Eosinophilic pneumonia associated with daptomycin: a case report and a review of the literature

Daptomycin eosinophilic pneumonia, a systematic review of the literature and case series

PURPOSE

Daptomycin-induced eosinophilic pneumonia (DIEP) is a rare yet severe adverse event that requires rapid recognition and management. Diagnosing a definite case is challenging and involves meeting the American Thoracic Society (ATS) criteria, although alternative criteria have been suggested. This study aims to conduct a systematic review of literature and includes a case series.

METHODS

Six cases of DIEP identified at Perugia Hospital, Perugia, Italy have been described. A systematic review was carried out adhering to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) Statement guidelines.

RESULTS

a total of 74 cases of DIEP were analysed. Using ATS clinical criteria, 15 were classified as definite (20.3%), 54 as probable (73.0%), and 5 as possible (6.8%). Phillips criteria and the Lyon Algorithm identified 43/74 (58.2%) and 64/67 (95.5%) cases as definite, respectively. Bronchoalveolar lavage (BAL) was performed in 43 cases, revealing an average eosinophil count of 28.6% (SD 24.4). Radiological findings highlighted recurring features like bilateral opacities (68.1%), ground-glass opacities (41.7%), patchy infiltrates (30.6%), and peripheral predominance (19.4%). Upon suspicion, daptomycin was discontinued; 20 cases required no additional treatment, 38 received corticosteroids, and 12 received both corticosteroids and antibiotics. Recovery rates were high across all treatment types (≥ 73.7%). Most reports described rapid improvement post-withdrawal (within 96 h).

CONCLUSIONS

DIEP is a rare, fast-progressing condition where early diagnosis and prompt treatment are vital. Diagnosis relies on clinical, laboratory, and radiological evaluations. Stopping daptomycin is essential, with corticosteroids often necessary. Further research is needed to enhance diagnostic accuracy for this disease.

Daptomycin-Induced Eosinophilic Pneumonia: Can an Antibiotic Cause Pneumonia?

We present an interesting case of a patient who was discharged from the hospital on daptomycin and ertapenem in the setting of osteomyelitis. The patient did not have any respiratory symptoms during that hospital stay. A few weeks after discharge, the patient came back to the hospital with complaints of fever and shortness of breath. Chest X-ray showed pulmonary infiltrates. Initially, the patient was treated for acute respiratory distress syndrome (ARDS) vs pneumonia, but she did not improve. When labs showed significant eosinophilia, daptomycin-induced eosinophilic pneumonia became the working diagnosis, and the patient improved significantly when daptomycin was discontinued and steroids were started.

Daptomycin for the treatment of acute bacterial meningitis: a narrative review

BACKGROUND

There is a growing interest in the utilization of daptomycin for the treatment of multi-drug resistant, Gram-positive infections. Pharmacokinetic studies suggest that daptomycin could penetrate into the cerebrospinal fluid, albeit to a small extent. The objective of this review was to evaluate the available clinical evidence for daptomycin use in acute bacterial meningitis of both pediatric and adult patients.

METHODS

Electronic databases were searched up to June 2022 for studies published on the topic. The inclusion criteria were met if the study reported the use of intravenous daptomycin (more than a single dose) for the treatment of diagnosed acute bacterial meningitis.

RESULTS

A total of 21 case reports were identified that met the inclusion criteria. These suggest that daptomycin could be safe and effective alternative in achieving clinical cure of meningitis. In these studies, daptomycin was used in the event of treatment failure, patient intolerance, or bacterial resistance to first-line agents.

CONCLUSIONS

Daptomycin has potential to be an alternative to standard care for meningitis caused by Gram-positive bacteria in the future; however, more robust research is required to establish an optimal dosing regimen, duration of therapy, and place in therapy for the management of meningitis.

Clinical characteristics, management, and outcome of eosinophilic pneumonia associated with daptomycin

OBJECTIVE

The association between daptomycin exposure and eosinophilic pneumonia (EP) is mainly based on case reports. The purpose of this study was to evaluate the clinical characteristics and provide more evidence for better identify and management of daptomycin-induced eosinophilic pneumonia in clinical practice.

METHODS

Literature from 1991 to October 31, 2021 on EP induced by daptomycin were collected for retrospective analysis.

