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JNJ-Q2 is a fluoroquinolone with broad coverage including methicillin-resistant Staphylococcus aureus (MRSA). A double-blind, multicenter, phase II noninferiority study treated 161 patients for 7 to 14 days, testing the efficacy of JNJ-Q2 (250 mg, twice a day [BID]) versus linezolid (600 mg, BID) in patients with acute bacterial skin and skin structure infections (ABSSSI). The prespecified criterion for noninferiority was 15%. Primary intent-to-treat analysis was unable to declare noninferiority, as the risk difference lower bound of the 95% confidence interval between treatments was 19% at 36 to 84 h postrandomization for the composite end point of lesion assessment and temperature. Prespecified clinical cure rates 2 to 14 days after completion of therapy were similar (83.1% for JNJ-Q2 versus 82.1% for linezolid). Post hoc analyses revealed that JNJ-Q2 was statistically noninferior to linezolid (61.4% versus 57.7%, respectively; P = 0.024) based on the 2010 FDA guidance, which defines treatment success as lack of lesion spread and afebrile status within 48 to 72 h postrandomization. Despite evidence of systemic disease, <5% of patients presented with fever, suggesting fever is not a compelling surrogate measure of systemic disease resolution for this indication. Nausea and vomiting were the most common adverse events. Of the patients, 86% (104/121) had S. aureus isolated from the infection site; 63% of these were MRSA. The results suggest JNJ-Q2 shows promise as an effective treatment for ABSSSI, demonstrating (i) efficacy for early clinical response (i.e., lack of spread of lesions and absence of fever at 48 to 72 h), and (ii) cure rates for ABSSSI pathogens (especially MRSA) consistent with the historical literature.
Fluoroquinolones target two bacterial enzymes, DNA gyrase (topoisomerase II) and DNA topoisomerase IV, which play essential roles in the replication, transcription, recombination, and repair of DNA in bacteria (6). Fluoroquinolones have previously been effective against some Staphylococcus aureus isolates in vitro and have been used to treat staphylococcal infections. However, extensive use of these agents has led to increased resistance in S. aureus, particularly methicillin-resistant Staphylococcus aureus (MRSA) (2, 21), with 70% of MRSA isolates from a recent U.S. clinical study showing resistance to levofloxacin (15). No currently marketed fluoroquinolone is recommended for the treatment of MRSA-related infections (16) due to insufficient activity against this pathogen.
Although MRSA was once considered a nosocomial pathogen, in the past decade community acquired (CA)-MRSA has reached epidemic levels in acute bacterial skin and skin structure infections (ABSSSI) (5). Currently, vancomycin, daptomycin, and linezolid are antibiotic agents of choice for treating MRSA (3, 12, 17), but resistance to vancomycin and linezolid has surfaced (12, 13, 22, 24, 26). Thus, the need for new antimicrobial agents against MRSA is evident.
JNJ-Q2 is a novel fluoroquinolone with broad-spectrum coverage, including MRSA, and is being developed for treatment of ABSSSI and other infectious diseases. JNJ-Q2 displays potent in vitro bactericidal activity against Gram-positive bacteria, including fluoroquinolone-resistant MRSA (FQR-MRSA) isolates (7). Recent surveillance studies demonstrated that 90.6 to 97.9% of S. aureus isolates and 86.7 to 95.1% of FQR-MRSA isolates were inhibited at 0.5 μg/ml JNJ-Q2 (7, 8). JNJ-Q2 displays in vitro activity against other Gram-positive and Gram-negative anaerobes and many aerobic Gram-negative organisms (19), making it potentially well-suited for the treatment of polymicrobial skin structure or wound infections. JNJ-Q2 displayed a lower propensity for resistance selection than ciprofloxacin by at least 2 orders of magnitude (19). No JNJ-Q2-resistant mutants were selected in MRSA biofilms, where MRSA isolates are often found (1). JNJ-Q2 was effective in murine models of septicemia and in lower respiratory tract and skin infections and it did not select for resistance in a MRSA skin abscess model (9).
