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Archived Comments for: Daptomycin for methicillin-resistant Staphylococcus epidermidis native-valve endocarditis: a case report

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  1. Daptomycin resistant Staphylococcus epidermidis: an emerging threat?

    Metaxia Papanikolaou, Hippokrateion General Hospital of Athens

    25 February 2011

    Daptomycin-resistant Staphylococcus epidermidis: an emerging threat?
    M.N. Papanikolaou1, P. Drimousis1, M. Balla1, T. Papavasilopoulou1, J. Deves1, A. Xanthaki2, A. Tsirigga2, S.P. Karatzas1
    Intensive Care Unit1 and Microbiology Department2
    Hippokrateion General Hospital, Athens, Greece
    We read with interest the case report by Dr. Duah, regarding the activity of daptomycin against Staph epidermidis causing native-valve endocarditis [1]. As Dr Duah points out, daptomycin seems to be a promising alternative, if vancomycin has failed to control the infection.
    Although resistance of several gram positive cocci to daptomycin, like enterococcus and Staphylococcus aureus, is unfortunately established [2,3,4], there was not such evidence concerning Stapylococcus epidermidis until recently. Two such cases of critically ill patients were registered in our ICU .
    Patient #1. A 87 year old man, who had undergone a colectomy for colon cancer, was admitted in the ICU, after being reoperated due to an anastomosic rupture. The patient was in septic shock. Blood and trauma cultures were obtained and daptomycin was prescribed empirically on postoperative day 3. The next day, daptomycin resistant Staph epidermidis (MIC= 8 μg/mL) was isolated from the trauma exudate. Daptomycin was discontinued and replaced by tigegycline. The patient did well and was extubated 3 days later.
    Patient #2. A 19 year old woman was admitted in the ICU on Feb 5th 2010, after an incident of ventricular fibrillation due to cardiomyopathy, resulting to hypoxemic encephalopathy. Due to her prolonged hospitalization, recurrent catheter- related blood stream infections by Gram-positive pathogens, mainly Staph epidermidis, have been recorded. Among other antimicrobials, she was given daptomycin at least 5 times during her 11 month-stay. Daptomycin resistant Staph epidermidis (MIC= 3 μg/mL) was isolated from a blood culture, obtained on Jan 18th, after ten days administration of this particular drug. Daptomycin was discontinued, but the patient had clinically improved.
    The MIC of ≥ 3.0 μg/mL is three dilutions above the proposed breakpoint for non-susceptible of 1.0 μg/mL (E-test methodology, AB BIODISK) and clearly above the MIC at which the 90% isolates tested are inhibited of 0.5 μg/mL for MRSA found in prior studies [3]. It is surprising, that for patient #1, resistance developed while on therapy with daptomycin for the first time, and only 2 days after its initiation. Daptomycin resistance of MRSA and Enterococcus has been noted since 2005 [2,3,4]. Resistance of Staph epidermidis to daptomycin has not been reported to our knowledge, though linezolid resistant Staphylococcus epidermidis has been susceptible for a recent endemic outbreak in two Spanish ICUs [5,6] .
    The emergence of daptomycin resistant Staph epidermidis, and particularly during the last month, is a rather alarming situation, narrowing therapeutic options for coagulase negative Staph epidermidis. Prolonged and repeated exposure to the drug is certainly a leading cause of resistance emergence. Routine testing for daptomycin susceptibility is not a current strategy. Disk diffusion method is not recommended and an E-test must be used alternatevily. However, daptomycin susceptibility testing may be considered for gram positive cocci infections in high risk critically ill patients.

    1. Duah M. : Daptomycin for methicillin-resistant Staphylococcus epidermidis native-valve endocarditis: a case report. Annals of Clinical Microbiology and Antimicrobials 2010, 9:9
    2. Sabol K, Lewis JS, Owens A, Cadena J, Jorgensen JH: Emergence of Daptomycin Resistance in Enterococcus faecium during Daptomycin Therapy. Antimicrobial agents and Chemotherapy. Apr 2005, 1664-5
    3. Skiest D: Treatment Failure Resulting from Resistance of Stahylococcus aureus to Daptomycin. Journal of Clinical Microbiology, Feb 2006, 655-6.
    4. Hayden MK, Rezai K, Hayes RA, Lolans K, Quinn JP, Weinstein RA: Development of Daptomycin Resistance In Vibo in Methicillin –Resistant Staphylococcus Aureus. Journal of Clinical Microbiology, Oct 2005, 5285-7.
    5. Trevino M, Martinez- Lamas L, Romero- Jung PA, Giraldez JM, Alvarez- Escudero J, Regueiro BJ: Endemic linezolid –resistant Staphylococcus epidermidis in a critical care unit. Eur J Clin Microbiol Infect Dis, 2009 May; 28(5):527-33
    6. Seral C, Saenz Y, Algarate S, Duran E, Luque P, Torres C, Castillo FJ: Nososcomial outbreak of methicillin- and linezolid- resistant Staphylococcus epidermidis associated with catheter-related infections in intensive care unit patients. Int J Med Microbiol. 2011 Jan 12 [Epub ahead of print]

    Competing interests

    None declared