Safety and Efficacy Study of Daptomycin Compared to Active Comparator in Pediatric Participants With Acute Hematogenous Osteomyelitis (AHO) (MK-3009-006)

Cubist Pharmaceuticals LLC, a subsidiary of Merck & Co., Inc. (Rahway, New Jersey USA)

Status and phase: Completed; Phase 3

Conditions: Acute Hematogenous Osteomyelitis

Treatments: Drug: Vancomycin (or equivalent); Drug: Daptomycin; Drug: Nafcillin (or equivalent)

Study type: Interventional

Funder types: Industry

Identifiers

NCT01922011

2013-000864-28 (EudraCT Number)

DAP-PEDOST-11-03 (Other Identifier)

3009-006

Details and patient eligibility

About

The purpose of the study is to determine whether daptomycin is effective and safe in the treatment of pediatric participants with AHO when compared to vancomycin (or equivalent) or nafcillin (or β-lactam equivalent). The primary hypothesis is that daptomycin is non-inferior compared with vancomycin (or equivalent) or nafcillin (or β-lactam equivalent) with respect to improvement in Pain, Inflammation, and Limb Function on or before study Day 5.

Full description

Acute hematogenous osteomyelitis is a common problem in the pediatric population, affecting approximately 5/10,000 children each year and accounting for approximately 1% of all pediatric hospitalizations. In children, osteomyelitis arises from bacteremic seeding of the bone metaphysis.

Daptomycin, is a cyclic lipopeptide antibacterial active against most clinically significant gram-positive pathogens including drug-resistant strains such as Methicillin Resistant Staphylococcus (S.) aureus (MRSA) and Methicillin Susceptible S. aureus (MSSA). Daptomycin has proven clinical efficacy in adults in the treatment of complicated skin and skin structure infections (cSSSI) caused by aerobic gram-positive pathogens and the treatment of S. aureus bloodstream infections (bacteremia; SAB), including those complicated by right-sided infective endocarditis, caused by MSSA and MRSA. Although not indicated for osteomyelitis, daptomycin has been successfully used to treat osteoarticular infections in adults and children as salvage therapy and at medical centers with increasingly high rates of vancomycin resistant organisms.

In addition, more comparative clinical trials are needed in pediatric AHO to better elucidate the optimal treatment regimen and clinical response.

Enrollment: 149 patients

Sex: All

Ages: 1 to 17 years old

Volunteers: No Healthy Volunteers

Inclusion and exclusion criteria

Inclusion Criteria:

• Obtain Informed Consent;
• Be 1 year to < 18 years old; a stepwise approach will be implemented to gate enrollment as follows: enrollment will begin with children aged 2-17 years; after an external Drug Safety Monitoring Board (DSMB) review, enrollment will be broadened to 1-17 years.
• Have diagnosis of suspected or confirmed AHO warranting IV antibacterial therapy as inpatient, based on clinical, imaging and/or microbiological evidence as outlined below:

I. Clinical evidence of fever accompanied by symptoms on the affected limb that include but it is not limited to pain, tenderness on palpation, inflammation, warmth, swelling, difficulty bearing weight, motion restriction, loss of function

II. Radiologic imaging (magnetic resonance imaging [MRI], bone scan, x-ray, or computed tomography [CT] scan) consistent with osteomyelitis OR Microbiological evidence (gram stain, culture or polymerase chain reaction (PCR)) from a bone biopsy or bone aspirate (if available), or blood

III. Laboratory evidence: C-reactive protein (CRP) elevated, Erythrocyte sedimentation rate (ESR) elevated, leukocytosis or leukopenia, immature neutrophils

•Confirmed (I, II, and III) OR suspected (I and III) that must be confirmed post-randomization

Participants will not be allowed into the study if they:

• Have documented history of any hypersensitivity or allergic reaction to daptomycin
• Have septic arthritis only (without AHO)
• Have acute hematogenous osteomyelitis that is located in the spine
• Have chronic osteomyelitis (i.e. symptoms of osteomyelitis > 21 days) or osteomyelitis with complications requiring non-routine surgical treatment (i.e. sequestration).
• Have major trauma, penetrating trauma (including a puncture wound of the foot), postoperative osteomyelitis, foreign body in or adjacent to affected bone or joint, or other iatrogenic bone or joint infections present at the site of infection
• Have acute hematogenous osteomyelitis due to a proven gram-negative organism
• Have transient tenosynovitis, juvenile rheumatoid arthritis (JRA), reactive arthritis, bony tumors, and other osteoarticular diseases suspected to be due to a nonbacterial (eg, fungal or mycobacterial) etiology
• Receive more than 24 hours of effective intravenous antibacterial therapy for osteomyelitis within 96 hours before randomization unless microbiological or clinical failure is documented
• Require any potentially effective concomitant systemic antibacterial therapy for gram-positive infections
• Have history of seizures (except febrile seizure of childhood)
• Have peripheral neuropathy
• Have history of rhabdomyolysis (with the exception of muscle injury due to trauma)
• Have Sickle cell anemia
• Cannot be assessed clinically during the study
• Have any condition (eg, cystic fibrosis, current septic shock) that would make the subject, in the opinion of the Investigator, unsuitable for the study
• Have significant reduced creatinine clearance (CrCl) < 50 mL/min/1.73 m2
• Have evidence of significant hepatic, hematologic, or immunologic dysfunction
• Have Creatine kinase (CK) elevation ≥ 10 × ULN (upper limit of normal) without symptoms or ≥ 5 × ULN with symptoms
• If female, must not be pregnant or nursing and if required by age and life style take appropriate measures to not get pregnant during the study.
• Have participated in any study involving administration of an investigational agent or device or daptomycin within 30 days
• Are unable or unwilling to adhere to the study-specified procedures and restrictions
• Has suspected or confirmed pneumonia, empyema, meningitis, or endocarditis.

Trial design

Primary purpose: Treatment

Allocation: Randomized

Interventional model: Parallel Assignment

Masking: Quadruple Blind

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149 participants in 2 patient groups

Daptomycin

Experimental group

Description:

Intravenous (IV) daptomycin was dosed as follows: age 12 years to \<18 years (7 mg/kg); age 7 years to \< 12 years (9 mg/kg); age 24 months to \<7 years (12 mg/kg); age 12 months to \<24 months (12 mg/kg). Drug was infused over 60 minutes ± 10 minutes once daily followed by up to 3 dummy infusions every 6 hours (q6h) infused over 60 (± 10) min to maintain the blind.

Treatment:

Drug: Daptomycin

Vancomycin or Nafcillin

Active Comparator group

Description:

IV vancomycin (or equivalent), 10 to 15 mg/kg, was infused over 60 (± 10) minutes q6h (± 1 hour) or IV nafcillin (or β-lactam equivalent) at 100-200 mg/kg/day, in divided doses was infused over 60 (± 10) min q6h (± 1 hour)

Treatment:

Drug: Vancomycin (or equivalent)

Drug: Nafcillin (or equivalent)