JNJ-Q2 has been tested in the full set of safety pharmacology (central nervous sytem [CNS], cardiovascular, and respiratory) studies, genotoxicity studies, and toxicity studies recommended in ICH S7A, ICH S2B, and ICH M3(r2), respectively, and the toxicology program supports safe use of the dosing regimen used in the current study. Specifically, JNJ-Q2 has been tested in 1-month rodent and nonrodent studies, and no hepatotoxicity was noted with any doses. The no-adverse-effect levels in toxicology studies represented at least a 2-fold margin relative to systemic drug exposure and a 6-fold margin relative to the administered dose. Interestingly, unlike other fluoroquinolones, JNJ-Q2 was not phototoxic in in vitro and in vivo phototoxicity studies.
Human healthy volunteer studies have demonstrated a nonspecific rash rate of <4%, including a single reported case of reversible hypersensitive rash. Asymptomatic reversible isolated increases in alanine aminotransferase (ALT) have been seen in <5% of healthy volunteers, with the vast majority of cases showing increases <5 times the upper limit of normal (ULN). A single case of reversible isolated increased ALT elevation to 11.8× the ULN was seen in a healthy subject in a QTc (corrected QT interval) crossover study. The thorough human QTc study demonstrated that JNJ-Q2 prolongs the QTc, but less so than moxifloxacin. No evidence of significant CNS or dysglycemic effects has been noted.
In this phase II proof-of-concept study, JNJ-Q2 was evaluated for the treatment of ABSSSI.
The current study, conducted at 18 centers in the United States from June 2010 to August 2010, was a randomized double-blind, double-dummy trial to determine the clinical efficacy, safety, and tolerability of JNJ-Q2 (250 mg, twice a day[BID]) versus linezolid (600 mg, BID) in patients with ABSSSI. The dose of JNJ-Q2 was chosen based upon pharmacokinetic/pharmacodynamic (PK/PD) modeling using the ratio for the area under the time-concentration curve (AUC) and the MIC as the marker of interest and targeting a 1-log kill of FQR-MRSA while limiting potential side effects. A time and events overview of the study design, showing the treatment and evaluation schedule, is provided in Table 1. The study was conducted in accordance with all relevant federal guidelines and institutional policies, including, but not limited to, informed patient consent prior to enrollment and institutional review.
Adult males and nonpregnant, nonlactating females, age 18 to 70 years inclusive, with an ABSSSI were stratified by infection type (wound infection, cellulitis, or severe abscess) and fever (≥38.0°C) and randomly assigned (1:1) to receive either JNJ-Q2 or linezolid. Investigators were instructed to stop medication when the infection was considered clinically cured after a minimum treatment period of 7 days and a maximum treatment period of 14 days. Specimens from the primary infection site were collected for culture. Confirmation testing was performed on bacterial isolates for identification and susceptibility at the central microbiology reference laboratory (JMI Laboratories, North Liberty, IA). Qualifying ABSSSI included any wound infection, deep cellulitis, or severe abscess with a minimum lesion size of 75 cm2. Infections were not likely to be cured with surgical incision alone and did not require other antifungal, antimycobacterial, or other antibacterial agents in addition to study medication. Lesion surface area was determined by the product of the maximum length and width of the cross-sectional diameters of the leading edge of either the erythema or induration, whichever was greater. To be enrolled, patients were required to have at least 3 of the following 5 signs: purulent drainage/discharge; erythema with/without induration; fluctuation; heat/localized warmth; pain/tenderness. Additionally, at least one of the following six systemic findings had to be present: temperature of ≥38°C (100.4°F); hypothermia (<36.0°C [96.8°F]); white blood cell count of ≥10,000/μl; ≥15% band forms; leukopenia; lymphangitis/lymphadenopathy relative to the area of the infection (10, 11, 25). Patients who received 1 dose of a systemic antibiotic (with a half-life of 12 h or less) 24 h prior to the first dose were permitted in the study. Patients with surgical incisional wound infections who received prophylactic antibiotics ≥48 h before enrollment were also permitted in the study. All patients with infections involving prosthetic materials or foreign bodies (except cellulitis and purulence at the insertion site of an intravenous catheter), coexisting conditions, such as decubitus ulcer, diabetic foot ulcer, septic arthritis, gangrene or gas gangrene, burns, current evidence of deep vein thrombosis, or a severely compromised immune system, were not eligible for enrollment.
