Daptomycin for the Treatment of Osteomyelitis Associated With a Diabetic Foot Ulcer
- 0 Comments
- 10620 reads
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
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.
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.
1. Lipsky BA. Osteomyelitis of the foot in diabetic patients. Clin Infect Dis. 1997;25(6):1318–1326.
2. Calhoun JH, Manring MM. Adult osteomyelitis. Infect Dis Clin North Am. 2005;19(4):765–786.
3. Lazzarini L, Lipsky BA, Mader JT. Antibiotic treatment of osteomyelitis: what have we learned from 30 years of clinical trials? Int J Infect Dis. 2005;9(3):127–138.
4. Stengel D, Bauwens K, Sehouli J, Ekkernkamp A, Porzsolt F. Systematic review and meta-analysis of antibiotic therapy for bone and joint infections. Lancet Infect Dis. 2001;1(3):175–188.
5. Rice DA, Mendez-Vigo L. Daptomycin in bone and joint infections: a review of the literature. Arch Orthop Trauma Surg. In press.
6. Arbeit RD, Maki D, Tally FP, et al. The safety and efficacy of daptomycin for the treatment of complicated skin and skin-structure infections. Clin Infect Dis. 2004;38(12):1673–1681.
7. Owens RC Jr, Lamp KC, Friedrich LV, Russo R. Postmarketing clinical experience in patients with skin and skin-structure infections treated with daptomycin. Am J Med. 2007;120(10 Suppl 1):S6–S12.
8. Antony SJ, Angelos E, Stratton CW. Clinical experience with daptomycin in patients with orthopedic-related infections. Infect Dis Clin Pract. 2006;14(3):144–149.
9. Lamp KC, Friedrich LV, Mendez-Vigo L, Russo R. Clinical experience with daptomycin for the treatment of patients with osteomyelitis. Am J Med. 2007;120(10 Suppl 1):S13–S20.
10. Lalani T, Boucher HW, Cosgrove SE, et al. Outcomes with daptomycin versus standard therapy for osteoarticular infections associated with Staphylococcus aureus bacteraemia. J Antimicrob Chemother. 2008;61(1):177–182.
11. Finney MS, Crank CW, Segreti J. Use of daptomycin to treat drug-resistant Gram-positive bone and joint infections. Curr Med Res Opin. 2005;21(12):1923–1926.
12. Burns CA. Long-term use of daptomycin for MRSA osteomyelitis and joint infection. Scand J Infect Dis. 2008;40(2):183–186.
13. Soriano A, Marco F, Martínez JA, et al. Influence of vancomycin minimum inhibitory concentration on the treatment of methicillin-resistant Staphylococcus aureus bacteremia. Clin Infect Dis. 2008;46(2):193–200.
14. Lodise TP, Graves J, Evans A, et al. Relationship between vancomycin MIC and failure among patients with methicillin-resistant Staphylococcus aureus bacteremia treated with vancomycin. Antimicrob Agents Chemother. 2008;52(9):3315–3320.
15. Hidayat LK, Hsu DI, Quist R, Shriner KA, Wong-Beringer A. High-dose vancomycin therapy for methicillin-resistant Staphylococcus aureus infections: efficacy and toxicity. Arch Intern Med. 2006;166(19):2138–2144.
16. Tice AD, Hoaglund PA, Shoultz DA. Risk factors and treatment outcomes in osteomyelitis. J Antimicrob Chemother. 2003;51(5):1261–1268.
17. Senneville E, Legout L, Valette M, et al. Effectiveness and tolerability of prolonged linezolid treatment for chronic osteomyelitis: a retrospective study. Clin Ther. 2006;28(8):1155–1163.
18. Narita M, Tsuji BT, Yu VL. Linezolid-associated peripheral and optic neuropathy, lactic acidosis, and serotonin syndrome. Pharmacotherapy. 2007;27(8):1189–1197.
19. Beekmann SE, Gilbert DN, Polgreen PM, IDSA Emerging Infections Network. Toxicity of extended courses of linezolid: results of an Infectious Diseases Society of America Emerging Infections Network survey. Diagn Microbiol Infect Dis. 2008;62(4):407–410.