MKSAP Quiz: Assessment at hospital discharge
A 58-year-old man is assessed for discharge from the hospital. He was admitted 3 days ago with fever and chills. He has non-Hodgkin lymphoma and a tunneled subclavian venous catheter used for chemotherapy infusion. The patient is ready to be discharged to complete intravenous daptomycin therapy as an outpatient. What is the most appropriate weekly monitoring of his daptomycin therapy?
A 58-year-old man is assessed for discharge from the hospital. He was admitted 3 days ago with fever and chills. He has non-Hodgkin lymphoma and a tunneled subclavian venous catheter used for chemotherapy infusion. Blood cultures at admission grew vancomycin-resistant Enterococcus faecium. The patient's catheter was removed, a peripherally inserted central catheter (PICC) was placed for intravenous access, and daptomycin therapy was initiated. Blood cultures are now negative, and the patient is afebrile.
The patient is ready to be discharged to complete intravenous daptomycin therapy as an outpatient. At the time of discharge, his complete blood count and comprehensive chemistry profile are normal.
Which of the following is the most appropriate weekly monitoring of his daptomycin therapy?
A. Electrocardiography and blood glucose
B. Hemoglobin and platelet count
C. Serum amylase and triglycerides
D. Serum creatinine and creatine kinase
MKSAP Answer and Critique
The correct answer is D. Serum creatinine and creatine kinase. This content is available to MKSAP 18 subscribers as Question 46 in the Infectious Disease section. More information about MKSAP is available online.
Patients receiving outpatient daptomycin therapy should undergo baseline measurement of kidney function and creatine kinase (CK) followed by weekly monitoring. Patients should also be screened for symptoms of myopathy. Daptomycin is commonly used for outpatient parenteral antibiotic therapy (OPAT) because of its safety profile, ease of administration (once daily), and good activity against gram-positive bacteria, including vancomycin-resistant enterococci and methicillin-resistant Staphylococcus aureus. However, daptomycin is known to cause elevated levels of CK and can contribute to the development of myopathy during therapy. Daptomycin should be discontinued in asymptomatic patients if CK levels increase to greater than 10 times the upper limit of normal or the CK level is greater than 5 times the upper limit of normal with symptoms of myopathy. Concomitant treatment with statins (particularly simvastatin and atorvastatin) may increase the chance of developing an elevated CK level; it is suggested that statins be discontinued if possible during daptomycin treatment. If statins cannot be discontinued, or if kidney dysfunction is evident, the CK level should be monitored more frequently than once weekly. Likewise, the creatinine level should also be monitored because daptomycin dosing may require adjustment (lower dose or dosing interval of every other day), and CK may require more frequent monitoring if the creatinine level increases.
Daptomycin use does not require electrocardiographic monitoring, and it has no effect on the bone marrow (for example, erythrocyte or platelet suppression), pancreas, lipid levels, or blood glucose level; so weekly amylase, triglyceride, glucose, and hemoglobin measurements and platelet count monitoring are unnecessary (although periodic leukocyte counts may be necessary in some patients for monitoring of the primary infection). It is important for patients undergoing OPAT to have close follow-up to monitor for any adverse effects from antibiotic therapy (including development of vascular access infections) as well as resolution of the infection being treated.
Key Point
- Patients receiving daptomycin therapy should undergo baseline measurement of kidney function and creatine kinase level followed by weekly monitoring.