Patients who needed any other systemic antibiotic treatment or antibiotic treatment beyond 14 days were considered clinically not cured; investigators could choose to withdraw patients from the study at any time and treat with alternative therapy if the patient was not improving regardless of the presence or absence of a Gram-negative organism. The follow-up period included a test-of-cure (TOC) visit 10 to 14 days after randomization and a short-term follow-up (SFU) visit that occurred 2 to 14 days after the last dose of study medication. A secondary or long-term follow-up visit occurred between 84 and 98 days postrandomization.
Assessments included signs and symptoms of infection and infection site measurements. Postrandomization patients were required to take their oral body temperature at least 5 times daily while awake as well as just before consumption of an antipyretic through the SFU visit. All patients were provided with the same standard digital thermometers and daily temperature cards for recording the actual temperature reading as well as the date and time when they took their temperature. Signs and symptoms (erythema, edema/induration, purulence [including drainage], tenderness/pain, and lymphangitis/lymphadenopathy) of the primary lesion were assessed on a scale of 0 to 3 (none, mild, moderate, or severe).
Safety was assessed based on adverse event (AE) monitoring, 12-lead electrocardiogram measurements, physical examination findings, vital sign measurements, visual acuity assessments, and clinical laboratory assessments.
A 70% cure rate for linezolid, a 75% cure rate for JNJ-Q2, and a noninferiority margin of 15% were assumed in determining study sample size. These assumptions determined that a target of 80 patients per treatment group (i.e., 160 patients in total) would yield over 80% power to determine that JNJ-Q2 is not inferior to linezolid, assuming a 1-sided α-level of 0.025. The primary efficacy analysis of the ITT set (see below) was conducted on the composite endpoint of (i) cessation of spread of the primary infection site lesion and (ii) stable temperature below 38°C, evaluated at 36 to 84 h after the first dose of study medication. Although the protocol stipulated 48 to 72 h for the evaluation, the prospective statistical analysis plan (SAP) allowed an additional 12 h on both sides of the time frame, broadening the window to 36 to 84 h to allow scheduling flexibility for the sites and patients, especially those who were randomized on the afternoon of day 1 and required a morning visit on day 3. Stable temperature was defined as successive temperature readings falling within 2 standard errors of measurement of one another by 72 h postrandomization. The standard error was determined by regression of temperature measurements over time for all patients irrespective of treatment assignment.
A primary responder was any subject who met success on both elements of the composite end point, i.e., lack of spread of lesion and afebrile, during the evaluation window. Any other result pattern, including patients outside the visit window, was assigned as a treatment failure. The primary efficacy analysis was performed using logistic regression (14), where treatment and wound type were main effects and baseline temperature and lesion size were covariates.
Post hoc analyses were performed on the ITT set by using the same lesion response criteria but also meeting the FDA definition of afebrile and using the 48- to 72-h window (10). This analysis of early clinical response criteria was supplemented with a risk difference (RD) analysis (4). Table 2 provides a comparison of early end point criteria as defined by the protocol, the prospective SAP for the study, and FDA definitions.
Other prespecified secondary analyses on the ITT set included clinical response rates as determined by the investigator at the later time points on day 8, TOC, and SFU. Missing clinical responses or patient visits occurring outside the prospectively defined visit window, regardless as to investigator assessment, were assigned as clinical failures in the statistical analyses. These later time point clinical responses were compared using logistic regression (14), where treatment and wound type were main effects. Risk difference analyses (4) were conducted in addition to logistic regression (14) modeling for responses on day 8, TOC, and SFU.
Other post hoc analyses were done using a composite end point of early assessment of lesion response and investigator assessment of clinical cure at the TOC time point. The first secondary end point noted in the draft FDA ABSSSI guidance includes “evaluation and objective measurements of the infection site and overall assessment as clinical response or failure” (10). The ITT set was analyzed with respect to the number of patients who had both a clinical response of “cured” at the TOC visit and who were also considered lesion responders, i.e., those with cessation of spread or reduction in the size of the primary infection site lesion at visit 3 (day 4). This included only patients with a TOC visit within the appropriate analysis window of 10 to 14 days from the date of randomization. These analyses were conducted using both windows for lesion response, i.e., the window as defined in the SAP (36 to 84 h; primary analysis lesion responder) and the narrower FDA window (48 to 72 h; FDA lesion responder [Table 2]).
