https://orcid.org/0000-0003-0832-7975
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ABSTRACT
Introduction
Acute Bacterial Skin and Skin Structure Infections (ABSSSIs) are a common reason of Emergency Department (ED) access and account for a considerable number of hospital admissions and a high economic burden for the healthcare system. The long-acting lipoglycopeptides (LALs) allow for an outpatient management of subjects with ABSSSIs, still requiring parenteral therapy, but who do not need hospitalization.
Areas covered
The following topics were addressed: i) microbiological activity, efficacy, and safety of dalbavancin, ii) critical steps for the management of ABSSSIs in the ED (decision to hospitalize, risk of bacteremia and infection recurrence), iii) feasibility of direct/early discharge from the ED and potential advantage of dalbavancin.
Expert opinion
Authors’ expert opinion was focused on drawing the profiles of patients who could benefit most from an antimicrobial therapy with dalbavancin in the ED and positioning this drug as a direct or early discharge strategy from the ED in order to avoid hospitalization and its complications. We have provided a therapeutic and diagnostic algorithm based on evidence from the literature and authors’ expert opinion and suggest the use of dalbavancin in patients with ABSSSIs who are not eligible for oral therapies or Outpatient Parenteral Antibiotic Therapy (OPAT) programs and who would have otherwise been hospitalized only for antibiotic therapy.
Article highlights
Acute Bacterial Skin and Skin Structure Infections (ABSSSIs) are a common reason of access to the Emergency Department (ED), account for a considerable number of hospital admissions and exhibit a high financial burden for the health care system
Long-acting lipoglycopeptides (LALs) allow for an outpatient management of subjects with ABSSSI, still requiring parenteral therapy, but who do not need hospitalization
Dalbavancin is a LAL with activity against Gram-positive pathogens including MRSA and has been approved by the FDA and EMA for the treatment of ABSSSIs
In registration and observational studies, dalbavancin showed high efficacy and a remarkably good safety profile for the treatment of ABSSSIs
Crucial steps in the management of patients with ABSSSIs at the ED include the decision to hospitalize and the risk of bacteremia and/or infection recurrence
Dalbavancin may be considered as a strategy for a direct or early discharge from the ED of eligible patients with ABSSSIs
Dalbavancin’s favorable pharmacokinetic profile and its long elimination half-life represent a key advantage over other intravenous drugs requiring multiple daily doses or oral antibiotics, which require patients’ adherence and may be encumbered by adverse events
Dalbavancin use is cost-effective by reducing in-hospital length of stay and saving additional indirect costs related to the need of multiple daily infusion of antimicrobials, laboratory monitoring of potential toxicities and nurse assistance
A diagnostic and therapeutic algorithm for the management of ABSSSI at the ED is proposed
List of abbreviations
| (ABSSSIs) | = | Acute Bacterial Skin and Skin Structure Infections |
| (ED) | = | Emergency Department |
| (LALs) | = | long-acting lipoglycopeptides |
| (MRSA) | = | methicillin-resistant S. aureus |
| (FDA) | = | Food and Drug Administration |
| (EMA) | = | European Medicines Agency |
| (RCT) | = | randomized clinical trials |
| (POCUS) | = | point-of-care ultrasound |
| (VISA) | = | vancomycin-intermediate S. aureus |
| (hVISA) | = | heteroresistant VISA |
| (VSE) | = | vancomycin-susceptible enterococci |
| (VRE) | = | vancomycin-resistant enterococci |
| (PWID) | = | people who inject drug |
| (BCs) | = | blood cultures |
| (WBC) | = | White Blood Cells |
| (SIRS) | = | Systemic Inflammatory Response Syndrome |
| (CRS) | = | Cellulitis Recurrence Score |
| (OPAT) | = | Outpatient Parenteral Antibiotic Therapy |
| (MDROs) | = | Multi-Drug Resistant Organisms |
| (SoC) | = | Standard of Care |
| (PICC) | = | peripherally inserted central catheter |
| (LTCF). | = | Long-Term Care Facility |
Declaration of interest
A. Oliva participated to advisory boards or speaker’s bureau for MSD, Zambon and Angelini. E Durante-Mangoni reports research funding to his Institution from MSD, Pfizer, Angelini, Infectopharm, Advanz pharma, and personal fees or participation to advisory boards or speaker’s bureau of Roche, Genentech, Pfizer, MSD, Angelini, Advanz Pharma, Bio-Merieux, Shionogi, Menarini, Abbvie, Sanofi-Aventis, Medtronic, Trx and DiaSorin. M. Venditti participated to advisory boards for MSD, Angelini, Mundipharma and received personal fee for speaking bureau from Shionogi, Menarini, Angelini, Pfizer.
The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed.
Author contribution
Conceptualization of the study: MV, EDM; literature revision: AO, SC, VC, MC, EDD, MF, GG, EDM, MV; manuscript draft writing: AO, EDD, SC; supervision: MV, MF, EDM.
Reviewer disclosures
Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.