This descriptive investigation sought to evaluate the outcomes associated with a non-mandatory clinical pathway implemented at ARMC that permitted clinically stable, adult, hospitalized SSTI patients without compromised renal function to receive oritavancin in an effort to facilitate hospital discharge. Consistent with previous studies [3, 8], a review of internal data revealed there was an opportunity to improve the efficiency of care of SSTI patients as the majority of patients who received vancomycin for an SSTI stayed in the hospital post-resolution of acute symptoms of infection and there was a delayed transition to oral step-down antibiotic therapy. When evaluating the outcomes of patients who received oritavancin relative to those who received conventional oral step-down care after implementation of the pathway, there were several noteworthy findings. Patients who received oritavancin had a shorter hospital LOS relative to those who received oral step-down therapy post-receipt of IV vancomycin. The shorter LOS in the oritavancin group was most likely a function of implementing a standardized institutional process to assess SSTI patients and expediting discharge in hemodynamically stable hospitalized patients with SSTIs after administration of a single dose of oritavancin. When reviewing these findings, it should not be assumed that expedited discharge can be accomplished with a single-dose antibiotic like oritavancin alone, as data demonstrate that the implementation of institutional pathways along with healthcare provider education are often required to facilitate early hospital discharge in clinically stable patients with infections [14, 15].
Another notable finding was the observed numerical differences in 30-day SSTI-related readmissions and 30-day SSTI progression rates between patients who received oritavancin relative to oral step-down antibiotic therapy. Among the 99 patients who received oritavancin, seven (7.1%) were re-admitted and only one had a documented progression of their SSTI with a Gram-positive infection. The low 30-day readmission and infection progression rates observed among patients who received oritavancin are consistent with other studies of an identical nature. In a multicenter, retrospective study that evaluated the use of oritavancin upon hospital discharge to complete treatment of an SSTI, infection-related 30-day readmission rates were 2.6% . Similarly, no patients had to be readmitted within 14 days of oritavancin therapy in an evaluation of oritavancin use at a community hospital to facilitate hospital discharge .
Nearly 20% of patients in the oral step-down therapy group had a 30-day readmission, and disease progression was reported in seven patients. The exact reasons for the higher 30-day re-admission and disease progression rates in the oral step-down therapy are not entirely clear as most patients received at least 5 days of vancomycin therapy prior to switching to oral antibiotics. Unfortunately, patients’ compliance with oral therapy was not assessed. Studies indicate that poor patient adherence is commonplace with oral antibiotics and failure to take antibiotics post-hospital discharge for SSTIs is associated with suboptimal outcomes. In an assessment of the relationship between adherence to oral antibiotics and post-discharge clinical outcomes among patients hospitalized with S. aureus uncomplicated skin infections, mean electronically measured adherence to antibiotic therapy was only 57% and was considerably lower than self-reported adherence (96%). In the multivariable analysis, lower adherence was an independent risk factor for poor clinical outcome, which was defined as the presence of relapsing or a new SSTI or a need for additional antibiotics or surgical procedures . Another potential reason for the observed findings is the oral step-down antibiotics used. Patients included in this study most commonly received doxycycline, sulfamethoxazole-trimethoprim, ciprofloxacin, and cephalexin as oral step-down antibiotic therapy at the time of discharge. While these are considered appropriate antibiotics for management of most SSTIs, their efficacy for patients with more complicated SSTIs has not been well established in contemporary clinical trials.
This descriptive investigation does have limitations, which should be taken into account when interpreting these findings. First, this was a single-center, retrospective, cohort study, and it is subject to all the limitations and biases associated with this design. Most notably, we cannot fully gauge the impact of prescribing bias on the observed findings. After implementation of the “SSTI hospital discharge” pathway, clinicians were encouraged but not mandated to prescribe oritavancin post-receipt of empiric intravenous antibiotics and were able to choose the step-down therapy they deemed most appropriate. The choice to expedite discharge with oritavancin was frequently initiated by pharmacists or infectious diseases physicians rather than the provider. Furthermore, oritavancin was primarily used in patients perceived as potentially noncompliant, which was internally recognized as IVDUs, homeless, and those with social issues. We were not able to account for the potential effects of this prescribing bias on the observed results. However, the findings suggest that a collaborative, standardized institutional process is needed to expedite discharge with oritavancin. Furthermore, use of oritavancin to facilitate hospital discharge does not appear to lead to an increase in infection-related readmission or SSTI progression.
This was a study of adult, non-neutropenic, clinically stable, non-dialysis SSTI patients, and the observed findings may not be applicable to other populations. Although we included a number of proxy measures for patients’ disease severity, detailed clinical information to calculate acute disease severity measures like the acute physiology and chronic health examination (APACHE-II) or Pitt bacteremia score were not collected. The effect of the inability to include an acute disease severity measure on the observed outcomes is unknown, but it is likely to be minimal as patients had to be hemodynamically stable before switching to either oritavancin or oral step-down therapy. Clinical stability was also a part of the inclusion criteria for this study, further negating the potential influence of acute disease severity on the observed outcomes. Finally, our outcomes were limited to objective measures to minimize any subjective biases that may result from assessing and interpreting observational clinical data, and may not include all outcomes that are relevant to SSTI patients. This study did not take into account the patient perspective and patient-reported outcomes, which are an increasingly important metric for healthcare systems. However, data indicate that patients with SSTIs preferred to be treated at home versus the hospital and with a single IV dose therapy relative to other therapies .