Successful salvage therapy with Daptomycin for osteomyelitis caused by methicillin-resistant Staphylococcus aureus in a renal transplant recipient with Fabry-Anderson disease

Vancomycin, the first-line antibiotic choice for bone and joint infections caused by grampositive bacteria, has been reported with declining rates of efficacy against methicillin resistant Staphylococcus aureus (MRSA) isolates [1]. The treatment of osteomyelitis, septic arthritis and prosthetic joint infections with Vancomycin can therefore be difficult, often requiring prolonged administration [2-5]. The reduced susceptibility of S. aureus to Vancomycin may be partially due to biofilms, facilitating bacterial persistence [6-8]. Daptomycin, presently considered as a reliable alternative to the class of glycopeptides in these conditions [9], was recently used successfully, alone or in combination, for osteomyelitis caused by gram-positive pathogens including MRSA, unresponsive to other antibiotics [10]. Dosing of Daptomycin, however, and its ability to penetrate into inflamed target tissues are still a matter of controversy [11]. In this report we describe for the first time a case of right hell osteomyelitis caused by MRSA and successfully treated with third-line Daptomycin in a renal transplant recipient for Fabry-Anderson Disease (FAD).A 38-year-old patient, diagnosed with FAD in 1990, was put on hemodialysis since 1999 due to end-stage renal insufficiency and received a kidney transplant in 2007. Renal function did not recover immediately after renal transplantation, and sequential renal biopsies documented early rejection. For this reason, the patient was put on high dose oral Cyclosporine (150 mg twice daily) and was treated with high dose steroids without benefit. Everolimus (2.5 mg/daily) was therefore added and steroids tapered. Renal function improved 4 months after transplantation; hemodialysis was continued until that time. Due to relapsing decreases in renal function after each attempt to interrupt Everolimus, the association of these drugs could not be stopped ever since, although Cyclosporine could be reduced to 100 mg twice daily after 1 year. Levels