LAUSR

Critical Care Medicine • Volume 46 • Number 1 (Supplement) www.ccmjournal.org Learning Objectives: Antibiotic selection for the treatment of multidrug resistant empyema can be complicated due to a lack of information regarding antimicrobial penetration to the pleural space. We present a rare case of vancomycin resistant Enterococcus faecium (VRE) cultured in pleural fluid and treated with high dose daptomycin. Due to limited sensitivities and a lack of information supporting the penetration of daptomycin into the pleural space, serum and pleural fluid concentrations were obtained to guide treatment. Methods: A 60 year old female with an extensive medical history notable for nonspecific interstitial pneumonia presented with severe hypoxic respiratory failure and eventually underwent a right lung transplantation. After transplantation, the patient remained critically ill with a complicated course including the development of a right sided empyema requiring chest tube placement. Results: The patient was treated empirically with vancomycin and meropenem, dose adjusted for moderate renal impairment, while pleural fluid was sent for culture and analysis. Microbiology results showed VRE with intermediate sensitivity to linezolid and a daptomycin MIC of 4 mcg/ml. Four days following chest tube placement, therapy was changed to daptomycin (8 mg/kg). Steady state serum and pleural concentrations were obtained at 0.5, 4.5 and 24 hours post administration. Serum: pleural results were 133.8: 21.4, 119.6: 24.4, and 67.6: 32.5 μg/ml respectively. After three days of daptomycin monotherapy, the dose was increased to 10 mg/kg due to the high MIC and synergistic ampicillin was utilized for 15 days to enhance cell membrane binding. Repeat pleural fluid cultures cleared after 11 days of synergistic of treatment, chest tube drainage, and one surgical debridement. Total daptomycin treatment duration was four weeks in which no adverse effects were noted. The patient remains critically ill with a prolonged hospital admission unrelated to this case. This case is the first to our knowledge to describe the penetration of daptomycin into pleural space for the treatment of an empyema caused by VRE.