Patient preferences for treatment of acute bacterial skin and skin structure infections in the emergency department

Single Intravenous Dose Dalbavancin Pathway for the Treatment of Acute Bacterial Skin and Skin Structure Infections: Considerations for Emergency Department Implementation and Cost Savings

BACKGROUND

A pathway for the treatment of acute bacterial skin and skin structure infections (ABSSSI) with a single intravenous (IV) dose of dalbavancin was previously shown to reduce hospital admissions and shorten inpatient length of stay (LOS).

OBJECTIVES

To describe pathway implementation at the emergency department (ED) and evaluate cost-effectiveness of a single-dose dalbavancin administered to ED patients who would otherwise be hospitalized to receive usual care with multidose IV antibiotics.

METHODS

The dalbavancin pathway was previously implemented at 11 U.S. EDs (doi:10.1111/acem.14258). Patients with ABSSSI, without an unstable comorbidity or infection complication requiring complex management, were treated with a single dose of dalbavancin. At the emergency physicians' discretion, patients were either discharged and received outpatient follow-up or were hospitalized for continued management. A decision analytic cost-effectiveness model was developed from the U.S. healthcare's perspective to evaluate costs associated with the dalbavancin pathway compared with inpatient usual care. Costs (2021 USD) were modeled over a 14-day horizon and included ED visits, drug costs, inpatient stay, and physician visits. One-way and probabilistic sensitivity analyses examined input parameter uncertainty.

RESULTS

Driven largely by the per diem inpatient cost and LOS for usual care, the dalbavancin pathway was associated with savings of $5133.20 per patient and $1211.57 per hospitalization day avoided, compared with inpatient usual care. The results remained robust in sensitivity and scenario analyses.

CONCLUSION

The new single-dose dalbavancin ED pathway for ABSSSI treatment, which was previously implemented at 11 U.S. EDs, offers robust cost savings compared to inpatient usual care.

How to manage skin and soft-tissue infections in the emergency department

PURPOSE OF REVIEW

Our purpose is to review the state-of-the-art on the management of skin and soft tissue infections (SSTI) in emergency departments (ED).Although the information is scarce, SSTI may account for 3-30% of all cases presenting to an ED, of which 25-40% require hospital admission.SSTI include very different entities in aetiology, location, pathogenesis, extension, and severity. Therefore, no single management can be applied to them all. A simple approach is to classify them as non-purulent, purulent, and necrotising, to which a severity scale based on their systemic repercussions (mild, moderate, and severe) must be added.The initial approach to many SSTIs often requires no other means than anamnesis and physical examination, but imaging tests are an indispensable complement in many other circumstances (ultrasound, computerized tomography, magnetic resonance imaging…). In our opinion, an attempt at etiological filiation should be made in severe cases or where there is suspicion of a causality other than the usual one, with tests based not only on cultures of the local lesion but also molecular tests and blood cultures.

RECENT FINDINGS

Recent contributions of interest include the value of bedside ultrasound and the potential usefulness of biomarkers such as thrombomodulin to differentiate in early stages the presence of necrotising lesions not yet explicit.New antimicrobials will allow the treatment of many of these infections, including severe ones, with oral drugs with good bioavailability and for shorter periods.

SUMMARY

The ED has an essential role in managing SSTIs, in their classification, in decisions on when and where to administer antimicrobial treatment, and in the rapid convening of multidisciplinary teams that can deal with the most complex situations.

Cost-minimisation analysis of oritavancin for the treatment of acute bacterial skin and skin structure infections from a United Kingdom perspective

BACKGROUND

Early discharge (ED) from hospital and outpatient parenteral antibiotic therapy (OPAT) are effective approaches for the management of a range of infections, including acute bacterial skin and skin structure infections (ABSSSI). Strategies that facilitate ED, thereby reducing complications such as healthcare-acquired infection whilst enhancing patient quality of life, are being increasingly adopted in line with good antimicrobial stewardship practice. This study presents a cost-minimisation analysis for the use of oritavancin at ED versus relevant comparators from a National Health Service (NHS) and personal and social services United Kingdom perspective.

METHODS

A cost-minimisation model considering adult patients with ABSSSI with suspected or confirmed methicillin-resistant Staphylococcus aureus (MRSA) infection, was developed based on publicly available NHS costs, practice guidelines for ABSSSI and clinical expert's opinion. Cost of treatment and treatment days were compared for oritavancin at ED to dalbavancin, teicoplanin, daptomycin and linezolid.

