Early Transition to Oral Levonadifloxacin in Two Divergent Staphylococcal Infections: Integrating Features of Levonadifloxacin and Evidence from POET and OVIVA Trials

Abstract

Newer methicillin-resistant antimicrobials are needed to address the rising prevalence of methicillin-resistant Staphylococcus aureus (MRSA) and coagulase-negative (MRCONS) infections. We describe two contrasting, recalcitrant staphylococcal infections successfully managed using early transition to the oral benzoquinolizine antibiotic alalevonadifloxacin, highlighting its utility in complex clinical settings. Two high-severity cases of staphylococcal infections are presented. Patient 1, a 58-year-old metastatic lung and orthopedic implant infection on hemodialysis, developed catheter-associated MRSA sepsis with bacteremia, endocarditis, and metastatic lung and orthopedic implant infection. Patient 2, a 41-year-old male with a prior craniotomy, presented with a chronic cranial wound infection due to methicillin-resistant Staphylococcus hominis (MRCONS) originating from an infected ex vivo bone flap. Both patients initially received intravenous therapy and were transitioned to oral alalevonadifloxacin upon availability of susceptibility data. Levonadifloxacin susceptibility testing showed an MIC of 2 µg/mL for MRSA and 0.047 µg/mL for MRCONS-SCV. Patient 1 received 7 weeks of oral therapy aligned with POET recommendation for endocarditis, while Patient 2 completed 8 weeks of oral therapy consistent with OVIVA-based management of osteomyelitis. Despite significant challenges, both patients demonstrated rapid clinical improvement, resolution of infection, and no relapse during follow-up. These cases support oral alalevonadifloxacin as an effective and safe step-down option for complex MRSA and MRCONS infections, including endocarditis, osteomyelitis and meningitis. Alalevonadifloxacin (prodrug of levonadifloxacin) offers a promising oral treatment option when conventional agents are not suitable.