Rosina Albisinni

High-Dose Daptomycin for Cardiac Implantable Electronic Device–Related Infective Endocarditis

BACKGROUND Cardiac implantable electronic device (CIED)-related endocarditis is a growing challenge because of increasing incidence and significant mortality. Current treatment is based on complete hardware removal coupled with long-term administration of effective and safe antimicrobials. Daptomycin at the dose of 6 mg/kg/day has been found to be effective in staphylococcal endocarditis, but limited data exist on CIED endocarditis. Moreover, whether higher doses could be more effective but equally safe in this setting is currently unknown. METHODS We report here our experience with high-dose daptomycin in the treatment of 25 cases of CIED endocarditis due to staphylococci. RESULTS Patients were mostly elderly and male, with large lead vegetations and severe comorbidities. Pathogens were Staphylococcus epidermidis (56%), Staphylococcus aureus (28%), and other coagulase-negative staphylococci (16%). Only 4 patients (16%) had a normal pretreatment renal function. The median daptomycin daily dose was 8.3 mg/kg (range, 6.4-10.7). Daptomycin was administered for a median of 20 days (range, 8-52). Percutaneous lead extraction was performed in 88% of patients. Two patients (8%) failed to clear bacteremia. The overall clinical success of treatment was 80%, whereas a complete microbiological success was observed in 92% of patients. Creatine phosphokinase values were monitored and increased above normal in 5 cases (20%). No serious adverse event related to high-dose daptomycin was observed and no patient required discontinuation because of muscle toxicity. CONCLUSIONS Our experience suggests that high-dose daptomycin may be a safe therapeutic option in staphylococcal CIED endocarditis and may be associated with high microbiological responses and clinical success.

Management of Gram-negative and fungal endocarditis

Infective endocarditis is infrequently caused by Gram-negative bacteria or fungi. Gram-negative organisms are responsible for <4% of cases, whilst fungal endocarditis accounts for <1.5% of culture-positive cases worldwide. Endocarditis due to Gram-negative organisms or fungi is a rare but severe disease. It often has a nosocomial origin, is caused by virulent and often resistant organisms and presents a high rate of complications and high mortality. In this article we present the most recent literature data and address the current management of Gram-negative and fungal infective endocarditis. We also discuss the major challenges of antimicrobial treatment and discuss some issues related to surgical decision-making in difficult-to-manage cases. We finally present our centres experience with Gram-negative infective endocarditis, with a special focus on the demanding issues that the management of these complex and severely ill patients raise.

Severe pancytopenia and intrahepatic cholestasis in a patient with a history of Hodgkin’s disease.: Responsiveness to high-dose pulse steroid therapy and diagnosis of a late relapse

A 47-year-old male, treated 7 years earlier for Hodgkins disease (HD), was admitted with persistent fever, liver enlargement, and increased cholestasis parameters. He developed acute bone marrow failure and progressive worsening of his clinical condition and cholestasis markers without showing evidence of HD recurrence or second malignancy. High-dose intravenous pulse methylprednisolone therapy was given, after which resolution of pyrexia and progressive improvement in performance status and in hematological counts and cholestasis parameters were observed. During this phase, a bone biopsy showed HD marrow infiltration. This clinical course may reflect tumor cytokine-induced phenomena, significantly affected by high-dose steroids.