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090 USE OF DAPTOMYCIN IN INFECTIVE ENDOCARDITIS: REPORT ON TRHEE CLINICAL CASES
Antimicrobial Treatment/New Drugs Age/ sex
Final Cause diagnosis
2007 82/F PLI S. aureus with VO
Indication for daptomycin Outcome
Pen-allergic patient. Failure of therapy on vancomycin, gentamicin and rifampicin 55/M NVE S. epidermidis Flucloxacillin, gentamicin, rifampicin, vancomycin-“resistant” organism 65/M PVE Corynebacterium Pen-allergic kroppenstedtii patient developed thrombocytopaenia on vancomycin 45/M NVE MRSA Failure with vancomycin + gentamicin + rifampicin 61/M NVE S. aureus Failure with flucloxacillin + gentamicin + rifampicin and failure with linezolid + gentamicin + rifampicin 2008 32/M PVE S. epidermidis Flucloxacillin-resistant, vancomycin-“resistant” organism 67/M PLI S. epidermidis Failure with vancomycin + gentamicin + rifampicin 79/F
PVE
S. epidermidis
S but relapsed, subsequently cured with teicoplanin S
S
S D
S
S, but relapsed. Daptomycin stopped due to rash Failure with vancomycin + D gentamicin
Key: PLI = Pacing lead infection; VO = vertebral osteomyelitis; NVE = Native valve endocarditis; S = Survived; D = Died.
090 USE OF DAPTOMYCIN IN INFECTIVE ENDOCARDITIS: REPORT ON TRHEE CLINICAL CASES A. Carretta1 *, A. Saracino1 , R. Ieva2 , A. Mangano1 , F. Campanale1 , T. Santantonio1 , G. Angarano1 . 1 University of Foggia, Ospedali Riuniti, Clinic of Infectious Diseases, Foggia, Italy, 2 University of Foggia-Ospedali Riuniti, Cardiology Department, Foggia, Italy Background: Daptomycin demonstrates potent bactericidal activity against gram-positive bacteria, including MRSA. It is unclear if this option can offer a real advantage compared to cheaper glycopeptides. Case report: We report three cases for whom daptomycin was preferred to vancomycin as a first-line treatment for IE: the clinical rationale for this choice is discussed. A 37-year old IVDU was admitted with mild dyspnoea and fever. TTE showed a 1.5 cm2 friable tricuspidal vegetation. Blood culture was negative due to previous antibiotics. Acute renal failure was noted and daptomycin/ceftazidime were initiated, resulting in progressive reduction of vegetation and clinical improvement. Surgery was avoided. A 22-year old man with aortic bicuspid valve, submitted to otorinolaringoiatric surgery 40 days before without antibiotic prophylaxis, complained fever for 10 days despite two 7-days antibiotic cycles with ciprofloxacin and ceftriaxone. A MRSA (vancomycin MIC > 2) was isolated on blood culture. TTE revealed an endocardial aortic valve thickening and pericardial effusion. Fever disappeared after 5 days of therapy with daptomycin/ceftazidime/amikacin. TTE two weeks later showed reduction of thickening and pericardial effusion. The patient continued daptomycin in day-hospital for another two weeks with complete resolution. A 37-year old IVDU was hospitalized for left-side paresis and fever. A cranial TC scan revealed a right cortical-subcortical lesion while TTE evidenced an aortic vegetation prolapsing in left ventricule with severe aortic failure. Blood cultures were negative due to previous antibiotics. Administration of daptomycin/ceftazidime/amikacin
S35
determined rapid improvement. He underwent a successful valve replacement after 20 days continuing daptomycin for 2 weeks. Conclusion: Three cases of successful IE treatment based on daptomycin are described, without toxicity. The concomitance of acute renal failure influenced our choice in the first case as significantly less nephrotoxicity was reported for daptomycin compared to vancomycin. In the second case, a MIC > 2 for vancomycin lead us to prefer daptomycin as the breakpoint for vancomycin susceptibility for MRSA was recently reduced to 2 mg/L. Lastly, rapid bactericidal activity of daptomycin was the reason of the choice in the third case. As MRSA are prevalent and empirical therapy is frequently required, daptomycin represents a valid alternative in IEs. 091 CLINICAL EXPERIENCE WITH DAPTOMYCIN MONOTHERAPY FOR PACE-MAKER (PM)/IMPLANTABLE CARDIAC DEFIBRILLATOR (ICD) INFECTIONS AND ENDOCARDITIS C. Tascini1 *, R. Doria1 , S. Fondelli1 , E. Soldati1 , M. Bongiorni1 , A. Leonildi1 , F. Menichetti1 . 