Duru, F.

Enseleit, F.

Lachat, M.

Mueller, N.

Noll, G.

Ruschitzka, F.

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Teicoplanin-Induced Complete AV-Block in a HeartTransplant RecipientTeicoplanin is a glycopeptide antibiotic used againstestablished or assumed methicillin-resistant gram-positiveinfections. An association between teicoplanin treatmentand advanced heart block has not been reported to date.A 52-year-old man with end-stage heart failure wasadmitted for implantation of a left ventricular assistdevice (Berlin Heart INCOR). Two days after implanta-tion the patient received vancomycin (2 · 1 g/day) andrifampicin (4 · 450 mg/day) because of a central venouscatheter infection with coagulase-negative Staphylococci.Thirteen days after LVAD device implantation, thepatient developed severe pneumonia. Two days latervancomycin was stopped because of drug-induced leuco-penia. Subsequently, vancomycin was then replaced withthe glycopeptide teicoplanin at a dose of 600 mg on day 1and 400 mg QD the following days. The white blood cellcount returned to normal in the following days. Five daysafter begin of teicoplanin therapy orthotopic heart trans-plantation (HTX) was performed. Immunosuppressivetherapy was started with anti-T-lymphocyte-immunglob-uline (ATG), cyclosporine, azothioprin and prednisone.Trough plasma levels of teicoplanin were in the rangebetween 13 and 14 mg/l (normal therapeutic range10–15 mg/l). On day 17 after begin of teicoplanin therapy(day 12 after HTX) the patient developed completeAV-block III (CAVB) (Figure 1). The time interval of12 days after HTX made a surgical insult during HTXunlikely. Similarly, endomyocardial biopsy (EMB),showed no clinically relevant signs of rejection (ISHT1A), thus further suggesting potential side effect of drugtherapy. Hence, teicoplanin therapy was suspended.Subsequently, sinus rhythm with normal AV conduction(Figure 1) was restored, suggesting that the medicationwas indeed a likely cause of the AV-block. After inci-dental reexposition to teicoplanin (on day 19 after HTX),the patient developed a rapid decrease in heart rate andCAVB again with hemodynamic instability, which furthercorroborates this hypothesis. Teicoplanin was stopped,vancomycin started and the sinus rhythm reoccurred again(Figure 1).Transient or permanent atrioventricular conductiondisturbances are well recognized after cardiac surgery.However, only few data on persistent or permanentAV-blockade after heart transplantation are available. Ina retrospective study by Cui et al. [1] including 1,047consecutive patients the overall incidence for AV-block-ade was 10.8%. The incidence of complete AV-block inthis study was 1.8% (19 of 1,047 patients). In four patientsCAVB occurred immediately after HTX as result of asurgical insult. In seven patients complete AV-blockoccurred during EMB or coronary angiography, fourepisodes of cellular or humoral rejection were associatedwith CAVB. The time interval of 12 days after HTXmakes a surgical insult as a cause of the CAVB unlikely,since the consequences of a surgical insult result in CAVBdirect after HTX. EMB performed the day after theoccurrence of CAVB showed no clinically significantrejection (ISHT 1A).Concomitant medications include pipamperon,amphotericin B, captopril, citalopram, calcitriol, predni-sone, cyclosporine, azothioprine, torasemid and valgan-cyclovir, in usual dosages. The combination of the drugsused in the described patient may lead to nephrotoxicity,myelosupression, first-dose hypotension and hypokale-mia. The drugs usually are not reported to causeAV-block and drug–drug interactions between thesedrugs and teicoplanin are unknown and teicoplanin–plasma levels remained within the normal therapeuticrange throughout the course of the treatment. In patientsduring citalopram therapy, however, sinusbradycardia andsecond-degree AV-block are described previously [2, 3].In our patient, citalopram was given during the wholetime of the in-hospital-course at the same dose(1 · 20 mg/day). Even after development of CAVB,citalopram was not discontinued.At usual therapeutic doses teicoplanin is generallywell tolerated and severe toxic or allergic reactions areuncommon [4, 5]. Known adverse effects include injectionsite intolerance (pain, redness, phlebitis), hypersensitivityevents (skin reaction, bronchospasm, anaphylactoidreaction), ototoxicity and hematological alterationsInfection 2008; 36: 291–292DOI 10.1007/s15010-008-7424-5F. Enseleit (corresponding author), N.J. Mueller, F. Duru, M. Lachat,G. Noll, F. RuschitzkaCardioVascular Center Cardiology, University Hospital Zurich, 8091Zurich, Switzerland; Phone: (+41/44) 25-5842, Fax: -859,e-mail: frank.enseleit@usz.chN.J. MuellerDivision of Infectious Diseases and Hospital Epidemiology, UniversityHospital Zurich, 8091 Zurich, SwitzerlandM. LachatClinic for Cardiac and Vascular Surgery, University Hospital Zurich, 8091Zurich, SwitzerlandReceived: November 5, 2007 Æ Revision accepted: February 21, 2008Published online: May 12, 2008Infection CorrespondenceInfection 36 Æ 2008 Æ No. 3  URBAN & VOGEL 291(neutropenia, eosinophilia). Nephrotoxicity is alsouncommon, even in combination with cyclosporine A. [6]No data exist about heart rhythm disturbances and the useof teicoplanin.As we here report first evidence of a potentiallylife-threatening complication, the use of teicoplaninshould be exercised with caution, in patients after hearttransplantation and concomitant immunosuppressivetherapy in particular.F. Enseleit, N.J. Mueller, F. Duru, M. Lachat,G. Noll, F. RuschitzkaAcknowledgmentsThe authors have no conflict of interest.References1. Cui G, Kobashigawa J, Margarian A, Sen L: Cause of atrioven-tricular block in patients after heart transplantation. Trans-plantation 2003; 76: 137–142.2. Favre MP, Sztajzel J, Bertschy G: Bradycardia during citalopramtreatment: a case report. Pharmacol Res 1999; 9: 149–150.3. Gambassi G, Incalzi RA, Gemma A: Atrioventricular blocksassociated with citalopram. Am J Geriatr Psychiatry 2005; 13:918–919.4. Davey PG, Williams AH: A review of the safety profile ofteicoplanin. J Antimicrob Chemother 1991; 27: 69–73.5. Finch RG, Eliopoulos GM: Safety and efficacy of glycopeptideantibiotics. J Antimicrob Chemother 2005; 55: ii5–ii13.6. Shea KW, Cunha BA: Teicoplanin. Med Clin North Am 1995; 79:833–844.Figure 1. Heart rate after orthotopic heart transplantation (HTX).Treatment with teicoplanin began 5 days before HTX and wasassociated with a complete AV-block and consecutive drop in heartrate starting on day 12 after HTX (17 days after start of teicoplanintherapy). The left ECG strip shows complete AV-block III (CAVB) onday 14 after HTX (19 days after begin of teicoplanin therapy). Afterstop of teicoplanin sinusrhythm (ECG strip in center) was restored.After incidental reexposition to teicoplanin (on day 19 after HTX),heart rate dropped again due to CAVB (ECG strip on the right).F. Enseleit et al. Teicoplanin-Induced Complete AV-Block in a Heart Transplant Recipient292 Infection 36 Æ 2008 Æ No. 3  URBAN & VOGEL

Teicoplanin-Induced Complete AV-Block in a Heart Transplant Recipient

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Teicoplanin-Induced Complete AV-Block in a Heart Transplant Recipient

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