RESULTS

A total of 47 patients (40 male and 7 female) from 35 studies were included. The median age was 67 years (range 28-89), and 78.7% of patients were ≥60 years. Daptomycin was mainly used in patients undergoing osteoarticular infections (63.8%). Typical initial symptoms were fever (91.5%), cough (55.3%) and dyspnea (59.6%). The median onset time of symptom was 3 weeks. EP recurred in 14.9% of patients after the re-administration of daptomycin, and 57.1% of EP recurred within 24h. Most cases were accompanied by marked accumulation of eosinophils in peripheral (41 cases) and/or bronchoalveolar lavage fluid (27 cases). The main radiological features were pulmonary infiltration, ground glass opacity or consolidation in CT/CXR. All patients had symptom resolution after discontinuation of daptomycin except for one patient died due to the progression of the primary disease, the median time to symptoms relief was 3 days. Corticosteroids have been shown to help symptoms relief in some cases (59.6%).

CONCLUSION

Daptomycin-induced eosinophilic pneumonia is a rare and serious complication. Physicians should consider eosinophilic pneumonia as a differential diagnosis when receiving daptomycin therapy, particularly in elderly male patients.

Daptomycin associated eosinophilic pneumonia: case report and differential diagnoses

Daptomycin is a bactericidal antibiotic approved for treatment of gram-positive skin and soft tissue infections. We present a case of an 89-year-old man who presented with fever, shortness of breath and nonproductive cough on week 4 of starting daptomycin for infective endocarditis. Computerized tomography scan showed bilateral interstitial infiltrates predominantly affecting the lower lobes. He also had peripheral eosinophilia of 6%. He was diagnosed with eosinophilic pneumonia secondary to daptomycin use. His symptoms improved with discontinuation of daptomycin and initiation of corticosteroids. Clinical correlation of pneumonia-like presentation with recent use of daptomycin should make physicians rule out this rare adverse effect for early institution of correct treatment.

Daptomycin-induced Eosinophilic Pneumonia and a Review of the Published Literature

A 53-year-old man was admitted to the hospital with a diagnosis of cellulitis and osteomyelitis. Twenty-four days after the initiation of daptomycin and sulbactam/ampicillin, he developed a fever and pulmonary infiltration. Bronchoalveolar lavage revealed a high number of eosinophils, while an intracutaneous test revealed positivity for daptomycin. The patient improved after discontinuing antimicrobial therapy. The plasma daptomycin minimum concentration (C_min) was elevated (27.4 μg/mL), but plasma protein binding of daptomycin was low (87.8%). Although the pathophysiology of eosinophilic pneumonia remains unclear, antigenic stimulation due to daptomycin accumulation in the alveoli may have caused continuous immune activation.

Two patients with daptomycin induced eosinophilic pneumonia with different presentations and treatment

We present two cases of daptomycin-induced eosinophilic pneumonia with characteristic chest x ray, CT scan and bronchoalveolar lavage (BAL) findings. It is not a commonly seen complication of Daptomycin but when it happens, it could cause a diagnostic and treatment dilemma. Patients could present acutely with hypoxic respiratory failure or a less dramatic chronic presentation is also possible. Our two patients presented with acute hypoxic respiratory failure and presentation resembles that of an infectious etiology. Diagnosis is confirmed by bronchoscopy with BAL in one of them and the other was treated empirically as the clinical and radiologic presentation was typical. Treatment includes removal of the offending agent, daptomycin. Corticosteroids are used if symptoms are severe and can result in rapid clinical improvement. There is no agreed upon dose and duration of steroids and we suggest a long taper of steroids for patients who present with severe symptoms and a short course steroid for patients with milder symptoms.

Daptomycin-Induced Acute Eosinophilic Pneumonia: Late Onset and Quick Recovery

Background

Daptomycin is a cyclic lipopeptide antibiotic that provides great coverage for gram positive cocci. From the early years of daptomycin use, concerns were raised regarding the pulmonary side effects of daptomycin and potential development of acute eosinophilic pneumonia (AEP) secondary to daptomycin therapy.

Discussion

AEP could be idiopathic or induced by drugs or toxins. It is a distinct entity from atopic diseases and autoimmune, parasitic, or fungal infections that can also cause pulmonary eosinophilia. Multiple medications are associated with acute eosinophilic pneumonia. Multiple cases of daptomycin-induced AEP have been reported in the literature. Diagnosis of AEP is based on clinical history, laboratory tests, and radiographic studies. Obtaining bronchoalveolar lavage or lung biopsy is needed to confirm the diagnosis. Timing of the drug use and clinical presentation is crucial in the diagnosis of drug-induced AEP. Discontinuation of the offending drug and systemic corticosteroids are the mainstay treatment with great outcomes and recovery.

