A 65-year-old man with hospital-acquired pneumonia is found to have bacteremia with vancomycin-resistant Enterococcus faecium. The isolate is susceptible to daptomycin. The clinician wants to use daptomycin for both bacteremia and pneumonia. What is the most appropriate response?

• A Daptomycin can be used at 10 mg/kg for both indications
• B Daptomycin is contraindicated because VRE is inherently resistant
• C Daptomycin should be combined with ceftaroline for pneumonia
• D Daptomycin should not be used for pneumonia because it is inactivated by pulmonary surfactant ✓

Explanation

Daptomycin is a lipopeptide antibiotic that is inactivated by pulmonary surfactant, making it ineffective for pneumonia despite in vitro susceptibility. It is used at 8-12 mg/kg for bacteremia and endocarditis but never for pneumonia. Option A is wrong because the inactivation precludes pneumonia use. Option C is wrong because combination does not overcome surfactant inactivation. Option B is wrong because VRE can be daptomycin susceptible.

Reference: Katzung Basic and Clinical Pharmacology, 15th ed.

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