Peter L. Salgo, MD; Yoav Golan, MD; and Bruce M. Jones, PharmD, BCPS, identify the commonalities of ABSSSI, including the predominant pathogens, such as 

 Hello, and thank you for joining us today for this 

 panel discussion. Acute bacterial skin and skin structure infections (ABSSSI) have become a challenging medical problem often associated with high direct and indirect costs. These infections are responsible for an astounding 750,000 hospitalizations per year, representing a 17.3% increase in hospitalized ABSSSI patients from 2005 to 2011. If left untreated, these infections can cause potentially life-threatening infections in bones, joints, surgical wounds, bloodstream infections, heart valves, and lungs, to name just a few. This 

 panel of experts in infectious diseases is going to discuss the trends in ABSSSI incidence, cost considerations, and patient selection for outpatient parenteral antibiotic therapy.

I’m Dr. Peter Salgo, and I’m a professor of medicine and anesthesiology at Columbia University College of Physicians and Surgeons and an associate director of surgical intensive care at New York-Presbyterian Hospital. Participating today on our distinguished panel are Dr. Yoav Golan, an attending physician at Tufts Medical Center in Boston, Massachusetts, and associate professor at Tufts University School of Medicine, and Dr. Bruce Jones, infectious diseases clinical pharmacy specialist for St. Joseph’s/Candler Health System of Savannah, Georgia. Thank you so much for joining us. Let’s get right to the point and discuss some basic, simple definitions. How do you define acute bacterial skin and skin structure infections?

Well, it’s important to remember, this is an FDA indication; that is, when new antibiotics are being approved.

You are telling me, first of all, that it’s a bureaucratic definition, but there is also a clinical definition, too. So, how do we go about this?

It’s not what we use in everyday medicine, and if you translate that to everyday medicine, it includes cellulitis, erysipelas. It includes abscesses, and it includes wound infections—this could be surgical wound infections, trauma-related wound infections, and so forth. Those 3 together make this FDA indication of ABSSSI.

 But it wouldn’t be a definition somewhere, by some bureaucratic standard, if there wasn’t a number in it. Do we know how big it needs to be to make that definition?

Absolutely. The FDA has established that it needs to be greater than 75 cm to be considered a major cutaneous abscess. They want to know that it’s a good size.

That’s huge—75 square centimeters is a lot of centimeters.

The size of a baseball, yes—that’s a big infection. Just this once, I think we can all agree, you get 75 square centimeters involved, you have a problem&mdash;whether it’s cellulitis, erysipelas, or wound infection, that’s a big infection. Given that big of an infection, how big of a problem is ABSSSI?

In this day and age, it’s one of the most common infections that we’re seeing in inpatients that we deal with. In terms of emergency department visits, we’re seeing over 3 million a year; outpatient visits, over 14 million a year—so it is a big problem in society today.

I’m not sure I’ve ever really focused on it quite like that. That’s a lot of infected tissue, so we can lump that together into a big skin infection. That’s a lot of people.

Is that getting bigger? Is it a bigger problem than it used to be? You read about it in the paper sometimes.

Absolutely. I think we’re seeing linear growth. If you look at the numbers now, every year we see more and more of these patients. They’re coming to physician offices, and where are they sending them? They’re sending them to the emergency departments.

You hear stories in the popular press: There is some kid who’s a wrestler…he’s a hockey player…he’s a baseball player…and he comes in with some MRSA (methicillin-resistant 

) infection on his skin, and he loses an arm. Is that common?

In the past, you actually needed to have risk factors to have

 known as MRSA. Nowadays, everyone can develop those, and, in fact, recurrent data from several studies in emergency departments show that MRSA is more prevalent than methicillin-susceptible, which is the susceptible version of this bacteria in the emergency department. In the past, you needed to be a pro athlete and then just an athlete, and now you don’t have to be an athlete at all, and those infections have become very, very common in the community. As you know, the MRSA version of 

 was particularly prevalent in ICUs many years ago, then in the wards, then in other institutions in the community, but now it’s prevalent in the community itself.

The gram-positive organisms that we typically see are what? There are 

 species, and you were talking about MRSA. It has always been my understanding that the resistance isn’t the same as its virulence—that is you can be resistant to antibacterial agents, but 

I would say so, and I think that skin infections are increasing tremendously in the community, among community providers, in the emergency department, in the hospital, and in other institutions. There are 2 main drivers to that when you talk about the pathogen. What is interesting is that the 

 we see circulating nowadays not only is more resistant to the common antibiotics that we use in the community but actually also is a more virulent strain. In other words, it’s a strain that’s more capable of causing infection. There was a recent study that was done among military recruits showing that if you are colonized with this strain of 

, before your preliminary or first training, you are far more likely to get infected during the training. This is the 

 that is more capable of causing an infection, and the infection is harder to treat because the 

Did I misspeak? I always thought that resistance is 1 thing, and then the virulence of the organism is another. Are you implying that there’s a link between antibiotic resistance and virulence?

One way to look at antibiotic resistance is as a virulence factor, because the more resistant you are, the treatment options that we have are not as good. The likelihood that you get early, adequate therapy is reduced because there are fewer antibiotics that can be used reliably. The disease is going to run its course, and the infection is going to be more severe at the end of the day.