The intent-to-treat analysis set included patients receiving at least one dose of drug and was employed for the primary efficacy analysis and other post hoc analyses. The microbiological ITT (mITT) set contained patients in the ITT set that had microbiologic confirmation of disease. Patients in the clinically evaluable (CE) set were mITT patients that also met inclusion/exclusion criteria, had adequate description of the infected area/lesion, had adequate follow-up (at or after the timing for the TOC visit), and a culture obtained (if an appropriate site to culture was available), received at least 80% of planned study medication therapy, had a TOC visit from 10 to 14 days postrandomization, and did not receive any concomitant systemic antibacterial therapy. The microbiologically evaluable (ME) set consisted of CE patients who had a pathogen isolated at baseline that was susceptible to study medications.
A total of 161 patients were randomized, with 83 patients receiving JNJ-Q2 and 78 patients receiving linezolid. Demographic characteristics were generally similar between treatment groups. The mean age was 36.9 (range, 18 to 69) years. The majority of patients were male (64.6% [104 of 161]), and most patients were white (79.5% [128 of 161]). Details about baseline diagnosis and patient disposition are shown in Table 3. Although patients with diabetic foot ulcers were not eligible for enrollment, patients with diabetes were permitted in the study and represented 13% of patients enrolled (16.9% in the JNJ-Q2 arm and 9.0% in the linezolid arm).
Approximately one-third of patients in each treatment group had abscesses, wound infections, and cellulitis. Although the initial lesion sizes were large (mean and median lesion sizes were 266 and 162 cm2, respectively, per study sample), the overall rate of fever across both groups was low (4.3%). A total of 21 patients, 10 (12%) on JNJ-Q2 and 11(13.9%) on linezolid, received prior antibiotic therapy as allowed by the protocol. Discontinuations due to adverse events were low (2.4% for JNJ-Q2 and 2.6% for linezolid), and there was no use of rescue antibiotics.
Approximately 75% of patients (121 of 161) had a baseline pathogen isolated from the infection site. All pathogens isolated at baseline were susceptible to JNJ-Q2. All Gram-positive pathogens were susceptible to linezolid; linezolid susceptibility testing against Gram-negative organisms was not checked. Investigators were allowed to withdraw patients from the study if they grew Gram-negative organisms and were not improving, but none chose to do so. A total of 104 patients grew S. aureus pathogens; 63% of these patients grew MRSA (38 MRSA isolates from 36 patients in the JNJ-Q2 group and 32 MRSA isolates from 29 patients in the linezolid group). Seventy of 139 baseline pathogens were identified as MRSA.
Early treatment response data were analyzed using the approaches noted in Table 2. In the primary efficacy analysis based on the SAP criteria for early clinical response, 62/83 (74.7%) and 62/78 (79.5%) patients in the JNJ-Q2 and linezolid groups, respectively, were considered to have achieved success; JNJ-Q2 did not meet criterion for noninferiority under the SAP (odds ratio [OR], 0.758; 95% confidence interval [CI], 0.361-1.594), i.e., the lower bound of the 95% CI needed to be greater than 0.469 to conclude noninferiority. In post hoc analyses based on the FDA end point criteria, JNJ-Q2 was statistically noninferior to linezolid (Table 4). A total of 61.4% of patients in the JNJ-Q2 group were considered treatment responders, compared with 57.7% of patients in the linezolid group (RD, 3.8%; 95% CI, −12.7 to 20.2%; P = 0.024).
In prespecified, secondary analyses, JNJ-Q2 had a higher percentage of clinical response, as determined by the investigator, at day 8, TOC, and SFU and was also statistically noninferior to linezolid for clinical response at all 3 time points (Table 5) for the ITT population. At SFU, 83.1% of patients (69 of 83) in the JNJ-Q2 group and 82.1% (64 of 78) of ITT patients in the linezolid group were assessed as cured. Additionally, for the diabetic subgroup 12/14 (two patients were identified as cured but were evaluated outside the SFU window of 2 to 14 days posttreatment) who received JNJ-Q2 and 7/7 in the linezolid group were identified as cured. Similar findings were noted for the mITT, the CE, and the ME populations. (Note that the CE and ME populations were identical.)