Conclusion

We present a case of AEP caused by daptomycin, with complete recovery after discontinuation of daptomycin and administration of steroids. The patient had AEP after almost 6 weeks of daptomycin therapy which has never been reported in literature and our patient achieved complete recovery with appropriate management.

Treatment of Staphylococcus aureus Infections

Staphylococcus aureus, although generally identified as a commensal, is also a common cause of human bacterial infections, including of the skin and other soft tissues, bones, bloodstream, and respiratory tract. The history of S. aureus treatment is marked by the development of resistance to each new class of antistaphylococcal antimicrobial drugs, including the penicillins, sulfonamides, tetracyclines, glycopeptides, and others, complicating therapy. S. aureus isolates identified in the 1960s were sometimes resistant to methicillin, a ß-lactam antimicrobial active initially against a majority S. aureus strains. These MRSA isolates, resistant to nearly all ß-lactam antimicrobials, were first largely confined to the health care environment and the patients who attended it. However, in the mid-1990s, new strains, known as community-associated (CA-) MRSA strains, emerged. CA-MRSA organisms, compared with health care-associated (HA-) MRSA strain types, are more often susceptible to multiple classes of non ß-lactam antimicrobials. While infections caused by methicillin-susceptible S. aureus (MSSA) strains are usually treated with drugs in the ß-lactam class, such as cephalosporins, oxacillin or nafcillin, MRSA infections are treated with drugs in other antimicrobial classes. The glycopeptide drug vancomycin, and in some countries teicoplanin, is the most common drug used to treat severe MRSA infections. There are now other classes of antimicrobials available to treat staphylococcal infections, including several that have been approved after 2009. The antimicrobial management of invasive and noninvasive S. aureus infections in the ambulatory and in-patient settings is the topic of this review. Also discussed are common adverse effects of antistaphylococcal antimicrobial agents, advantages of one agent over another for specific clinical syndromes, and the use of adjunctive therapies such as surgery and intravenous immunoglobulin. We have detailed considerations in the therapy of noninvasive and invasive S. aureus infections. This is followed by sections on specific clinical infectious syndromes including skin and soft tissue infections, bacteremia, endocarditis and intravascular infections, pneumonia, osteomyelitis and vertebral discitis, epidural abscess, septic arthritis, pyomyositis, mastitis, necrotizing fasciitis, orbital infections, endophthalmitis, parotitis, staphylococcal toxinoses, urogenital infections, and central nervous system infections.

Eosinophilic pneumonia caused by daptomycin: Six cases from two institutions and a review of the literature

Here we report six cases of daptomycin (DAP)-induced eosinophilic pneumonia (DIEP) encountered at two medical centers and present a review of 43 DIEP patients from 26 studies to compare the clinical characteristics and radiographic findings of acute and chronic eosinophilic pneumonia (AEP; CEP). Four of the six patients did not exhibit respiratory symptoms, and one patient with only fever was misdiagnosed with DAP-induced fever. According to our literature review and the present findings, male sex and old age were dominant risk factors for DIEP. Fever and fine crackles were the most common clinical manifestations. The DAP dose and duration of administration were not significant risk factors for DIEP, and we also could not find any association between allergic predisposition and DIEP. Among the reviewed patients, 51.8% did not show more than 25% eosinophils in bronchoalveolar lavage, which is a criterion for the diagnosis of drug-induced eosinophilic pneumonia. Chest images of all patients showed CEP patterns such as multiple reticulonodular infiltrates in the subpleural region and diffuse bilateral pulmonary infiltrates with ground-glass opacities. However, 66.7% of patients also exhibited pleural effusion, a feature specific to AEP. All patients showed prompt recovery after DAP withdrawal. Our results suggest that clinicians should consider DIEP as a differential diagnosis when patients receiving DAP therapy, particularly men and elderly patients, present with fever, even in the absence of respiratory symptoms. Furthermore, they should be aware that the occurrence of DIEP is independent of the DAP dose and administration duration, and allergic reaction.

Daptomycin-induced eosinophilic pneumonia - a systematic review

PURPOSE

Eosinophilic pneumonia comprises a group of lung diseases in which eosinophils appear in increased numbers in the lungs and sometimes in the bloodstream. Several case reports link daptomycin use to this phenomenon.

