Daptomycin (IV)

Criteria & Principles

A summary table of daptomycin dosing guidelines is attached

Adjustment of Dose & Administration

Indication-Specific Adjustment

Indication	CrCl (mL/min)
	>30	10-30	<10, IHD	CRRT
Skin and soft tissue (complicated) Urinary tract infection (complicated)	4 mg/kg q24h	4 mg/kg q48h	6 mg/kg q48hr OR 4 mg/kg for 48hr inter-dialytic session AND 6 mg/kg for 72hr inter-dialytic session	4 mg/kg q48h
Bacteremia (non-S. aureus/enterococci) Intra-abdominal Febrile Neutropenia (empiric use for VRE colonization or history of VRE)	6 mg/kg q24h	6 mg/kg q48h	6 mg/kg q48hr OR 6 mg/kg for 48hr inter-dialytic session AND 8 mg/kg for 72hr inter-dialytic session	6 mg/kg q48h
Bacteremia (Staph aureus or vanc-susceptible enterococci) Bone and Joint Endocarditis	8 mg/kg q24h	8 mg/kg q48h	8 mg/kg q48hr OR 8 mg/kg for 48hr inter-dialytic session AND 10 mg/kg for 72hr inter-dialytic session	8 mg/kg q48h*
Vanc Resistant Enterococci bacteremia Invasive, refractory enterococcal infections	10 mg/kg q24h	10 mg/kg q48h	10 mg/kg q48hr OR 10 mg/kg for 48hr inter-dialytic session AND 12 mg/kg for 72hr inter-dialytic session	10 mg/kg q48h*

*Consider q24h dosing in CRRT for patients recieving effluent rates >30 mL/kg/hr or those not responding to standard dosing, with close CK monitoring

Pneumonia and Meningitis: DO NOT USE!  Daptomycin is inactivated by lung surfactant and does not adequately cross the blood brain barrier.

Use total body weight (TBW) for non-obese (BMI <30).  In obese patients (BMI > 30), use Adjusted Body Weight (ABW).

Daptomycin requires ID consult and approval UNLESS the patient meets "Per Protocol" exception criteria noted in Adult Febrile Neutropenia guidelines. 

NOTE: Enterococcus breakpoint of SDD refers to a breakpoint of </= 4 ug/mL.  Use dosing recommended in the table above.

All daptomycin orders should be rounded to the nearest 50 mg in accordance with the dose-rounding protocol.

 

Daptomycin Discharge Considerations for ID Consultants (more information about OPAT processes click here)

Clinical criteria to consider for OPAT daptomycin use:

Pathogens: Staphylococcus spp. (MRSA, MSSA, coagulase negative Staphylococcus)

Exclusion criteria:

Pulmonary infections

CNS infections

Infections with high risk of treatment resistance:

• Extensive vancomycin use beforehand, defined as >6 weeks of vancomycin with a likely persistent source of infection
• Insufficient source control

Steps for ID to fascilitate discharging on daptomycin:

1. Use the “treatment teams” function to secure chat the primary team case manager and request a cost estimate for daptomycin vs vancomycin for OPAT.
2. If approved for a switch, notify the primary team about plan to transition to daptomycin and request a first dose be administered inpatient.
3. Add or update the treatment plan.

Renal Adjustment

See indication-specific dosing for creatinine clearance < 30 mL/min and hemodialysis

Serum Concentration Monitoring

Baseline and weekly monitoring of CK is suggested. More frequent CK monitoring may be considered in:

• On concomitant statin therapy (recommended to hold statin if possible during daptomycin therapy)
• Receiving high doses of daptomycin (>8 mg/kg/day)
• With morbid obesity and receiving >1200 mg/day
• With elevated baseline CK

Discontinue daptomycin if:

• Asymptomatic patients when CK >10x upper limit of normal (2000 IU/L)
• Symptomatic or sedated/non-verbal patients when CK >5x upper limit of normal (1000 IU/L)

 

Drug-Specific Information

Administer IV in saline or lactated ringer’s only.

Daptomycin Dose Rounding & Batching Policy

Full policy with background is attached.

Orders for q24h (creatinine clearance > 30ml/min) 

The first dose will be prepared and dispensed at the initiation of the order. For orders received 0000 – 1159 (first dose before noon), the subsequent dose will be scheduled for administration at 2100 on the same day. For an order received 1200 – 2359 (first dose after noon), the subsequent dose is administered at 2100 on the subsequent day. All subsequent doses are prepared together in the IV room as a batch, using the 500-mg single-use vials with the unused portion of each vial used to prepare the subsequent dose. Approximately 60% of orders are expected to be placed after 1200, therefore the majority of patients will receive a single dose on day 1*. 

*For specific circumstances of concern and under the discretion of the pharmacist and infectious diseases consult service, daptomycin dosing may be modified to allow for the subsequent dose to be later (i.e. for very underweight or overweight patients) or earlier (i.e. for critical illness) than the protocol-based dosing.  

Orders for q48h regimen (CrCl < 30 ml/min) 

The first dose is prepared and dispensed at the initiation of the order (day 1). For orders received 0000 – 1159 (first dose before noon), with the subsequent dose administered at 2100 on the subsequent day (day 2). For an order received 1200 – 2359 (first dose after noon), the subsequent dose is administered at 2100 on day 3. 

Orders for three times weekly after hemodialysis (Post-hemodialysis dosing) 

For orders received 0000 – 1159 (first dose before noon), and orders received 1200-2359 (first dose after noon), the first dose is prepared and dispensed at the initiation of the order, with a maintenance dose administered at 2100 following the next dialysis session.

Restricted Use

NOTE: In light of the Baxter IV fluid shortage, daptomycin restriction to ID consult has temporarily transitioned to ID telephone approval for ADULT patients

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ID consult is REQUIRED unless meeting exception criteria in Adult Febrile Neutropenia Guideline.

General Notes

1. Up-to-date cost information, click here 
2. IV antimicrobials outpatient (OPAT) dosing, click here
3. Obesity dosing weight recommendations here
4. Helpful drug-drug interaction check website here 
5. When dosing guidance is provided it is important to note the following:

Fixed (ie non weight-based) doses in adults are historically based on a 70 kg patient. Specific disease states or individual patients may warrant dosages that differ from the above recommendations. Since product-specific criteria for dose adjustment based on creatinine clearance exist, consult product information regarding specific recommendations for dosage adjustment based on estimated creatinine clearance.