Advantages of Outpatient Treatment with Long‐Acting Lipoglycopeptides for Serious Gram‐Positive Infections: A Review

Abstract

Treatment of serious gram-positive infections presents multiple challenges. Treatment often results in prolonged hospitalization for administration of intravenous antimicrobials and presents an inefficient use of hospital resources. Prolonged hospitalization is typically also unfavorable to patient preferences and potentially subjects patients to additional health care-associated complications. Current strategies of transition to outpatient settings-outpatient parenteral antimicrobial therapy and use of oral antibiotics-often do not adequately serve vulnerable populations for whom there is often no alternative to inpatient therapy. Specifically, people who use drugs, those who cannot reliably adhere to unsupervised treatment (poor mental or physical health), people with complicating life circumstances (e.g., homelessness, incarceration, rural location), and those with inadequate health insurance remain hospitalized for weeks longer than persons without such conditions. We suspected that long-acting lipoglycopeptides (laLGP), such as dalbavancin and oritavancin, may be useful in patient transitions to outpatient settings. Thus, we conducted a search of the peer-reviewed literature using the PubMed, Google Scholar, and MEDLINE databases. Based on accumulating literature, it appears that laLGPs offer a reliable alternative therapeutic strategy that addresses many of the personal and systemic barriers to the traditional transitioning approaches. Current evidence also suggests that these agents may be cost-effective from patient, payer, and hospital perspectives. Barriers to broader use of laLGPs include, among others, a relative lack of prospective data regarding efficacy in serious infections, a narrow United States Food and Drug Administration-approved indication restricted to only acute bacterial skin and skin structure infections, and lack of reimbursement infrastructure for inpatient settings.

Use of Dalbavancin in Skin, Bone and Joint Infections: A Real-Life Experience in an Italian Center

“…In our case series, frequency of use of dalbavancin was similar in both “on-label” and “off-label” settings. This is in agreement with other European retrospective studies in which this antibiotic was used above all to treat non-ABSSSI [ 10 , 14 , 18 ]. In contrast, another multicenter observational Italian study that was published recently reported that dalbavancin was mostly used in ABSSSI [ 17 ].…”

“…Several studies of the “off-label” use of dalbavancin have recently been published. In particular, this antibiotic is being used for outpatient parenteral antimicrobial therapy (OPAT) and in infections, such as endocarditis and osteomyelitis, that require long-term antibiotic therapy and long periods of hospitalization [ 11 , 12 , 14 , 15 , 16 ]. The “off-label” use of dalbavancin and the utility of OPAT has also been described in patients classified as vulnerable or high-risk for complications (persons who inject drugs or those who lack social support) [ 17 ].…”

The role of dalbavancin for Gram positive infections in the COVID-19 era: state of the art and future perspectives

“…Specifically, some clinical signs may suggest Gram-negative or anaerobic etiology, thus excluding dalbavancin: infection close to the perineal region, diabetic foot infections or the presence of refractory ulcers. On the contrary, if disease or patientrelated signs may suggest a MRSA etiology, dalbavancin administration should strongly be supported [43].…”

“…However, these strategies do not adequately serve vulnerable populations (i.e. people who use drugs, those with difficulties to comply to unsupervised treatment or with complicating life circumstances), and dalbavancin may represent a modern alternative and its use may overcome many of the barriers that complicate traditional treatment approaches, even if some aspects should be further addressed (i.e lack of prospective data regarding efficacy in serious infections and a narrow indication) [43].…”

Outpatient Subcutaneous Antimicrobial Therapy (OSCAT) as a Measure to Improve the Quality and Efficiency of Healthcare Delivery for Patients With Serious Bacterial Infections

“…For serious bacterial skin infections requiring longer treatment durations, tedizolid may offer an advantage over linezolid due to the reduced potential to cause myelosuppression (52)(53)(54). In addition to oral antibiotics, the availability of long-acting lipoglycopeptides (e.g., dalbavancin and oritavancin) may also provide additional alternatives to OPAT as these drug half-lives ranged from 250 to 350 h (corresponding to 10-14 days), thus requiring only a few doses to provide a 4-6-week treatment course (55). As with OSCAT, additional data are required to further elucidate the utility of oral antibiotics and long-acting antibiotics in the management of serious bacterial infections where intravenous antibiotics have been recognized as a standard of care.…”