title: Successful treatment of ventriculostomy-associated meningitis caused by multidrug resistant coagulase-negative Staphylococcus epidermidis using low-volume intrathecal daptomycin and loading strategy.
abstract: OBJECTIVE
  To report successful use of low-volume intrathecal (IT) daptomycin and loading strategy for the treatment of ventriculostomy-associated meningitis.
  
  
  METHODS
  A 23-year-old man with a history of multiple ventriculoperitoneal shunt revisions resulting from multidrug-resistant Staphylococcus epidermidis shunt infection presented with meningitis despite suppressive antibiotic therapy. After source control surgery, the patient improved with intravenous daptomycin plus IT vancomycin. Then, 4 days later, significant ventriculostomy output occurred, and the S epidermidis was confirmed to be intermediately sensitive to vancomycin (MIC = 8 µg/mL) and susceptible to daptomycin (MIC = 2 µg/mL). IT vancomycin was changed to IT daptomycin 5 mg in 3 mL normal saline (NS) every 24 hours for 3 days, then every 72 hours for 18 days. The cerebrospinal fluid (CSF) was sterile after 1 day of IT daptomycin and remained so. Creatine kinase remained normal throughout the course of treatment. The patient was discharged on hospital day 50 without antibiotics.
  
  
  CONCLUSIONS
  IT daptomycin has been reported for adult doses ranging from 5 to 10 mg once every 24 to 72 hours in volumes ranging from 5 to 10 mL; drug accumulation has been seen after the third dose of once every 24 hours dosing, and delayed improvement has been seen with once every 72 hours dosing. We planned for rapid load and CSF sterilization and extended the dosing interval once drug accumulation was expected to have occurred.
  
  
  CONCLUSIONS
  IT daptomycin 5 mg diluted to 3 mL in NS and dosed in a loading strategy was effective and without adverse sequelae.
authors.affiliation: University of California, San Francisco, CA, USA denetclawt@pharmacy.ucsf.edu.
authors.forename: Tina Harrach
authors.initials: TH
authors.lastname: Denetclaw
authors.affiliation: University of California, San Francisco, CA, USA.
authors.forename: Ion
authors.initials: I
authors.lastname: Suehiro
authors.affiliation: University of California, San Francisco, CA, USA.
authors.forename: Phyllis K
authors.initials: PK
authors.lastname: Wang
authors.affiliation: Marin General Hospital, Greenbrae, CA, USA.
authors.forename: Gregg L
authors.initials: GL
authors.lastname: Tolliver
mesh_terms: D000328:Adult; D000900:Anti-Bacterial Agents / Q000627:therapeutic use*; D003030:Coagulase / Q000378:metabolism; D017576:Daptomycin / Q000627:therapeutic use*; D024901:Drug Resistance, Multiple, Bacterial; D006801:Humans; D060186:Infusions, Spinal; D008297:Male; D016920:Meningitis, Bacterial / Q000188:drug therapy* / Q000382:microbiology; D013203:Staphylococcal Infections / Q000188:drug therapy* / Q000382:microbiology; D013212:Staphylococcus epidermidis / Q000187:drug effects* / Q000201:enzymology; D014640:Vancomycin / Q000627:therapeutic use; D014696:Ventriculostomy / Q000009:adverse effects
chemical_list: D000900:Anti-Bacterial Agents; D003030:Coagulase; D014640:Vancomycin; D017576:Daptomycin
keywords: daptomycin; intrathecal; meningitis; ventriculostomy