Dalbavancin Reduces Hospital Stay and Improves Productivity for Patients with Acute Bacterial Skin and Skin Structure Infections: The ENHANCE Trial
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.
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.
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).
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.
ClinicalTrials.gov identifier, NCT03233438.
KeywordsAcute bacterial skin and skin structure infection Cost Dalbavancin Long-acting antibiotic
Key Summary Points
Why carry out this study?
Admissions for acute bacterial skin and skin structure infections (ABSSSI) are often prolonged because of administration of intravenous (IV) antibiotics
Use of a long-acting IV antibiotic, dalbavancin, may reduce length of stay (LOS) on a hospitalist service when compared to usual care
What was learned from the study?
Determined the impact on LOS and work productivity in ABSSSI patients treated with long-acting IV antibiotic therapy vs. usual care at an urban tertiary-care center
After implementing the ENHANCE ABSSSI pathway, LOS was significantly reduced by almost 2 days and improved patient’s work productivity and the ability to complete daily activities
Implementation of the ENHANCE ABSSSI pathway could have a significant impact on hospital cost and efficiency
Quality of care and efficiency are paramount to improving US healthcare systems, particularly in the high-cost inpatient setting where hospitalists practice. Hospital admissions are under evaluation through a number of measures and must be critically assessed for improvement . Care for acute bacterial skin and skin structure infections (ABSSSIs) has traditionally involved routine hospital admission and potentially prolonged hospital length of stay (LOS). The primary reason for hospitalization is the need to receive intravenous (IV) antibiotic therapy , despite the majority of ABSSSIs being non-life-threatening compared with other infections [3, 4]. ABSSSIs comprise as much as 2% of all US hospital admissions, causing a substantial burden to US hospitals, largely due to room and board costs . ABSSSIs also commonly occur among employed adults (18–44 years of age) [5, 6, 7]; patients would value the option to complete ABSSSI treatment at home to avoid interference with daily activities and work .
Current guidelines support shifting ABSSSI care to outpatient settings for appropriate patients to improve hospital efficiency and reduce cost [4, 9, 10, 11, 12]. However, operational barriers exist to shifting care to outpatient settings for many hospitals in the emergency department (ED). Implementation may suffer from lack of feasibility in care coordination between ED physicians and Antimicrobial Stewardship Teams before admission or because of high patient flow through many EDs.
For certain hospitals, ABSSSI treatment with a long-acting antibiotic once patients are admitted to the hospital floor and are stabilized is a potential option to facilitate discharge. Among those admitted for ABSSSI, those who may be eligible for early discharge would have few risk factors for readmission or ED care [4, 9, 11, 12, 13]. Careful patient selection is necessary to support efficiency and to ensure that treatment outcomes are similar versus standard care.
We reasoned that a long-acting lipoglycopeptide may be utilized to facilitate discharge for eligible patients because of an abbreviated administration schedule [9, 12, 14], allowing patients to finish their treatment course in the outpatient setting [4, 10]. Long-acting antibiotics, such as dalbavancin, are administered either as a single 30-min parenteral infusion or two 30-min infusions once a week for 2 weeks [15, 16] or, in the case of oritavancin, as a 3-h infusion . Long-acting antibiotics may improve patient and health system convenience as well as reduce risks of infection from the peripheral or central catheter lines that are used for some patients to receive daily parenteral antibiotics. Additionally, single-dose antibiotic treatment of ABSSSI is aligned with patient preferences , which are increasingly important as patient satisfaction is included in CMS hospital quality measures .
ENHANCE (A Pragmatic Trial Designed to Evaluate a New Critical Pathway for Treatment of Patients with ABSSSI) was a controlled trial that sought to determine the impact on LOS and work productivity in patients treated with the long-acting IV antibiotic, dalbavancin, vs. usual care at an urban, tertiary care center.
Study Design and Setting
ENHANCE was a single-center, pre- versus post-period pragmatic trial (NCT03233438) conducted at New York-Presbyterian/Weill Cornell Medicine (NYP/WCM), a university-based urban medical center with > 1000 hospital beds, almost 50,000 hospital admissions, and nearly 75,000 ED visits per year. At the start of the trial, the site did not have dalbavancin routinely available.
