Long-Acting Lipoglycopeptides and Infectious Complications of Injection Drug Use

Abstract

Purpose: People who inject drugs (PWID) are vulnerable to invasive bacterial infections of the heart valves, bones, and joints. These patients also have high rates of departing the hospital “against medical advice,” placing them at high risk of recurrence, with important consequences for long-term morbidity and mortality. As current treatment modalities require patients to receive up to six weeks of intravenous antibiosis, new therapeutic options are needed. Novel long-acting lipoglycopeptide antibiotics dalbavancin and oritavancin may offer important alternatives for the right patient. Methods: A focused literature review was performed utilizing search terms related to the lipoglycopeptide antibiotics, injection drug use, and Gram-positive bacterial infections to identify relevant article published between 2002 and 2019. Findings: Many challenges to the successful completion of extended courses of parenteral antibiotics among PWID were identified. While harm reduction strategies and access to medication-assisted therapy remain critical to preventing severe bacterial infections in this population, there remains an important treatment gap that means a large proportion of PWID do not receive complete courses of therapy after developing one of these complications of injection drug use. Dalbavancin and oritavancin, novel antibiotics with excellent coverage of staphylococcal, streptococcal, and enterococcal organisms and with terminal half-lives over two weeks, have been used in a range of settings across Europe and the United States to bridge this gap. Early results are promising, though uncertainties regarding patient selection criteria, optimal dosing schedules, and the potential for resistance remain. Conclusion: Off-label use of the lipoglycopeptides in PWID appears likely to be a safe and effective option in certain cases of endocarditis, septic arthritis, and osteomyelitis caused by Gram-positive organisms, and can be considered by clinicians who treat this population while further studies are conducted.