Dalbavancin treatment in a deep sternal wound MRSA infection after coronary artery bypass surgery: a case report

Dalbavancin real-life utilization among diabetic patients suffering from infections in Italy and Spain: The DALBADIA retrospective cohort study

OBJECTIVES

To retrospectively describe the patterns of use of dalbavancin for treating infections in diabetic patients in Italian and Spanish standard clinical practice.

METHODS

DALBADIA [NCT04959799] was a multicentre, observational, retrospective cohort study, conducted in Italy and Spain. The study enrolled 97 adults with type 1 or 2 diabetes mellitus, treated with dalbavancin as per standard clinical practice for a Gram-positive bacterial infection or the Gram-positive component of a mixed infection.

RESULTS

Dalbavancin was used to treat cellulitis (18/92 patients, 19.6%), followed by prosthetic joint infection (14 patients, 15.2%), endocarditis (13 patients, 14.1%), and primary bacteraemia (10 patients, 10.9%); 78/92 (84.8%) patients had Gram-positive infections only, and 14 (15.2%) had mixed infections. The most frequently isolated microorganisms were Staphylococcus aureus in 43 (55.8% of the patients with microbial isolation), 25.6% of which methicillin-resistant; Staphylococcus epidermidis in 13 (16.9%), 53.8% of which methicillin-resistant; Enterococcus faecalis in 11 (14.3%). The main reason for the dalbavancin choice was the intent to simplify the antibiotic regimen (81.5% of cases). A multidisciplinary team participated in the treatment choice process for 53 (57.6%) patients. Dalbavancin was given as first-line antibiotic in 34 (37.0%) patients and administered as one infusion in 32 (34.8%), and as two infusions in 39 (42.4%). In total, 57/62 (91.9%) eligible patients with available assessment were judged clinically cured or improved at the end of observation.

CONCLUSION

In clinical practice, dalbavancin was used in diabetic patients to treat ABSSSIs and other difficult-to-treat infections with a favourable safety profile and a high rate of positive clinical responses.

A Retrospective multicenter Study on Dalbavancin Effectiveness and cost-evaluation In Sternotomic Wound Infection Treatment. DALBA SWIT-Study

OBJECTIVE

To evaluate the cost-effectiveness of dalbavancin compared with standard of care (SoC) treatment as daptomycin or teicoplanin in patients with sternal wound infections (SWI).

METHODS

Multicentre retrospective study of patients diagnosed with SWI from January 2016 to December 2019 at two cardiac surgery facilities treated with dalbavancin, teicoplanin or daptomycin. Patients with SWI treated with dalbavancin were compared with SoC to evaluate resolution of infection at 90 and 180 days from infection diagnosis, length of stay (LoS) and management costs.

RESULTS

48 patients with SWI were enrolled, 25 (50%) male, median age 67 (60-73) years, Charlson index score 5 (4-7). Fiftheen patients were treated with dalbavancin (31%), and 33 with SoC (69%): teicoplanin in 21 (63%), and daptomycin in 12 (37%). Staphylococcus species were the most frequent isolates (44, 92%), mostly (84%) resistant to methicillin. All patients were treated with surgical debridement followed by negative pressure wound therapy. Wound healing at day 90 and 180 was achieved in 46 (95.8%) and 34 (82.9%) of patients, respectively. A shorter length of hospitalization in patients treated with dalbavancin compared with SoC [12 (7-18) days vs 22 (12-36) days, p:0.009] was found. Treatment with dalbavancin resulted in total cost savings of 16026 € (95%CI 5976 - 26076, p<0.001). Savings were mainly related to the LoS that was significantly shorter in the dalbavancin group generating significantly lower cost as compared to SoC group.

CONCLUSIONS

Dalbavancin treatment of sternal wound infections is effective and seems to reduce hospitalization length, leading to significantly lower costs.

Multiple-Dose Dalbavancin Regimens as the Predominant Treatment of Deep-Seated or Endovascular Infections: A Scoping Review

Off-label use of dalbavancin for deep-seated and endovascular infections has been increasing. We performed a scoping review to evaluate the evidence for use of multiple-dose dalbavancin regimens as the predominant therapy for these indications. Predominant therapy was defined as use of dalbavancin without other concurrent antibiotics for more than half of the total treatment duration. Fifteen publications were identified; 2 were small, open-label randomized controlled trials and the remainder were retrospective observational studies or case reports. A total of 144 cases from these publications met eligibility criteria for inclusion in this review. Types of infections included osteoarticular infections, catheter-related or complicated bloodstream infections, and infective endocarditis. Overall, the evidence for use of multiple-dose regimens of dalbavancin for deep-seated and endovascular infections is limited by a paucity of data from controlled trials, heterogeneity of dosing regimens, and a lack of standardized clinical outcomes.

