Adult outpatient parenteral antimicrobial therapy (OPAT) good practice prescribing guide

Dalbavancin

Dalbavancin is a lipoglycopeptide with bactericidal activity against Gram-positive bacteria only. It is licensed for acute bacterial skin and skin structure infections.

This guide shares practical experience of the use of dalbavancin in an OPAT setting. We took an evidence based approach to create the guidance. We also used expert consensus and practical experience from across NHS Scotland.

This drug summary does not provide specific treatment guidance. Individual patient treatment should take into account the core principles of antimicrobial stewardship. This includes selection of the appropriate antimicrobial for the shortest duration with oral therapy being preferred, whenever possible.

For information on Route and method of administration, Contraindications, Cautions and adverse effects and Drug interactions please refer to the following approved resources:

British National Formulary (BNF), https://bnf.nice.org.uk/
Summary of Product Characteristics (SPC), https://www.medicines.org.uk/emc/
The Renal Drug Database, https://renaldrugdatabase.com
NHS Injectable Medicines Guide (Medusa), https://www.medusaimg.nhs.uk/ or local IV Drug monographs
Stockley’s Drug Interaction, https://www.medicinescomplete.com/

These resources also have more information on licensed indication, use in pregnancy and use in breast feeding. When using unlicensed medicines, and/or off-label doses or indications, follow local health board governance processes.

It is strongly recommended that OPAT services in Scotland adhere to the Key performance indicators for the management of patients in an outpatient parenteral antimicrobial therapy (OPAT) setting.

Dalbavancin

1. Indication and dose

Licensed indication(s) in the OPAT setting	Dose
Acute bacterial skin and skin structure infections	Day 1 - 1000mg one-off dose and review on Day 8 for consideration of oral therapy or further 500mg one-off dose OR Day 1 - 1500mg one-off dose (equivalent to a 2 week course of treatment)

Off-label indications

It is recommend that off-label use is agreed with local OPAT infection specialist.

Scottish Experience of use in practice for off-label indications are below.

Off-label indications in the OPAT setting	Dose
Uncomplicated Staphylococcal aureus bacteraemia (no deep source of infection identified or suspected and clinically well)	If suitable for OPAT and it is 7 days or less since last positive blood culture; 1500mg one-off dose If suitable for OPAT and it is more than 7 days since last positive blood culture; 1000mg one-off dose
Bone and joint infection (eg first stage revision of joint)	1500mg dosed on Day 1 and repeated on Day 8 Equivalent duration 4-6 weeks
Bone and joint infection (eg debridement and implant retention)	1000mg one-off dose on Day 1 then 500mg on Day 8 and weekly thereafter Duration dependent upon source of infection and availability of oral antibiotic options
Infective Endocarditis (Native and Prosthetic valves)	1000mg one-off dose on Day 1 then 500mg on Day 8 and weekly thereafter Duration usually to complete 6 weeks total effective therapy

Complicated skin and soft tissue infections (cSSTI)

SAPG has developed an OPAT pathway for the management of adults with complicated skin and soft tissue infections (SSTI).

This pathway supports reduced hospital admissions and promotes early discharge for patients with complicated skin and soft tissue infections.

2. Dose adjustments

2a. Renal impairment

Licensed indication; ‘Acute bacterial skin and skin structure infections’

Renal function Creatinine Clearance (CrCl)	Dose adjustment
30 – 79 ml/min	No dose adjustment necessary
less than 30ml/min OR Irregular haemodialysis	Day 1; 1000mg single dose (equivalent to a 2 week course of treatment) OR Day 1; 750mg single dose and review on Day 8 for consideration of oral therapy or further 375mg single dose
Regular three times weekly haemodialysis (eg Mon/Wed/Fri)	No dose adjustment necessary

Unlicensed indications

Discuss all patients with pharmacy
Information on dosing and efficacy for those with creatinine clearance less than 30 ml/min is limited especially for unlicensed or off-label indications.

The following dose suggestions are unlicensed.

Consider reducing all doses as follows:

if 500mg is indicated give 375mg
if 1000mg is indicated give 750mg
if 1500mg is indicated give 1000mg

2b. Other dosage adjustments

Patient characteristic	Dosage advice
Hepatic impairment	No dose adjustment necessary
Obesity	No dose adjustment necessary
Underweight	Body Mass Index (BMI) calculation BMI = weight in kg/ (height in m)² Information on dosing and possible toxicity in patients with low body weight (BMI less than 15mg/kg² or weight less than 40kg) is limited especially for unlicensed or off-label indications. The following dose suggestions are unlicensed: · Discuss all patients with pharmacy · Consider reducing all doses as follows: -if 500mg is indicated give 375mg -if 1000mg is indicated give 750mg -if 1500mg is indicated give 1000mg

3. Monitoring requirements

Frequency	Recommended monitoring
Baseline	Urea and Electrolytes (U&Es), liver function tests (LFTs), C-reactive protein (CRP) and full blood count (FBC)
Weekly monitoring (Note this may be more frequent if clinically necessary)	U&Es, LFTs, CRP and FBC Consider waiting for results before redosing
Therapeutic drug monitoring	No therapeutic drug monitoring required
Follow up	Ensure follow-up arranged with referring specialty and/ or with an infection specialist

For the use of other antibiotics in an OPAT setting please refer to SAPG website

Scottish Antimicrobial Prescribing Group (SAPG) | January 2024 for review January 2027

Content updated: April 2024