Eravacycline as a last resort for difficult-to-treat resistant Acinetobacter baumannii infections in critically ill patients: three case reports with pharmacokinetic insights

Abstract Objectives To describe eravacycline use as a salvage treatment for ventilator-associated pneumonia (VAP) caused by difficult-to-treat resistant (DTR) Acinetobacter baumannii in critically ill patients. Methods We reported three cases of DTR A. baumannii VAP with multiple organ failure treated with eravacycline. Patients were critically ill with confirmed VAP by distal pulmonary cultures. Eravacycline was administered at 1 mg/kg q12h in combination with IV colistin or as primary therapy. Clinical and microbiological outcomes were assessed. Results Eravacycline MICs ranged from 0.25 to 0.75 mg/L. Microbiological success was observed in the three cases, including one patient who was successfully weaned and discharged alive with no further samples submitted for microbiological culture, and two other patients who were repeatedly sampled and remained negative for A. baumannii. Clinical success could not be confirmed in one case. No adverse effects were observed. Pharmacokinetic analysis of concentrations from a single patient revealed a maximal concentration (Cmax) of 1.47 mg/L at 1 h and an AUC0–6 of 2.88 mg·h/L. The epithelial lining fluid/plasma concentration ratio was 0.1. Conclusions Eravacycline showed promise as a salvage therapy for DTR A. baumannii VAP in critically ill patients. Further studies are needed to confirm its efficacy and optimal dosing in this setting.