Lisa Dumkow, PharmD, BCPS, BCIDP, clinical pharmacist, antimicrobial stewardship, Mercy Health Saint Mary's, provides an overview of the current treatment landscape for community-acquired pneumonia.

Interview transcript: (modified slightly for readability)

It's a really exciting time for community-acquired pneumonia. The new guidelines from the Infectious Diseases Society of America and the American Thoracic Society just came out in early October. So we have some new recommendations, some updated recommendations and some things that we're really excited about. We've also got a new drug, so lefamulin just came out also in the third quarter of this year. It's a novel antimicrobial with a novel mechanism of action, so something that could potentially change the landscape of community-acquired pneumonia treatment. So it's a really exciting time to be a steward in treating pneumonia.

I think the main challenges in treating CAP, actually, you have to take a step back, because the main challenges I think are actually in diagnosing community-acquired pneumonia. So we have some really great treatments, the problem is that viruses actually cause up to 30% of pneumonia and we just don't have great testing for that. So the majority of patients actually end up with getting antibacterial agents. So we're giving antibiotics, a lot of patients who potentially don't need them.

The issue is that the rapid diagnostic testing that we do that tests for viruses, they're expensive, they're time-intensive, potentially, and a lot of sites don't have them. And then the interpretation of those tests, again, is also up for debate in terms of how beneficial those are for patients as well. So again, we know that there's a lot of pneumonia due to viruses. It's just we just don't have the best testing.

ASHP 2019 News Network: Current Treatment Landscape for CAP

Lisa Dumkow, PharmD, BCPS, BCIDP, clinical pharmacist, antimicrobial stewardship, Mercy Health Saint Mary's, discusses how to reduce costs of treating pneumonia and highlights new agents in the pipeline.

I think, for reducing the overall cost of pneumonia, we have to go back to preventing pneumonia. So vaccination is probably one of our most important things that we can do. As stewards and as patient advocates [we can] advocate for our patients to get the pneumococcal vaccine, as well as influenza vaccine seasonally. So again, just going back to a lot of those pneumonias are caused by viruses and just making sure that our patients are at their best level of health by being fully vaccinated would be probably the best thing that we can do in terms of reducing costs.

On a treatment standpoint, again, we need to be picking the most appropriate agent for our patients, as well as appropriate durations of therapy. So the new guidelines are very solid in terms of saying that 5 days of therapy is appropriate for most patients. And so actually in Michigan, HMS has been looking at Michigan data statewide and just showing that a lot of patients are receiving, you know, 2, 3, maybe even 4 days of excess antibiotics when they're discharged. And so reducing costs that way to making sure that patients are receiving just the minimum number of days that they need, not excess days on discharge.

So in terms of new antibiotics, lefamulin did just come out in the third quarter of this past year. So it's a novel antibiotic, a novel mechanism of action, something that we haven't seen before. So that is a potential new drug that we could use as monotherapy for community-acquired pneumonia. Other than that, there aren't a ton of new oral options for community-acquired pneumonia, but we still have our tried and true beta-lactam therapy. Targeting 

 is our No. 1 pathogen so it's exciting to have a new agent and a non-fluoroquinolone agent as well so I will just say that for us as stewards and not having to reach for fluoroquinolones is a nice option.

ASHP 2019 News Network: Cost Reduction and New Options for CAP Treatment

Lisa Dumkow, PharmD, BCPS, BCIDP, clinical pharmacist, antimicrobial stewardship, Mercy Health Saint Mary's, discusses the updates to the CAP guidelines.

So the new IDSA [Infectious Diseases Society of America]/ATS [American Thoracic Society] guidelines came out in early October. I've definitely reviewed them. It's been a hot topic in infectious disease and stewardship. I think as stewards and as pharmacists, we were really excited for those guidelines.

So the previous guidelines were from 12 years ago. Probably the biggest change that I think is beneficial is the removal of that HCAP definition. So the health-care associated pneumonia, they recommended retiring that definition. So that opens up a lot of patients who are receiving extremely broad spectrum antibiotics, so those targeting anti-MRSA [methicillin-resistant Staphylococcus aureus] and the anti-Pseudomonas, and actually just bringing them back to Strep pneumo [

] coverage, so it gives them an option for more narrow coverage up front. So that's a big change and a big deal that a lot more patients will not need to receive such broad antibiotics, which hopefully will reduce their risk of adverse effects such as 

, so we'll hopefully just reduce their overall burden of antibiotics that they need to receive.

Then the other big thing there too is their update to the outpatient recommendations for community-acquired pneumonia. So that Z-Pak, like give me a Z-Pak, has been really ingrained in our society for the past 10 or more years. And so these guidelines recommend against azithromycin monotherapy for outpatient antibiotics, which is something we've been doing locally at our site for over 5 years now, just knowing that our local Strep pneumo susceptibilities, were only about 60% or less over the last 5 years, and it's not really safe for our patients locally to be doing that. So these guidelines recognize that actually nationwide, it's not safe to be doing that, and now recommend dual coverage with a beta-lactam plus a macrolide, or plus a tetracycline for outpatient therapy. So that is a really great thing that they did with those guidelines.

