No abstract

Background Daptomycin pulmonary eosinophilia (DPE) has been well described in case reports and reporting from the Food and Drug Administration. We report 3 eosinophilic syndromes associated with daptomycin use. Methods This is a retrospective review of all patients who received daptomycin (inpatient or outpatient) from 2010 to 2020 at the Veterans Affairs Portland Healthcare System. Patients who developed DPE while receiving daptomycin were evaluated to determine risk factors. Data collected included daptomycin dose and duration, body mass index, creatinine clearance, and peripheral eosinophilia. Results Of 330 patients who received daptomycin, 81.5% developed a peripheral eosinophilia, with 109 (33%) developing peripheral eosinophilia ≥5%. Fifty-one (16%) met criteria for DPE. Primary DPE occurred in 38 of the 51 patients with a median 26 days of treatment, and 49% had peripheral eosinophilia ≥5%. Re-exposure DPE occurred in the other 13 patients and occurred a median of 3 days after initiation of daptomycin. The presence of an elevated peripheral eosinophilia of ≥5% during daptomycin usage was significantly associated with primary (odds ratio [OR], 2.23; 95% CI, 1.2–4.09; P = .008) and re-exposure DPE (OR, 12; 95% CI, 1.6–103; P = .003). All patients recovered after withdrawal of daptomycin without complications. Conclusions There are 3 daptomycin eosinophilic syndromes: peripheral eosinophilia, primary DPE occurring about 4 weeks into therapy, and re-exposure DPE. Elevated peripheral eosinophilia ≥5% was a risk factor for both primary and re-exposure DPE, but still identified about half the cases. Peripheral eosinophilia should be carefully monitored during daptomycin treatment, and clinicians should be aware that prior eosinophilia may predict an acute pulmonary reaction upon daptomycin re-exposure.

We analyzed the impact of a fluoroquinolone patient safety initiative on the weekly fluoroquinolone prescription rate in Veterans Affairs community-based outpatient clinics. We observed a significant initial but unsustained reduction. Such an initiative can function as an antimicrobial stewardship intervention; however, strategies to promote sustainability should be explored.

An OPAT program using a self-administration model treating patients who were military veterans had successful outcomes. Patients with diabetes and osteomyelitis had worse clinical outcomes 90 days after the completion of OPAT therapy.

BackgroundDaptomycin pulmonary eosinophilia (DPE) has been described as a rare event. Since the Food and Drug Administration (FDA) first described the syndrome which occurs about 3 weeks after starting the drug, it continues to be a miss diagnosed. Most outpatient antibiotic treatment (OPAT) programs focus on screening for CPK elevations. We describe an unusual increase in DPE at our center including acute reactions on re-exposure to daptomycin.MethodsRetrospective review from local VA pharmacy and OPAT database of adverse drug events (ADE) with daptomycin from 2010 to April 2018. Data evaluated include, age, gender, weight, body mass index (BMI), daptomycin dosing, indication for use, duration of therapy, time to symptom onset, Creatinine clearance, white cell count (WCC), %eosinophilia (%eos), admission to intensive care unit (ICU), and clinical outcomes or interventions.ResultsThere were 363 unique initiations of Daptomycin in the time period. There were 17 DPE (5%) and 3 CPK (0.6%) events in that time period. The medians for all DPE was; Age 68 years (range 55–95), BMI 29 m/kg2 (range 21–49.5), daptomycin dose 500 mg (>7 mg/kg), baseline CrCl 35.5 mL/minute, eosinophilia at onset of DPE 9% (8–44%), and duration of therapy to onset was 21 days (1–33). All recovered on removal of daptomycin, but 5 patients required adjunctive corticosteroid therapy. Four patients had a severe and novel hyperacute DPE within 48 hours of a new initiation of daptomycin therapy. All 4 patients had prior exposure to daptomycin in the last 12 months. They presented with hypoxic respiratory failure, abnormal chest x-rays and/or CT chest scans, with preceding systemic fevers and fatigue after the first dose. All had low grade %eos (3–5%) on prior use, and all recovered rapidly with discontinuation of daptomycin.ConclusionDPE may be underreported and is associated with doses of 500 mg or >7 mg/kg, with CrCl <35 mL/minute and older age. Of concern are the new cases of hyperacute DPE within 48 hours of re-exposure to daptomycin that we have seen, who had prior low-grade eosinophilia. Close monitoring of these factors may be warranted in at risk individuals.Disclosures All authors: No reported disclosures.