Allow me to say in my own defense that academically I might be right but pragmatically I’m not. We were talking about gram-positives…When I was a medical student, it was always gram-positives in skin, but gram-negatives are out there, too, right?

Absolutely. I think if you look at specifically surgical-site infections as an example, if they include the gastrointestinal tract, I think gram-negatives come into play. We spoke earlier about how if you look at certain wound infections especially, if purulence is found, it leans more toward 

. If you have a quick-growing cellulitis, for example, many times it’s 

An Overview of ABSSSI

Peter L. Salgo, MD; Yoav Golan, MD; and Bruce M. Jones, PharmD, BCPS, discuss the prevalence of acute bacterial skin and skin structure infections, including MRSA, in the community, as well as risk factors, susceptibility, and increased resistance to oral antibiotics such as Keflex.

 I’m a hospitalist, if you will; I’m an intensivist. All my patients have already been admitted. I don’t even see those folks until they get so bad that they’re near death. But in the community, what’s going on with ABSSSI and MRSA? What’s happening here?

 I think we’re starting to see a trend more toward inpatient. We have developed antibiograms specific to our emergency departments, and when you compare them with our inpatients, they’re starting to look more and more similar. You’re seeing higher rates of MRSA, and I think that’s causing a lot of the same concerns we’re seeing on the inpatient side.

 Are we seeing different bugs? Are we seeing a different profile of these patients? You said that it used to be more immunocompromised patients—not so much?

 In the past, you really needed to be special to be infected, particularly with MRSA. That was not very prevalent, but now it’s so prevalent in our communities that it doesn’t make you special—the fact that you are infected by MRSA. What happens is, you have such an infection, you go to your primary care physician, you may get an antibiotic such as Keflex (cephalexin) or doxycycline or one of those. It may or may not work, but many of those don’t work against MRSA, and just very few oral antibiotics are actually reliable. You end up not responding, and after a few days, you find yourself in the emergency department, when a few years ago this wouldn’t happen. Then all of a sudden, the emergency department is getting to see so many patients that they haven’t in the past.

 They definitely are. Also, they have to make very quick decisions as to what to do with those patients, knowing that they can’t keep them in the emergency department—and in many cases the perspective is that maybe they already failed or exhausted whatever we could do in the community.

 If you give somebody an oral antibiotic like Keflex, and you send them home and it fails, have you made it worse by ensuring that there’s increased resistance? What do you think?

 No, I wouldn’t say that. The main gram-positive bacteria are 

 would be susceptible to Keflex almost always and will not become resistant to Keflex if you started someone on Keflex. When it comes to 

, it will never become resistant to Keflex if it was initially susceptible to Keflex.

 But, again, if it wasn’t susceptible, then Keflex is not going to work if the patient required some drainage of an abscess, for example. There are multiple reasons for failing therapy. I just wanted to mention 1 more thing. You talk about trends of skin infections. Another thing that I think we must take into consideration—and I think it’s a very strong call for action for us&mdash;is the fact that if you look at the risk factors for skin infections, they become more prevalent in our society. People are older, they are heavier, they have more diabetes, they become more susceptible to skin infections. That’s one of the reasons people develop ulcers, and that’s one of the reasons we’ve seen such an increase. The expectation is that this will continue to increase.

 It seems to be one of the counterintuitive issues with the wellness of the American public: We keep people alive longer. We keep people with chronic diseases going further. But on the other side of that, here comes MRSA, here comes susceptibility because of poor peripheral perfusion. Are you seeing that?

 A little bit. Speaking back to his point before, I think it depends on the patient who presents and whether it’s a simple cellulitis picture. You start looking at systemic signs of infection, whether or not they’re febrile, and then comorbidities. That plays a big role regarding the type of patient we’re treating.

 When you talk about this sort of thing and emergency room visits and antibiotics and repeat infections—whenever you talk about this in terms of public health, we come back to money.

 Right, because these tend to be expensive.

Understanding the Prevalence of ABSSSI in the Community

Peter L. Salgo, MD; Yoav Golan, MD; and Bruce M. Jones, PharmD, BCPS, share the typical presentation of an acute bacterial skin and skin structure infection patient in the emergency department and the standard protocol of IV antibiotics.

 So, how does a typical patient with ABSSSI present into the ED to begin with?

 That’s an interesting question, because patients with skin infections may actually present differently than patients with other type of infections. Many people with these infections present to the ED as a last resort, when they are really sick, and they may need to be admitted and monitored and so forth. Many patients with skin infections present to the emergency department because it’s very common or because they may not have access to a primary care physician. Most of those patients are not terribly sick, and I think we would agree that this is the common denominator. They may have a fever, but they’re unlikely to be septic; they’re unlikely to have the type of skin infection that makes us very concerned, like necrotizing fasciitis. Most of them are stable; they may have comorbidities, but most of those people with comorbidities seem to be doing fine, as well. Most of them have received some antibiotic in the community and either failed or were not patient enough to allow the antibiotic to actually work. When they come to the emergency department, they’re not among the most unstable infected patients.

 Does that mean they get triaged to the back of the line, and some of them walk out and then they come back in sicker?

 I think you’ll see some of that. If you look at it, probably a little over two-thirds of them are treated as an outpatient. Some of that is kind of what you mentioned—triaging. Compliance&mdash;adherence&mdash;comes into play with this population. I also find that many of them usually don’t have a lot of comorbidities, either. As you mentioned, these aren’t the sickest of patients.

