High-Dose Daptomycin an Option in
Cardiac Device-Related Endocarditis
NEW YORK (Reuters Health) Dec 12 - High-dose daptomycin
appears to be a safe and effective therapeutic option for cardiac implantable
electronic device (CIED)-related infective endocarditis due to staphylococci,
clinicians from Italy report.
In a small study, they observed that daptomycin at a daily
dose greater than 6 mg/kg was associated with "high microbiological
responses and clinical success." They didn't see any serious
treatment-related adverse events.
In a report online November 18 in Clinical Infectious
Diseases, Dr. Riccardo Utili and colleagues from University of Naples and
Monaldi Hospital note that the incidence of CIED infections has increased
disproportionately more than the rate of new implants.
"The major challenges of CIED endocarditis are the
rapid development of bacterial biofilms on the intravascular leads that are
relatively impermeable to antimicrobial agents as well as the overall poor
cardiac performance, often associated with significant medical comorbidities,
of those affected," they write.
Management involves removing the hardware and appropriate
long-term antimicrobial treatment. Daptomycin, at the dose of 6 mg/kg/day, has
demonstrated efficacy in staphylococcal endocarditis, but limited data exist on
CIED endocarditis. It's unknown whether higher doses could be more effective
but equally safe in this setting.
Dr. Utili's team treated 25 patients with CIED endocarditis
due to staphylococci with daptomycin at a median daily dose of 8.3 mg/kg
(range, 6.4 to 10.7 mg/kg) for a median of 20 days (range 8 to 52 days).
Overall, clinical success with complete cure was achieved in
20 patients (80%) and complete microbiological success was achieved in 23
patients (92%). The treatment failed in two patients (8%). No patient died from
the infection.
The cohort was made up largely of elderly white men with
large lead vegetations. The infected CIED was a pacemaker in 68% and a
defibrillator in 32% of cases. All patients had staphylococcal species isolated
from blood cultures and/or removed from intracardiac leads.
Pathogens were Staphylococcus epidermidis (56%),
Staphylococcus aureus (28%), and other coagulase-negative staphylococci (16%).
Most patients (88%) had a history of fever.
There was a high prevalence (93%) of methicillin-resistant
staphylococcal isolates as well as a predominance of patients with impaired
renal function.
High-dose daptomycin did not cause clinically significant
adverse events or biochemical abnormalities and was well tolerated. The renal
toxicity profile, they note, was "very good overall" and no
significant reductions in glomerular filtration rates were observed. No patient
had to discontinue treatment due to muscle toxicity.
"Our clinical experience suggests that in patients with
CIED endocarditis due to staphylococci, a setting where vancomycin may fail or
be toxic, high-dose daptomycin may produce good clinical responses with no
significant adverse events," Dr. Utili and colleagues say.
Based on their experience, the researchers think high-dose
daptomycin "deserves further consideration in CIED endocarditis,"
especially if caused by methicillin-resistant staphylococcal strains and when
vancomycin fails.
Clin Infect Dis 2011.
沒有留言:
張貼留言