The ENHANCE study design consisted of an initial observational period (pre-period); second, an interventional period (post-period) was subsequently implemented. In the pre-period only, treating physicians were not included in the study enrollment decision or trained on the protocol to prevent biasing the provision of usual care, which was defined as site or physician’s usual care for ABSSSI. Once the pre-period was completed, site-training materials were provided to the study team on the post-period of the study. Post-period training materials were based on the study protocol and prior literature . Over a 2–4 week period, principal site investigators (MM and TW) trained treating physicians and staff; training was documented before beginning the post-period of the study. During the post-period, a separate set of enrolled patients was treated, which included (1) ABSSSI patient identification (inclusion/exclusion criteria applied) and (2) long-acting antibiotic treatment, administered as a single intravenous (IV) dose of 1500 mg dalbavancin over 30 min; patients with renal impairment (creatinine clearance < 30 ml/min) and no regularly scheduled dialysis received a single IV dose of 1125 mg dalbavancin over 30 min . All patients enrolled in the post-period received dalbavancin. At the discretion of the treating physicians, patients were discharged from the hospital to an outpatient setting after receipt of dalbavancin. While randomization at the site level at NYP/WCM was not feasible, the study was controlled temporally through the pre- vs. post-period design [20, 21, 22, 23].
The study was conducted in accordance with the protocol, rules, and regulations of the WCM IRB and standard operating procedures, and sponsor at WCM, and informed consent regulations. Only patients providing informed consent were included in the study. The study followed the hospital’s applicable local regulatory requirements, was governed according to local laws and regulations, and was in accordance with the Declaration of Helsinki.
Adult patients (≥ 18 years) admitted to the NYP/WCM hospitalist service with an ABSSSI infection (e.g., diagnosis of cellulitis/erysipelas, wound infection, or major cutaneous abscess) [4, 10, 24] were identified and enrolled based on inclusion and exclusion criteria through patient interview and medical chart review. Enrollment criteria were based on ABSSSI treatment guidelines regarding patients for whom parenteral therapy was indicated because of infection severity, yet could otherwise receive treatment in an outpatient setting [4, 11]. Those with life-threatening infections, requiring multiple antibiotics or intensive care, or with unstable comorbidities were not eligible (Supplementary Text: Inclusion/Exclusion Criteria).
Follow-up and Outcomes
Patients were followed for 44 days after study enrollment to account for the first 10–14 days of initial ABSSSI treatment and for 30 days after treatment; baseline characteristics (Supplementary Text: Study Definitions), health resource utilization, patient-reported outcomes, response to treatment, and adverse events (AEs) were captured (Table S1). Baseline characteristics were collected before patient enrollment in the study at the screening visit and were based on physical examination, patient interview, and medical chart review. Follow-up visits were scheduled between 48 and 72 h after hospital discharge, 10–14 days after enrollment (end of treatment visit), and 44 days after enrollment. Health resource utilization through patient interviews and medical chart review as well as patient-reported outcomes was captured through follow-up visits at 10–14 days and 44 days. Response to treatment was determined by patient interview and examination at 48–72 h and visits at 10–14 days. Safety monitoring was conducted at each visit through the 44-day follow-up period.
Baseline characteristics included demographics, comorbidities, Charlson Comorbidity Index, infection type, infection and clinical characteristics, and utilization of the healthcare service within the past 3 months. The primary outcome was infection-related LOS. Secondary outcomes included other healthcare resource utilization during follow-up, such as all-cause LOS, all-cause 30-day re-admissions, ED visits, and outpatient visits, patient-reported outcomes, response to treatment, and AEs. Patient-reported outcomes including quality of life and work productivity were collected through validated questionnaires (Health-Related Quality-of-Life Medical Outcomes Study Short Form-12 [SF-12] , Work Productivity and Activity Impairment Questionnaire: Specific Health Problem V2.0 [WPAI:SHP]) . Patient satisfaction with care was captured using a descriptive survey developed for use in this study. These questionnaires are included in Supplementary Text: Patient Satisfaction Survey.
We hypothesized that administration of dalbavancin, a long-acting lipoglycopeptide, in the post-period would decrease LOS and facilitate discharge for eligible patients vs. patients who received usual care in the pre-period. Sample size was determined through a power calculation; with 80% power, a sample size of 86 patients (43 patients per period) supported a decrease in LOS of 2 days in the post-period vs. the pre-period. Outcomes were calculated for the analysis sample, which was defined as all enrolled patients who received ≥ 1 antibiotic dose in the pre-period or one dose of dalbavancin in the post-period. Descriptive statistics, including continuous and categorical variables, were reported for all outcomes. Two-sided Student’s t tests were used for applicable continuous variables, and Mann-Whitney U tests were used if the event normality assumptions were not met. For categorical variables, periods were compared using Chi-squared tests or Fisher’s exact tests, as appropriate. All statistical testing applied a significance level of 0.05.
