Teicoplanin Use During Breastfeeding

In this short report, we would like to describe the outcome of an infant who was breastfed during his mother's short-term intravenous (IV) teicoplanin treatment. In addition to teicoplanin, the mother was also prescribed ceftriaxone, topical mupirocin, ipratropium, salbutamol (albuterol), and iohexol. To our knowledge, no report to date describes the infantile outcome regarding teicoplanin use of the mother during breastfeeding.

A 27-year-old mother was breastfeeding her 52-day-old son who was born at the 35th gestational week (birth weight: 3,700 g, length: 51 cm) through cesarean section without any postnatal complications. At the time of referral, the infant was breastfed 12 times and at least for 20 minutes on each occasion per day. The mother was hospitalized in the dermatology ward because of soft tissue infection in her right lower quadrant that did not improve with a 10-day treatment of topical antimicrobials. After hospitalization, IV ceftriaxone (1 g/day), topical fusidic acid (2%), and clobetasol (0.05%) were started. A dry tap puncture by the surgeon suggested a spontaneously drained abscess. Infectious diseases consulting physician suggested to add teicoplanin. Subsequently, our teratology/drug information service was asked whether teicoplanin and topical antimicrobials were compatible with breastfeeding.

A search in PubMed/Medline, LactMed^®, and Reprotox^® databases identified no cases or reports regarding teicoplanin use during breastfeeding. Therefore, we assessed the human pharmacokinetic data to estimate the possible exposure of the infant. Teicoplanin is a glycopeptide antibiotic, which is a mixture of six major and four minor components. ¹ Studies reported its oral absorption as poor to none. ¹ Product info stated no detectable serum or urine concentrations after a single oral dose (250 or 500 mg) administration to healthy volunteers, whereas about half of the administered dose was recovered in feces unchanged. ² Teicoplanin is highly protein bound (90%) and its tissue distribution is highly variable. Breast tissue teicoplanin levels were much lower than those in serum (0.5 to 5.0 mg/kg versus 14.7 to 36.3 mg/L) in patients who had undergone breast surgery.^1,3 Teicoplanin is used in the treatment of pediatric infections with a total loading dose of 30 mg/kg/day and a maintenance dose of 10 mg/kg/day. ¹ Taking a theoretical approach by considering its high protein binding, low abundance in the fat tissue, and poor oral bioavailability, our interpretation was that teicoplanin would not pose any significant risks for the infant through breast milk. Further weighing the benefits of breastfeeding against the possible minor risks such as the local gastrointestinal reactions that may be led by the unabsorbed drug, we decided to suggest breastfeeding during teicoplanin therapy. We also suggested that a switch from topical fusidic acid to mupirocin may be considered because LactMed indicated low risk to the nursing infant, ensuring that the infant's skin does not directly contact with the applied areas. ⁴

The mother breastfed the infant for 5 days of IV teicoplanin administration (three loading doses of 400 mg with 12-hour intervals and a maintenance dose of 400 mg/day). She concomitantly received IV ceftriaxone 1 g/day (8 days), mupirocin cream (2%, twice a day), ipratropium and salbutamol (albuterol) (nebulizer, 0.5/2.5 mg, once a day, 4 days) to control her asthma symptoms and iohexol (contains 647 mg iohexol equivalent to 300 mg organic iodine per mL, once, 60 mL) for the abdominal computed tomography scan. A close clinical follow-up of the infant was held regarding the previously recorded adverse effects, particularly with the exposure to antibiotics during breastfeeding (diarrhea, allergic reactions, thrush, etc.). No adverse effects were detected.

The main limitation of our case was not measuring the teicoplanin concentrations in milk and serum of the mother with which the exposure parameters such as the relative or the absolute infant dose and milk-to-plasma ratio can be computed. Of note, teicoplanin concentrations in the feces of the infant would have also led us provide an indirect estimate regarding its passage to breast milk, if any. Nevertheless, we believe that the normal outcome of this infant, which is the first report regarding teicoplanin exposure during breastfeeding to date, may offer some value to the clinicians who counsel similar exposures.