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Abstract: Background. The diabetic foot is a common site of infections that frequently result in significant patient morbidity and mortality. Antibiotic treatment is an important part of therapy with selection of the specific agent depending on the stage of ulceration. Recently, ertapenem has entered use as first line therapy for moderate to severe diabetic foot infections. The following prospective study recounts the experience of using ertapenem as tertiary salvage therapy following failure of first and second-line antibiotics. Methods. Forty consecutive patients with diabetic foot ulcers (IDSA classification moderate-severe), 28 with soft tissue infections alone, 12 with concomitant osteomyelitis, were included in the study. Patients were referred from the diabetic foot clinic at the authors’ institution after failure of treatment with cephalexin and ciprofloxacin/clindamycin combination, and were treated with ertapenem 1-g daily intravenously (IV). Endpoints were significant clinical improvement (resolution of fever, leukocytosis, surrounding erythema, and purulent discharge). Results. Clinical improvement was noted in all 28 individuals with soft tissue infections—all of these individuals had complete ulcer closure after a mean of 30 ± 8 treatment days. Of the 12 patients with concomitant osteomyelitis, only 25% required surgical intervention. Nine individuals were cured following a mean of 60 ± 15 treatment days of home IV antibiotic therapy. Conclusion. Ertapenem is an efficacious, easy to use, and cost saving antibiotic for the treatment of diabetic foot infections that have failed therapy with traditional antibiotics.

From the Department of Internal Medicine “D” and the Diabetic Foot Clinic, Kaplan Medical Center, Rehovot Affiliate to the Hebrew University School of Medicine, Jerusalem, Israel

Address correspondence to:
Edward B. Miller, MD
Department of Internal Medicine “D”
Kaplan Medical Center
P.O. Box 1
Rehovot 76100
Israel
Phone: 972-8-9441-901
Email: edward_m@clalit.org.il  

  The diabetic foot is a common site of infections that frequently results in significant patient morbidity and mortality. Antibiotic treatment is an important component of therapy along with local wound care and pressure offloading. First generation cephalosporins are usually employed for mild infections, whereas more serious cases usually require broad-spectrum IV antibiotics.¹
  In the authors’ center, the first generation cephalosporin cephalexin is the usual first line therapy for mild infections, whereas an oral combination of a quinolone with clindamycin has been the preferred second line regimen. Hospitalized patients with limb-threatening infections traditionally received IV piperacillin/tazobactam with vancomycin added in cases where methicillin resistant Staphylococcus aureus (MRSA) infection is proved or suspected.
  Recently, ertapenem has entered use as primary therapy for moderate to severe diabetic foot infections. Use is based on the study by Lipsky et al² who showed equal efficacy of ertapenem and piperacillin/tazobactam. Advantages of this antibiotic include cost effectiveness and once-daily dosing.³ To the authors’ knowledge the use of ertapenem as salvage therapy in diabetic foot infections unresponsive to traditional antibiotics has not been reported. This prospective study recounts the authors’ experience with this therapy.