An unusual occurrence of methicillin resistant staphylococcal endocarditis with vancomycin creep phenomenon – A therapeutic chall

Infective endocarditis by Methicillin Resistant Staphylococcus aureus (MRSA) bacteraemia is a common association and carries a high mortality. However, rising Minimum Inhibitory Concentrations (MICs) for vancomycin amongst MRSA strains is an emerging threat which carries poor prognosis and higher mortality. Here we report a case of 41-year-old young non-addict gentleman presenting with fever of 3 days duration following recovery from an acute kidney injury necessitating haemodialysis. Systemic examination revealed signs of mitral regurgitation and left sided cerebellar signs. Laboratory investigations revealed anaemia, MRSA bacteraemia and transthoracic echocardiogram showed a mitral valve vegetation. He was diagnosed with MRSA mitral valve endocarditis with acute left cerebellar infarct. He was initially treated with intravenous vancomycin based on MIC at the dose of one gram every twelfth hourly. As the MRSA strain was shown to demonstrate a vancomycin creep phenomemon along with worsening clinical condition of the patient, treatment was changed to intravenous daptomycin at dose of 9mg/kg as per blood culture and sensitivity pattern which was administered for 6 weeks. Following initiation of daptomycin patient became afebrile and vegetations reduced in size and finally disappeared.