How is Daptomycin infusion administered in an adult patient with a serious vancomycin-resistant Enterococcus faecium infection and potential impaired renal function?

Daptomycin Administration for VRE Infections

Standard Administration Method

Daptomycin must be administered as an intravenous infusion over 30 minutes in adults, never as a 2-minute IV push when treating serious enterococcal infections. 1

Reconstitution Protocol

• Remove the polypropylene flip-off cap and wipe the rubber stopper with alcohol, allowing it to dry 1
• Slowly transfer 10 mL of 0.9% sodium chloride through the center of the rubber stopper into the 500 mg vial, pointing the needle toward the vial wall (use 21-gauge or smaller beveled needle) 1
• Avoid vigorous agitation or shaking to minimize foaming 1
• Ensure all powder is wetted by gently rotating the vial, then allow to stand undisturbed for 10 minutes 1
• Gently rotate or swirl for a few minutes until completely reconstituted to achieve 50 mg/mL concentration 1

Dilution and Infusion for Adults

• Withdraw the appropriate volume from the reconstituted vial (50 mg/mL) using a 21-gauge or smaller needle 1
• Further dilute into a 50 mL IV infusion bag containing 0.9% sodium chloride 1
• Infuse over 30 minutes (infusion rate of 1.67 mL/minute) 1
• Never use dextrose-containing diluents—daptomycin is incompatible with dextrose solutions 1

Dosing for VRE Infections

For vancomycin-resistant Enterococcus faecium bacteremia, use high-dose daptomycin at 8-12 mg/kg IV daily, not the standard 6 mg/kg dose approved for other indications. 2

Specific Dosing Recommendations

• VRE bacteremia: 8-12 mg/kg IV daily, preferably combined with beta-lactams (ampicillin, penicillin, cephalosporins, or carbapenems if susceptible) 2
• Standard doses of 4-6 mg/kg are inadequate for enterococci due to reduced susceptibility and risk of resistance development 3
• Doses of 10-12 mg/kg/day are required to prevent emergence of daptomycin resistance in serious enterococcal infections 3

Renal Dosing Adjustments

For patients with creatinine clearance <30 mL/min (including hemodialysis and CAPD), administer daptomycin every 48 hours instead of every 24 hours. 1

• CrCl ≥30 mL/min: Standard dosing every 24 hours 1
• CrCl <30 mL/min: Dose every 48 hours 1
• Hemodialysis patients: Administer following completion of hemodialysis on dialysis days 1
• Mean AUC increases approximately 2-fold with CrCl <30 mL/min and 3-fold in dialysis patients compared to normal renal function 1

Stability and Storage

• Reconstituted solution in vial: Stable 12 hours at room temperature or 48 hours refrigerated (2-8°C) 1
• Diluted solution in infusion bag: Stable 12 hours at room temperature or 48 hours refrigerated 1
• Combined storage time (vial + bag) must not exceed 12 hours at room temperature or 48 hours refrigerated 1
• No preservatives present—use aseptic technique and discard unused portions 1

Critical Incompatibilities

Do not use daptomycin with ReadyMED® elastomeric infusion pumps—stability studies show incompatibility. 1

• Only compatible with 0.9% sodium chloride for both reconstitution and dilution 1
• Incompatible with all dextrose-containing solutions 1

Monitoring Requirements for High-Dose Therapy

Weekly CPK monitoring is mandatory when using high-dose daptomycin (≥8 mg/kg) due to myopathy risk. 4

• Obtain baseline CPK before initiating therapy 4
• Monitor CPK weekly throughout treatment course 4
• Discontinue if CPK elevation occurs with muscle symptoms or if CPK >5× upper limit of normal 4