Median infection site area decreased from baseline to SFU for both treatments (Fig. 1). Although lesion size measurements were highly variable in both treatment groups at baseline, the variation was notably larger in the linezolid group at the day 8, TOC, and SFU visits. Improvement was observed for all signs and symptoms of infection in both treatment groups, as indicated by a decrease in symptom scores, starting at day 2. Marked improvement was observed for the signs and symptoms recorded from day 2 to day 4 and from day 4 to day 8.
The additional post hoc analysis that combined the early lesion assessment with a later assessment of clinical cure demonstrated similar results between the treatment groups based on the 36- to 84-h primary analysis lesion responder window (JNJ-Q2, 59.0%; linezolid, 57.7%) as well as based on the more narrow 48- to 72-h FDA lesion responder window (JNJ-Q2, 50.6%; linezolid, 41.0%).
The clinical cure rate for patients with MRSA was higher for JNJ-Q2 (50.0% [18 of 36]) compared with the linezolid group (44.8% [13 of 29]) at day 8 (Table 6). The clinical cure rate for patients with MRSA was more than 60% at TOC (OR, 0.942 (0.335–2.652) and at SFU were 80.6% and 86.2% for JNJ-Q2 and linezolid, respectively (OR, 0.664 [0.173–2.546]).
At the SFU visit, approximately 84% of patients in both treatment groups had a microbiological response of presumed or confirmed eradication. Four patients (two per treatment group) had a microbiological response of presumed persistence. No patient had a microbiologically confirmed persistent pathogen.
Microbiologically confirmed posttreatment new infection (isolation of a new pathogen from a posttreatment culture, with signs and symptoms of infection) was observed in one subject in each group (JNJ-Q2, Staphylococcus epidermidis; linezolid, Enterobacter cloacae and Escherichia coli). Long-term clinical follow-up data collected 12 weeks after the last dose of medication showed similarly low rates of microbiologically confirmed recurrent infections for both treatment groups: 1.2% (n = 1) for JNJ-Q2 (MRSA isolate) and 2.6% (n = 2) for linezolid (MRSA in one subject and methicillin-susceptible S. aureus in one subject). However, it must be emphasized that the definitions used for “new infections” and “recurrent infections” were overly conservative, in that the definitions did not require the same location as the index lesion, nor did the definition require the use of additional antibiotics. Importantly, only one linezolid patient required additional antibiotics.
Clinical responses at the TOC visit for patients with a polymicrobial infection are noted in Table 7, while clinical responses at TOC for patients that grew a baseline pathogen by infection type (wound infection, abscess, and cellulitis) are presented in Table 8. Similar outcomes for clinical cure were noted between the two arms for both of these approaches.
There were several key clinical signs of infection considered in the current study, including fever, C-reactive protein (CRP), white blood cell (WBC) count, and lymphadenopathy. Body temperature measurements were similar between treatment groups, with a mean baseline body temperature of 36.7°C for both groups, which showed little mean change over time. At baseline, more than 80% of patients (131 of 161) had CRP levels higher than the ULN (5 mg/liter) and >45% of patients (77/161) had a CRP >5 times the ULN. At TOC more than 75% of patients in both groups had CRP levels within the normal range. Of the 68 and 63 patients that had elevated CRP values at baseline in the JNJ-Q2 and linezolid groups, respectively, 44 (65%) and 49 (78%) reported normal levels at SFU. At baseline, 22/83 (26.5%) and 26/78 (33.3%), respectively, for JNJ-Q2 and linezolid had elevated (>10,000/mm3) white blood cell levels, and by SFU there were 5 patients on JNJ-Q2 and 9 patients on linezolid with elevated white cell counts. Seventy (84%) of JNJ-Q2 and 64 (82%) of linezolid patients reported some lymphadenopathy at baseline; by SFU, 80 (96%) and 77 (99%) of JNJ-Q2 and linezolid patients, respectively, reported no lymphadenopathy. Clinical responses at the TOC visit based on presence of baseline local and systemic findings are presented in Table 9.
