Successful use of dalbavancin in the treatment of gram positive blood stream infections: a case series

Patients in our study who received Dalbavancin for infective endocarditis or bloodstream infection had no reported adverse events, complications on follow up, or recorded mortality directly related to their infection. While our cohort was small, this supports previous studies showing Dalbavancin, even for BSI, is both well tolerated and efficacious [1]. Considering the frequency of side effects or adverse events from competing antibiotics, such as acute kidney injury with vancomycin, it is encouraging Dalbavancin is so well tolerated among patients who are severely sick with multiple comorbidities. Our cohort also included a wide variety of bacterial species, sources of infection, and comorbidities, all of which responded well.

A large percentage of our patients were immunocompromised in some way. 26% of patients were receiving some form of immunosuppressive therapy, either in the form of steroids for chronic disease or chemotherapy for cancer treatment. These patients are at significantly increased risk of nosocomial infection, making them ideal candidates for outpatient versus inpatient therapy, particularly when indwelling catheters can be avoided. The source for many of these infections was also long-term IV access in the setting of a surgically placed port. This includes the patients on chemotherapy, and a patient with malabsorption requiring long term TPN therapy. Because of the need to replace ports when they are the source of infection, particularly with organisms like S. aureus, these patients potentially would have faced the acquisition of multiple central access sites, thus forcing them to undergo additional procedures with heightened infectious risk in order to complete therapy. Dalbavancin, with its prolonged half-life, was an optimal therapy here as it both expedited discharge as well as limited procedures and central access catheters.

Other patients who were not good candidates for long term antibiotic therapy included one patient where PICC line could not be placed per nursing, and others who had a history of IVDU (Additional file 1: Table S1). As previously stated, there is increased risk for infection or readmission to the hospital for patients with history of IVDU [16]. 6 out of 23 in our cohort had a history of IV drug use and were not given central venous access for this reason. All 6 were treated successfully with Dalbavancin, with no reported readmission or adverse outcome. This is not only beneficial for the health of the patients but is indeed also a positive aspect of therapy aimed at decreasing costs associated with readmission or prolonged hospital stays for inpatient antibiotics.

A significant portion of our cohort, 48%, received Dalbavancin due to refusal of medical treatment or threatening to leave against medical advice (Additional file 2: Table S2). For these patients, Dalbavancin presents an excellent alternative due to its long half-life which enables weekly dosing. Even though these patients have poor follow up data, our cohort did not have any readmissions to the hospital for worsened infection. Additionally, there was no mortality attributable to their infection. This is significant, as many studies have shown patients who leave AMA have a significantly increased rate of readmission or death [13, 14]. Readmission due to inadequate treatment adds tremendous financial strain to our healthcare system, and Dalbavancin provides an attractive option for alleviating this issue [15].

Despite positive data in this review, there remain significant limitations to our study. Most notably, we have an extremely small cohort of 23 patients who qualified during this 6-year time frame. This is expected, due to the treatment not being first line for such severe infections. This lack of sample size and patient variability makes it difficult to accurately assess the treatment. Furthermore, our data only includes readmission and follow-up data associated with our hospital system. It is possible that patients experienced adverse events associated with their original infection or infusion that this study was unable to document. Another challenge with our study is the fact that the majority of our cohort cleared cultures while on a different antibiotic and received an average of 10 days of antibiotics prior to transition to Dalbavancin. Of note, the average days of treatment prior to transition is skewed by two patients who received prior antibiotics for 59 and 36 days respectively, and without including these two outliers the average length of initial antibiotic use decreases to 7 days. Regardless of length of treatment, we still have documented evidence of culture clearance on 22 out of 23 patients prior to transition (Additional file 1: Table S1). To note, though, documentation of clearance is likely due to our patients receiving antibiotic therapy beginning in the emergency department prior to admission, and typically broad-spectrum coverage. While this is presently the standard of care, it limits our ability to fully assess the efficacy of Dalbavancin alone on these infections or as a primary agent for treatment. This is the same challenge seen in previous studies by Hidalgo-Tenorio and Tobudic, where they were unable to accurately assess Dalbavancin’s impact in the vacuum as a first line treatment of gram-positive infective endocarditis or bloodstream infections [9, 10].

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