RESULTS

Following the empiric use of either flucloxacillin or vancomycin in the inpatient setting, oritavancin was compared to OPAT with dalbavancin, teicoplanin and daptomycin, and oral linezolid from day 4 of treatment. Oritavancin at ED reduced treatment duration by 0.8 days and led to cost savings of £281 in comparison to dalbavancin. In comparison to teicoplanin, daptomycin and linezolid, oritavancin reduced treatment duration by 5 days, with marginally higher costs (£446, £137, and £1,434, respectively).

CONCLUSION

Oritavancin, used to support ED, is associated with lower costs compared with dalbavancin and reduced treatment duration relative to all comparators. Its use would support an ED approach in MRSA ABSSSI management.

Expediting Discharge in Hospitalized, Adult Patients with Skin and Soft Tissue Infections Who Received Empiric Vancomycin Therapy with Oritavancin: Description of Findings from an Institutional Pathway

Background

An internal quality assurance review at AtlantiCare Regional Medical Center (ARMC) revealed that patients admitted with skin and soft tissue infections (SSTIs) remained in hospital post-resolution of acute symptoms and demonstrated a delayed transition to step-down oral antibiotic therapy. A non-mandatory institutional pathway was developed and implemented in 2016 to expedite hospital discharge in hemodynamically stable SSTI patients by utilizing oritavancin.

Objective

To describe the outcomes associated with use of single-dose oritavancin therapy to expedite hospital discharge in hemodynamically stable inpatients with SSTIs.

Methods

A retrospective, descriptive cohort was evaluated for outcomes of patients with SSTIs who received either oritavancin to expedite discharge or were discharged on oral step-down antibiotics. Patients were included in this analysis if they were: ≥ 18 years old; hospitalized; received empiric vancomycin; not pregnant or nursing; hemodynamically stable at the time of assessment; and received either oritavancin or oral step-down antibiotics to facilitate discharge. The primary outcomes were index hospital length of stay (LOS), 30-day SSTI-related readmissions, and 30-day SSTI progression.

Results

Overall, 199 patients met the study criteria (oritavancin = 99 and oral step-down antibiotics = 100). Groups were well matched at baseline. Patients who received oritavancin had a shorter mean index hospital LOS than those in the oral step-down antibiotic group (3.5 days vs. 5.6 days). Patients receiving oritavancin also had lower SSTI 30-day readmission and SSTI-progression rates.

Conclusions

An institutional pathway that used oritavancin to expedite hospital discharge of hemodynamically stable SSTI patients resulted in shorter hospital LOS, less 30-day SSTI-related hospital readmissions, and decreased SSTI progression relative to those discharged on conventional oral step-down therapy.

Early Directed Oritavancin Therapy in the Emergency Department May Lead to Hospital Avoidance Compared to Standard Treatment for Acute Bacterial Skin and Skin Structure Infections: A Real-World Retrospective Analysis

OBJECTIVES

Acute bacterial skin and soft tissue infections (ABSSSIs) are a leading cause of presentation to the emergency department (ED). This study aimed to determine the potential impact of utilizing oritavancin in the ED or observation unit (OBS) on hospital inpatient admission.

METHODS

A single-center community teaching hospital developed a pharmacy-led pilot to evaluate the use of oritavancin as a measure to avoid hospital admissions/readmissions in appropriate patients with ABSSSIs. Prior to initiation of the oritavancin pilot, prespecified inclusion and exclusion criteria were determined for proper patient selection. The pilot ran from January 1 to December 31, 2017. The data were compared to corresponding data for an equal number of patients during the pilot period who had similar ABSSSI diagnoses to the oritavancin pilot group but received vancomycin. The primary outcome was length of stay (LOS), defined as the total time in hours from presentation to the ED until discharge home, including time spent in the OBS or inpatient unit.

RESULTS

During the study period, 122 patients met the study criteria and 61 patients received oritavancin in the ED or OBS unit. These patients were compared to 61 consecutive patients during the pilot period who received vancomycin. Administration of oritavancin in the ED or OBS was associated with a significantly shorter mean LOS relative to the standard of care group (19.5 vs. 85.98 h, p < 0.01). All-cause 30-day readmissions were the same for both groups (6 vs. 6, p = 1).

CONCLUSIONS

These results suggest that use of oritavancin in the ED or OBS setting for ABSSSIs may shorten LOS without negatively affecting readmissions.