The incidence, relationship to study medication, seriousness, and severity of AEs and the incidence of AEs of special interest were similar between the JNJ-Q2 and linezolid groups, except nausea and vomiting, which were greater in the JNJ-Q2 group. In the JNJ-Q2 group, 50 patients (60.2%) experienced a total of 111 AEs, of which three events in 2 patients (3.6%) were considered severe. In the linezolid group, 51 patients (64.6%) experienced a total of 110 AEs, of which five events in 4 patients (5.1%) were considered severe.
The most common AEs (>5% of patients overall) were nausea, diarrhea, vomiting, and headache. The incidences of nausea and vomiting were higher in the JNJ-Q2 group than the linezolid group. For patients who experienced nausea and vomiting in the JNJ-Q2 group, ≥80% of patients experiencing these events had resolution of their symptoms within the first 2 days of therapy; no patients discontinued treatment due to these symptoms, which were typically mild. Adverse events occurring in at least 5% of patients are listed in Table 10.
Adverse events of special interest for quinolones were prospectively monitored. Patients with diarrhea were evaluated for Clostridium difficile and no cases were identified. All rashes (<4% and with similar rates across both treatments) were considered grade 1/2 based on the DAIDS AE grading table. One subject (JNJ-Q2 group) discontinued due to a nonserious AE of allergic dermatitis. Rates of headache and dizziness were comparably recorded across both treatments. There were no other signals for CNS or other neurological adverse events in patients receiving JNJ-Q2; specifically, there were no AEs of visual disturbances or seizure disorders.
Laboratory and other investigations of special interest for quinolones were also closely monitored. There were no clinically significant AEs or SAEs of hematologic abnormalities, hyperglycemia, or hypoglycemia in patients receiving JNJ-Q2. Overall, liver chemistries were similar between the two treatment groups: 7/83 patients (8.4%) and 7/79 patients (8.9%) in the JNJ-Q2 and linezolid treatment groups, respectively, demonstrated the combination of at least a 1.5-fold rise above the ULN for ALT and at least a 1.5-fold increase above baseline in ALT. However, one JNJ-Q2 subject who had an elevated baseline ALT (61 U/liter, with ULN of 33U/liter) was found, on routine monitoring at day 8 (at the end of her treatment course with JNJ-Q2), to have an asymptomatic ALT elevation to 875 without concomitant increase in bilirubin. This finding was reported as an AE and resolved to the normal range by 30 days postrandomization. Additionally, mild, transient, asymptomatic lipase elevations were observed in 2 patients (1 in each treatment group).
AEs of asymptomatic, slight prolongation of the QTc interval, without cardiovascular sequelae were reported for 2 patients receiving JNJ-Q2 and 2 patients receiving linezolid. At the SFU visit (time of detection) both JNJ-Q2 patients had been off drug for at least 2 days: one had a baseline QTc of 450 ms that increased to 492 ms, while the other had a baseline value of 437 ms that increased to 459 ms. Similarly, one subject in the linezolid group had a baseline value of 430 ms that increased to 470 ms (day 8), while the other had a baseline of 444 ms that increased to 450 ms on day 13.
In the JNJ-Q2 group, 2 patients experienced SAEs. One subject experienced a road traffic accident with multiple injuries and compartment syndrome approximately 8 weeks after completing therapy. The second subject was reported to have an SAE of sepsis. However, the diagnosis was based on suspicion of bacteremia; only 1 of 4 predose blood cultures demonstrated a Gram-positive organism on Gram stain, but all four cultures failed to grow any bacteria. The sepsis was interpreted by the investigator to be present prior to therapy. In the linezolid group, 3 patients experienced 4 SAEs: cellulitis with allergic dermatitis requiring hospitalization, cholecystitis, and supraventricular tachycardia.