Primary LOS outcome was compared between periods through a two-sided t test. To account for baseline differences in characteristics between periods, a generalized linear mixed model was also used in an adjusted analysis using a negative binomial distribution with a log link. The final multivariable model was created through stepwise selection and a statistical significance threshold of α < 0.1 for clinically relevant variables specified a priori (Table S2). The final model was adjusted for age and immunocompromised status.
Patient Demographics and Disease Characteristics
Patient demographics and disease characteristics
Pre-period (N = 48)
Post-period (N = 42)
Male, n (%)
Mean (SD) age, years
Ethnicity, n (%)
Race, n (%)
Mean (SD) BMI, kg/m2
Admitted to hospital from location, n (%)
Private home/independent senior living facility
Long-term care or skilled nursing facility, nursing home or rehab facility
Primary insurance, n (%)
Private commercial plan
Infection type, n (%)
Purulent drainage from primary lesion, n (%)
Mean (SD) primary lesion size, cm2
Fever, n (%)
SIRS criteria met (≥ 2 criteria present), n (%)
Recurrent/ABSSSI infection in prior 6 months, n (%)
Comorbid conditions, n (%)
Moderate to severe chronic kidney disease
Peptic ulcer disease
Peripheral vascular disease
Chronic obstructive pulmonary disease
Connective tissue disease
Congestive heart failure
Other medical history, n (%)
Disease characteristics and medical history were similar between groups (Table 1). Systemic inflammatory response syndrome criteria were met in 11 (22.9%) patients of the pre-period and 8 (19.0%) patients of the post-period. The mean (standard deviation)/median primary lesion size in the pre-period was 533.5 (647.9)/255 cm2 and in the post-period was 685.0 (703.5)/458 cm2. One patient in the pre-period and two patients in the post-period had evidence of a recurrent ABSSSI infection in the prior 6 months.
Antibiotic Treatment Received
In the pre-period group, most patients (66.7%) received multiple antibiotic therapies, with 17.8% of patients receiving > 4 antibiotics. In contrast, most patients (85.7%) received one antibiotic (i.e., dalbavancin) in the post-period. Oral (85.4%) and IV (58.3%) antibiotics were used in the pre-period group, while IV antibiotics were the predominant administration route in the post-period group (100%). Among patients with a reported oral administration route, the majority (64.4%) received oral and IV antibiotics. Moreover, among the pre-period group, 87.5% of patients completed their initial antibiotic treatments compared with 100% in the post-period group.
Effects on LOS
Primary outcome over follow-up
Pre-period (N = 48)
Post-period (N = 42)
Unadjusted total infection-related LOS (days)
Median (Q1, Q3)
4.0 (3.0, 5.5)
3.0 (2.0, 3.0)
Adjustedb total infection-related LOS (days)
Half of all patients from the post-period group (21 patients, 50%) were discharged to complete care in an outpatient setting on the same day dalbavancin was provided. Of the 50% who were not discharged on the same day, the most common reasons were due to additional monitoring/procedures for ABSSSI (10 patients; 47.6%) or non-ABSSSI reasons (9 patients; 42.9%).
Effect on Other Health Resource Utilization
Health resource utilization outcomes over follow-up
Pre-period (N = 48)
Post-period (N = 42)
Health resource utilization, n (%)
Infection-related major surgical intervention that required OR time
All-cause hospitalization in the 30 days following discharge
Infection-related hospitalizations during follow-up
Infection-related hospitalizations during follow-up that required ICU admissions
Effects on Patient-reported Outcomes
Other outcomes over follow-up
Pre-period (N = 48)
Post-period (N = 42)
Work productivity and activity impairment, % (95% CI) at day 14 visita
n = 17
49.9 (30.1, 69.7)
n = 16
36.7 (12.2, 61.3)
Impairment while working
n = 14
47.9 (24.7, 71.0)
n = 9
8.9 (1.8, 16.0)
Overall work impairment
n = 14
59.3 (36.7, 81.9)
n = 9
18.0 (0.0, 36.0)
Activity Impairment (non-work related)
n = 42
60.2 (48.1, 72.3)
n = 33
18.5 (9.2, 27.8)
Quality of life (mean, SD)a
SF-12 MCS at baseline
n = 47
n = 42
SF-12 MCS at day 14 visit
n = 42
n = 34
SF-12 PCS at baseline
n = 47
n = 42
SF-12 PCS at day 14 visit
n = 42
n = 34
Response to treatment (n, %) at day 14 visita
Adverse events, n (%)
Severity of AEsd,e
AEs with possible causal relationship to study drugd,e
AEs leading to study discontinuation
AEs leading to death
Serious adverse events
Patient satisfaction survey results
Pre-period (N = 48)
Post-period (N = 42)
Number of patients with any survey data, n (%)
Number of patients with all survey questions completed, n (%)
Concerned about receiving your IV therapy, n (%)
None of the time
A little of the time
Some of the time
Most of the time
All of the time
Regimen preferred if treated again for a similar skin infection with IV, n (%)
One single IV antibiotic dose to complete your course of treatment
One or two daily IV antibiotic doses every day for 7–14 days to complete your course of treatment
One or two daily IV antibiotic doses for a few days, then oral antibiotics three or four times per day for the remaining 7–14 days course of treatment
Time willing to spend receiving each IV, n (%)
About 30 min or less
About 1 h
About 1.5–2 h
About 3 h or longer
Find value in a physician who recommended that you receive an IV antibiotic therapy that may shorten your hospital length of stay, n (%)
The percentage of patients with complete treatment response was similar between periods (50.0% in the pre-period and 57.1% in the post-period; Table 4).
