Role of linezolid in the treatment of complicated skin and soft tissue infections

The emerging problem of linezolid-resistant enterococci

Enterococcus is a significant pathogen in numerous infections, particularly in nosocomial infections, and is thus a great challenge to clinicians. Linezolid (LNZ), an oxazolidinone antibiotic, is an important therapeutic option for infections caused by Gram-positive bacterial pathogens, especially vancomycin-resistant enterococci. A systematic review was performed of the available literature on LNZ-resistant enterococci (LRE) to characterise these infections with respect to epidemiological, microbiological and clinical features. The results validated the potency of LNZ against enterococcal infections, with a sustained susceptibility rate of 99.8% in ZAAPS and 99.2% in LEADER surveillance programmes. Patients with LRE had been predominantly exposed to LNZ prior to isolation of LRE, with a mean treatment duration of 29.8±48.8days for Enterococcus faecalis and 23.1±21.4days for Enterococcus faecium. Paradoxically, LRE could also develop in patients without prior LNZ exposure. LNZ resistance was attributed to 23S rRNA (G2576T) mutations (51.2% of E. faecalis and 80.5% of E. faecium) as well as presence of the cfr gene (4.7% and 4.8%, respectively), which could transfer horizontally among the strains. In addition to the cfr gene, 32 cases of optrA-positive LRE were identified. Further study is required to determine the prevalence of novel resistance genes. The emergence of LRE thus hampers the treatment of such infections, which warrants worldwide surveillance.

History of antibiotics: from fluoroquinolones to daptomycin (Part 2)

In the Modern Era, physicians attested to the reciprocal influence among a technologically advanced society, rapid scientific progresses in medicine, and the need for new antimicrobials. The results of these changes were not only seen in the prolongation of life expectancy but also by the emergence of new pathogens. We first observed the advent of Gram-negative bacteria as a major source of nosocomial infections. The treatment of these microorganisms was complicated by the appearance and spread of drug resistance. We first focused on the development of two major classes of antimicrobials still currently used for the treatment of Gram-negative bacteria, such as fluoroquinolones and carbapenemes. Subsequently, we directed our attention to the growth of the incidence of infections due to Methicillin-Resistant Staphylococcus aureus (MRSA). Although the first MRSA was already isolated in 1961, the treatment of this new pathogen has been based on the efficacy of vancomycin for more than four decades. Only in the last 15 yr, we assisted in the development of new antimicrobial agents such as linezolid and daptomycin.

Anxiolytic-like effect of linezolid in experimental mouse models of anxiety

Linezolid, an oxazolidinone class antibiotic is a reversible and nonselective inhibitor of monoamine oxidase (MAO) enzyme, mainly for MAO-A subtype. Its antidepressant-like effect has been previously demonstrated in the rodent models of depression. MAO-A enzyme has been shown to play a role in the pathophysiology of anxiety disorders and inhibition of MAO-A in the brain could be used to treat anxiety disorders. Thus, the objective of this study was to investigate the putative anxiolytic effects of linezolid in rodent models of anxiety. Mice were acutely injected with linezolid (5-40 mg/kg, i.p.), diazepam (2 mg/kg, i.p.) and moclobemide (10 mg/kg., i.p.). Linezolid (20 and 40 mg/kg), diazepam and moclobemide significantly (p<0.05) increased the percentage of time spent and entries into open arms in the elevated plus maze (EPM) test without altering the closed arm entries. Linezolid (10-40 mg/kg) significantly (p<0.05) increased the latency time to leave the light compartment, linezolid (20 and 40 mg/kg) significantly (p<0.05) increased total time spent in light compartment and linezolid (40 mg/kg) significantly (p<0.05) increased the number of transition between compartments in the light/dark (L/D) aversion test. Moreover, diazepam and moclobemide also showed significant (p<0.05) effects on all parameters in the (L/D) test. In addition, linezolid (20 and 40 mg/kg), diazepam and moclobemide significantly (p<0.05) increased the number of and time spent in head dipping, whereas significantly (p<0.05) decreased the head dipping latency in hole board (HB) test. In the present study linezolid at higher doses (20 and 40 mg/kg), diazepam and moclobemide showed more pronounced anxiolytic effects as compared to lower doses of linezolid (5 and 10 mg/kg). Whereas, the effects of linezolid at higher doses, diazepam and moclobemide on mice behavior in anxiety models was found quite similar. In conclusion, these results verified, for the first time, the anxiolytic properties of linezolid and suggest that linezolid may be considered an alternative approach for the management of anxiety disorders.

Future strategies for treating Staphylococcus aureus bloodstream infections

Bloodstream infections are potentially life-threatening diseases. They can cause serious secondary infections, such as infective endocarditis and osteomyelitis, and may result in severe sepsis. One of the most critical determinants of survival is the induction of timely and effective antibiotic therapy. One of the leading causes of bloodstream infections is Staphylococcus aureus, with an increasing proportion of isolates being resistant to methicillin. Methicillin-resistant S. aureus (MRSA) is associated with greater morbidity and mortality rates than methicillin-sensitive S. aureus (MSSA). Standard-of-care antibiotic treatments for S. aureus bloodstream infections are limited by toxicity and/or differential efficacy against MRSA and MSSA, which makes the choice of empirical therapy difficult. New management strategies are required to address the challenges raised by S. aureus bloodstream infections and MRSA in particular. These may include the use of techniques that allow the early identification of complications arising from S. aureus bacteraemia, rapid pathogen identification to enable the administration of appropriate antibiotic therapy, and the identification of new drugs with novel modes of action that may circumvent antibiotic resistance and enable effective empirical treatment of both MSSA and MRSA infections.

New oxazolidinones

Due to the emergence of resistance to known antibiotics to various organisms, for example, Staphylococcus, Streptococcus, Enterococci, and Pseudomonas there is a renewed interest in the discovery of new antibacterials. Oxazolidinones, totally synthetic class of novel antibacterials, possess activity against drug-resistant Gram-positive pathogens, especially MRSA. Linezolid, the first approved drug from this class, has shown a great promise in saving lives of many patients by acting against drug-resistant Gram-positive organisms. However, its use is somewhat limited because of its myelotoxicity when used long term (>21 days). Various research groups are active in this area either to improve myelotoxicity profile of linezolid or to expand the spectrum of activity of linezolid. In spite of active research in this area, the discovery of an oxazolidinone possessing improved myelotoxicity compared to linezolid, linezolid-like efficacy, and PK remains challenging.

Clinical management of diabetic foot infection: diagnostics, therapeutics and the future

Diabetic foot infection accounts for a substantial global burden of morbidity, psychosocial disruption and economic cost. Recommendations for best practice are continuously evolving in parallel with improvements in imaging modalities, development and clinical use of new antimicrobial agents and data surrounding novel adjunctive strategies. We discuss this complex group of infections with a particular emphasis on medical management of osteomyelitis, while also highlighting the importance of a broad multidisciplinary approach to eradicating infection.