Daptomycin-induced eosinophilic pneumonia treated with intravenous corticosteroids

Design

Case presentation 1

A 77-year-old man with a history of hypertension, diabetes, dyslipidemia, and chronic kidney disease was transferred for worsening pleuritic chest pain, dyspnea, and hypoxemia (77% on 4 L/min O₂) after recently completing a 6-week course of daptomycin for osteomyelitis. On admission, he had leukocytosis, elevated inflammatory markers, and bilateral airspace opacities on imaging. Despite initial treatment for healthcare-associated pneumonia (azithromycin, linezolid, aztreonam), he rapidly deteriorated, requiring intubation. Bronchoalveolar lavage revealed eosinophilic predominance (18%), prompting a diagnosis of daptomycin-induced eosinophilic pneumonia (DIEP). Intravenous methylprednisolone led to rapid clinical and radiographic improvement, allowing extubation. Antibiotics were discontinued after negative cultures, and steroids were tapered over 8 weeks. Daptomycin was not reintroduced.

Case presentation 2

A 74-year-old woman with a history of COPD, fibromyalgia, and recurrent hip infections developed probable daptomycin-induced eosinophilic pneumonia (DIEP) after restarting daptomycin for osteomyelitis. Initially treated with daptomycin and ciprofloxacin post-surgical drainage, she was switched to linezolid due to acute kidney injury. Two weeks later, daptomycin was resumed alongside ceftriaxone, but within 72 hours, she developed fever (100.4°F) and rapidly progressive hypoxemia, requiring escalating oxygen support up to 80% FiO₂ via noninvasive ventilation. Chest imaging showed worsening bilateral airspace disease without signs of pulmonary embolism or infection. Despite lacking eosinophilia, DIEP was suspected due to the temporal association with daptomycin and exclusion of alternative causes. High-dose IV methylprednisolone (60 mg every 6 hours) led to rapid improvement within 24 hours, avoiding intubation. Steroids were transitioned to oral prednisone for a planned taper. Daptomycin was discontinued permanently.

Study Author Conclusions

Diagnosis and Management of Daptomycin-Induced Acute Eosinophilic Pneumonia: A Case Report

Design

Case Report

Case Presentation

A 70-year-old white male with a past medical history of chronic obstructive pulmonary disease (COPD), asthma, obesity, and hypertension was admitted with septic shock secondary to MRSA bacteremia. Empiric therapy with vancomycin, ceftriaxone, and metronidazole was initiated, but he remained on vancomycin alone after blood cultures confirmed MRSA. The patient clinically improved and was transitioned to daptomycin 8mg/kg intravenous (IV) every 24 hours for 6 weeks for presumed endovascular infection upon discharge. Twelve days later, the patient was readmitted for progressive dyspnea and a significant cough. He was found to be hyponatremic, which improved with IV fluids and discontinuation of hydrochlorothiazide. Chest X-ray showed developing patchy infiltrates, and labs revealed leukocytosis with peripheral eosinophilia. Given the need to complete a six-week antibiotic course, daptomycin was discontinued, and vancomycin was resumed. The patient was treated with prednisone 40 mg daily for 5 days during hospitalization. Clinical improvement was noted, with resolution of hypoxia and down-trending eosinophil count.

Study Author Conclusions

In severe cases, particularly those with respiratory distress, initiation of prednisone may lead to significant clinical improvement, often within 24-48 hours.

DAPTOMYCIN-INDUCED ACUTE EOSINOPHILIC PNEUMONIA

Design

Case presentation

An 81-year-old male with congestive heart failure (CHF) presented with acute hypoxic respiratory failure, cough, and bilateral lung infiltrates. He had been on daptomycin for MRSA osteomyelitis for 23 days. After ruling out pulmonary embolism and CHF exacerbation, daptomycin-induced eosinophilic pneumonia (DIEP) was suspected. Daptomycin was stopped, and empiric antibiotics (vancomycin, piperacillin-tazobactam) were given until infection was excluded. IV methylprednisolone led to rapid improvement within 48 hours. He was discharged on a steroid taper and vancomycin for osteomyelitis, with DIEP as the presumed diagnosis.

Study Author Conclusions

This case describes a rare but serious adverse event related to daptomycin. Since the mechanisms of adverse events are still unknown and the management with supportive therapies, i.e steroids, is still debatable, it is important for case reports like this one to increase awareness. Early detection is key to preventing other serious effects, such as acute respiratory distress syndrome.

Two Patients with Daptomycin-Induced Eosinophilic Pneumonia With Different Presentations And Treatment

Design

Case presentation 1

A 68-year-old white male who was seen at the infectious disease clinic when he was remaining with 2 more weeks of a 6-week course of Daptomycin/Rifampin for Staphylococcus epidermidis septic arthritis. He had been switched from vancomycin due to significant renal toxicity. The patient reported having a dry cough with occasional clear sputum and a low-grade fever of 100.3°F but denied rash or joint swelling. Vitals were stable except for fever and oxygen saturation of 89%, dropping to 84% on ambulation. Fine basilar crackles were auscultated bilaterally, but no murmurs, jugular venous distention (JVD), or edema. Chest x-ray (CXR) showed bilateral ill-defined opacities on the left side, and high-resolution computed tomography (CT) revealed interstitial and ground-glass opacities. Labs showed white blood count (WBC) 5700/μL with 11% eosinophils, hemoglobin 9.9 g/dL, CRP 34.1, ESR 25, creatinine kinase (CK) 92, and arterial blood gas (ABG) with PO₂ of 63, and bronchoscopy with BAL revealed 28% eosinophils. Patient was admitted and placed on high-flow oxygen and diagnosed with daptomycin-induced eosinophilic pneumonia (DIEP). He was started on methylprednisolone 60 mg intravenous (IV) Q6H, and then changed to prednisone 40 mg PO daily, and tapered over 4 weeks. He showed significant improvement after initiating daptomycin and steroid treatment and was discharged on 3L of oxygen. 

Case Presentation 2

A 71-year-old male patient was transferred from another facility for evaluation of dyspnea, cough, fever, and diaphoresis after being discharged on IV daptomycin to complete a 6-week treatment course. He was initially diagnosed with healthcare-associated pneumonia and started on antibiotics, including daptomycin. While admitted, he required 2L of nasal cannula oxygen and had stable vitals except for a temperature of 100°F. Saturated oxygen was 92% on 2L. Examination revealed decreased breath sounds in the lower lung fields bilaterally with fine crackles. Labs revealed WBC 6500/μL with 6.4% eosinophils, hemoglobin 9.6 g/dL, platelets 134,000/μL, creatinine 1.28 mg/dL, and procalcitonin 0.26 ng/mL. Chest high-resolution computed tomography (HRCT) showed upper lobe bilateral infiltrates. The clinical and radiologic findings were consistent with DIEP. Daptomycin was stopped, and the patient was treated with methylprednisolone 60 mg IV, switched to prednisone 40 mg PO for 5 days. His symptoms and hypoxemia improved, and he was discharged without oxygen. 

Study Author Conclusions

Daptomycin is being used extensively by infectious disease specialists and ICU physicians. Its indications are being extended from time to time because of its excellent antimicrobial activity and coverage. Because of this, the relatively rare complication of DIEP is expected to rise significantly proportional to the use of daptomycin. Life-threatening respiratory failure can happen if the diagnosis is missed and appropriate treatment is not instituted. Physicians should make themselves aware of this condition and properly treat these patients.

Daptomycin-Induced Pulmonary Toxicity: A Case Series

Design

Case presentation 1

Case presentation 2

Study Author Conclusions