 I got it. In the Sturm und Drang of the emergency room, patients are crashing in with myocardial infarctions and strokes. Here’s a guy with a skin infection who may get put to the back of the line.

 I think it’s also fair. Let me just ask this: There seem to be, from listening to you, 2 silos. The first silo is somebody who went to his local practitioner, was treated and failed. Things are worse; he’s in the ED or she’s in the ED. The other one is “I don’t have a private practitioner. I have a skin infection—I’m going to the ED because that is my private practitioner.” That’s a different subset, isn’t it?

 I think so, yes. We see a lot now with our private physicians, with the prevalence of MRSA in the community, they’re seeing these patients, and they’re sending them directly to the emergency room. I think there’s a missing link now between treating them as outpatients.

 So, wait, let me see if I understood that, because that’s a little scary to me. You’re going to go see your local doctor, you have a skin infection, and they just bump you to the ED.

 I think its concern over failure. Maybe it’s comorbidities—a lot of issues coming in&mdash;and they’re busy. They’re going to see a lot of patients in a given day, and sometimes it’s easier, especially if they have any incidence of anything&mdash;comorbidities, fever&mdash;anything that might push them over the edge just a little bit.

 And the inability to infuse—that is one of the biggest drivers of care determinations. With skin infections, it’s the idea that some people have to receive IV antibiotics, and that’s very different from other infections where you would give IV antibiotics to patients who are very unstable. In this case, you’ll give them IV antibiotics because they didn’t seem to do better with whatever you’ve done so far. This brings us to a really important kind of corner in our discussion, which is, how do we perhaps change what we’ve done until now?

 One thing I want to add to that is that I think allergies play a role. In this day and age, so many people carry allergies—10% of patients are carrying a penicillin allergy. It limits the options you have.

 All right, but I don’t want to let private practitioners off the hook completely. If they’re going to come to the ED, what’s the ED going to do—give them antibiotics, maybe IV antibiotics, treat a skin infection? Is there anything here that this poor overworked ED physician can do that you can’t as this person’s private physician, who knows this patient better, at least to start?

 One thing you can do in the ED, which many private practitioners don’t feel comfortable doing even though they could, is drain an abscess. To be fair for this discussion, it is important to remember that not every skin infection actually requires antibiotic therapy. Patients who have an abscess less than 5 cm, without the rim of erythema that’s greater than 5 cm in diameter, actually benefit from drainage of an abscess, and antibiotics don’t make any difference.

 So, you drain them and let the T cells go to work?

 Exactly—T cells, B cells&mdash;and their good nutrition. This could be done by primary care physicians, but many of them just don’t do that in the office. Many of those patients can do that in the emergency department and can then be discharged.

 What ever happened to the term “laudable pus”? “You express the laudable pus.” You’ve heard that, right?

 That’s sad. Let’s approach this from a different direction. What is the standard protocol for treating one of these skin infections? I don’t care if you’re in your private practitioner’s office or the ED. Is there a standard protocol, and, if so, what is it?

 I’ll be honest—being a community health system, we don’t. We don’t have what I would consider to be a standard protocol. I will joke around, and what a lot of patients, especially the ones that are admitted, get is what I like to call nothinkamycin. They get piperacillin/tazobactam/vancomycin because it’s easy, and they know that it will cover everything.

 That’s it—covers everything, right? We see a lot of that, and I think that’s one of the issues we struggle with…trying to streamline and trying to standardize what we do.

 Antibiotic stewardship alone would say, “Whoa, wait a minute.”

 When you say “standard protocol,” in the minds of many, patients are seen in the emergency department and then the question is, have they graduated to IV vancomycin? Because they are going to get admitted. When you talk about variations, you may talk about what else is going to be given in addition to vancomycin, but vancomycin has become the standard of therapy. By saying that, you understand that we have a problem. We have a problem because vancomycin may not be such a great antibiotic as compared with oxacillin (Bactocill) and cephalexin (Keflex) and other antibiotics that we’ve been using for a long time. The susceptibility to vancomycin is decreasing, even though resistance almost does not exist, and we have to use more vancomycin.

 I’ve got to stop you right there, because that’s a technical issue, isn’t it? Resistance versus susceptibility? At some point when you’re really resistant or you’re really not susceptible, aren’t you de facto resistant?

 Well, if you can overcome this increasing minimum inhibitory concentration or decreased susceptibility with increasing the dose of the antibiotic, then you’re not resistant, but you require more of the antibiotic.

 Nobody wants to back a dump truck of vancomycin up to a patient’s bed, right?

 That’s what we do. As you know, we monitor vancomycin levels with trough levels, and 15 years ago, the textbook said you have to keep the patient between 5 μg/ml and 10 μg/ml. Now with severe infections, we keep patients between 15 μg/ml and 20 μg/ml.

ABSSSI: Standard Protocol of Admission and Treatment

Peter L. Salgo, MD; Yoav Golan, MD; and Bruce M. Jones, PharmD, BCPS, consider and discuss the costs of acute bacterial skin and skin structure infections patient hospital admissions, extended lengths of stay, and IV antibiotic protocol and reimbursements.

 Buried in your comment, and I was listening, was this whole thing of “Well, they’re going to get admitted.” Who’s going to get admitted? Who gets into the hospital with this problem?

