Ann Thorac Surg 2007;84:269-270
© 2007 The Society of Thoracic Surgeons
Case Reports
Daptomycin for Eradication of a Systemic Infection With a Methicillin-Resistant-Staphylococcus Aureus in a Biventricular Assist Device Recipient
Florian Weis, MDa,*,*,
Andres Beiras-Fernandez, MDb,*,
Ingo Kaczmarek, MDb,
Ralf Sodian, MDb,
Calin Vicol, MDb,
Bruno Reichart, MDb,
Marion Weis, MDa
a Department of Anesthesiology, University Hospital Grosshadern, Ludwig-Maximilians-University, Munich, Germany
b Department of Cardiac Surgery, University Hospital Grosshadern, Ludwig-Maximilians-University, Munich, Germany, Munich, Germany
Accepted for publication February 1, 2007.
* Address correspondence to Dr Florian Weis, Department of Anesthesiology, University Hospital Grosshadern, Ludwig-Maximilians-University, Munich, 81377, Germany (Email: florian.weis{at}med.uni-muenchen.de).
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Abstract
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The rate of infection in patients who require ventricular assist devices is estimated at more than 35%. Infections with multi-resistant organisms such as methicillin-resistant Staphylococcus aureus in ventricular assist device recipients are often difficult to treat and present a high mortality rate. Daptomycin is a new cyclic lipopeptide antibiotic, useful in gram-positive organisms resistant to standard treatment. We report a case of a 65-year-old man suffering from a dilatative cardiomyopathy and concomitant MRSA infection who received a biventricular assist device. The patient had MRSA sepsis develop resistant to conventional therapy, which was successfully treated with daptomycin.
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Introduction
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Patients awaiting cardiac transplantation often require ventricular assist devices (VADs) due to instable circulatory condition. As patients with high New York Heart Association functional classes are often hospitalized for long periods, they are especially susceptible to infections with multi-resistant organisms (eg, methicillin-resistant Staphylococcus aureus [MRSA]). The rate of infection in VAD recipients is estimated to be more than 35% [1]. Daptomycin is a new cyclic lipopeptide antimicrobial drug, especially useful in gram-positive organisms resistant to standard treatment. Daptomycin has been successfully used in the treatment of endocarditis and complicated cardiac device infections [2, 3]. We report a case of a 65-year-old man suffering from a dilatative cardiomyopathy and concomitant MRSA infection who received a biventricular assist device (Berlin Heart Excor [Berlin Heart AG, Berlin, Germany]) after cardiac decompensation. The patient had MRSA sepsis develop that was resistant to conventional therapy and successfully treated with daptomycin. The treatment with daptomycin was decided in agreement with the chairman of the department of microbiology.
A 65-year-old man was admitted to an outside hospital with a dilatative cardiomyopathy. The patient received an automatic implanted cardiac defibrillator (AICD), who had a postoperative wound infection develop at the site of implantation; microbiological examination of the wound secretion revealed S. aureus sensible to penicillin. The device was removed and a pacemaker was implanted on the opposite side. The patient was treated with ampicillin and clavulanic acid for 2 weeks, and afterward he was discharged home. After progressive deterioration of his clinical status, 2 months later the patient was readmitted and referred to our department with initial signs of cardiac decompensation requiring mild catecholaminergic support. The patient showed no significant clinical or laboratory signs of infection. An intraaortic counter pulsation device was implanted after worsening of the symptoms. Finally the patient underwent the implantation of a biventricular assist device (Berlin Heart Excor). The operative procedure was uncomplicated. Postoperatively the patient’s circulatory condition was stable without catecholaminergic support. Microbiological analyses were performed that showed skin smears in the neck, axilla, groin, and nose that were positive for MRSA. Drainage secretion, urine, endotracheal secretions, and blood cultures were also positive for MRSA. Thus the patient suffered from pneumonia, urinary tract infection, and colonization of the skin with MRSA. We isolated the patient and initiated antimicrobial therapy with linezolid (2 x 600 mg/d) in combination with local antiseptic washings. After 3 days of therapy, skin swabs were free of MRSA, as were urinary cultures and specimen of endotracheal suction. However, blood cultures remained positive for MRSA. Thus we added rifampin to the antimicrobial therapy. After 5 days of this regimen the patient continued to have MRSA bacteremia diagnosed by daily blood cultures. The laboratory measurements showed a progredient infection (maximal figures: procalcitonin, 2.9 ng/mL; C-reactive protein, 11.8 mg/dL; leukocytes, 17.8 G/L). A deep swab from the exit site of the cannulas of the assist device revealed MRSA in a high concentration.
