C42-13 Antibiotic Turned Adversary: A Case Series of Daptomycin Induced Eosinophilic Pneumonia

Abstract Daptomycin-induced eosinophilic pneumonia (DIEP) is a life-threatening adverse drug reaction akin to a T-lymphocyte-mediated hypersensitivity reaction. DIEP is defined as concurrent exposure to daptomycin associated with fever, dyspnea, hypoxemia, new pulmonary infiltrates, bronchoalveolar lavage (BAL) fluid with 25% eosinophils, and clinical improvement following drug discontinuation. This case series highlights one definite and two probable cases of DIEP. Case 1 An 81-year-old man with infected total knee arthroplasty (TKA) was admitted after 20 days of treatment with daptomycin, when he presented with dyspnea, hypoxemia, patchy ground glass opacities on CT chest, and 9% peripheral eosinophilia. Hypoxemia and pulmonary opacities worsened despite antibiotics targeted for community acquired pneumonia. Daptomycin was discontinued after the tenth day, and BAL revealed 60% eosinophils. He received two days of corticosteroids with rapid improvement in pulmonary opacities and resolution of hypoxemia. Case 2 A 61-year-old man was admitted for dyspnea and extensive right left pulmonary opacities after 17 days of treatment with daptomycin for septic TKA. Labs noted 2.7% eosinophilia. The patient received broad spectrum antibiotics. On the third day, daptomycin was discontinued and empiric steroids began. BAL performed on the fourth day revealed 14% eosinophils. Symptomatic and radiologic improvement was noted by the fifth day. He was discharged on a steroid taper, and chest CT one month later revealed clear lungs. Case 3 After 21 days of treatment with daptomycin for a hip prosthetic joint infection, an 87 year-old man was hospitalized with dyspnea, dry cough, hypoxemia, and right upper lobe peripheral infiltrate on CXR. Labs noted 9.2% eosinophilia. DIEP was suspected, thus daptomycin was immediately switched to linezolid, and empiric steroids were started. Bronchoscopy was not performed because by day 3 radiographic abnormalities were rapidly fading and hypoxemia had resolved, at which time the patient was discharged on a prednisone taper. Conclusion All patients displayed features of DIEP and rapidly improved after daptomycin discontinuation and corticosteroid initiation, consistent with a recently proposed diagnostic algorithm that makes a presumptive diagnosis of DIEP in the presence of daptomycin exposure along with CT chest findings consistent with eosinophilic pneumonia and the presence of peripheral eosinophilia. Without peripheral eosinophilia, BAL eosinophilia 5% would support the diagnosis. Although rare, DIEP should be highly suspected in patients who develop pulmonary infiltrates and hypoxemia while receiving daptomycin, leading to prompt imaging, evaluation for eosinophilia, and in the absence of alternative diagnoses, discontinuation of daptomycin and consideration of treatment with steroids. This abstract is funded by: None