Study of Daptomycin Safety and Efficacy for Complicated Skin and Skin Structure Infections (cSSSI) and Bacteremia in Renal Impairment
Condition: Complicated Skin and Skin Structure Infections; S. Aureus Bacteremia; Renal Impairment
MeSH terms: Infections; Communicable Diseases; Bacteremia; Skin Diseases, Bacterial; Renal Insufficiency
Intervention: Vancomycin; Daptomycin; Semi-Synthetic Penicillin
Intervention MeSH terms: Vancomycin; Penicillins; Daptomycin; Cloxacillin; Oxacillin; Nafcillin
Phase: Phase 4
Study type: Interventional
Primary purpose: Treatment
Allocation: Randomized
Intervention model: Parallel Assignment
Masking: Single (Outcomes Assessor)
Enrollment: 92.0
Sex: All
Minimum age: 18 Years
Healthy volunteers: No

Summary:

      This is a multicenter, randomized, evaluator-blinded, comparator-controlled study.
      Participants were to be randomized (1:1) to daptomycin or comparator, stratified by degree of
      renal impairment (creatinine clearance [CLcr] 30 - 50 milliliters per minute [mL/min]
      [moderate impairment] and <30 mL/min [severe impairment]) and by type of infection
      (bacteremia and complicated skin and skin structure infections [cSSSI]) to create 4 cohorts
      defined as follows:

        -  Cohort 1: Bacteremia and CLcr <30 mL/min

        -  Cohort 2: Bacteremia and CLcr 30 - 50 mL/min

        -  Cohort 3: cSSSI and CLcr <30 mL/min

        -  Cohort 4: cSSSI and CLcr 30 - 50 mL/min

      Participants will be treated and evaluated for safety and microbiological and clinical
      efficacy in accordance with their type of infection and degree of renal impairment. Peak and
      trough samples will be collected to assess exposure to daptomycin for participants on Day 1
      and following the 5th dose.
    

Eligibility criteria:

        Inclusion Criteria:

          -  Written informed consent

          -  Male or female ≥18 years of age

          -  Diagnosis of cSSSI or Staphylococcus aureus (S. aureus) bacteremia

          -  Renal impairment of CLcr of 30 - 50 mL/min or CLcr <30 mL/min per Cockcroft-Gault
             equation using actual body weight

          -  Functioning hemodialysis access and on stable regimen for those receiving dialysis

          -  In appropriate health for the study with no acute or chronic illnesses that could
             adversely impact safety or ability to complete the study

        Specific inclusion criteria for cSSSI:

          -  Presence of a wound infection, major abscess, severe carbunculosis, infected ulcers,
             dialysis access site infection, or other type of infection in presence of complicating
             factor

          -  At least 3 of the following symptoms, signs, or laboratory values of a skin infection:
             elevated temperature; elevated white blood cell (WBC) count; pain; tenderness;
             swelling; erythema greater than 1 centimeter (cm) beyond wound edge; induration; pus
             formation

          -  Evidence of a Gram-positive infecting pathogen as indicated by positive Gram stain or
             culture obtained within 96 hours prior to study drug administration

          -  Infection of sufficient severity to require parenteral antimicrobial therapy

        Specific inclusion criteria for S. aureus bacteremia:

        • Documented S. aureus bacteremia defined as at least one positive blood culture for S.
        aureus obtained within 96 hours prior to the first dose of study medication

        Exclusion Criteria:

          -  Pregnant or lactating females, or unwilling to practice barrier methods of birth
             control

          -  Received an investigational drug (including experimental biologic agents) within 30
             days of study entry

          -  Unable to discontinue use of HMG-CoA reductase inhibitor therapy while on study

          -  Known allergy or intolerance to daptomycin, penicillin, or vancomycin

          -  Active intravenous (IV) drug abuse

          -  Confirmed or suspected osteomyelitis, septic arthritis, meningitis, epidural abscess,
             intra-abdominal infection, pneumonia, or infective endocarditis

          -  Required use of non-study systemic antibacterial agent with activity against target
             pathogen

          -  History of muscular disease

          -  Neurological disease except stroke >6 months prior to study entry

          -  Intramuscular injection within 7 days of study drug administration

          -  Moribund clinical condition (high likelihood of death during next 3 days)

          -  Shock or hypotension (supine systolic blood pressure <80 millimeters of mercury
             [mmHg])

          -  Body mass index (BMI) <18 or >40 kilograms per meter squared (kg/m^2) [BMI = weight
             (kg)/height (m^2)]

          -  Known human immunodeficiency virus (HIV) infection with CD4 count ≤200
             cells/millimeter (mm)^3

          -  Neutropenic participants with an absolute neutrophil count ≤500 cells/mm^3

          -  Anticipated to develop neutropenia absolute neutrophil count ≤500 due to prior or
             planned chemotherapy

          -  Alanine aminotransferase (ALT) value >3 × upper limit of normal (ULN)

          -  Aspartate aminotransferase (AST) value >3 × ULN

          -  Total bilirubin values ≥ 1.5 x ULN associated with ALT values >3 x ULN

          -  Creatine phosphokinase (CPK) value >2 × ULN

          -  Hemoglobin <8 grams per deciliter (gm/dL)

          -  Unlikely to comply with study procedures or to return for evaluations

          -  History of rhabdomyolysis

          -  Prior enrollment into this study

          -  Infections caused by Gram-positive pathogens known to be resistant to daptomycin or
             selected comparator agent

        Specific exclusion criteria for cSSSI:

          -  Minor or superficial skin infections as the primary site of infection

          -  Cellulitis or erysipelas not associated with complicating factor as primary site of
             infection

          -  Perirectal abscess, hidradenitis suppurativa, concomitant gangrene, myositis, multiple
             infected ulcers at distant sites, necrotizing fasciitis, or infected third-degree burn
             wounds

          -  Infections requiring emergency surgery

          -  Infections suspected or documented to be due exclusively to gram-negative, anaerobic,
             or fungal organism

          -  Confirmed or suspected disorder that could interfere with the evaluations (for
             example, primary skin disorders)

          -  Use of a topical antibiotic at the site of the infection

          -  Use of systemic antibacterial therapy for the infection for >24 hours within 48 hours
             prior to start of study drug unless (a) infecting Gram-positive pathogen resistant to
             therapy or (b) therapy administered for 3 or more days with worsening or no
             improvement

          -  Planned surgical treatment that is considered curative of the infection

        Specific exclusion criteria for S. aureus bacteremia:

          -  Has intravascular foreign material at the time the positive blood culture was drawn
             (for example., intracardiac pacemaker wires, percutaneous or implanted venous
             catheters, vascular grafts) unless material removed within 4 days after first dose of
             study medication or approval of medical monitor (exceptions: vascular stents in place
             for >6 months, permanent pacemaker attached via epicardial leads, or any dialysis
             access device unless this material is felt to be infected)

          -  Prosthetic heart valve

          -  Cardiac decompensation or valve damage or both with high likelihood of valve surgery
             in the 3 days after randomization

          -  Polymicrobial blood infection