Background: Dalbavancin, a long-acting lipoglycopeptide, offers vancomycin-like coverage with potent activity against MRSA, MSSA, Enterococcus, and Streptococcus. Although FDA-approved for skin and soft tissue infections, emerging data support its use in deep-seated MRSA infections such as osteomyelitis, endocarditis, and bacteremia requiring prolonged courses of 4-6 weeks of IV antibiotics. This creates discharge barriers (PICC-related complications, vancomycin monitoring/toxicity, infusion copays, follow-up logistics) that disproportionately impact people with intravenous substance use disorder or socioeconomic disadvantage, leading to prolonged inpatient stays.
Purpose: To design and implement a dalbavancin-based care pathway that safely transitions eligible MRSA/MSSA bacteremia patients out of the hospital, reduces excess inpatient days, and avoids central line-related complications and therapeutic monitoring burdens.
Description: We created a structured workflow across Hospital Medicine, Infectious Disease, Pharmacy, and the Emergency Department:• Patient selection: adults needing 4–6 weeks of IV therapy for MRSA/MSSA bacteremia who would otherwise remain inpatient due to socioeconomic or clinical barriers (e.g., not candidates for PICC, high risk for line complications, limited outpatient infusion access, uninsured).• Clinical review: clinical pharmacist identifies candidates; ID physician confirms eligibility; Hospitalist Director operationalizes discharge plan; shared decision-making with patient/caregivers.• Dosing and discharge: administer 1,500 mg IV dalbavancin on day of discharge; no enhanced monitoring required.• Second dose workflow: Hospitalist Director coordinates with ED leadership to schedule return in 7 days for second 1,500 mg dose when indicated.• Follow-up: Hospitalist Director, attending hospitalist, and clinical pharmacist jointly monitor labs and cultures.Implementation outcomes from six cases:1. MRSA bacteremia after facial abscess I&D; 4-week course; 24 excess days saved.2. MSSA bacteremia with endocarditis; 6-week course; 32 excess days saved.3. MSSA bacteremia with osteomyelitis post-toe amputation; 4-week course; 16 excess days saved.4. MRSA bacteremia in active IV drug use (both doses inpatient); 6-week course; 19 excess days saved.5. Streptococcus dysgalactiae bacteremia with septic arthritis; 6-week course (4 weeks ceftriaxone, then dalbavancin); 14 excess days saved.6. MRSA bacteremia following 14 days of conventional therapy; 4-week total; 14 excess days saved.
Conclusions: A dalbavancin-centered, multidisciplinary pathway safely shortened hospitalization for patients requiring prolonged IV antibiotics for MRSA/MSSA bacteremia. Across six cases, the program saved 119 excess inpatient days and an estimated $37,500 while maintaining patient safety and quality metrics, including zero readmissions, no mortality, no complications, successful treatment outcomes, and increased patient satisfaction. Successful partnership between Hospital Medicine, Infectious Disease, Pharmacy, and Emergency Departments enabled operational feasibility and scalability across our health system. This model is adaptable to other prolonged-IV-therapy scenarios, offering a pragmatic approach to reduce length of stay while maintaining quality of care.