The incidence of MRSA has markedly increased in recent years, such that it has become the most frequent cause of skin and soft tissue infections presenting to emergency departments in the United States (18). This trend is borne out in the current data as well; 53.8% of patients with demonstrable clinical pathogens grew cultures positive for MRSA. The current study evaluated the efficacy and safety of JNJ-Q2, a novel broad-spectrum fluoroquinolone with potent MRSA coverage, in a phase II proof-of-concept study for the treatment of ABSSSI, by employing both traditional test-of-cure end points, as well as end points involving early clinical response based on the 2010 FDA draft guidance (10). The current study demonstrates that the investigational quinolone, JNJ-Q2, was safe and efficacious in treating severe cases of ABSSSI on an outpatient basis with an oral dosing regimen.
The rates of clinical cure at SFU were similar for JNJ-Q2 (83.1%) and linezolid (82.1%) and were consistent with the incidence of clinical cure in comparable populations for a series of previously studied antibiotics, including antibiotics known to have activity against MRSA, such as ceftaroline, ceftobiprole, and telavancin (11, 20, 23, 25). JNJ-Q2 met statistical criteria for noninferiority to linezolid for clinical response at various time points (day 8, TOC) and at SFU for both ITT and mITT sets, and with a single exception in these two analysis sets, a higher proportion of JNJ-Q2-treated patients were considered to have clinical cures compared with linezolid. The results of the current study for clinical response in patients treated with JNJ-Q2 were also supported by investigators' subjective scores of signs and symptoms of infection, which included improvements in purulence/drainage, lymphangitis/lymphadenopathy, edema/induration, and erythema. Additionally, marked reductions in quantitative measures, e.g., mean lesion area, CRP levels, and white blood cell count, were also noted. Similar improvement in clinical signs and symptoms of infection, lesion size, and CRP levels were observed in the linezolid group.
Early clinical response criteria using temperature and wound measurement have not traditionally been used in the efficacy evaluation of antibiotics for ABSSSIs. Rather, efficacy has previously been determined through evaluation of clinical response at a time point analogous to the SFU time point used in this study. Based on the SAP-defined early clinical response criteria of stabilization of temperature and cessation of spread or reduction in lesion size at 36 to 84 h, JNJ-Q2 was quantitatively lower. However, when applying criteria as defined in the FDA draft guidance based on the 48- to 72-h window, JNJ-Q2 was statistically noninferior to linezolid. Note that the disparity between the SAP and FDA definitions for time of assessments is due to small differences in classification of success, which are amplified by the relatively small sample size in the current study.
Additionally, the difference in outcome between the early clinical response analyses based on SAP-specified criteria versus the FDA response criteria was due almost entirely to the timing of the assessment of lesion response. The difference in lesion response resulted from the window (SAP, 36 to 84 h, versus FDA, 48 to 72 h) for acceptable lesion measurements. The early response end point criterion of stabilization of temperature had no impact on the difference in the efficacy outcomes for this study versus the FDA response criteria, but this also acknowledges that the vast majority of patients did not exhibit temperature elevation at baseline.
Importantly, the analysis combining the early end point of lack of spread of lesion at days 3 to 4 plus a clinical assessment of cure at the TOC visit demonstrated a greater response rate for JNJ-Q2 compared to linezolid regardless of which window for the early visit was used.
The relative lack of temperature response likely reflected the general absence of fever at baseline (only 4.3% of patients had demonstrable fever prior to randomization). However, definitive improvement in clinical response suggests that body temperature was not a robust surrogate measure of disease resolution for the current set of patients, who clearly had systemic evidence of disease as noted by elevations of CRP and the presence of lymphadenopathy or other signs of systemic inflammation at baseline. Safety results from this study are consistent with results from prior studies with JNJ-Q2 and with the known effects of quinolone antibiotics.
JNJ-Q2 was well tolerated at a dose of 250 mg BID for up to 14 days. The incidence of SAEs was low, and the majority of AEs were mild or moderate in severity. The most common AEs were nausea, vomiting, diarrhea, and headache which, for the majority of patients, were mild in intensity. No patients discontinued due to AEs of nausea or vomiting, and ≥80% of these events occurred within the first or second day of randomization. In this study, patients were not specifically instructed to take the medication with food, which is being done in subsequent studies to potentially lower the frequency of these gastrointestinal events. The incidence of the AE of diarrhea was similar between treatment groups: 12.0% in the JNJ-Q2 group and 13.9% in the linezolid group; no cases of C. difficile infection were diagnosed in either treatment group. One patient in the JNJ-Q2 group with a slightly elevated baseline ALT developed a transient, >10× ULN, ALT elevation that was detected during the routine monitoring process; the patient did not experience clinically symptomatic hepatitis or hyperbilirubinemia, and ALT levels rapidly returned to normal. There were no signals for other adverse events that have been associated with quinolones (e.g., visual changes, neurologic symptoms, dysglycemia, etc.). Centrally analyzed electrocardiogram data showed no difference in the QT profile compared with linezolid.
