Selecting Lipoglycopeptide Therapy for Gram-Positive NIs

Peter L. Salgo, MD: What about the newer long-acting lipoglycopeptides to treat MDR gram-positive infections? What are they? How long have they been out there? What do they do? Who wants to jump in on this to start?

Sandy J. Estrada Lopez, PharmD, BCPS (AQID): I’ll start that one. So, the new lipoglycopeptide is kind of like the rapid diagnostics have been game changing, as was referred to earlier. They can be game changing in the treatment of skin infections with MRSA—really because we’ve talked about the risk of health care exposure—to potentially provide an option for a patient who needs an IV antibiotic for a MRSA skin infection to remain in the outpatient setting, so admission avoidance or possibly early discharge. So, these agents are oritavancin and dalbavancin. They were both approved in 2014, so we have about 3 years of experience now. And the key thing is they require 1 dose to get about 7 to 10 days of active therapy.

Peter L. Salgo, MD: One dose?

Sandy J. Estrada Lopez, PharmD, BCPS (AQID): One IV infusion, correct.

Peter L. Salgo, MD: Nifty. How do you use them? When would you use them? How do you pick one versus the other? What are the nuts and bolts?

Sandy J. Estrada Lopez, PharmD, BCPS (AQID): OK, that’s a few questions there.

Peter L. Salgo, MD: I can do them one at a time.

Sandy J. Estrada Lopez, PharmD, BCPS (AQID): We’ll see if I can take them.

Peter L. Salgo, MD: I’ll bet you can.

Sandy J. Estrada Lopez, PharmD, BCPS (AQID): The focus is the outpatient setting for a few reasons. There is a tremendous cost associated with these antibiotics. And so, if you compare that cost to the cost of a hospitalization, then all of a sudden that cost is not at all high. But if you compare that cost to a few days of a different antibiotic, then the cost would appear high. So, it’s how you’re framing it. Really, the target is that patient who needs an IV antibiotic either due to severity of infection, having failed previous oral antibiotics, resistance to oral antibiotics, or perhaps the patient where there’s significant concerns for adherence. So, we’ve had patients like that where even we did try to keep them out of the hospital but bring them in for IV infusion every day for vancomycin/daptomycin. They come for 2 days, they don’t show up anymore. So, there’s a big cost associated with that, right, if they get readmitted a week later, and now maybe we don’t want to give them that antibiotic again when moving further down the line.

Peter L. Salgo, MD: What are the differences between these 2 drugs? How do you pick one versus the other?

Sandy J. Estrada Lopez, PharmD, BCPS (AQID): As far as efficacy, they both work. They have similar mechanisms of action. They are both lipoglycopeptides. They both have activity at the cell wall. Oritavancin has additional activity at the cell membrane. Coverage is very similar, gram-positive organisms only. So, really it gets into some practicalities with regards to how to use them. They both do now have a 1-dose strategy, although dalbavancin also has a 2-dose strategy. So, from all of those standpoints, they’re the same. Many times, it’s going to come down to cost. Insurance coverage can come into play. Dalbavancin has a 30-minute infusion, oritavancin has a 3-hour infusion. So, on occasion, that can come into play as far as convenience for the patients.

Peter L. Salgo, MD: So, they’re both IV drugs.

Sandy J. Estrada Lopez, PharmD, BCPS (AQID): Absolutely.

Peter L. Salgo, MD: You’re going to be in the doctor’s office, or in the emergency room somewhere, and you’re going to make the diagnosis and you’re going to give this 1 dose and say see ya in a week?

Sandy J. Estrada Lopez, PharmD, BCPS (AQID): Most facilities are doing this in the emergency department—again, as a means of avoiding an admission for that patient. In some cases, such as in our facility, we primarily administer it in the infusion center. So, that patient may perhaps come to the emergency room, get 1 dose of IV vancomycin or something like that, and then they’re referred to the outpatient infusion center. We could also get referrals directly from the ID clinic or other places where, again, previously they may have been sent from the clinic to the emergency department. Now they can go directly to infusion.

Debra Goff, PharmD, FCCP: I want to add one patient population that’s a little different than what you described. So, I’d agree with you that outpatient is usually where we think of this, until the opioid crisis has plagued many states, including the state of Ohio. And it has caused us to rethink some of these drug abusers that have bacteremia, and Staph is primarily what they’re coming in with. As a health care provider, you want to treat their bacteremia correctly, not just a couple days’ worth and they’re going to leave. And so, this has been a very complicated discussion, but sometimes sending a drug abuser out with a PICC line is just a different discussion. So, giving an IV drug in the hospital that you know is going to assure 1 more week of coverage is sometimes a good option. It’s a very unique role, and people have very different opinions on it, but it’s an area where I’ve started to see clinicians doing that.

Sandy J. Estrada Lopez, PharmD, BCPS (AQID): We’ve had that population as well, and actually that was what we thought would be our biggest population. When we started using oritavancin, it was for the IV drug users for the reasons that you mentioned. We can keep them out of the hospital. We don’t need to put in a PICC line if they don’t come back. So, these weren’t necessarily patients that we knew were bacteremic but still focusing on that skin infection, although we have gone over into some of those other scenarios as well. But as time has gone on, in addition to those patients, we have a lot of elderly patients who travel a lot. And so, there’s a lot of logistical convenience considerations with those. And so, if they are saying, “I’m getting on a plane in 3 days, I can’t come for these infusions, I definitely don’t want to be in the hospital,” we want to treat them with something that’s one-and-done, so to speak. And so, that has been really good in that scenario.

Peter L. Salgo, MD: It sounds great, right? Who on earth wants to admit an IV drug user with a MRSA endocarditis? Let’s talk about disaster here. But something occurred to me, too. If this drug is on board for a week and there’s more bacteria being introduced because of the lifestyle, is that a good thing? Does it kill those bugs, too?

Debra Goff, PharmD, FCCP: Well, we haven’t been able to enroll them in a study, so I can’t really answer that. But, no, that’s the patient population you’re very uncomfortable with. And I think that’s where you engage a group of experts to decide what makes the most sense for this case right in front of us. And each one, it depends on the scenario. But it is very individualized because sometimes it’s almost an emotional decision of how you want to approach that young drug addict and what is the home scenario. It’s very complex. So, there’re pros and cons of each decision. It’s just an area that some are choosing to use some of these agents in patient populations.

Peter L. Salgo, MD: Did you actually give us the doses? Can you do that?

Sandy J. Estrada Lopez, PharmD, BCPS (AQID): I can, yes. Oritavancin is a 1200 mg dose, so it’s that 1-time infusion over 3 hours, and dalbavancin is a 1500 mg dose, also a 1-time infusion.

Peter L. Salgo, MD: It’s probably on the label, but I just thought we’d get this out.