Retrospective Real-World Evaluation of Outcomes in Patients with Skin and Soft Structure Infections Treated with Tedizolid in an Outpatient Setting

INTRODUCTION

Outcomes data for patients who received tedizolid for acute bacterial skin and skin-structure infections (ABSSSIs) are scant. We provide a real-world analysis of economic and clinical outcomes following tedizolid use in the outpatient setting.

METHODS

This retrospective study of adults with skin infections treated with tedizolid (index period: 1 July 2014-31 May 2016) used data from the Optum Research and Impact National Benchmark databases.

RESULTS

Ninety-one patients received tedizolid for the treatment of skin infections (with complications, n = 18; without complications, n = 73). Some patients had > 1 complication and infection site. Among patients with complications, pre-index complications during the [index date - 30] through [index date + 1] period included osteomyelitis (44.4%), septicemia (44.4%), and prosthetic joint/device/graft infection (16.7%). For the [index date - 7] through [index date + 1] period, the infection site included abscesses (55.6%) and chronic ulcers (38.9%). Mean (standard deviation [SD]) days supplied for the index tedizolid claim was 6.8 (2.3) days. Healthcare resource utilization (HCRU) during the 30-day post-index period included ≥ 1 ambulatory visit (100.0%), ≥ 1 emergency department (ED) visit (16.7%), and ≥ 1 hospitalization (22.2%). Median 30-day post-index all-cause costs were $11,098 [lower quartile (Q1), $5688; upper quartile (Q3), $16,246; mean (SD), $14,637 ($11,435)]. Among patients without complications, the pre-index infection site from ([index date - 7] through [index date + 1]) included abscesses (60.3%), chronic ulcers (37.0%), and cellulitis (2.7%). Mean (SD) days supplied for the index tedizolid claim was 6.6 (2.5) days. Thirty-day post-index HCRU included ≥ 1 ambulatory visit (91.8%), ≥ 1 ED visit (17.8%), and ≥ 1 hospitalization (5.5%). Median 30-day post-index all-cause costs were $3230 (Q1, $2345; Q3, $6847; mean [SD], $6898 [$11,129]).

CONCLUSIONS

Patients treated with tedizolid in the outpatient setting experienced a short duration of therapy, low hospital admission, and modest post-index HCRU indicators, suggesting its utility for outpatient therapy of ABSSSIs.

Dalbavancin Reduces Hospital Stay and Improves Productivity for Patients with Acute Bacterial Skin and Skin Structure Infections: The ENHANCE Trial

INTRODUCTION

Admissions for acute bacterial skin and skin structure infections (ABSSSI) are often prolonged because of intravenous (IV) antibiotics. Use of a long-acting IV antibiotic may reduce length of stay (LOS) on a hospitalist service. The ENHANCE ABSSSI trial sought to determine the impact on LOS and work productivity in patients treated with a long-acting IV antibiotic, dalbavancin, vs. usual care at an urban tertiary-care center.

METHODS

A single-center, pre- vs. post-period pragmatic trial at Weill-Cornell Medical Center assessed usual care for consecutively enrolled admitted ABSSSI patients during an observational period (pre-period). Identification and treatment of eligible admitted ABSSSI patients with dalbavancin were implemented in the post-period. Those with life-threatening infections, requiring multiple antibiotics/intensive care, or with unstable comorbidities were excluded. Outcomes were assessed over a 44-day follow-up period.

RESULTS

Of 48 and 43 patients enrolled, respectively, in the pre- and post-periods, mean infection-related LOS was reduced in the post-period (3.2 days vs. 4.8 days; P = 0.003). Similar results were found in an adjusted LOS analysis. Work productivity and activity impairment outcomes significantly improved in the post-period (P ≤ 0.01). Complete response rates were similar: 50% (pre-period) and 57% (post-period). Among AEs identified, 17% (n = 7) were found to have possible causal relation to dalbavancin in the post-period. Few AEs were serious (n = 3; 7% post-period versus n = 1; 2% pre-period).

CONCLUSION

After implementing the ENHANCE ABSSSI pathway, LOS was significantly reduced by almost 2 days, with potential improvements in work productivity and ability to complete daily activities.

TRIAL REGISTRATION

ClinicalTrials.gov identifier, NCT03233438.

FUNDING

Allergan plc.