Real-World Use of Dalbavancin in the Era of Empowerment of Outpatient Antimicrobial Treatment: A Careful Appraisal Beyond Approved Indications Focusing on Unmet Clinical Needs

Dalbavancin is a novel, long-acting lipoglycopeptide characterized by a long elimination half-life coupled with excellent in vitro activity against multidrug-resistant Gram-positives. Although it is currently approved only for the treatment of acute bacterial skin and skin structure infections, an ever-growing amount of evidence supports the efficacy of dalbavancin as a long-term therapy in osteomyelitis, prosthetic joint infections, endocarditis, and bloodstream infections. This article provides a critical reappraisal of real-world use of dalbavancin for off-label indications. A search strategy using specific keywords (dalbavancin, osteomyelitis, endocarditis, long-term suppressive therapy, bloodstream infection, pharmacokinetic/pharmacodynamic profile) until April 2021 was performed on the PubMed-MEDLINE database. As for other novel antibiotics, a conundrum between approved indications and potential innovative therapeutic uses has emerged for dalbavancin as well. The promising efficacy in challenging scenarios (i.e., osteomyelitis, endocarditis, prosthetic joint infections), coupled with the unique pharmacokinetic/pharmacodynamic properties, makes dalbavancin a valuable alternative to daily in-hospital intravenous or outpatient antimicrobial regimens in the treatment of long-term Gram-positive infections. This makes dalbavancin valuable in the current COVID-19 scenario, in which hospitalization and territorial medicine empowerment are unavoidable.

Treatment of osteoarticular, cardiovascular, intravascular-catheter-related and other complicated infections with dalbavancin and oritavancin: A systematic review

BACKGROUND

There is increasing interest in the use of oritavancin and dalbavancin for complicated Gram-positive infections as an alternative to in-hospital intravenous or outpatient antimicrobial therapy.

OBJECTIVE

To evaluate the efficacy and safety of long-acting lipoglycopeptides (laLGPs) in patients with osteoarticular, cardiovascular, intravascular-catheter-related and other complicated infections.

METHODS

A systematic literature search was performed using 'dalbavancin' and 'oritavancin' as search terms. For inclusion in this review, studies had to include at least one human subject treated for an indication other than acute bacterial skin and skin structure infections. The primary outcome for this review was clinical success as defined by each individual study, and patients were stratified by type of infection.

RESULTS

In total, 38 studies (18 randomized controlled trials/case series and 20 case reports) met the inclusion criteria. The most common off-label indication for oritavancin and dalbavancin was osteoarticular infection, with a median success rate of 73% [interquartile range (IQR) 58-85%] among the 14 studies with more than one patient. The success rate for endocarditis and cardiac-device-related infections was 68% (IQR 56-86%) among nine studies, and the success rate for catheter-related bloodstream infection was 75% (IQR 59-90%) among seven studies. Among the 16 studies of almost 700 patients receiving laLGPs, there were 98 reports of adverse events, resulting in 13% of treated patients reporting an event.

CONCLUSIONS

This review provides evidence that laLGPs are safe and efficacious for osteoarticular, cardiovascular, intravascular-catheter-related and other complicated infections. Further research is needed to confirm these results.

Postoperative complications associated with coronary artery bypass graft surgery and their therapeutic interventions

Coronary artery disease is one of the commonest surgery demanding cardiovascular diseases. Coronary artery bypass graft surgery is practiced all over the world for the treatment of coronary artery disease. Systemic trauma during the surgery is associated with a wide range of complications, some of which are fatal. Preoperative risk factors such as age, previous illness and obesity are common predictors of these adverse events. Advances in therapeutic medicine have allowed timely treatment of these adverse events and co-morbidities. This review summarizes some of the most occurring complications associated with coronary artery bypass graft and corresponding treatment options.

Mammary Dysbiosis and Nipple Blebs Treated With Intravenous Daptomycin and Dalbavancin

INTRODUCTION

Mammary dysbiosis, also known as subacute mastitis, may be associated with nipple blebs. These overlapping diagnoses represent a challenging clinical scenario during lactation. Little research has been published on etiology, management strategies, and outcomes of these concurrent diagnoses.

