Audit project on the appropriateness of teicoplanin prescribing in Milton Keynes University Hospital (MKUH)
Authors: Yoong S 
Published: November 2024

Abstract

Introduction
Teicoplanin is the Trust’s preferred glycopeptide antibiotic compared to vancomycin due to the once-daily dosing, less toxic side effects and monitoring requirements1. Teicoplanin dosing regimen is weight-dependent, including loading and maintenance doses adjusted according to creatinine clearance (CrCl) from Day 52. As antimicrobial resistance emergence continues to be a public health concern, appropriate teicoplanin use is vital to avoid treatment failure in line with antimicrobial stewardship3.

Aim and Standards
To assess teicoplanin prescribing compliance with the Trust guideline.
100% compliance was expected for the following standards:
1. Teicoplanin is prescribed for an approved indication according to Trust guideline or by a Consultant Microbiologist.
2. Loading dose of teicoplanin is prescribed for treatment initiation.
3. Appropriate teicoplanin loading dose is prescribed based on actual body weight (ABW) and indication.
4. Appropriate teicoplanin maintenance dose is prescribed until Day 4 based on ABW and indication.
5. Appropriate teicoplanin maintenance dose is prescribed from Day 5 onwards based on CrCl, ABW and indication.

Method
This study did not require ethics approval. To assess audit feasibility, a pilot was done looking at teicoplanin prescriptions and clinical notes against the audit standards. CrCl was calculated where appropriate. Retrospective data of 18 teicoplanin prescriptions between 08/11/2022-14/11/2022 were extracted from the Electronic Prescribing and Medicines Administration (EPMA) system onto an Excel data collection spreadsheet. No changes were made to the data collection tool. One month’s data between 11/10/2022-07/11/2022 were further extracted and process was repeated. Paediatric patients and indications for surgical prophylaxis and Clostridioides difficile infection were excluded.

Results
88 patients were included in the study. 90% (n=79) of teicoplanin prescriptions were prescribed for an indication approved on the Trust’s antimicrobial guideline or by a Consultant Microbiologist. Teicoplanin loading dose was prescribed for 82% (n=71) of patients. 1 patient was excluded as loading dose was administered in another hospital. 46% (n=40) of patients were prescribed the appropriate teicoplanin loading dose. 60% (n=34) of the 57 patients who continued teicoplanin up until Day 4 were prescribed the appropriate teicoplanin maintenance dose. 56% (n=22) of the 39 patients treated with teicoplanin past Day 4 were prescribed the appropriate teicoplanin maintenance dose. None of the 5 standards were met.

Conclusion
The results indicate inappropriate teicoplanin prescribing against the current Trust guideline which need improvement. Training with prescribers on utilising the EPMA’s pre-populated teicoplanin dose prescription function alongside encouraging pledges to be an Antibiotic Guardian are recommended during their induction. This would help avoid prescription errors and reduce antimicrobial resistance development. The data collected did not subdivide patients under specific specialities, which could highlight areas where training should be focused on. This limitation should be addressed when the re-audit due in 1 years’ time is carried out, to evaluate the changes implemented.

References
1. Wood M. J. The comparative efficacy and safety of teicoplanin and vancomycin. The Journal of antimicrobial chemotherapy 1996, 37(2), 209–222.
2. MicroGuide. Teicoplanin. https://viewer.microguide.global/guide/1000000241#content,4aff3eb4-e9a0-4490-92b6-b28370f78da0(Accessed 10 November 2022).
3. UK Health Security Agency. Start smart then focus:antimicrobial stewardship toolkit for inpatient care settings. https://www.gov.uk/government/publications/antimicrobial-stewardship-start-smart-then-focus/start-smart-then-focus-antimicrobial-stewardship-toolkit-for-inpatient-care-settings(Accessed 17 August 2023).