Cefazolin/daptomycin/vancomycin

Abstract

Lack of efficacy: case report An 80-year-old man experienced lack of efficacy following the antibiotic therapy with cefazolin, vancomycin and daptomycin [dosages and routes not stated]. The man, who had dilated hypertrophic cardiomyopathy, hypertension and chronic heart failure, received a dual-chamber pacemaker for sick sinus syndrome and atrioventricular block in February 2010. On 30 May 2019, he developed pocket erosion, with streaks of pus exuding from the pocket. He was readmitted on 5 June 2019 due to worsening symptoms. There was no evidence of blood stream infection. As a result, the pacemaker generator was removed, although both capping leads were left buried under the skin, and a leadless pacemaker was implanted into the right ventricular apex one day after explanation of the pacemaker generator. Post-operatively, he received cefazolin [cefazolin sodium] for 3 days. On 12 July 2019, the pus streaks recurred along with high fever. Blood and pus cultures on 15 July 2019 grew methicillin-resistant Staphylococcus aureus (MRSA). He received vancomycin for 2 days. Due to liver dysfunction, vancomycin was replaced by daptomycin [aetiology of liver dysfunction not stated]. A transesophageal echocardiography did not reveal vegetations on the leads or valves. The blood infection caused by MRSA did not improve with the antibiotic therapy. In August 2019, he was transferred to the hospital for sepsis control and simultaneous removal of both the devices. Laboratory findings revealed an elevated CRP level. Blood culture results were positive for MRSA. A transthoracic echocardiography revealed severe left ventricular dysfunction with an ejection fraction of 22%. No vegetations were detected on the leads, leadless pacemaker or valves upon transesophageal echocardiography. The right ventricular lead and right atrial lead were extracted using a laser sheath and a mechanical sheath. Subsequently, the newly implanted leadless cardiac pacemaker was also removed. Culture results for the lead tip and the newly implanted leadless cardiac pacemaker were found to be positive for MRSA. Post-operatively, the man was continued on daptomycin for 6 weeks. Blood culture results were negative at 72h after the extraction. He subsequently underwent cardiac resynchronisation therapy on the opposite side 10 days after the extraction procedure. During 9 months of observation, there were no subsequent recurrence of the MRSA infection. It was concluded that an insufficiently treated pocket infection resulted in persistent MRSA bacteraemia in this case.