Use of Daptomycin in the Treatment of Vancomycin-Resistant Enterococcal Urinary Tract Infections

A Short Case Series

Divya Pradeep Ramaswamy; Maria Amodio-Groton; Stephen J Scholand

Disclosures

BMC Urol. 2013;13(33) 

In This Article

Methods

This study was conducted at St. Mary's Hospital, a small community-based institution with approximately 200 beds, serving an urban population in Waterbury, Connecticut. Our catchment area included a number of nursing homes that contributed up to one-third of our inpatients. On request, one of the authors (SJS) provided expertise in the management of infectious diseases (ID). The current retrospective case series includes patients for whom ID consultation was requested over a 3-year period (from January 1, 2007, to December 8, 2009) and who ultimately received daptomycin for treatment of symptomatic VRE UTI. In summarizing the cases we managed for this report, we sought approval from the ethics committee of our institution ("the Saint Mary's Hospital IRB") (protocol 12–18–09). After IRB permission was granted, written informed consent was obtained from all patients for inclusion in this study and for publication of their medical information. A copy of the written consent is available for review by the editor of this journal.

A large majority of VRE-infected patients in our hospital are seen by an ID specialist because of intrinsic limitations in the treatment options and the hospital requirement of gown-and-glove contact isolation procedures for these patients. For this retrospective case series, patients were identified for consultation after a telephone call about a VRE-positive urine culture. To be treated with daptomycin and included in this analysis, patients had to exhibit urinary symptoms, pyuria (>5 white blood cells per high-power field), or both on urinalysis with a positive VRE culture.

VRE susceptibility was determined according to a VITEK 2 (bioMérieux, Inc, Durham, NC) microbial identification system, with daptomycin susceptibility determined by Etest (bioMérieux, Inc) on request. Patients who had positive VRE urinary cultures without significant pyuria on urinalysis were considered colonized rather than infected and, therefore, were not included in this analysis.

Once a patient was determined to have a VRE UTI, screening creatinine values were measured in all cases, and creatine phosphokinase (CPK) levels were determined in most cases. Daptomycin was generally administered at a planned dosage regimen of ≥5 mg/kg every 24 hours (if creatinine clearance [CrCl] ≥30 mL/min) or every 48 hours (if CrCl <30 mL/min). Dosage was determined based on actual body weight for all patients in this analysis. A dose of ≥5 mg/kg was chosen to provide ample urinary concentrations of the drug.

Clinical cure was defined by the resolution of symptoms in the best judgment of the ID clinician involved in the care of the patient (SJS). These included urinary symptoms such as dysuria, urinary frequency, and changes in urine character. Other symptoms such as abdominal pain, fever, malaise, and anorexia were also monitored for improvement. Follow-up urinalysis and urine culture were typically performed at the end of the daptomycin treatment course. The presence or absence of pyuria in urinalysis at the end of treatment was not in itself a strict criterion for clinical cure because it might have resulted from bladder irritation, drugs, or other causes. Regardless of whether pyuria was initially present and remained present at the end of the treatment course, microbiologic data were examined to help determine whether microbiologic cure was achieved. Microbiologic cure was defined by the eradication of VRE in urine cultures taken after completion of the daptomycin treatment course.

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