title: An Unusual Occurrence of Methicillin Resistant Staphylococcal Endocarditis with Vancomycin Creep Phenomenon - A Therapeutic Challenge.
abstract: Infective endocarditis by Methicillin ResistantStaphylococcus aureus(MRSA) bacteraemia is a common association and carries a high mortality. However, rising Minimum Inhibitory Concentrations (MICs) for vancomycin amongst MRSA strains is an emerging threat which carries poor prognosis and higher mortality. Here, we report a case of 41-year-old young non-addict gentleman presenting with fever of 3 days duration following recovery from an acute kidney injury necessitating haemodialysis. Systemic examination revealed signs of mitral regurgitation and left sided cerebellar signs. Laboratory investigations revealed anaemia, MRSA bacteraemia and transthoracic echocardiogram showed a mitral valve vegetation. He was diagnosed with MRSA mitral valve endocarditis with acute left cerebellar infarct. He was initially treated with intravenous vancomycin based on MIC at the dose of one gram every twelfth hourly. As the MRSA strain was shown to demonstrate a vancomycin creep phenomemon along with worsening clinical condition of the patient, treatment was changed to intravenous daptomycin at dose of 9mg/kg as per blood culture and sensitivity pattern which was administered for 6 weeks. Following initiation of daptomycin patient became afebrile and vegetations reduced in size and finally disappeared.
authors.affiliation: Assistant Professor, Department of Internal Medicine, Kasturba Medical College , Manipal, Karnataka, India .
authors.forename: S
authors.initials: S
authors.lastname: Sneha
authors.affiliation: Junior Resident, Department of Internal Medicine, Kasturba Medical College , Manipal, Karnataka, India .
authors.forename: Shanthan
authors.initials: S
authors.lastname: Venishetty
authors.affiliation: Professor, Department of Internal Medicine, Kasturba Medical College , Manipal, Karnataka, India .
authors.forename: Shubha
authors.initials: S
authors.lastname: Seshadri
authors.affiliation: Registrar, Department of Cardiology, Kasturba Medical College, Manipal University , Manipal, Karnataka, India .
authors.forename: M Sudhakar
authors.initials: MS
authors.lastname: Rao
authors.affiliation: Professor, Department of Microbiology, Kasturba Medical College, Manipal University , Manipal, Karnataka, India .
authors.forename: Chiranjay
authors.initials: C
authors.lastname: Mukhopadhyay
keywords: Daptomycin; Minimum inhibitory concentration; Mitral valve endocarditis