Several studies recently did surveys among emergency department doctors and asked the physician, “For the patient that you admitted, what was the reason for admission, and what were the secondary reasons?” What they found was that in about 80% of the cases, the most common reason by far to admit someone was the need for IV antibiotics. In about 40% of the admissions, the need for IV antibiotic was the only reason to admit someone. They needed to get something, with the perception that it’s just given in the hospital, and therefore you need to admit them. In fact, many of those patients did not have comorbidities, and of those who had comorbidities, most of them did not have any exacerbation of their comorbidities. There was no concern that their infection was out of control, and just with monitoring, they need to be admitted.

This was simply pragmatic—which is that IV antibiotics are what you need. You can’t get that in XYZ home office. Is that a fair reason to admit somebody?

I don’t think so, because many times these are limited-comorbidity patients. They’re not that sick in terms of what we would associate, a lot of times, with being sick. As he mentioned, IV antibiotics are the main reason why these patients are being admitted.

But you said it yourself—these are not sick folks for the most part; they just need a therapy that mechanically is tricky in some settings to give outside the hospital.

Let’s pull this back to money. Not sick, just needed an IV, just need some antibiotics…That should be cheap, but now you’re occupying some very expensive real estate.

 I think that you touch the heart of the point. We talk about the incidence—we talk about the increasing skin infections&mdash;and it causes some major, major issues, first of all for patients. Infections that could be treated at home now require admission to the hospital. Most people don’t like that. It’s an issue for hospitals, interestingly, because patients with skin infections tend to stay in the hospital longer than what the hospital is going to get reimbursed for. Skin infections are not the best way to fill your beds if you can do it otherwise. Of course, it’s a major issue for the community because we end up paying for that. We are now in a crisis situation, and the biggest question is, how do we do it better? To be fair, until recently, we didn’t really have any options. Someone comes into the emergency department stating, “I took this, I took that.…I took Bactrim (trimethoprim and sulfamethoxazole), I took Keflex (cephalexin).…It didn’t work. Now it’s 2 or 3 days&mdash;I have a fever,” and the ED doctor is looking at the cellulitis. The next step is IV vancomycin, and the only way to give vancomycin is to admit the patient, so there were no other treatment options.

Let’s explore some of these issues that you brought up, because a lot of them are—whenever you discuss money&mdash;bureaucratic to some degree, because there’s somebody out there evaluating your treatment plan, your program, and your reimbursement. The first thing is, they’re going to be in the hospital longer than what the reimbursement folks are going to pay for, yet there are protocols for IV antibiotic therapy. How come the reimbursement protocols aren’t in sync?

Patients, when they come in—to your original point&mdash;was length of stay; they’re staying for at least 5 days. Many times, when we’ve looked at our numbers, they stay even 6, 7, 8 days, and it’s just being able to get these patients out. Many times, you can’t; it’s the DRG (diagnosis-related group) that loses money. On average, every patient that we admit, you lose money. A lot of times, it’s case management being able to set these patients up.

So, here’s a DRG, right? The DRG says—and I’m going to make up a number&mdash; “Here’s 20 cents; go treat this patient.” You know you can’t do it for 20 cents if you’re going to follow all the protocols in the infectious disease literature. It’s going to cost you $20. Where’s the disconnect here? Is it just some bureaucrat who says, “No, I’m not going to pay you for it,” or does it make sense to find something that you can use that will get them out of the hospital more quickly?

I think it’s both sides. It’s finding a way to either not admit those patients, or target them and get them out for an earlier discharge.

If somebody has to stay for medical reasons, and the hospital keeps them and if there’s a DRG, they’re going to lose money. If there’s no DRG, there’s still a penalty. What kind of penalty does the hospital look at?

 Well, I’m not a reimbursement specialist—I should say that&mdash;but I think that when you look at the DRG, there are some patients who stay for a short period of time, and there are some patients who stay for a longer period of time. With skin infections, they tend to stay longer than the DRG would. There’s really no reason for payers to incentivize hospitals to keep the patients longer. We are in a DRG era, and that’s how we get paid. So, I think that at the end of the day, we’re stuck with that.

Yes, and I think a big concern for us is readmission. You worry about these patients.

If they’re coming back within 30 days, your hospital is going to eat that cost. That is where a lot of the concern comes in.

If I’m going to put on my cost accountant hat for a minute. OK, I’m going to lose money if I keep them longer than what the DRG will pay for or what the length of stay protocol is from this insurer. But if I send them home too early, they’re going to bounce back, and I’m going to eat that money.

So maybe it’s cheaper to keep them and eat a small amount rather than bring them back and eat a big chunk.

Absolutely. In this day and age, compliance, adherence—such big issues. Sometimes with being able to see them in the hospital every day and know they’re getting their IV antibiotic, it’s easier to think, “Maybe I can prevent that 30-day readmission.”

 I agree with that. First of all, as a clinician, I think that the cost comes second to patient’s benefit.