1 Azienda Ospedaliera Universitaria Pisana, Trapiantologia Epatica e Malattie Infettive, Pisa, Italy Background: Daptomycin (D) may be a valuable option for the treatment of infections related to intravascular devices. Methods: We retrospectively evaluated 11 patients treated with D at Pisa tertiary care-university Hospital in the period from April 2007 to December 2008. Age, gender, type of infection, microorganism, daily dose of D, days of treatment, adverse events and outcome were reviewed. Outcome were defined as failure, improvement or healing. Results: 11 patients were included in the study, 8 were treated with antibiotic therapy and transvenous removal of the cardiac device. Mean age ± SD was 68±28 years, all patients were male. 5 patients had endocarditis (2 of these with embolic pneumonia, 4 caused by S. aureus and 1 by S. epidermidis), 4 patients had local PM/ICD infections, 2 patients had systemic infection due to S. aureus without endocarditis. The causative microorganism were: 4 S. epidermidis, 3 MRSA, 3 MSSA, 1 Propionibacterium spp. Four out of the 10 staphylococci included in the study were methicillin-resistant. Mean D dose ± SD was 6.5±0.6 mg/kg/die. Mean treatment duration ± SD was 37±25 days. All endocarditis related to PM/ICD were cured, including 3 S. aureus and 1 S. epidermidis endocarditis treated with transvenous removal of the device (2 pts with negative cultures of the leads) and 1 S. aureus endocarditis treated with antibiotic therapy only. The 4 patients with local PM/ICD infections were also cured with antibiotic therapy and device removal. Both systemic infection due to S. aureus were treated with antibiotic therapy only, one of the two patients failed, having local infection relapse due to same microorganism. In 8 out of 11 patients with PM/ICD infections a new device was implanted 48 hours after the removal of the infected one, during D therapy, without relapse of infection. None of the treated patients experienced adverse events. Conclusions: D monotherapy might be an effective therapy in the treatment of local infections and endocarditis related to PM/ICD. 092 CLINICAL EXPERIENCE WITH LINEZOLID FOR ENDOCARDITIS: MONOTHERAPY, COMBINATION THERAPY AND CONTINUING INFUSION C. Tascini1 , R. Doria1 , S. Fondelli1 , M. Polidori1 , M. Bongiorni1 , F. Menichetti1 . 1 Azienda Ospedaliera Universitaria Pisana, Trapiantologia Epatica e Malattie Infettive, Pisa, Italy Background: Linezolid (L) may be a valuable option for the treatment of severe infections due to gram positive bacteria. L might be bactericidal against Streptococcus spp. and may have slow bactericidal activity against S. aureus. Therefore we reviewed the case of endocarditis admitted to Pisa Hospital in Italy, in the last 8 years, to determine the outcome of those patients treated with linezolid. Methods: We retrospectively evaluated patients with endocarditis and treated with linezolid. We considered linezolid therapy as first, second or third line therapy. Clinical outcome was defined as
Final Cause diagnosis
2007 82/F PLI S. aureus with VO
Indication for daptomycin Outcome
Pen-allergic patient. Failure of therapy on vancomycin, gentamicin and rifampicin 55/M NVE S. epidermidis Flucloxacillin, gentamicin, rifampicin, vancomycin-“resistant” organism 65/M PVE Corynebacterium Pen-allergic kroppenstedtii patient developed thrombocytopaenia on vancomycin 45/M NVE MRSA Failure with vancomycin + gentamicin + rifampicin 61/M NVE S. aureus Failure with flucloxacillin + gentamicin + rifampicin and failure with linezolid + gentamicin + rifampicin 2008 32/M PVE S. epidermidis Flucloxacillin-resistant, vancomycin-“resistant” organism 67/M PLI S. epidermidis Failure with vancomycin + gentamicin + rifampicin 79/F
PVE
S. epidermidis
S but relapsed, subsequently cured with teicoplanin S
S
S D
S
S, but relapsed. Daptomycin stopped due to rash Failure with vancomycin + D gentamicin
Key: PLI = Pacing lead infection; VO = vertebral osteomyelitis; NVE = Native valve endocarditis; S = Survived; D = Died.
