited to local effects or hypersensitivity reactions. While there is potential for nephrotoxicity and ototoxicity, the incidence of such organ toxicity is rare if recommended serum concentrations are successfully maintained.
Considerations Reduced kidney function slows teicoplanin clearance, consequently increasing its elimination half-life. Elimination half-life is longer in the elderly due to the reduced kindey function in this population.
Chemistry Teicoplanin (TARGOCID, marketed by Sanofi Aventis Ltd) is actually a mixture of several compounds, five major (named teicoplanin A2-1 through A2-5) and four minor (named teicoplanin RS-1 through RS-4). All teicoplanins share a same glycopeptide core, termed teicoplanin A3-1 — a fused ring structure to which two carbohydrates (mannose and N-acetylglucosamine) are attached. The major and minor components also contain a third carbohydrate moiety — β-D-glucosamine — and differ only by the length and conformation of a side-chain attached to it. Teicoplanin A2-4 and RS-3 have chiral side chains while all other side chains are achiral. Teicoplanin A3 lacks both the side chains as well as the β-D-glucosamine moiety. The structures of the teicoplanin core and the side-chains that characterize the five major as well as four minor teicoplanin compounds are shown below.
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