 Well, I think that if you do it right for the patients, the cost will follow as well. First, you have to do what’s right for the patient, and in this case, I think it’s aligned with also reducing your cost. This is a great opportunity with those 2 things, and then when you talk about cost—I just want to mention 1 thing&mdash;cost for one person is different than cost for the other person. You can talk about length of stay, but then the pharmacy director sees the cost of the antibiotics; someone else who’s the payer is looking at the overall cost of the admission. We as a society pay for our premiums, so everyone’s cost is different. As we discuss cost&mdash;and I have this suspicion that we are going to discuss it further later&mdash;I think we have to take it out of the silo mentality, and actually look at what is worth investing in and what is not.

I know you are an ICU doctor, and when you see a patient who’s a little diaphoretic and maybe unstable—or maybe you are in the ICU but an internist sees a patient and says, “I’m really concerned about this patient; I’m not sure what’s going on, maybe he’s bleeding”&mdash;God knows, we’ll send him to the ICU. Every day in the ICU is $2000, $3000. Why would he do that? It’s so expensive to send. Why do we have ICUs? The question is not what is the cost but what do we get for the cost, and how do we come up with that rationale, just as a segue?

You mention again—there’s a lot buried in the stuff you say that’s fascinating, which is that it’s time to get rid of silos. I’ve always made this argument, and I’ve always gotten strange answers. If I’m going to save money at the pharmacy level&mdash;maybe the cost is a little more on the bed occupancy level but, at the end of the day, the net is a savings to the institution&mdash;I get “Yeah, but that’s not my money. My money is in the drugs. I’m losing money here.” How do you get people to talk to one another?

Actually, that’s a fight I deal with every day, because I have a manager. Depending on what antibiotic we use, you get into more expensive ones—they may treat a patient better, they may get them out faster. Trying to make administrators understand that that was the best antibiotic in that case to use is always hard.

I think they understand it, but there’s something about budgets. My budget is not your budget, and the whole hospital budget doesn’t really impinge my decision to kick you out because I’m going to lose money on your next dose of vancomycin.

Absolutely. There’s an inpatient budget for drugs, and antibiotics get lumped into it. When they see it tick higher, that’s what they see. It’s not the outcome side of it, it’s not the right therapy—sometimes that’s the magical big number.

Do you have any insight into how this evolved? It doesn’t make clinical sense, right? If I can get somebody with a moderate stay, with a cheaper antibiotic, or even outpatient with a more expensive antibiotic that never comes in, isn’t that better?

 Well, I think that when you start to fragment your institution and look at different parts as cost centers, all of a sudden, they have to justify their existence. In some parts of the country, people are recruited to the job in order to contain cost. When you do that, you really narrow the perspective, and you need to have a broader perspective. If you do what you need to do to benefit patients, this will follow with shorter length of stay, and it will follow with prevention of unnecessary admissions. At the end of the day, it will also follow with the pharmacy budget, but you have to take the approach in which you are looking at that in a systematic way. You monitor that, you document that, and you actually can show that, and then the system will accept that.

With antimicrobial stewardship, what we always like to associate that with is cost savings. It’s always the term that’s tied with it. Especially early, you usually see a return on that, and it tends to plateau. They start coming to you: “Why aren’t you saving us more money?” I think sometimes it’s just tying those 2 words together.

 That’s a problem, but again, I think you really start with putting together a system in which people buy in; people understand it. You ask, how do I benefit my patients in a way that’s cost responsible, that I can justify the cost? It starts with putting together a team that really cares about patient and patient care, and I think that it is important. That’s why I brought the example of the ICU—because no one doubts that if someone needs ICU care, they should be in the ICU. That’s why we have ICUs. If you think about a more costly antibiotic that can save a life, it’s just the same, principle wise, as an ICU bed, only that it’s much cheaper, even if it’s the most expensive antibiotic.

You have to collect numbers. People in the C-suite, that’s what they’re used to; they’re used to being given numbers. I think if you can show them that what you’re doing is benefiting patients—maybe it’s saving money, but more than anything you have to be able to show them. Usually they’re kind of interested and excited, and they just didn’t know what was going on.

Cost Considerations of IV Antibiotics for ABSSSI

Peter L. Salgo, MD; Yoav Golan, MD; and Bruce M. Jones, PharmD, BCPS, emphasize the importance of patient education, patient compliance, oral antibiotic adherence, and managing expectations of prescriptions for acute bacterial skin and skin structure infections.

 Now, there is another cost factor that I haven’t seen really rolled into this, but it is important: nonadherence. You send somebody out early, and you say, “Please take your drugs,” and then they don’t—now all breaks loose, no?

Well, compliance is a major issue, that’s for sure. People sometimes don’t take their medications because they can’t afford them. Sometimes they can’t afford them because they think they’re already fine. Sometimes they don’t take them because they have some side effect, or they have to take them 3 times a day, but maybe 2 times a day is just fine. So, compliance could be an issue for sure, and that’s an issue that’s typical to oral antibiotics, because usually we control the administration of intravenous antibiotics. On the other hand, I should say that we have a more modern definition of compliance, as compared with the past, when you were given the course of antibiotics, and you always had to follow the course of antibiotics. Talking about skin infections, if you have cellulitis and you received 10 days or 2 weeks of antibiotics, if after 6 days your cellulitis is gone, there are really no data that you must continue the antibiotics. While you need them, you have to take them as prescribed. That also means that if you have to take them on an empty stomach—as would be the case with dicloxacillin, for example, which is very important for skin infections&mdash;then you have to do it, because otherwise you are undertreated. You have to take it a number of times a day, and you have to take it until your symptoms are gone. But if your symptoms are gone, I suggest you call your doctor and say, “You gave me 10 days; my symptoms are gone after 5 days&mdash;should I continue the course?” Very often the answer is going to be no.