090 USE OF DAPTOMYCIN IN INFECTIVE ENDOCARDITIS: REPORT ON TRHEE CLINICAL CASES A. Carretta1 *, A. Saracino1 , R. Ieva2 , A. Mangano1 , F. Campanale1 , T. Santantonio1 , G. Angarano1 . 1 University of Foggia, Ospedali Riuniti, Clinic of Infectious Diseases, Foggia, Italy, 2 University of Foggia-Ospedali Riuniti, Cardiology Department, Foggia, Italy Background: Daptomycin demonstrates potent bactericidal activity against gram-positive bacteria, including MRSA. It is unclear if this option can offer a real advantage compared to cheaper glycopeptides. Case report: We report three cases for whom daptomycin was preferred to vancomycin as a first-line treatment for IE: the clinical rationale for this choice is discussed. A 37-year old IVDU was admitted with mild dyspnoea and fever. TTE showed a 1.5 cm2 friable tricuspidal vegetation. Blood culture was negative due to previous antibiotics. Acute renal failure was noted and daptomycin/ceftazidime were initiated, resulting in progressive reduction of vegetation and clinical improvement. Surgery was avoided. A 22-year old man with aortic bicuspid valve, submitted to otorinolaringoiatric surgery 40 days before without antibiotic prophylaxis, complained fever for 10 days despite two 7-days antibiotic cycles with ciprofloxacin and ceftriaxone. A MRSA (vancomycin MIC > 2) was isolated on blood culture. TTE revealed an endocardial aortic valve thickening and pericardial effusion. Fever disappeared after 5 days of therapy with daptomycin/ceftazidime/amikacin. TTE two weeks later showed reduction of thickening and pericardial effusion. The patient continued daptomycin in day-hospital for another two weeks with complete resolution. A 37-year old IVDU was hospitalized for left-side paresis and fever. A cranial TC scan revealed a right cortical-subcortical lesion while TTE evidenced an aortic vegetation prolapsing in left ventricule with severe aortic failure. Blood cultures were negative due to previous antibiotics. Administration of daptomycin/ceftazidime/amikacin
S35
determined rapid improvement. He underwent a successful valve replacement after 20 days continuing daptomycin for 2 weeks. Conclusion: Three cases of successful IE treatment based on daptomycin are described, without toxicity. The concomitance of acute renal failure influenced our choice in the first case as significantly less nephrotoxicity was reported for daptomycin compared to vancomycin. In the second case, a MIC > 2 for vancomycin lead us to prefer daptomycin as the breakpoint for vancomycin susceptibility for MRSA was recently reduced to 2 mg/L. Lastly, rapid bactericidal activity of daptomycin was the reason of the choice in the third case. As MRSA are prevalent and empirical therapy is frequently required, daptomycin represents a valid alternative in IEs. 091 CLINICAL EXPERIENCE WITH DAPTOMYCIN MONOTHERAPY FOR PACE-MAKER (PM)/IMPLANTABLE CARDIAC DEFIBRILLATOR (ICD) INFECTIONS AND ENDOCARDITIS C. Tascini1 *, R. Doria1 , S. Fondelli1 , E. Soldati1 , M. Bongiorni1 , A. Leonildi1 , F. Menichetti1 . 1 Azienda Ospedaliera Universitaria Pisana, Trapiantologia Epatica e Malattie Infettive, Pisa, Italy Background: Daptomycin (D) may be a valuable option for the treatment of infections related to intravascular devices. Methods: We retrospectively evaluated 11 patients treated with D at Pisa tertiary care-university Hospital in the period from April 2007 to December 2008. Age, gender, type of infection, microorganism, daily dose of D, days of treatment, adverse events and outcome were reviewed. Outcome were defined as failure, improvement or healing. Results: 11 patients were included in the study, 8 were treated with antibiotic therapy and transvenous removal of the cardiac device. Mean age ± SD was 68±28 years, all patients were male. 5 patients had endocarditis (2 of these with embolic pneumonia, 4 caused by S. aureus and 1 by S. epidermidis), 4 patients had local PM/ICD infections, 2 patients had systemic infection due to S. aureus without endocarditis. The causative microorganism were: 4 S. epidermidis, 3 MRSA, 3 MSSA, 1 Propionibacterium spp. Four out of the 10 staphylococci included in the study were methicillin-resistant. Mean D dose ± SD was 6.5±0.6 mg/kg/die. Mean treatment duration ± SD was 37±25 days. All endocarditis related to PM/ICD were cured, including 3 S. aureus and 1 S. epidermidis endocarditis treated with transvenous removal of the device (2 pts with negative cultures of the leads) and 1 S. aureus endocarditis treated with antibiotic therapy only. The 4 patients with local PM/ICD infections were also cured with antibiotic therapy and device removal. Both systemic infection due to S. aureus were treated with antibiotic therapy only, one of the two patients failed, having local infection relapse due to same microorganism. In 8 out of 11 patients with PM/ICD infections a new device was implanted 48 hours after the removal of the infected one, during D therapy, without relapse of infection. None of the treated patients experienced adverse events. Conclusions: D monotherapy might be an effective therapy in the treatment of local infections and endocarditis related to PM/ICD. 092 CLINICAL EXPERIENCE WITH LINEZOLID FOR ENDOCARDITIS: MONOTHERAPY, COMBINATION THERAPY AND CONTINUING INFUSION C. Tascini1 , R. Doria1 , S. Fondelli1 , M. Polidori1 , M. Bongiorni1 , F. Menichetti1 . 1 Azienda Ospedaliera Universitaria Pisana, Trapiantologia Epatica e Malattie Infettive, Pisa, Italy Background: Linezolid (L) may be a valuable option for the treatment of severe infections due to gram positive bacteria. L might be bactericidal against Streptococcus spp. and may have slow bactericidal activity against S. aureus. Therefore we reviewed the case of endocarditis admitted to Pisa Hospital in Italy, in the last 8 years, to determine the outcome of those patients treated with linezolid. Methods: We retrospectively evaluated patients with endocarditis and treated with linezolid. We considered linezolid therapy as first, second or third line therapy. Clinical outcome was defined as