Among AEs identified, 16.7% (n = 7) were found to have a possible causal relation to a study drug in the post-period. A greater proportion of AEs occurred in the post-period (n = 20; 47.6%) vs. pre-period (n = 3; 6.3%) with most AEs being mild in severity and not related to antibiotic use; few AEs were serious (7.1% post-period vs. 2.1% pre-period) (Table 4). One of the serious AEs (vomiting) was considered to be probably related to the study drug; it was mild in severity and occurred 2 h after dalbavancin treatment for a patient in the post-period. The most common AEs were unrelated infection in the pre-period and fever in the post-period.
As hospitals are under pressure to improve quality of care, a critical evaluation of current pathways and processes is warranted. Admission to the hospitalist service for ABSSSI imposes a significant economic burden on the US health system, with hospital LOS as a key cost driver [5, 6, 12, 27, 28, 29]. We found that LOS was ~ 5 days on average in our study for those patients in the pre-period vs. the post-period LOS of ~ 3 days. Due to the increasing emphasis on efficiency and quality of care, the development of new ABSSSI care pathways that improve hospital efficiency and reduce the costs associated with unnecessary or prolonged hospital admissions is warranted [4, 9, 10, 11, 12]. A key component of a new care pathway may leverage long-acting antibiotic therapy, such as dalbavancin. Yet, it is necessary to not only support process improvements, but also to establish the safety and efficacy of new care pathways in a real-world setting.
Our study is the first pragmatic clinical trial to date to implement use of a long-acting antibiotic, dalbavancin, for ABSSSI treatment among admitted patients on a hospitalist service in a large hospital setting. Following implementation of dalbavancin treatment in this real-world study, infection-related hospital LOS and overall LOS were significantly decreased by nearly 2 days. Additional health resource utilization, indicative of poor outcomes or the need for follow-up care, such as 30-day hospitalization rates, use of the intensive care unit, and ED and outpatient visits, was found to be similar between periods. As patient satisfaction is of increasing importance in measuring quality of care , patient-reported work or activity impairment were also significantly reduced in patients in the post- vs. pre-period. Patients in the post-period reported similar health related quality of life and patient satisfaction. Our results were similar to prior patient preference research  in that the majority of patients preferred antibiotic regimens similar to dalbavancin (i.e., single dose, shorter infusion durations) over other options, and most would find value in a physician who provided an option that could shorten their hospital LOS. This latter option is likely linked to the improved patient-reported indices of work productivity. It should be noted, however, that there was a higher attrition rate and a higher percentage of patients readmitted to the hospital in the post-period. These cases included individuals with concomitant medical conditions requiring further care and did not represent antimicrobial treatment failure for ABSSSI.
In addition to increasing quality and efficiency of care, ensuring the response to treatment and safety profile of the dalbavancin pathway is paramount. Response to treatment was similar between the treatment groups. As a more clinically meaningful measure of safety versus AEs overall, 16.7% (n = 7) of AEs were found to have a possible causal relation to dalbavancin in the post-period. The number of AEs in patients within the post-period were higher vs. the pre-period, while serious AEs were similar between periods. Moreover, no patients discontinued treatment, and mortality did not occur in either period. The AEs were largely unrelated to the infection being treated or due to known toxicities of dalbavancin . The more involved informed consent process in the post-period versus the pre-period (observational design) may have contributed to difference in AEs between periods. These measures support our hypothesis that ENHANCE may be an effective alternative care pathway.