MAIN ISSUE

We document the treatment and outcome of a patient who presented with left-breast dysbiosis and nipple blebs and whose milk culture grew multi-drug-resistant, methicillin-resistant Staphylococcus aureus. She was treated safely and effectively with intravenous daptomycin and dalbavancin. This has not been described previously in the lactation literature.

MANAGEMENT

The 35-year-old lactating gravida 3, para 3 patient presented at 6 months postpartum to a breast surgery clinic with a 1-week history of worsening deep left-breast pain, blebs, and recurrent plugging. She was afebrile and she had no erythema or induration on her breast exam. A culture of her milk grew multi-drug-resistant, methicillin-resistant Staphylococcus aureus, and she was referred to infectious disease for assistance with intravenous antibiotic therapy. She continued to feed expressed milk throughout treatment and demonstrated complete resolution of symptoms 8 weeks later.

CONCLUSIONS

We report that in patients with a multi-drug-resistant, methicillin-resistant Staphylococcus aureus-positive human milk culture and a clinical presentation of mammary dysbiosis and nipple blebs, intravenous daptomycin and dalbavancin may be an effective treatment.

Infective endocarditis - can we treat it more effectively?

Infective endocarditis (IE), despite the diagnostic and therapeutic advances, still remains a serious disease associated with high mortality and serious complications. The present guidelines of the European Cardiology Society of 2015 recommend administration of the antibiotics indicated in empirical therapy for multiple weeks and in targeted treatment often for 6-8 weeks. This is associated with a risk of adverse effects of antibiotic therapy in the form of nephro- and/or hepatotoxicity and an increased risk of infections with Clostridioides difficile, while long-term hospitalisation is associated with high non-drug costs. The recommendations developed by the Austrian Society for Infectious Diseases and Tropical Medicine list dalbavancin among the new antibiotics that may find application in the treatment of IE of staphylococcal aetiology. This antibiotic is a lipoglycopeptide antibiotic alternative to vancomycin in the treatment of Staphylococcus aureus MRSA infections, especially in a situation where the minimum inhibitory concentration for vancomycin is high but below the breakpoint. Dalbavancin has very good pharmacokinetic and pharmacodynamic properties, with a long duration of action of up to 14 days after administration of a single dose (1500 mg in a 30-minute infusion). This antibiotic is characterised by high clinical efficacy with good treatment tolerance and safety profile, without causing toxic effects in internal organs in comparison with vancomycin. In view of its safety, clinical efficacy and convenient dosing, dalbavancin may prove a useful therapeutic option in the treatment of IE.

Clinical experience with dalbavancin for the treatment of deep sternal wound infection

OBJECTIVES

Deep sternal wound infection (DSWI) is a complication of major heart surgery with high morbidity as well as prolonged antimicrobial treatment and hospital length of stay (LoS). Dalbavancin is a new lipoglycopeptide antibiotic active against Gram-positive micro-organisms, including methicillin-resistant Staphylococcus aureus (MRSA), with a long half-life. This small case series assessed the feasibility of dalbavancin for the treatment of DSWI.

METHODS

This was retrospective, observational, cohort study of patients treated with dalbavancin for DSWI over a 2-year period (March 2016 to April 2018) in two cardiac surgery departments in Italy. All patients with DSWI underwent surgical accurate debridement. Dalbavancin was administered during the hospital stay or in an outpatient facility.

RESULTS

Among 15 patients enrolled in the study, MRSA was isolated in 7 (47%), methicillin-resistant Staphylococcus epidermidis in 6 (40%) and other coagulase-negative staphylococci in 2 (13%). Dalbavancin was administered by two infusions in 9 patients (60%), whereas 5 patients (33%) received a median of four doses. Fourteen patients received a first dose of 1000mg followed by 500mg, whereas one patient received two doses of 1500mg each. All patients were defined as clinically cured. The median hospital LoS was 13 days (interquartile range, 8-18 days). At 6 months after discharge, 14 patients (93%) showed no relapse of DSWI, whereas 1 patient recurred with a diagnosis of DSWI caused by another pathogen (Candida sp.).

CONCLUSION

Dalbavancin may be an alternative option for DSWI caused by Gram-positive bacteria when first-line treatments are contraindicated or as salvage treatment.