Finding the niche: An interprofessional approach to defining oritavancin use criteria in the emergency department

INTRODUCTION

Cellulitis is commonly treated in the emergency department (ED). Oritavancin is a novel, broad-spectrum antibiotic which provides an entire treatment course for cellulitis with one dose. However, optimal ED prescribing scenarios for oritavancin have not been well defined. The purpose of this study was to identify a population of ED patients with cellulitis who would be most appropriate to receive oritavancin.

METHODS

This was a descriptive, retrospective study conducted at a Midwest healthcare system with two EDs. Over a 1 year period, all adult patients admitted from the ED to an inpatient ward with an ICD-10 diagnosis for cellulitis were reviewed using a priori defined criteria to identify potentially avoidable admissions (PAA). Potentially avoidable admissions were further characterized and compared to the non-avoidable admission population. Identified patient-specific criteria for PAAs were used to develop oritavancin inclusion/exclusion criteria and a case selection flowchart.

RESULTS

Eighty-six patients were identified during the study period. Nine patients (10.5%) were deemed a PAA. A majority of the PAA population had at least one risk factor for treatment failure (55% with diabetes mellitus) and this group was significantly younger than the non-PAA group (42.2 vs 58.6 years; P = 0.01). There were no differences between the PAA group and the non-PAA group in regard to non-age demographics, other risk factors for outpatient treatment failure, comorbidities, or length of stay.

CONCLUSION

Oritavancin is an outpatient treatment alternative for cellulitis patients whose only justification for planned admission is the presence of one or more risk factors for treatment failure.

Comparisons of 30-Day Admission and 30-Day Total Healthcare Costs Between Patients Who Were Treated With Oritavancin or Vancomycin for a Skin Infection in the Outpatient Setting

Objective

Hospital admission is a key cost driver among patients with skin and soft tissue infections (SSTI). Data suggest that many SSTI patients are hospitalized unnecessarily and can be managed effectively and safely in an outpatient setting at a substantially lower cost. Oritavancin (ORI) is a single-dose treatment that has the potential to shift care from the inpatient to the outpatient setting. This study sought to compare the 30-day hospital admission rates and mean healthcare costs among SSTI patients who received outpatient ORI or vancomycin (VAN).

Method

Over a 1-year period, outpatient prescription claims for VAN and ORI among patients with SSTIs and no hospitalization in past 3 days were for VAN and ORI were analyzed using a retrospective cohort analysis of the Truven Health MarketScan Databases.

Results

During the study period, 120 and 6695 patients who received ORI and VAN, respectively, met inclusion criteria. Groups were well matched at baseline. After covariate adjustment, patients who received ORI had a significantly lower 30- day admission rate versus patients who received VAN (6.1% vs 16.2%, respectively; P = .003). Mean healthcare costs 30-day post index were comparable between ORI and VAN patients ($12 695 vs $12 717, respectively; P = 1.0).

Conclusions

Results suggest that ORI provides a single-dose alternative to multidose VAN for treatment of SSTI in the outpatient setting and may result in lower 30-day hospital admission rates.

Modeling operational quality metrics and costs of long-acting antibiotics for acute bacterial skin and skin structure infection treatment in the emergency department

Aims: To model implementation of a new treatment pathway leveraging long-acting antibiotics (LAs) for treatment of acute bacterial skin and skin structure infections (ABSSSIs) in a hospital emergency department (ED) with an observation unit, and to quantify health resource utilization and economic outcomes versus standard care (intravenous vancomycin). Materials and methods: Discrete-event simulation was used to model implementation of the LA treatment pathway in the ED versus standard care from the US Medicare perspective. Model inputs were derived from published sources to simulate a real-world hospital ED with an observation unit. Outcomes included key ED metrics such as patient throughput rate and length of stay (LOS) and cost (estimated through reimbursed amounts in 2017 USD). Results: Implementation of an LA pathway in the ED improved ABSSSI patient throughput rate by 350% (+5.8 dispositions/ED and observation unit day) and reduced LOS by 68% (-7.2 h/patient). These improvements in patient outcomes are driven by the reduced infusion time required for LA antibiotics and are greater for dalbavancin than oritavancin owing to the shorter infusion duration (30 min vs. 3 h). Limitations: External validity of the model was not assessed. The model was limited to care received in EDs; therefore, certain clinical variables outside the ED were not captured for this analysis. Conclusions: LA pathway implementation for ABSSSI treatment in the ED supported improved efficiency, which may translate to economic value. As EDs continue to focus on improving key metrics such as throughput rate and LOS, LA pathway implementation should be considered as a potential approach for abbreviated ABSSSI treatment in the ED.