Our research builds on prior evidence that dalbavancin is a safe, effective [30, 31, 32], and potentially cost-saving option for outpatient ABSSSI treatment . Outpatient treatment has been shown to result in reduced hospital stay resulting in lower costs [5, 12, 27, 29], highlighting the importance of alternative treatment options. Indeed, the estimated cost of a day in a non-profit hospital located in New York (similar to the characteristics of NYP/WCM) is approximately $2719 . Considering LOS for ENHANCE post-period patients was reduced by 1.6 days, the estimated savings would partially or fully offset the cost of long-acting antibiotic therapy, such as dalbavancin. Such an estimate does not take into account the costs of pharmacy and nursing for administration.
Despite the higher acquisition cost of dalbavancin one could hypothesize that the reduced LOS, increased work activity, and reduction in the use of multiple inpatient antibiotics could lead to significant cost savings. We also suggest that a registry of the use of dalbavancin be implemented in those institutions adapting the ENHANCE ABSSSI pathway to prospectively monitor the impact of this strategy.
Although a potential limitation of the study might be the single-center design, this design feature eliminated variability that could occur in a study involving multiple hospitals, such as number of hospital staff, staffing hours, etc. However, it may limit the generalizability of our findings. A prospective multicenter registry could be implemented to validate this approach to management of patients hospitalized with ABSSSI. Another limitation was lack of randomization in this study, which could bias results because of differences between pre- and post-period patients at baseline. Yet, our study was consistent with real-world clinical practices, as randomization of patients or hospitals to receive different clinical pathways is not always feasible, and we found similar baseline characteristics between both periods . Consistent with other studies, we observed a seasonality to ABSSSI (i.e., infections were more prevalent during the summer months). Although randomization at the level of the patient or site was not implemented, the pre-period of the study served as an observational control group, supporting a controlled trial design. We acknowledge that selection bias is an important factor that can impact study design; however, we believe that selection criteria were similarly applied in each study period through consistently implemented site training.
In summary, the ENHANCE ABSSSI pathway among eligible patients on a hospitalist service significantly reduced LOS by 1.6 days with improvements in work productivity and the ability to complete daily activities.
We thank the participants of the study who made the ENHANCE trial possible.
Sponsorship for this study and the journal’s Rapid Service Fees were funded by Allergan plc (Dublin, Ireland). All authors had full access to all of the data in this study and take complete responsibility for the integrity of the data and accuracy of the data analysis.
Medical Writing, Editorial, and Other Assistance
Administrative support for article submission was provided by Jennifer Venzie, PhD, and John E. Fincke, PhD, at ICON plc (North Wales, PA), and funded by Allergan plc (Dublin, Ireland). Study support was provided by ICON, a contract research organization.
All authors met the International Committee of Medical Journal Editors (ICMJE) criteria for authorship for this article, take responsibility for the integrity of the work as a whole, and have given their approval for this version to be published.
Financial arrangements of the authors with companies whose products may be related to the present report are listed below, as declared by the authors. Matthew McCarthy served as a consultant to Allergan and also received research support from Allergan that was paid to Weill Cornell Medicine. Katelyn Keyloun is an employee of Allergan plc. Patrick Gillard is an employee of Allergan plc and holds stock in Allergan plc. Justin Choi has no conflicts to disclose. Nicholas Pickell received Allergan-sponsored support through his employment at Weill Cornell Medicine. Ronald Copp was an employee of ICON plc, the CRO supporting study conduct at the time of study conduct and analysis, and is currently an employee of Array Biostatistics, Wilmington, NC. Thomas Walsh has received grants for experimental and clinical antimicrobial pharmacology and therapeutics to his institution from Allergan, Amplyx, Astellas, Lediant, Medicines Company, Merck, Scynexis, and Tetraphase and has served as consultant to Amplyx, Astellas, Allergan, ContraFect, Gilead, Lediant, Medicines Co., and Merck.
Compliance with Ethics Guidelines
The study was conducted in accordance with the protocol, rules, and regulations of the WCM IRB and standard operating procedures, and sponsor at WCM, and informed consent regulations. Only patients providing informed consent were included in the study. The study followed the hospital’s applicable local regulatory requirements, was governed according to local laws and regulations and was in accordance with the Declaration of Helsinki.
The datasets generated during and/or analyzed during the current study are available from the corresponding author on reasonable request.
This article is distributed under the terms of the Creative Commons Attribution-NonCommercial 4.0 International License (http://creativecommons.org/licenses/by-nc/4.0/), which permits any noncommercial use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made.
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