Daptomycin is a novel bactericidal antibiotic with excellent activity against grampositive organisms. It is a large cyclic lipopeptide with a unique mechanism of action. Daptomycin is given once a day and is renally cleared, requiring dose adjustment in patients with impaired renal function. Unfortunately, there have been case reports of resistant grampositive organisms. Daptomycin is generally well tolerated, though myopathy has been reported. 3-hydroxy-3-methylglutaryl coenzyme A (HMG-CoA) reductase inhibitors should be stopped in patients on daptomycin. Daptomycin shows promise in experimental models of endocarditis, meningitis, ventriculitis, and peritonitis, and is currently approved for use in skin and soft-tissue infections. Daptomycin is a welcome newcomer to the gram-positive antimicrobial arsenal.

Qamar ahmad ,* adam Green , † abhimanyu Chandel , ‡ James lantry, § mehul desai, § Jikerkhoun simou, § erik osborn , § ramesh sinGh , ¶ nitin Puri, † PatriCk moran , ¶ǁ heidi dalton , § alan sPeir , ¶ and ChristoPher kinG §The impact of the duration of noninvasive respiratory support (RS) including high-flow nasal cannula and noninvasive ventilation before the initiation of extracorporeal membrane oxygenation (ECMO) is unknown. We reviewed data of patients with coronavirus disease 2019 (COVID-19) treated with V-V ECMO at two high-volume tertiary care centers. Survival analysis was used to compare the effect of duration of RS on liberation from ECMO. A total of 78 patients required ECMO and the median duration of RS and invasive mechanical ventilation (IMV) before ECMO was 2 days (interquartile range [IQR]: 0, 6) and 2.5 days (IQR: 1, 5), respectively. The median duration of ECMO support was 24 days (IQR: 11, 73) and 59.0% (N = 46) remained alive at the time of censure. Patients that received RS for ≥3 days were significantly less likely to be liberated from ECMO (HR: 0.46; 95% CI: 0.26-0.83), IMV (HR: 0.42; 95% CI: 0.20-0.89) or be discharged from the hospital (HR: 0.52; 95% CI: 0.27-0.99) compared to patients that received RS for <3 days. There was no difference in hospital mortality between the groups (HR: 1.12; 95% CI: 0.56-2.26). These relationships persisted after adjustment for age, gender, and duration of IMV. Prolonged duration of RS before ECMO may result in lung injury and worse subsequent outcomes.

W e read with great interest the article published in a recent issue of Critical Care Medicine on the prevalence of intracranial hemorrhage (ICH) in COVID-19 patients on extracorporeal membrane oxygenation (ECMO) by Seeliger et al (1).We were struck by the high prevalence of ICH in COVID-19 patients on ECMO. This retrospective article analyzes ICH occurrence rate and clinical outcomes in patients on ECMO due to COVID-19-induced acute respiratory distress syndrome (C-ARDS) compared with other viral acute respiratory distress syndrome (ARDS). The article reported ICH in 29 of 142 COVID-19 patients (20%), including 15 major bleeds.We have not observed a similar predilection to ICH in COVID-19 at our institution. We have cared for 69 COVID patients requiring venovenous ECMO support for C-ARDS, of whom 66.6% survived to hospital discharge. Of these patients, only two patients (2.9%) suffered ICH, one while on ECMO and the other following her ECMO run. Both patients recovered completely without neurologic sequelae. The reason for the discrepant rates of ICH in C-ARDS patients is unclear. Our patient population was younger, with a mean age of 43 (range, 16-68). Severity of ARDS at the time of cannulation appears similar between the groups. Our practices for screening for ICH mirror those of Seeliger et al (1). However, only 13 patients in our cohort had head imaging which is a lower percentage of imaging than the authors' report, so some subclinical bleeds could be missed. Regardless, the rate of major/fatal bleeds observed by Seeliger et al (1) still far exceeds our observed rate.Perhaps the biggest difference between cohorts is the anticoagulation strategy. Unfractionated heparin (UFH) was primarily used by Seeliger et al (1). In contrast, ~80% (n = 55) of our patients were anticoagulated with bivalirudin targeting an activated partial thromboplastin time between 50 and 80 seconds. In our patients, 14.5% (n = 10) started out with UFH and were transitioned to bivalirudin, whereas only 5.8% (n = 4) were anticoagulated with UFH exclusively.Our institutional data does not show an increased prevalence of ICH in C-ARDS patients on venovenous ECMO. Based on our experience, we postulate that bivalirudin may represent a safer strategy for anticoagulation in C-ARDS patients on VV-ECMO. Further study with prospective clinical trials is warranted to confirm these findings.

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INTRODUCTION: Mycoplasma pneumonia is a common cause of pneumonia. Most patients run a benign course, however, rarely patients can present with severe acute respiratory failure. CASE PRESENTATION: A 43-year-old male with history of tobacco use presented with 2-week history of progressive shortness of breath, fever, congestion, sore throat and productive cough. He progressed to severe hypoxemic respiratory failure requiring intubation. CT scan of the chest displayed diffuse nodular infiltrates in a miliary pattern (Figure 1). He underwent bronchoscopy with bronchoalveolar lavage. Cultures for bacteria, fungi and acid-fast bacilli were negative. He was initially started on broadspectrum antibiotics but had progressively worsening hypoxemic respiratory failure requiring transfer to our tertiary care facility. On arrival, he was started on airway pressure release ventilation and levofloxacin. Serology was positive for cold agglutinins and was notable for IgM to Mycoplasma pneumonia at 7847 U/mL (positive is >770). He was successfully extubated on hospital day 3 and was transitioned to azithromycin to complete a 2-week course of antibiotics. Three weeks after discharge from the hospital repeat CT of the chest revealed resolution of the nodular miliary pattern (Figure 2). DISCUSSION: Mycoplasma pneumonia is a common cause of pneumonia. It usually resolves spontaneously or with antibiotics. 50 to 75% of patients develop cold agglutinins. The gold standard for diagnosis of M. pneumoniae respiratory infection is a fourfold increase in antibody titer. PCR techniques for diagnosis are also being used more frequently. Macrolides are considered the treatment of choice, though fluoroquinolones and tetracyclines are also effective. M. pneumonia infection rarely has major complications, but infection complicated by ARDS has rarely been reported in the literature. CONCLUSIONS: Mycoplasma pneumonia is a common cause of pneumonia. Most cases in immunocompetent hosts run a benign course and resolve with antibiotics. However, it has rarely been described as causing acute respiratory failure and should be suspected in patients presenting with ARDS.