Safety of prolonged thrice-weekly high-dose daptomycin in a hemodialysis patient with prosthetic valve endocarditis

Background

Daptomycin (DAP) is a cyclic lipopeptide antibiotic with in vitro, concentration-dependent bactericidal activity against many clinically relevant gram-positive organisms including Staphylococcus spp. and Enterococcus spp. High-dose DAP (i.e., > 9 mg/kg) has been associated with improved survival outcomes in patients with invasive enterococci infections. Although generally well tolerated, DAP is associated with myopathy and rhabdomyolysis. Limited data regarding the safety of high-dose DAP in hemodialysis (HD) patients, especially with doses ≥ 12 mg/kg, are available. Here, we describe the safety outcomes in a HD patient who received prolonged, thrice-weekly, high-dose DAP. To the best of our knowledge, this is the first case report looking at the safety of long-term DAP doses up to 18 mg/kg.

Case summary

A 65-year-old male with a medical history significant for end-stage renal disease on intermittent HD was diagnosed as having prosthetic valve endocarditis secondary to vancomycin-resistant Enterococcus faecium (VRE). He was deemed a poor surgical candidate and the decision was made for conservative management. DAP was continued for approximately 4 months at a dose of 12 mg/kg on 48-hour interdialytic days and 18 mg/kg on the 72-hour interdialytic day. Creatine phosphokinase (CPK) was monitored once or twice weekly. Average CPK during therapy was 92.3 U/L ± 38.9. Overall, DAP was well tolerated and the patient did not experience any signs or symptoms of myopathy or rhabdomyolysis based on daily review of systems.

Practice implications

Although more data are needed to assess the safety of this particular dosing strategy, our case findings suggest that prolonged DAP doses ≥ 12 mg/kg can be safely considered in those receiving intermittent HD, especially when aggressive treatment is needed for invasive VRE infection.