This extends to even beyond antibiotics. We’ve moved really within our “meds to beds” program, just trying to make sure these patients fill their prescriptions, even before they leave the hospital. They deliver them to the room before they walk out the door. With antibiotics, I think what ends up happening—as we discussed earlier with these patients who have failed&mdash;a lot of times, if you really speak to them, they never even filled the antibiotic, but they get lumped into a group of failures.

 Well, I don’t want to blame patients here. To some degree—you’re laughing&mdash;but I think it’s true.

 My view, for what it’s worth, is that regarding a patient who is noncompliant, we didn’t educate right. We didn’t somehow get that patient with the program. By the way, I didn’t miss the heretic alert here, which is “Well, maybe we don’t need 10 days; maybe 7 days is OK.” The problem is they’re not even taking them for 7 days! How do we do that?

I agree with you. Again, I think the most important thing is explaining to your patient. Patients who are prescribed antibiotics, unlike many others…When you get the blood pressure pill, you don’t really have a very clear end point unless you measure your own blood pressure—or with diabetes, for example, you measure your glucose. Patients who are getting antibiotics should be educated as to what they should expect. “Why do I get this antibiotic, doctor? What do you expect this to do?” If you tell the patient, “Listen, you’re getting the antibiotic because you have an infection of your skin that presents itself as redness and is painful and maybe have some fever. When your fever is gone and the redness is gone, then you don’t need the antibiotic anymore.” Patients will understand that, but you must also explain to them that if they don’t take the antibiotic as prescribed, the likelihood of that happening or happening fast will decrease. That is important for patients to understand, as well.

I laugh because you can make the right diagnosis, you can choose the right antibiotic, but sometimes it’s that 5 minutes spent with the patient, explaining to them at the end. That is the most important.

 You hear “I’ve only got 7 minutes—that’s all they’re paying me for.” Well, it’s tricky, and out there in society, if people are partially treating infections&mdash;whether it’s pneumonitis, whether it’s cellulitis&mdash;aren’t we risking the spread of multiply resistant organisms?

Yes—for some types of infections, particularly infections caused by gram-negative bacteria that have the ability to become resistant very quickly, absolutely. You don’t take the antibiotic the right way, you increase the likelihood of resistance. Your own infection may become resistant as you get the antibiotic, and your next infection will be more resistant.

Oral Antibiotic Compliance for ABSSSI

Peter L. Salgo, MD; Bruce M. Jones, PharmD, BCPS; and Yoav Golan, MD, consider the value of treating acute bacterial skin and skin structure infections with IV antibiotics in nonhospital settings, such as wound care centers, walk-in clinics, and infusion centers.

 If we could bring people back to a nonhospital-admission observed setting—whether it’s to the ED for a 1-hour visit or a half-an-hour visit, an observation unit, or an outpatient infusion center&mdash;does this make sense? Is there an advantage to this?

I think there is. The key is selecting the right patient, deciding whether they truly need a parenteral, an IV antibiotic, and then looking at compliance/adherence and other factors. For certain patients, it’s an excellent option.

Hospitals are great when you need them, but you have to remember, hospitals are very problematic when you don’t need them; and I’m not talking about cost now. I’m talking about the risk of getting infected with a hospital type of pathogen because you’re in a hospital. You may have a Foley catheter or a vascular line, and all of those serve as sources for infection. You may be in the hospital, where you lie in a bed. You’re not as active as you would be when you’re at home, so you may develop a deep vein thrombosis; you become confused; you vomit. We all know how it goes, and so hospitals are only good if you actually need. If you can avoid them, it would be the best for the patient, as well. We are entering an era in which we are trying to avoid hospitalization. Skin infections were one of the very first type of conditions, where people developed programs of hospital admission avoidance. This was actually started on the West Coast and disseminated throughout the country.

If you take that even further, look at patient satisfaction—it’s a very hot button topic these days.

Oh yes, absolutely. If you look at these patients and you look at studies, acceptance of this is very high; patients love it. I’ve been up to our infusion center. Unfortunately, we have had to evacuate for hurricanes in Savannah, Georgia, the past 2 years. That’s where I go up and sleep. They have these leather chairs, they fold all the way back; you get a snack, you have a nice little flat-screen television.

 You have been a house officer in the past, far too long. You’re sleeping in an infusion center.

Whatever it takes, right? But they’re nice areas. That’s the key takeaway, that patient satisfaction with this is very high.

 Could it be not a cost center but a revenue center for a hospital? What do you think reimbursement would be like for coming to a brief visit to an ED or an outpatient infusion center, getting your antibiotics, and going home?

That’s the big difference. If it’s an outpatient, whether it’s ED or whether it’s an infusion center type setting, you can now bill for the drug and you can bill for the visit. There are cost-generation sides of it from looking at that.

 Far from being a DRG sink, if you have this facility where you bring people back, you can make money on this.

