Daptomycin for the Treatment of Osteomyelitis Associated With a Diabetic Foot Ulcer

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Edmund Dos Remedios, DPM

Abstract: This report describes a case of Staphylococcus aureus osteomyelitis associated with a chronic foot ulcer that was successfully treated with surgical debridement and 6 weeks of daptomycin therapy. Daptomycin was chosen because of its excellent activity against the causative organism and the patient’s history of penicillin allergy. Its tolerability and ease of administration also facilitated long-term outpatient management. The present case provides further evidence that supports consideration of daptomycin as a treatment for S aureus osteomyelitis, especially in light of reports of methicillin-sensitive S aureus (MSSA) infection recurrence after vancomycin use and safety issues surrounding long-term use of linezolid.

Address correspondence to:
Edmund Dos Remedios, DPM
Clinical Assistant Professor of Orthopaedic Surgery
Warren Alpert School of Medicine
Brown University, University Foot Center
235 Plain St., #201
Providence, RI 02905
Email: dos35@cox.net
Phone: 401-861-8830

     Osteomyelitis is a common complication associated with diabetic foot infection.1 Thirty-three to 68% of patients with diabetic foot infections are found to have underlying osteomyelitis.1,2 Staphylococcus aureus is the most commonly isolated pathogen in diabetic foot osteomyelitis,1 although other gram-positive cocci or gram-negative bacilli may be isolated and polymicrobial infection including anaerobic organisms can also be seen.1,2

     A complicated infection, osteomyelitis can be difficult to treat and generally requires surgical intervention combined with at least 4 to 6 weeks of antimicrobial therapy for maximal response.1,2 Intravenous therapy is generally preferred; however, information regarding optimal antimicrobial therapy is lacking. Few large, well-designed comparative trials have been performed, and meta-analyses of these trials have been unable to determine the best type, route, or duration of antimicrobial therapy.3,4 Therefore, therapy is usually guided by bone culture results and patient-specific factors.1,2

     Daptomycin is a cyclic glycopeptide that kills gram-positive bacteria by disrupting multiple bacterial plasma membrane functions. As such, daptomycin possesses bactericidal activity against both methicillin-susceptible S aureus (MSSA) and methicillin-resistant S aureus (MRSA), as well as other gram-positive cocci including vancomycin-susceptible and vancomycin-resistant enterococci.5 It has been shown to be effective in the treatment of complicated skin and skin structure infections including diabetic foot ulcers.6,7 Though limited, retrospective analyses and case reports published thus far support the efficacy and safety of daptomycin in the treatment of osteomyelitis.5,8–12 This report describes a case of S aureus diabetic foot osteomyelitis that was successfully treated with daptomycin.

Case Report

     A 66-year-old man presented with a history of diabetes mellitus, hypertension, chronic lymphocytic leukemia (CLL), and penicillin allergy. His surgical history included right trans-metatarsal amputation (TMA) in 1994 with revision TMA in 2002. The patient had been managed previously for several episodes of minimal lower extremity breakdown, which were treated with numerous antibiotic agents including levofloxacin, ciprofloxacin, and clindamycin.

     The patient presented in May 2006 with a right plantar ulcer secondary to bony prominence that required hospital admission and was treated at that time with intravenous vancomycin and cefepime. Incision and drainage of the wound was performed. Wound cultures revealed S aureus resistant only to tetracycline. Bone cultures were negative.


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