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Case: Six-month-old infant with large ventricular septal defect (VSD) who underwent pulmonary artery banding as a part of initial surgery. He had a dying spell due to tracheal compression by dilated right pulmonary artery. Therefore, an emergency VSD repair and aortopexy were performed. Thereafter, peripheral vascular catheter-related blood stream infection due to Methicillin-resistant Staphylococcus aureus (MRSA) occurred andLed to infective endocarditis with vegetation on tricuspid valve. Antimicrobial therapy centering on vancomycin (VCM) was initiated. However, VCM minimum inhibitory concentration of isolates changed from 1 to 2 μg/mL and bacteremia did not improve even though the trough level of VCM was within recommended therapeutic concentrations. We suspected the presence of heterogeneous vancomycin-intermediate Staphylococcus aureus (hVISA), and teicoplanin (TEIC) was started instead of VCM. In addition, albekacin (ABK) and (linezolid) LZD were added on. Thereafter, bacteremia improved and only transient reticulocytopenia and anemia were confirmed as an adverse effect of the therapeutic drug. The multidrug therapy can be an alternative for refractory infective endocarditis due to drug resistant Staphylococcus aureus under adequate therapeutic drug monitoring (TDM).

Refractory Infective Endocarditis Due to MRSA which Vancomycin MIC Changed During Antimicrobial Therapy