Absolutely—in fact, this is the business of a lot of infectious disease doctors. When you shift inpatient into the outpatient setting, you provide new opportunities. One of them is, as you know, unlike in an inpatient setting, where we don’t get reimbursed for antibiotics that we infuse, you would actually get reimbursed for antibiotics, and you would also get reimbursed for the administration of those antibiotics. There are opportunities for care providers, as well, by doing the right thing, which is providing treatments that do not need to be given in a hospital out of the hospital setting.

 It also occurs to me that if patients have to come back and you say, “Please come back; we’re going to see you,” and if they miss an appointment, then compliance is better, and that has to be better for society.

Absolutely. That’s a big part of—especially with some of the newer agents&mdash;being able to know they received their full dose of an antibiotic in one setting and taking compliance and adherence out of the picture.

Treatment of ABSSSI: Inpatient Versus Outpatient

 Peter L. Salgo, MD; Yoav Golan, MD; and Bruce M. Jones, PharmD, BCPS, discuss how the severity of an acute bacterial skin and skin structure infection is important in determining whether to use an outpatient parenteral antibiotic therapy.

 Let’s discuss some of the medicine here—the risk stratification you go through and the patient selection for outpatient antibiotic therapy (OPAT), which is what we’ve been discussing now. We’ve morphed from oral inpatient to inpatient IV. Now, maybe we can do this periodically if we have the right drugs and the right clinical setting. What are the factors that go into the decision to use an outpatient parenteral antibiotic as empiric therapy, starting, perhaps, in the ED? In other words, you bring them into the ED and start this right away.

To summarize the opportunities, one would be in the ED, where the setting is to avoid an admission by infusing the antibiotics in the ED. There are 2 additional settings; 1 is before the ED. We have all those urgent care centers whose mission is to avoid unnecessary admissions and unnecessary ED visits. You can actually start that before the ED. Those patients don’t have to appear in the ED. It will be actually less costly to care for them at a wound center or at an urgent care center rather than send them to the ED.

 If I understand what you’re telling me, someone can go to an urgent care center, and at that center, they start them—and then where do they send them, or do they continue it there?

They can continue the follow-up, and they can also send the patient to his primary care for follow-up. It depends, but it’s a setting where many of those urgent care centers do have infusion capabilities, and so that’s 1 setting before the ED. Then you have the ED, and then the third one is actually an inpatient setting, because you can sometimes prevent longer admissions by using longer-acting antibiotics that we can discuss later.

If you’re looking at a patient, severity of infection is the first thing we look at. Do they present with a septic type of picture, are they hypotensive, are they tachycardic—things like that. Do they have a high-risk involvement area? Do they have a picture of necrotizing fasciitis or anything like that? It’s probably not appropriate up front to send straight to an OPAT strategy, but I still think there are 2 sides. Even the ones who are admitted could still be candidates later on to be able to try and get out early and do that.

 No one is going to send home somebody in gram-negative septic shock, one would hope, and necrotizing fasciitis is really scary. So, how do you clinically differentiate these patients? Let’s take these real sick cases; someone comes in with a blood pressure of 80, a temperature of 104 degrees; he’s going to the hospital, but there’s a middle ground. What’s the clinical judgment here?

Well, so many of those patients don’t appear very sick. As we stated earlier, most of the patients with skin infections have a localized infection with some systemic manifestation. Sometimes they don’t even have systemic manifestations, and the most common one would be a fever. In our emergency department, we educate our ED doctors to ask 4 questions. One is, does the patient have any severe deep soft tissue infection like necrotizing fasciitis and so forth? For most patients, there’s no suspicion; every once in a while, there’s disproportional pain. The patient is very septic, when the infection doesn’t appear to be that impressive, but in most patients, there is no sign of that. Then we train them to ask if the patient’s comorbidities are out of control and exacerbated. As you heard, many of the patients actually don’t have comorbidities, and with most of them, the comorbidities are fine. We train them to ask whether the patient is septic or shows any early signs of sepsis, and, again, most skin infection patients do not. Then the last question, if you want to qualify them for going home rather than being admitted, is if there is anyone at home who can assist them. They’re going to be sick for a day or two, and someone needs to give them some water and prepare some food for them. If not, you really don’t want to send them home. And most patients do have support, but some patients do not. If the answers are no, no, no, and no—those surveys that were published recently show that in most of the patients who actually get admitted, the answer for those 4 questions is no, and yet they still get admitted.

 Is it that they’re getting admitted because people haven’t learned not to, or is it they’re getting admitted because there’s no infrastructure to support them as outpatients and get this going?

That’s a big side of it. If you look at these patients, many of them have failed orals, or if it’s a social support issue at home, it’s the comfort of being admitted, being able to control. Then, I think, monitoring is a big side of it. Do they have proper follow-up if they are sent straight out from the emergency department to where they don’t come right back?

 Can any hospital right now, without thinking about this in a more systematic way, say, “From now on, we’re going to take all of our really severe or not even severe ABSSSI cases”? Can they say right now that they’re going to start to do it, or do they need to think more about it first?

Well, if you want to put together a program, and you want it to be successful, and you want it to be used as the first measure of success, you have to make it feasible. I can give you an example from our emergency department. Patients come to our emergency department, and, as you know, the decision that the patient would benefit from IV antibiotics, I don’t think, is going to change any time soon. The same proportion of patients with skin infections will be labeled as “will benefit from IV antibiotics.” The question is going to be whether those IV antibiotics have to be given during an admission, or could they be given in an emergency department or infusion center or a wound center? That’s going to be the main decision from now on in the emergency department.