So I do think there were several questions that still remain with these guidelines, first and foremost, lefamulin and came out right around the same time that the guidelines did and so it was mentioned in the guidelines but they still do recommend fluoroquinolones, a second line to our beta line beta lactam therapy. Again, we're trying to really be fluoroquinolones spearing for several reasons. First and foremost, just being adverse effects. So there's quite a few black box warnings on fluoroquinolones. It's not the safest option for the majority of our patients. So having a another option that isn't a fluoroquinolone is exciting. 

Something that we hope future guidelines would maybe push a little higher to say "don't use a fluoroquinolone, use this first" and maybe a fluoroquinolone could be third line option. The other thing is that they still recommend beta-lactam plus macrolide therapy as first line. There's been several studies actually showing that beta-lactam monotherapy, might be just as efficacious as that combination, and they really didn't go into that data within those guidelines. So again, just another way that we could maybe be better stewards and not give such broad coverage to our patients if they don't need it.

But most of the things that they put in there we feel are great. So that short durations of therapy, that removal the HCAP, but yeah, there's a few things they could do to even improve more from a stewardship standpoint.

So they recommend against corticosteroids now in the guidelines, and that was something that was maybe controversial in the past as well. I think that could even still be controversial, because the guidelines also recommend against procalcitonin. We see new procalcitonin studies coming out for lower respiratory tract infections, including pneumonia, even every week still. So I think those 2 points, it was nice that they address them but I think those are still going to be controversial even in coming updates of the guidelines. The big issue with the guidelines is that it's taken 12 years to get a new version of the guidelines so who knows when the next guideline version that we're going to get is. It's an exciting time to be treating cap right now. And yeah, who knows when the next version will come out?

ASHP 2019 News Network: Reviewing the Updated CAP Guidelines

Krutika N. Mediwala, PharmD, BCPS, BCIDP, assistant professor, College of Pharmacy, Medical University of South Carolina, discusses the challenges behind treating ABSSSI including source control and readmissions.

Interview transcript (modified slightly for readability):

Acute bacterial skin and skin structure infections or I will just shorten it to ABSSSI as we like to lovingly call them. They can be quite notorious to treat just because by definition-so those were reclassified a little while ago- but by definition, they're usually comprised of cellulitis or some other major abscesses and then also have a measurement of 75 millimeters

. So it is a guidance but it is when you think of it it's very abstract when you're trying to figure out how your patient meets those criteria with that. So it is very difficult to figure out the scope of cellulitis without, trying to look at how much is spread and everything else. The other thing that we love in ID [infectious diseases] is source control. So not having a particular source that I can evacuate like an abscess or something like that. So it's very elusive when you have cellulitis because we don't necessarily have a source that I could point to. And so that can sometimes be difficult to treat.

A lot of the times the patients that I see come back on because they're prescribed oral antibiotics for a skin and skin structure, infection, but they end up coming back and needing to be readmitted in the inpatient setting for IV antibiotics. And I often wonder if maybe it's not the actual antibiotics failing because that's what they're classified as. It might be time that we, you know, we came out with a new guidance by the FDA, but maybe time that we restructure some of the ways we have the algorithm of treatment for these patients. So maybe identifying some patients that would qualify for IV treatment up front, and maybe it's 1 dose, or maybe it's more than a couple of doses, and then we can prescribe them oral antibiotics to finish the treatment versus giving them an oral antibiotic. And maybe they didn't, they needed a little bit more help than that. And then they get readmitted. The hospital gets docked. And then as well as the patient care, we run out of a little bit of options that we have.

ASHP 2019 News Network: Challenges Behind Treating ABSSI

Krutika N. Mediwala, PharmD, BCPS, BCIDP, assistant professor, College of Pharmacy, Medical University of South Carolina, highlights traditional agents being used to treat skin infections as well as recently approved agents.

In my opinion, we have plenty of antibiotics right now. Some of our old faithfuls such as doxycycline, cephalexin, Bactrim are still working. We have our IV treatments such as vancomycin, daptomycin, ceftraoline, so those are all options that in the past had been in the guidelines and we use for that. But we also have some of the newer antibiotics coming up and even some of the newer antibiotics that are in their pipeline they're aiming for ABSSSI indication, and I'm not really sure that we need that but it's exciting still to have that come.

Some of the newer agents such as the lipoglycopeptides, so dalbavancin and oritavancin are changing the landscape of ABSSSI with their long half-lives and the ability to just have 1 dose that kind of takes away the need for oral antibiotics, the need for admitting the patient. The most important thing that we sometimes worry about with our skin is soft tissue infection patients is compliance. So giving someone a drug that you know has side effects such as diarrhea and can really change someone's compliance. So not having to worry about that is really helpful.

