Cerebrospinal Fluid Penetration of High-Dose Daptomycin in Suspected Staphylococcus aureus Meningitis
Cerebrospinal Fluid Penetration of High-Dose Daptomycin in Suspected Staphylococcus aureus Meningitis
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大剂量达托霉素在疑似金黄色葡萄球菌脑膜炎中的脑脊液渗透
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发表时间：
2010
期刊：
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通讯作者：
P. B. Bookstaver
中科院分区：
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作者：
M Shawn Riser;Christopher M. Bland;C. Rudisill;P. B. Bookstaver
目的：报道1例甲氧西林敏感型金黄色葡萄球菌(MSSA)菌血症疑似MSSA脑膜炎用大剂量达托霉素治疗，同时测定血清和脑脊液(CSF)浓度。病例摘要：1例54岁男性患者在急诊科就诊时全身虚弱，胸部X线片显示为健康相关肺炎。根据经验，治疗开始于万古霉素、左氧氟沙星和哌拉西林/他唑巴坦。血培养显示金黄色葡萄球菌对苯唑西林敏感。第4天仅接受经验性抗生素治疗。第8天患者出现急性肾功能衰竭(血肌酐1.9 mg/dL，高于前一天的1.2 mg/dL和入院时的0.8 mg/dL)。患者的格拉斯哥昏迷评分为3分，第10天心脏骤停发作后72小时头部计算机断层扫描显示正常结果。患者在第9天出现复发的MSSA菌血症，增加了中枢神经系统(CNS)感染的怀疑。停用纳福西林，疑似脑膜炎患者开始每日注射达托霉素9 mg/kg，持续至第16天死亡。第3次给药前达托霉素血药浓度为11.21μg/m L，脑脊液谷值为0.52μg/m L。腰椎穿刺术的结果不确定，进一步的血培养也没有MSSA阳性。肌酸激酶水平在达托霉素治疗前是正常的，没有重新评估。讨论：达托霉素在我们的患者继发于可能的那福西林引起的急性间质性肾炎和复发性菌血症。在剂量为9毫克/公斤时，所产生的渗透率为5%，高于以前的报道，与发炎的脑膜更一致。结论：对于标准治疗失败或不耐受的患者，无论是否有中枢神经系统来源的MSSA菌血症，大剂量达托霉素可能是一种替代选择。对确诊为脑膜炎的患者进行进一步的临床评估是有必要的。
Objective: To report a case of methicillin-sensitive Staphylococcus aureus (MSSA) bacteremia with suspected MSSA meningitis treated with high-dose daptomycin assessed with concurrent serum and cerebrospinal fluid (CSF) concentrations. Case Summary: A 54-year-old male presented to the emergency department with generalized weakness and presumed health-care–associated pneumonia shown on chest radiograph. Treatment was empirically initiated with vancomycin, levofloxacin, and piperacillin/tazobactam. Blood cultures revealed S. aureus susceptible to oxacillin. Empiric antibiotic treatment was narrowed to nafcillin on day 4. On day 8, the patient developed acute renal failure (serum creatinine 1.9 mg/dL, increased from 1.2 mg/dL the previous day and 0.8 mg/dL on admission). The patient's Glasgow Coma Score was 3, with normal findings shown on computed tomography scan of the head 72 hours following an episode of cardiac arrest on day 10. The patient experienced relapsing MSSA bacteremia on day 9, increasing the suspicion for a central nervous system (CNS) infection. Nafcillin was discontinued and daptomycin 9 mg/kg daily was initiated for suspected meningitis and was continued until the patient's death on day 16. Daptomycin serum and CSF trough concentrations were 11.21 μg/mL and 0.52 μg/mL, respectively, prior to the third dose. Lumbar puncture results were inconclusive and no further blood cultures were positive for MSSA. Creatine kinase levels were normal prior to daptomycin therapy and were not reassessed. Discussion: Daptomycin was initiated in our patient secondary to possible nafcillin-induced acute interstitial nephritis and relapsing bacteremia. At a dose of 9 mg/kg, resultant penetration of 5% was higher than in previous reports, more consistent with inflamed meninges. Conclusions: High-dose daptomycin may be an alternative option for MSSA bacteremia with or without a CNS source in patients who have failed or cannot tolerate standard therapy. Further clinical evaluation in patients with confirmed meningitis is warranted.