Under these conditions we stopped the therapy with linezolid and started with daptomycin (6 mg/kg as loading dosage and 4 mg/kg/day thereafter) instead. After 3 days of therapy the blood cultures turned out to be free of MRSA (Table 1). Inflammatory measurements decreased (procalcitonin [PCT], 0.4 ng/mL; C-reactive protein [CRP], 4.5 mg/dL; leukocytes, 7.2 G/L). The skin swabs were negative for MRSA despite stopping the antiseptic washings for 3 days. Thus the patient no longer had to be isolated. When the patient was free of MRSA for 3 days, he underwent successful cardiac transplantation. Multiple intraoperative swabs from the assist device were sterile. Antibiotic treatment (daptomycin) was continued for 2 weeks after the transplantation.
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Table 1 Relationship Between the Antibiotic Therapy, Positivity (+) and Negativity (0) of Microbiological Analyses in the VAD Support Period
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Comment
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Infections suppose a significant risk in patients on VADs with the majority caused by gram-positive pathogens. Vancomycin was considered the gold standard treatment of complicated gram-positive infections; however vancomycin no longer seems to be a valid option in many cases due to increased resistances and very limited tissue penetration [4]. Nowadays linezolid, optionally in combination with rifampin or fosfomycin, is the standard treatment. However in some cases this regimen may not be successful. In such patients, alternative antimicrobial strategies have to be considered, especially if the infection involves the artificial material. Cunha and colleagues [3] demonstrated successful treatment of device related bloodstream infections with daptomycin in a high or regular dose. Fowler and colleagues [5] assessed the efficacy of daptomycin in the treatment of S. aureus bacteremia showing that high-dosed daptomycin was not inferior to the standard therapy in right-sided MRSA endocarditis and bacteremia. In our case the patient was submitted to our hospital with generalized colonization and infection with MRSA. Standard therapy with linezolid was able to eradicate the MRSA from the skin, lungs, and urine. However, blood cultures and prosthetic material (Berlin Heart) remained positive. In our patient, daptomycin proved efficient as a salvage therapy in a VAD infection with bacteremia. However, controlled studies are necessary to evaluate this antibiotic drug in patients presenting with VAD and MRSA bacteremia.
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Footnotes
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* These authors contributed equally to this work. 
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References
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- Simon D, Fischer S, Grossman A, et al. Left ventricular assist device-related infection: treatment and outcome Clin Infect Dis 2005;40:1108-1115.[Abstract/Free Full Text]
- Cunha BA, Eisenstein LE, Hamid NS. Pacemaker-induced Staphylococcus aureus mitral valve acute bacterial endocarditis complicated by persistent bacteremia from a coronary stent: Cure with prolonged/high-dose daptomycin without toxicity Heart Lung 2006;35:207-211.[Medline]
- Mohan SS, McDermott BP, Cunha BA. Methicillin-resistant Staphylococcus aureus prosthetic aortic valve endocarditis with paravalvular abscess treated with daptomycin Heart Lung 2005;34:69-71.[Medline]
- Smith TL, Pearson ML, Wilcox KR, et al. Emergence of vancomycin resistance in Staphylococcus aureusGlycopeptide-Intermediate Staphylococcus Aureus Working Group. N Engl J Med 1999;340:493-501.[Medline]
- Fowler Jr VG, Boucher HW, Corey GR, et al. Daptomycin versus standard therapy for bacteremia and endocarditis caused by Staphylococcus aureus N Engl J Med 2006;355:653-665.[Medline]
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J. Antimicrob. Chemother.,
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iii35 - iii39.
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Abstract
Introduction