Limitations to the interpretability of the study results include the departure of the observed pattern of results from a priori assumptions for noninferiority, lack of explanation for losses to follow-up for the LFU visit, and the relatively small sample size, especially when analyzing subpopulations. The current study assumed a 15% noninferiority margin with observed response rates of 70% and 75% for linezolid and JNJ-Q2, respectively. These prospectively defined rates were limited, as the response definition employed has not had wide use in clinical settings. As discussed above, the observed rate for JNJ-Q2 response was close to the assumption, 74.5% versus 75% response; however, this was not the case for linezolid, 79.5% versus 70% response. The discrepancy between assumed and observed linezolid response rates has an impact on the subsequent inferential testing performed. These departures from a priori assumptions would have been detrimental to a confirmatory study. However, as the current trial was designed as a proof-of-concept study, the results are informative toward constructing a more robust pivotal trial. Although 93.2% of patients were seen through the SFU visit, with similar losses between the two treatment groups, we note the discrepancy in patients who were lost to follow-up (9 patients versus 1 patient in the JNJ-Q2 and linezolid treatment groups, respectively) prior to the 3-month LFU visit. The protocol only specified a visit at 12 weeks postrandomization; no other procedures were specified if a patient failed to return. Finally, statistical analyses were intended for the complete population; caution should be exercised in drawing conclusions regarding subpopulations, e.g., outcomes relative to type of infection, presence or absence of any particular local or systemic finding, or presence of a polymicrobial infection due to the small sample size.
In conclusion, JNJ-Q2 was effective against MRSA, with a clinical cure rate of 80% at SFU, and all pathogens identified at baseline were sensitive to JNJ-Q2. The results of this study demonstrate that treatment with JNJ-Q2 for 7 to 14 days in patients with ABSSSIs, including ABSSSIs caused by MRSA, resulted in reduced lesion size and improvement in the clinical signs and symptoms of infection and, importantly, a clinical cure rate similar to linezolid. Based on these clinical results and on the broad-spectrum in vitro potency, JNJ-Q2 merits continued study as a future therapy of ABSSSI caused by either methicillin-sensitive or methicillin-resistant S. aureus, as well as for polymicrobial abscesses and wound infections.
We express our appreciation and thanks to the participating investigators and their staffs who contributed to this study: Simon Babazadeh, Santa Ana, CA; James C. Chen, Buena Park, CA; Robert C. Cockrell, Fountain Valley, CA; Sinikka L. Green, La Mesa, CA; Stephen Ho, Houston, TX; Luis Jauregui-Peredo, Toledo, OH; Jennifer L. Johnson-Caldwell, Houston, TX; Richard C. Keech, Anaheim, CA; Muhammad A. Khan, St. Cloud, FL; Paul J. Manos, Oceanside, CA; Arnold Markowitz, Keego Harbor, MI; Maria C. Mascolo, Savannah, GA; Purvi K. Mehra, Chula Vista, CA; Richard A. Nathan, Idaho Falls, ID; Alan E. Nolasco, Houston, TX; John Pullman, Butte, MT; Joseph G. Surber, Columbus, GA; Charles R. Tessier III, Baton Rouge, LA.
All authors affiliated with Furiex own Furiex shares and/or options.
We acknowledge Anthony Lynch and Brian Morrow from Johnson & Johnson Pharmaceutical Research and Development, L.L.C., for their input into and review of this paper. We also wish to acknowledge Randi M. Gress for preparation, formatting, and organization of the document.
†The authors have paid a fee to allow immediate free access to this article.
Published ahead of print on 26 September 2011.