In my post last week I mentioned I would write a follow up to discuss my opinions on the use of these drugs for lower extremity infections.  I have not yet had the opportunity to try either so these are really “top line” thoughts taken what I know, have read or heard from others, into consideration.

– These drugs are expensive and I wonder who will cover the cost. The two doses of dalbavancin reportedly cost somewhere in the neighborhood of $4500 while the single dose of oritavancin is considerable less at around $2600 for the required single dose. Given hospital pharmacies are always worried about their budgets (they complained about the cost of linezolid when it was originally only about $1500!) can they be convinced to stock these drugs? What about insurance companies when they can demand patients receive generic vancomycin for next to no cost at all?

– The argument is made by the companies that these drugs will keep patients out of the hospital thus saving costs. That does make a lot of sense…on the surface. If you don’t admit the patient you don’t run up costs for the actual stay and only the outpatient treatment. The problem with this line of thinking is that many, especially for profit, hospitals make money by having “heads in beds”. The last thing they would want to do is decrease the number of admissions from the E.D. I make this statement with the disclosure that I am far from expert in hospital reimbursement economics, it’s just what I have been told by some hospital administrators.

– Who will make the decision to administer these drugs? The Emergency Physician? I doubt most would feel comfortable with these antibiotics. Furthermore, would they just stock it in the E.D? Who’s budget does it go under? The Pharmacy or the E.D.? What about the out-patient infusion center. This is probably the most likely scenario, especially if run/owned by an ID specialist, depending or reimbursement considerations.

– If the patient did receive a dose in the E.D. and the decision was made to admit the patient, the patient no longer needs IV antibiotics. Would the admission be denied as not meeting hospital level care?

– What if the patient developed an adverse event (“AE”). Neither of these drugs is dialyzed out of the blood. Will the AE be present for the entire length of the half life? That being said the clinical trials showed that AEs were rare and those that did occur were self limiting. Of course, with widespread use of any new drug previously untoward reactions can be discovered.

I guess my bottom line is that I am totally fascinated by these drugs and their unique pharmacokinetics.  I can see weekly doses to treat osteomyelitis (although neither are FDA approved for this nor even tested).  I can see taking a patient with an infection who is not doing well on an oral MRSA drugs, such as doxycycline or TMP/SMX, and just treating them with an IV dose or two.  Perhaps, treating a patient who, for whatever reason, can’t take oral linezolid or tedizolid but does not require hospitalization for their infection is another potential use. I will continue to watch and learn about these two new drugs whenever I can and pass along any information I can.