Antibiotics And DFIs: What The Evidence Reveals
What About The Potential Of Moxifloxacin And Piperacillin/Tazobactam For Diabetic Foot Infections?
For the empirical treatment of diabetic foot infections, some antibiotics such as moxifloxacin (Avelox, Bayer) offer an advantage of being available intravenously (IV) or orally. Moxifloxacin has a broad spectrum of activity and the switch between the two formulations is simple as they have similar pharmacokinetics.
Schaper and coworkers conducted a randomized controlled trial in 2013 involving a total of 206 patients.14 The authors focused on patients with diabetic foot infections of mild to severe intensity and a diagnosis of complicated bacterial skin and skin structure infection that required hospitalization and initial parenteral antibiotic treatment for 48 hours or more. Researchers compared moxifloxacin IV followed by oral moxifloxacin with piperacillin/tazobactam (Zosyn, Pfizer) IV and subsequent oral amoxicillin/clavulanic acid. The study parameters included clinical cure rates and bacteriology eradication among others.
The results revealed that intravenous and oral moxifloxacin and the combination of IV piperacillin/tazobactam and oral amoxicillin/clavulanic acid had similar clinical efficacy rates in patients with moderate to severe diabetic foot infections.14 In addition, the study showed bacteriological eradication was higher for moxifloxacin versus piperacillin/tazobactam and amoxicillin/clavulanic acid in polymicrobial infections. There was no significant difference between the two treatment arms regarding the length of either oral or intravenous treatments as both durations of therapy in either groups were approximately eight days each. Therefore, IV/oral moxifloxacin monotherapy could be an alternative option for patients with moderate to severe diabetic foot infections.
It would be ideal to follow the aforementioned inpatient management proposed by Wukich and colleagues in all hospitals that admit patients with diabetic foot ulcers and diabetic foot infections.6 In addition, clinicians who are part of a multidisciplinary team that treats diabetic foot infections should be alert for an increase in MRSA prevalence in this population with foot infections and follow the IDSA specific recommendations when empirically treating a patient with diabetic foot infections and MRSA.7
Ceftaroline is a new cephalosporin with activity against MRSA and is a possible candidate for therapy when one detects or empirically suspects this microorganism. If broad spectrum coverage is necessary, a combination of ceftaroline-avibactam would be another possibility. A transition from an intravenous to oral route of administration with the same class of antibiotics (e.g., moxifloxacin), while patients start therapy during hospitalization, can be an alternative option.
Dr. Spichler is a researcher in the Department of Surgery, Division of Vascular and Endovascular Surgery at the Southern Arizona Limb Salvage Alliance (SALSA) at the University of Arizona Health Sciences Center in Tucson, Ariz.
Dr. Armstrong is a Professor of Surgery and the Director of the Southern Arizona Limb Salvage Alliance (SALSA) at the University of Arizona Health Sciences Center in Tucson, Ariz.