SUMMARY

We performed a systematic literature review to identify cases of eosinophilic pneumonia associated with daptomycin use. Relevant studies were identified by searching Pubmed/Medline, EMBASE, Google Scholar, Cochrane Database of Systematic Reviews, and Clin-Alert from inception to May 2016, and manual searches of reference lists. All case reports that include information regarding patient age, indication, clinical and objective findings, treatment and outcome were evaluated. Abstracts from conference proceedings as well as case reports not in English were excluded. Descriptive statistics were used to analyze the data. Thirty-five patient-cases were included in the final analysis. Patients most likely to be identified with daptomycin-induced eosinophilic pneumonia were male (83%) and elderly (mean age 65.4 ± 15 years). The dose for daptomycin ranged from 4 to 10 mg/kg/day, but included a large number of patients with renal dysfunction. The average duration of daptomycin therapy upon onset of EP symptoms was 2.8 ± 1.6 weeks. Majority of patients presented with dyspnea (94%), fever (57%) and were also found to have peripheral eosinophilia (77%) and infiltrates/opacities of CT/CXR (86%). Symptom improvement was seen after daptomycin discontinuation (24 h to 1 week). The majority of patients were also prescribed treatment with corticosteroids (66%).

CONCLUSION

Clinicians should be aware of daptomycin-induced eosinophilic pneumonia and its symptoms along with its presentation and treatment.

Daptomycin-associated eosinophilic pneumonia in two patients with prosthetic joint infection

BACKGROUND

Daptomycin is used increasingly to treat prosthetic joint infection (PJI). A possible side effect of this drug is eosinophilic pneumonia. We describe two patients with PJI treated with daptomycin who had this side effect with different clinical presentations.

METHODS

Case reports and review of the literature.

RESULTS

The first case was a 64-year-old male who received daptomycin as a part of the treatment for PJI caused by methicillin-resistant Staphylococcus epidermidis (MRSE). He developed fever without other symptoms; bronchoalveolar lavage (BAL) revealed eosinophils. The second was a 61-year-old male who also used daptomycin as part of the treatment of PJI caused by MRSE and developed severe lung symptoms. Bronchoalveolar lavage and pleural fluid showed an increased number of eosinophils.

CONCLUSION

Daptomycin-induced pneumonia can present with a wide range of symptoms, from fever alone to severe lung symptoms. Surgeons should be aware of this possible side effect when prescribing daptomycin.

Daptomycin-induced eosinophilic pneumonia treated with intravenous corticosteroids

OBJECTIVE

To describe 2 cases of drug-induced eosinophilic pneumonia in patients with variable exposure to daptomycin.

REPORT

In our first case, a 77-year-old male was transferred to our facility for hypoxic respiratory failure, which occurred 1 day after completing a course of daptomycin. There was high clinical suspicion for daptomycin-induced eosinophilic pneumonia, thus the patient was started on intravenous methylprednisolone 40 mg every 6 hours. Within 72 hours, he was liberated from mechanical ventilation, as he experienced dramatic clinical improvement in regard to his oxygenation and radiographs. Approximately 6 weeks after case 1, a second case of eosinophilic pneumonia related to daptomycin was diagnosed. This case occurred in a 74-year-old female who developed respiratory failure requiring noninvasive positive pressure ventilation 72 hours after initiation of a second course of daptomycin. She was treated with methylprednisolone 60 mg every 6 hours and avoided the need for endotracheal intubation and mechanical ventilation.

CONCLUSION

Since this potentially life-threatening adverse effect of daptomycin appears more common than previously reported, clinicians should have a high level of suspicion in any patient with recent daptomycin exposure who presents with pulmonary symptoms. In many cases, this process is highly responsive to prompt initiation of corticosteroid therapy.

Myopathy and eosinophilic pneumonia coincidentally induced by treatment with daptomycin

A 34-year-old man with 22q11.2 deletion syndrome (DiGeorge syndrome) concurrently suffered from myopathy and eosinophilic pneumonia shortly after receiving daptomycin (DAP) for right-sided infective endocarditis. The simultaneous occurrence of these phenomena in relation to DAP therapy has not been previously well described. An allergic reaction was suspected as a possible etiology of these DAP-related complications. This case highlights the need for close observation in order to detect both musculoskeletal and respiratory disorders from the start of DAP therapy. Physicians should pay more attention to this new drug, which is expected to be frequently used in various clinical settings.

Feasibility of in vivo diffusion tensor imaging of articular cartilage with coverage of all cartilage regions

OBJECTIVES

To investigate the value of diffusion tensor imaging (DTI) of articular cartilage to differentiate healthy from osteoarthritis (OA) subjects in all cartilage regions.