As far as unmet needs, and I often wonder that by the definition, you know, it doesn't include our diabetic foot infections, it doesn't include our animal bites. But I do wonder how we can classify some of our immunocompromised patients into these into these treatment algorithms. Because sometimes I find that we employ some of our broader agents because the patients are immunocompromised and sometimes rightfully so. But maybe we can have some delineation on when we can classify them as a patient that can probably benefit from what our normal agents are versus someone that may need our immunocompromised regimen. The other population that I'm seeing a lot of is our IV drug users. So they will have, besides just, you know, abscesses and everything else, they usually have complications such as bacteremia or osteomyelitis, but they often will present with cellulitis. So how can we identify them early on and see if any of these agents can be helpful in those settings?

ASHP 2019 News Network: The Landscape of ABSSSI

Krutika N. Mediwala, PharmD, BCPS, BCIDP, assistant professor, College of Pharmacy, Medical University of South Carolina, discusses improving algorithms to identify patients with skin infections in order to decrease length of stay and improve patient outcomes.

From a clinician point of view, I think education is very important in trying to identify those patients. Again, like I mentioned, maybe we need a change in the algorithms and a way to early identify these patients to see if we can they can benefit from IV treatment early on, 1 or 2 doses fine. And then having a landscape where maybe we don't need an inpatient setting, but we don't need and maybe clinic setting either like maybe halfway point would be better to assess these patients, monitor them while these doses are being given. And then see if we can finish out the treatment course with some of the oral antibiotics.

Some of the longer lasting agents like I had mentioned that lipoglycopeptides, they're really changing the landscape we're seeing more and more use of dalbavancin and oritavancin for ABSSSI. It's very helpful because from a coverage point of view, compliance point of view that patients are able to get this dose very quickly and move on with their lives and then just making sure we have a follow up appointment. Even though these agents are FDA [US Food and Drug Administration] approved for ABSSSI there is more and more evidence that's coming forward for maybe other indications and other infections. Which in general will decrease their length of stay in the inpatient setting and have more options for patients that are, you know, walking and talking and they're not really fit for the hospital, but they still have that infection to deal with.

ASHP 2019 News Network: Decreasing Length of Stay for ABSSSI

Krutika N. Mediwala, PharmD, BCPS, BCIDP, assistant professor, College of Pharmacy, Medical University of South Carolina, discusses cutting readmission rates for ABSSSI.

Readmittance rates are very high with ABSSSI. Like I mentioned before, it's mostly because I believe we have to change the algorithm of how we're treating them. The indirect costs of these patients getting admitted for you know, 7 days of treatment, 5 days of treatment because of them having failed oral antibiotics is a lot more than their risk for other hospital-acquired infections. Cost is a great aspect for both the patient as well as the health care institution. And then like just some direct costs as well of just length of stay, duration of therapy, just, you know, all the things kind of come together to really make us look at our readmittance rate, and maybe having another place to for these patients to get identified and treated appropriately.

Then setting them up for success afterwards and educating them like, "hey, this is going to last, you know, for 14 days," for example, for dalbavancin, and like really making sure we identified that specific patient. Now, this doesn't mean that it's for everybody. They're really trying to create more and more protocols to see how can identify these patients. The other thing is, the access to these agents is quite difficult in the inpatient setting. For example, I've had it be used in a patient and inpatient setting and I had to fax 3 different things, get them on the phone and be like, "hey, we need a 24 hour turnaround, I really need you guys to look at this patient" for the insurance and the copay.

So making sure that legwork is a little bit easier on everybody to make sure we get the patient the best care possible as soon as possible. Then the other thing I thought about was and this is a new buzzword right now is the outpatient stewardship. ABSSSI is a great aspect that outpatient stewardship can help with really identifying those patients in the clinic settings and other outpatient settings and eating with them in drug acquisition prices and algorithms and education, like that's a really good thing that that patient stewards can help with.

ASHP 2019 News Network: Cutting Readmission Rates for ABSSSI

Krutika N. Mediwala, PharmD, BCPS, BCIDP, assistant professor, College of Pharmacy, Medical University of South Carolina, highlights the importance of site of care for acute bacterial skin and skin structure infection.

So the site of care is very important right now, especially with the new drugs coming out as far as reimbursement goes, as well as the ability for our patients to get these drugs. Usually with the way they have been going, especially our lipoglycopeptides that are available for much cheaper and much more readily available in the outpatient settings. Really our most uses seen in the ED [emergency department] with patients because that's what they're been approved for. The whole point is to identify these patients in the ED or an outpatient setting, administer the drugs so we avoid them getting actually admitted in the hospital and incur all those costs as well as possible adverse events.

But the site should also get expanded to inpatient or other ambulatory settings just because access is a huge thing for a lot of patients. My institution specifically takes care of a lot of the indigenous population from rural South Carolina, so having that access, again, outpatient stewardship can help with that. So they don't have to come all the way to my institution, just to come to the ED, get this drug and then have to go drive back. It's going to be a shorter time to get that drug than they took to drive to the hospital with that. So just access to care for these patients as well as acquisition ease.

ASHP 2019 News Network: Advances in Treating and Managing ABSSSI and Community Acquired Pneumonia