New Study Cites Benefits Of Ertapenem For Diabetic Foot Infections

Author(s): 
By Brian McCurdy, Associate Editor

   In the past, the majority of comparative studies of antibiotics for diabetic foot infections have been relegated to smaller, unblinded trials. However, a new randomized, multicenter study of over 500 patients found that the simpler dosing regimen of ertapenem (Invanz, Merck) had comparable results to piperacillin/tazobactam in treating these infections.    In what study co-author David G. Armstrong, DPM, MSc, PhD, calls “easily the largest ever randomized controlled trial of diabetic foot infections,” the double-blinded SIDESTEP Study of Diabetic Foot Infections found that patients treated with once-a-day dosing of ertapenem had similar clinical and microbiological outcomes with those who were treated with piperacillin/tazobactam every six hours.    Data from the study, which was recently presented at the 44th Interscience Conference on Antimicrobial Agents and Chemotherapy, will also be presented as an abstract at the upcoming Symposium on Advanced Wound Care in April.    Patients in the study received either 1 g/d of ertapenem or 3.375 g qid of piperacillin/tazobactam. According to the study protocol, the patients remained on IV for five days but could subsequently be switched to oral amoxicillin/clavulanate for a total treatment period of 28 days.    At the end of IV therapy, ertapenem had a success rate of 94.3 percent (+/- 3 percent) while piperacillin/tazobactam had a success rate of 92.3 percent (+/- 3.5 percent). The study authors also observed similar clinical success rates at the 10-day follow-up visit as ertapenem had a 87.7 percent success rate and piperacillin/tazobactam had a 82.8 percent success rate.

Assessing The Advantages Of Ertapenem

   Both Dr. Armstrong and Benjamin A. Lipsky, MD, FACP, the lead author of the study, cite ertapenem as a useful empiric agent, given its broad spectrum of activity and its once-a-day parenteral dosing.    With the exception of methicillin resistant staphylococci, ertapenem covers “most of the aerobic gram-positive cocci that are the primary pathogens in diabetic foot infections,” explains Dr. Lipsky, a Professor of Medicine at the University of Washington and the Director of the General Internal Medicine Clinic with the VA Puget Sound Health Care System in Seattle.    Dr. Lipsky, a Fellow of the Infectious Diseases Society of America, says ertapenem is also effective against aerobic gram-negative rods and obligate anaerobes that are often part of mixed infections in chronic or previously treated infections. He also notes that ertapenem has a bactericidal action and “good penetration to infected soft tissues.”    As far as drawbacks go for ertapenem, Dr. Lipsky concedes the drug does not cover Pseudomonas or some other non-fermentative gram-negative rods. However, he notes these are “not usually primary pathogens in diabetic foot infections.”

What Impact Will The Study Have?

   Dr. Armstrong, a member of the National Board of Directors of the American Diabetes Association, expressed enthusiasm about the potential application of the study results.     “I believe the myriad of data we will have to pore through will yield a treasure trove of information that will ultimately help us better treat this most high risk patient population,” says Dr. Armstrong, a Professor of Surgery, Chair of Research and Assistant Dean at the Dr. William M. Scholl College of Podiatric Medicine at the Rosalind Franklin University of Medicine. Editor’s Note: The Symposium on Advanced Wound Care will be held from April 21 to 24 in San Diego, Calif. For more information, go to www.woundcaresymposium.com. For related articles on diabetic foot infections, see the supplement “Treating MRSA Infections” at www.podiatrytoday.com.

Collaborative Curriculum Fuels Student Success At Des Moines University

By Brian McCurdy, Associate Editor    Can podiatric students compete academically with their counterparts in other fields of medicine? Given that students at Des Moines University’s College of Podiatric Medicine and Surgery (CPMS) are taking courses alongside students in other medical disciplines, professors of podiatric medicine believe they can answer the question.     “CPMS has answered that question for the profession with a resounding yes,” says Dean R. Tim Yoho, DPM, MS, who emphasizes that the first-year podiatry students take the same basic science classes as the first-year osteopathic students in the university’s College of Osteopathic Medicine.    Dr. Yoho says CPMS was the first to respond to a 1985 call for podiatric medicine colleges to become affiliated with academic health science centers.     “This unique collaborative relationship in the curriculum is what differentiates CPMS from other podiatric medical programs and serves as one of the most influential reasons students enroll in the college,” says Dr. Yoho, Vice President for Academic Administration. “By succeeding that first year, podiatric students develop a sense of confidence and self-esteem they carry with them throughout their education and careers.”

Emphasizing Evidence-Based Medicine And Critical Thinking

   After establishing a foundation in basic medicine, the future DPMs begin to think as physicians and the college can then direct the focus to the lower extremity, according to Dr. Yoho.     “The first year teaches them to be physicians first and specialists in foot and ankle care second,” concurs James Mahoney, DPM, an Assistant Professor in Podiatric Surgery. “We feel this not only instills a strong work ethic, but is the main reason our students have such a high first-time pass rate on Part I of the boards.”    The Des Moines program was the first college to formally implement evidence-based medicine into its curriculum, according to Dr. Yoho. Shortly afterward, Dr. Yoho says the college introduced a problem centered learning style, which has spurred independent learning and also encourages students to “challenge anecdotal solutions to clinical problems.” The program’s evidence-based medicine curriculum comprises the entire second semester of the students’ third year, according to Dr. Mahoney.    In groups of six to eight, students work on solving clinical cases in medicine, infection, trauma, forefoot and rearfoot pathology. Students say this experience ties together their first two and a half years of education, according to Dr. Mahoney, and provides an effective outlet for learning the complexities of medicine.    Kevin Smith, DPM, Associate Dean for Clinical Affairs, cites the small class sizes as a key advantage that facilitates critical thinking and reflection.    Dr. Mahoney says podiatry students use the Standardized Patient Assessment Lab (SPAL), which hones their history-taking and physical exam skills. As part of this program, he notes the SPAL staff trains people in the Des Moines community to exhibit signs and symptoms of various illnesses, and students diagnose them as they would at an office visit, with their diagnoses evaluated by a physician.

Documenting Student Success And Expanding Research Efforts

   For faculty members, it is important to communicate that Des Moines podiatric medicine students are performing as well as those in other fields of medicine. As Dr. Yoho says, little research has been published concerning the academic performance of podiatric students and for that matter podiatric medical education in general. He believes it is important to inform the public about the educational outcomes of students.     “Through publications and public forums related to academic issues, we can gain additional credibility and become more worthy of the profession’s and medical community’s respect,” he comments.    Dr. Yoho says he sees an opportunity for CPMS to take the lead nationally in documenting and communicating its findings on the aptitude of its podiatric students, and identifying the best educational practices that have led to student successes.    Dr. Mahoney wants the college to collaborate with the other podiatric schools to share research to benefit the profession. In the future, he sees CPMS taking advantage of Des Moines University’s commitment to research. Research is “an area of deficiency” in the podiatric field compared to other medical fields, concedes Dr. Mahoney, but he feels with more podiatric research, the rest of the medical profession will see podiatrists as more of a learning resource than in the past.    The fact that the college is integrated with mainstream medical education “shows the future osteopaths and allopathic physicians that our training is no different than theirs, and that our students can hold their own in the basic science and clinical science arena,” says Dr. Mahoney.

In Brief

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