From the Guidelines
Daptomycin-induced eosinophilic pneumonia should be suspected in patients on daptomycin therapy who develop new respiratory symptoms, especially fever, dyspnea, cough, and hypoxemia, typically after 2-4 weeks of treatment, as described in the clinical practice guidelines by the Infectious Diseases Society of America 1. The diagnosis of daptomycin-induced eosinophilic pneumonia requires a combination of clinical, laboratory, and radiographic findings, including:
- Peripheral eosinophilia (>500 cells/μL)
- Pulmonary infiltrates on chest imaging (often bilateral and peripheral)
- Bronchoalveolar lavage showing >25% eosinophils
- Exclusion of other causes of eosinophilic pneumonia The most important step in management is immediate discontinuation of daptomycin, as this adverse reaction is thought to be related to the drug's accumulation in pulmonary surfactant, triggering an immune-mediated hypersensitivity reaction 1. Most patients improve within 1-2 days of stopping the medication, though corticosteroids (prednisone 40-60 mg daily with a 2-4 week taper) may be required in severe cases. Alternative antibiotics should be substituted based on the original indication and susceptibility patterns. It is essential to note that patients with a history of daptomycin-induced eosinophilic pneumonia should not be rechallenged with the drug due to the risk of recurrence, as reported in several case reports 1. The incidence of this adverse reaction is approximately 0.1-0.4% of patients receiving daptomycin, highlighting the need for close monitoring of patients on daptomycin therapy 1.
From the FDA Drug Label
5.3 Eosinophilic Pneumonia Eosinophilic pneumonia has been reported in patients receiving daptomycin for injection [see Adverse Reactions (6. 2)] . In reported cases associated with daptomycin for injection, patients developed fever, dyspnea with hypoxic respiratory insufficiency, and diffuse pulmonary infiltrates or organizing pneumonia. In general, patients developed eosinophilic pneumonia 2 to 4 weeks after starting daptomycin for injection and improved when daptomycin for injection was discontinued and steroid therapy was initiated Recurrence of eosinophilic pneumonia upon re-exposure has been reported. Patients who develop these signs and symptoms while receiving daptomycin for injection should undergo prompt medical evaluation, and daptomycin for injection should be discontinued immediately. Treatment with systemic steroids is recommended.
Diagnosis of Eosinophilic Pneumonia associated with daptomycin involves:
- Monitoring patients for signs and symptoms such as fever, dyspnea, and diffuse pulmonary infiltrates
- Prompt medical evaluation if these signs and symptoms occur
- Discontinuation of daptomycin immediately if eosinophilic pneumonia is suspected
- Treatment with systemic steroids is recommended 2
From the Research
Diagnosis of Eosinophilic Pneumonia Induced by Daptomycin
- Eosinophilic pneumonia is a group of lung diseases characterized by an increased number of eosinophils in the lungs and sometimes in the bloodstream 3.
- Daptomycin-induced eosinophilic pneumonia (DIEP) is a rare complication of daptomycin use, manifesting with fever, hypoxia, dyspnea, cough, eosinophilia, and lung changes on radiographs and CT 4.
- Patients typically develop symptoms after recent daptomycin exposure, including fever, dyspnea, infiltrates on chest radiograph, and more than 25% eosinophils on bronchoalveolar lavage, with improvement of symptoms after withdrawal of daptomycin 4.
Clinical Presentation and Treatment
- Common symptoms of DIEP include dyspnea (94%), fever (57%), and peripheral eosinophilia (77%), with infiltrates/opacities of CT/CXR (86%) 3.
- Treatment includes discontinuation of daptomycin, corticosteroids, and supportive measures such as supplemental oxygen 4, 5.
- Intravenous corticosteroids have been used to treat DIEP, with significant improvement in symptoms and radiographs 5.
- Prompt identification and treatment of DIEP are crucial, as delayed diagnosis and treatment can lead to severe consequences, including respiratory failure and death 6.
Challenges in Diagnosis and Management
- Multifactorial eosinophilia can pose challenges in diagnosis and management, particularly in patients with concurrent parasitic infections, such as strongyloidiasis 7.
- The use of corticosteroids in patients with parasitic infections can be complicated, and the timing of corticosteroid taper requires careful consideration 6, 7.
- A high index of suspicion for DIEP is necessary in patients who develop new onset of pulmonary and systemic signs and symptoms after initiation of daptomycin 3, 4.