In that case would high dose dapto and eventual switch to LZD (you didn’t give us species so not sure if Amp/Amox is an option for treatment or SAT?). This does make longer therapy a dicier proposition.
I don’t think either of the long-acting drugs are meaningfully dialyzed so you’re probably OK, but HD dosed dapto (if the dialysis center will do it) is prob cheaper and no more burdensome.
I’m with Nico on this one. Risk of failure is prob closer to 100% mortality given where the graft lies. I would try to treat with IV as long as possible and then SAT thereafter.
I’d just say that in theory could do linezolid with TDM although I would need someone to help with what the TDM targets are. Would be high risk of toxicity in ESKD though. Can always test tetracycline susceptibilities for SAT purposes if lucky even if imperfect
I would do 6 weeks. I think with surgery should have excellent source control. Does the datipo trial suggest longer for you? Or would you do something different?
Does vre matter for you? For me it doesn’t…but I’m open
I see. But guidelines post valve replacement are 4-6 weeks when cultures are positive, so what is wrong with those recommendations? Do you do something different? Seems reasonable to me. I wonder if can go shorter even, but would want a good trial of course
There simply aren’t comparative clinical outcomes data to give us a sense of the optimal antibiotic duration in this situation. I don’t know that arguing which set of expert opinion guidance is best is all that useful. That said, some cohort suggest tx outcome of VGI even with >6wk abx is not great
12 weeks IV dapto & fosfo / beta lactam then consider longer term linezolid / tedizolid / pristinamycin. Pet scan at 6 - 12 months to see if ongoing inflammatory change
I think both--synergy and delayed dapto resistance--may be true. In a high-risk case like this, I'd consider reaching out to a subject matter expert in enterococcal infections like Cesar Arias in Houston.
Comments
What are you planning on doing?
I agree w/ 12wk here fwiw
The STAR review on graft infections made me appreciate the complexity of graft inf
https://academic.oup.com/cid/article/78/6/e69/7657454?searchresult=1
Does vre matter for you? For me it doesn’t…but I’m open