Novel approach in treatment of Burkholderia pseudomallei osteomyelitis: salvage therapy with levonadifloxacin.

BACKGROUND

Melioidosis, caused by Burkholderia pseudomallei, is a deadly infection with a case fatality rate of 10%-50%. Osteomyelitis, a rare manifestation, is particularly challenging due to diagnostic delays, misidentification, limited bone penetration of antibiotics and frequent relapses. Antibiotic intolerance emerges as a significant hurdle, with up to 26%-51% of patients developing severe allergies to trimethoprim/sulfamethoxazole, along with intolerability to ceftazidime and meropenem. These limitations demand innovative therapeutic approaches to combat this pathogen.

OBJECTIVES

To report a novel case of B. pseudomallei-induced radial osteomyelitis successfully managed with levonadifloxacin, a broad-spectrum benzoquinolizine antibiotic, after intolerance to the conventional therapies.

METHODS

A 59-year-old man presented with radial osteomyelitis requiring multiple rounds of surgical debridement. Severe allergic reactions to trimethoprim/sulfamethoxazole and ceftazidime, and meropenem-associated leukopenia made traditional therapies unfeasible. Levonadifloxacin was introduced as a salvage therapy, leveraging its efficacy against B. pseudomallei, favourable bone penetration, antibiofilm activity and tolerability. The patient received IV levonadifloxacin for 5 days, followed by almost 8 months of its oral prodrug, alalevonadifloxacin.

CONCLUSIONS

Levonadifloxacin emerged as the salvage therapy for this patient, achieving significant clinical improvement without relapse after more than 6 months of therapy cessation, despite the life-threatening combination of melioidosis-associated osteomyelitis and antibiotic intolerance. This first reported use of levonadifloxacin in melioidosis underscores its potential as an alternative therapy in such complex infections. Aggressive surgical intervention and tailored antimicrobial strategies remain crucial to overcoming these dual challenges.