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Case Reports
.2012 Oct;56(10):5296-302.
doi: 10.1128/AAC.00797-12. Epub 2012 Aug 6.

Addition of ceftaroline to daptomycin after emergence of daptomycin-nonsusceptible Staphylococcus aureus during therapy improves antibacterial activity

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Case Reports

Addition of ceftaroline to daptomycin after emergence of daptomycin-nonsusceptible Staphylococcus aureus during therapy improves antibacterial activity

Warren E Rose et al. Antimicrob Agents Chemother.2012 Oct.

Abstract

Antistaphylococcal beta-lactams enhance daptomycin activity and have been used successfully in combination for refractory methicillin-resistant Staphylococcus aureus (MRSA) infections. Ceftaroline possesses MRSA activity, but it is unknown if it improves the daptomycin potency comparably to other beta-lactams. We report a complex patient case of endocarditis who was treated with daptomycin in combination with ceftaroline, which resulted in clearance of a daptomycin-nonsusceptible strain. An in vitro pharmacokinetic/pharmacodynamic model of renal failure was used to simulate the development of daptomycin resistance and evaluate the microbiologic effects of daptomycin plus ceftaroline treatment. Combination therapy with daptomycin and ceftaroline restored daptomycin sensitivity in vivo and resulted in clearance of persistent blood cultures. Daptomycin susceptibility in vitro was increased in the presence of either ceftaroline or oxacillin. Daptomycin at 6 mg/kg of body weight every 48 h was bactericidal in the model but resulted in regrowth and daptomycin resistance (MIC, 2 to 4 μg/ml) with continued monotherapy. The addition of ceftaroline at 200 mg every 12 h after the emergence of daptomycin resistance enhanced bacterial killing. Importantly, daptomycin plus ceftaroline as the initial combination therapy produced rapid and sustained bactericidal activity and prevented daptomycin resistance. Both in vivo- and in vitro-derived daptomycin resistance resulted in bacteria with more fluid cell membranes. After ceftaroline was added in the model, fluidity was restored to the level of the initial in vivo isolate. Daptomycin-resistant isolates required high daptomycin exposures (at least 10 mg/kg) to optimize cell membrane damage with daptomycin alone. Ceftaroline combined with daptomycin was effective in eliminating daptomycin-resistant MRSA, and these results further justify the potential use of daptomycin plus beta-lactam therapy for these refractory infections.

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Figures

Fig 1
Fig 1
Course of therapy timeline until definitive clearance of bacteremia in a patient with prosthetic valve endocarditis treated with daptomycin alone and then combined with ceftaroline. Following the collection of the timeline data presented here, the patient was hospitalized for an additional 48 days, received combination therapy throughout, and all remaining blood cultures were negative.
Fig 2
Fig 2
Pharmacokinetic concentration-time profiles of expected and observed concentrations in the one-compartmentin vitro pharmacodynamic model over the 7-day simulation. (A) Daptomycin; (B) ceftaroline.
Fig 3
Fig 3
Antibiotic activity in thein vitro PK/PD model of daptomycin alone and in combination with ceftaroline in the initial daptomycin-susceptible clinical isolate W3148. (A) Single antibiotic exposure. black circles, growth control; black squares, daptomycin at 6 mg/kg every 48 h; white circles, ceftaroline at 200 mg every 12 h. (B) Combination antibiotic exposure results. Black circles, growth control; black triangles, DAP treatment every 48 h with CPT added on day 3; white diamonds, initial therapy with DAP every 48 h combined with CPT on day 1.
Fig 4
Fig 4
Emergence of daptomycin (DAP) resistance in the pharmacodynamic model detected after screening plates containing daptomycin at 3 μg/ml. Daptomycin resistance occurred in each model of daptomycin monotherapy, but it varied in the initiation and degree of formation up to 72 h. The addition of ceftaroline (CPT) at 72 h to the DAP regimen eliminated DAP resistance in model isolates. Black squares, DAP at 6 mg/kg every 48 h; black triangles, DAP at 6 mg/kg every 48 h with CPT added on day 3.
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References

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