METHODS

DTI was acquired sagittally at 7 T in ten healthy and five OA (Kellgren-Lawrence grade 2) subjects with a line scan diffusion tensor sequence (LSDTI). Three healthy volunteers and two OA subjects were examined twice to assess the test-retest reproducibility. Averaged mean diffusivity (MD) and fractional anisotropy (FA) were calculated in each cartilage region (femoral trochlea, lateral and medial femoral condyles, patella, and lateral and medial tibia).

RESULTS

The test-retest reproducibility was 2.9% for MD and 5.6% for FA. Averaged MD was significantly increased (+20%, p < 0.05) in the OA subjects in the lateral femoral condyle, lateral tibia and the femoral trochlea compartments. Averaged FA presented a trend of lower values in the OA subjects (-12%), which was only significant for the lateral tibia.

CONCLUSIONS

In vivo DTI of articular cartilage with coverage of all cartilage regions using an LSDTI sequence is feasible, shows excellent reproducibility for MD and FA, and holds potential for the diagnosis of OA.

KEY POINTS

• DTI of articular cartilage is feasible at 7 T in all cartilage regions • DTI of articular cartilage can potentially differentiate healthy and OA subjects.

Treatment of Gram-positive left-sided infective endocarditis with daptomycin

The aim of this study was to evaluate the effectiveness of daptomycin in left-sided infective endocarditis (IE) patients. Fourteen patients with left heart endocarditis, monitored with a diagnosis of IE based on modified Duke criteria between July 2010 and May 2011, and receiving daptomycin as monotherapy, were enrolled. The success of daptomycin in these patients was revealed with improvements in microbiological, biochemical, and radiologic findings, as well as physical examination findings. Patient average age was 63.5 ± 14.2 years (36-80 years); 8 (57 %) were men and 6 (43 %) women. The pathogens methicillin-resistant Staphylococcus aureus (71.5 %), Streptococcus mutans (21.5 %), and methicillin-sensitive Staphylococcus aureus (7 %) were isolated from our patients. Daptomycin was used in initial treatment in 5 (36 %) patients; treatment was subsequently modified to daptomycin in 9 (64 %) patients as a consequence of drug serum level insufficiency, agent sensitivity to the drug administered, or drug side effects. Thirteen patients were discharged in a healthy condition, with successful surgical treatment in 5 (36 %). Only 1, an 80-year-old IE patient, was lost from advanced cardiac failure. No significant side effects were seen in any patient receiving daptomycin. The most frequent side effects were minimal rises in serum CPK levels during treatment; these values returned to normal after treatment. Daptomycin can be used successfully in left heart endocarditis with no significant side effects. Studies involving a wider patient series are now needed to support the use of daptomycin in left heart endocarditis.

Eosinophilic pneumonia in patients treated with daptomycin: review of the literature and US FDA adverse event reporting system reports

BACKGROUND

Eosinophilic pneumonia (EP) has been noted in association with daptomycin use. The product labelling was recently updated to include EP in the Warnings and Precautions and Post-Marketing Experience sections.

OBJECTIVE

The objective of this study was to analyse adverse event (AE) reports submitted to the US FDA as well as published cases to characterize the clinical features and course of EP in daptomycin-treated patients.

METHODS

We searched for EP cases associated with daptomycin administration in the FDA Adverse Event Reporting System (AERS) submitted from 2004 to 2010, and the published literature. Cases were defined as definite, probable, possible and unlikely in terms of the diagnosis of EP and the potential association with daptomycin exposure. Definite cases had concurrent exposure to daptomycin, fever, dyspnoea with increased oxygen requirement or required mechanical ventilation, new infiltrates on chest imaging, bronchoalveolar lavage with >25% eosinophils and clinical improvement following daptomycin withdrawal. Additionally, we assessed inpatient daptomycin utilization.

RESULTS

We identified 7 definite, 13 probable, 38 possible cases of daptomycin-induced EP, and 23 unlikely cases. The seven definite EP cases had resolution after daptomycin was stopped, including two with EP recurrence following daptomycin rechallenge. Regarding the definite cases: (i) ages ranged from 60 to 87 years; (ii) dosing ranged from 4.4 to 8.0 mg/kg/day; and (iii) EP developed 10 days to 4 weeks after starting daptomycin. There was a gradual increase in the number of patients with an inpatient hospital discharge billing for daptomycin from the year 2004 to 2010.

CONCLUSIONS

We report 7 definite, 13 probable and 38 possible EP cases associated with daptomycin administration. As AERS is based on voluntary reporting, the incidence of EP cannot be assessed. Healthcare providers should have heightened awareness of this serious AE associated with daptomycin use.