 Where I’m coming from is that everybody watching this broadcast says, “What a great idea! I have ABSSSI patients. I want to treat them as outpatients with IV therapy, and starting today, my ED is going to give them a first dose and say, ‘Please come back.’” Good luck with that.

What we have done is, we have a wound center, someone else has an urgent care center next to their institution or a walk-in medicine clinic. We leave a few appointments in our wound center open for ED calls for patients who were seen in the ED and need to be followed. When the ED doctor wants to discharge them, he knows that they can come to the wound center, and he won’t have to fight for an appointment in 3 weeks. If you do that, you make the system and the program feasible. That’s 1 example.

You have to look at what kind of infrastructure you have, too. What does your emergency department look like? Do you have ED physicians, ED pharmacists as your case-management structure? Do you have an infusion center as part of your hospital? Who is in charge of setting up follow-up visits? You have to look at infrastructure and what is feasible from your particular environment.

 Nobody, from a patient’s perspective, wants to walk into a combat zone 3 days a week, where there are gunshot wounds, myocardial infarctions, and everything else floating around. You want to go in, get a pleasant experience, and have your antibiotics.

For a very long period of time, people come in with pneumonia. They don’t seem to be terribly sick, but they have a fever, they are coughing, they have a patch on their X-ray. They may not be 80 years old, but they may be 50 or 60, and they’ll get an infusion of ceftriaxone that can be infused relatively quickly in the emergency department and then pills. Who is doing the follow-up? There are a lot of patients who come to the emergency department with chest pain; they get an EKG, maybe they have stable angina; I don’t know. Who is going to do the follow-up? I don’t think that we have to re-create the system, we just have to channel those skin patients. Until now, there was no other way. You had to admit them, and therefore, we didn’t have an alternative system. Now we understand that there are other ways because we have infusion capabilities out of the hospital, and now we have several antibiotics that we can give as 1 infusion.

We are now creating the support for outpatients.

ABSSSI: Outpatient Parenteral Antibiotic Therapy

 Peter L. Salgo, MD; Yoav Golan, MD; and Bruce M. Jones, PharmD, BCPS, provide insight on how to determine the severity of an acute bacterial skin and skin structure infection based on location and extent of lesions, purulent versus nonpurulent, pain, fever, and lymph node enlargement, as well as signs of necrotizing fasciitis.

 Let’s talk again about risk stratification, because we have to now pick those patients who are going to do best and then decide that those are the ones we’re going to triage to this new system. If you want to determine the severity of the infection, how do you do that? What are the laboratory tools you’re going to use? How do you set about stratifying these folks?

 People with abscesses sometimes don’t have any systemic symptoms or signs. As I mentioned earlier, just drainage is fine. If they have a huge abscess, some of those patients may need to be admitted, because there needs to be a surgical procedure that’s more than just bedside. Most of those can be drained in the emergency department, and they are fine. People with cellulitis very often have fever and they have some leukocytosis, and I would expect that. But when they become hemodynamically unstable, for example, they have slight hypotension—and if this is in an older person, even 110/80 could be a slight hypotension; tachycardic&mdash;that is out of the usual and would make me a little concerned, and I would admit them. The general cases&mdash;fever, leukocytosis, a patch of erythema and tenderness&mdash;would be considered to be a normal routine presentation.

 None of those is a stand-alone, live-or-die, I’m going to admit you; fever, leukocytosis, patch of skin, even purulence, if I heard you correctly—you could drain this, yes?

 Right. I think it has to be some combination. There is some subjectivity that obviously comes into play when you’re choosing these patients.

 What about lymph nodes? Does lymph node enlargement per se mean you’re coming “in the house”?

 No, of course not. Most patients with lymphadenopathy or lymphadenitis we actually are very successful in treating in the community. With skin infections, particularly with 

, you can see some lymph nodes, but these by themselves are not a reason to admit the person.

 If you start to parse this out, those things that if you were to almost by knee-jerk reaction say, “We’ve got to bring you in,” I think we’ve begun to exclude. In other words, erythema, no, not going to come in; purulence, no, not going to come in; lymph nodes, you don’t need to come in; pain, don’t really need to come in all the time. What am I missing? Nothing much. Clearly size, sepsis, and necrotizing fasciitis, but that’s a small group, isn’t it?

 Well, also exacerbated comorbidities. Infection causes a fever, causing tachycardia, and then your ischemic heart disease is out of control. Those are obviously reasons to be concerned.

 Somebody coming in with tachycardia, fever, ST elevations and chest pains, he’s coming in because he has about a million things to come in for.

 Not necessarily a priority because of the infection.

 I would agree. Again, as this survey found, almost half of the patients who actually get admitted are admitted for the sole reason of the need for IV therapy and not for monitoring.

 Let me ask you an unfair question then. When we peel the onion skin back, we’re left with a very small core of patients who have to come in. What percent of all-comers to the ED with a skin infection actually need to come in for something that can only be done in the hospital and can’t be done on an outpatient basis?

 It’s hard for me to say. I would say half.

 I would be even more aggressive than that. I think it’s a pretty small number, I really do. I think when you really, as you said, peel back that onion, you evaluate those patients—small amounts of comorbidities, mainly IV therapy. I think you’d find that it’s a small number that truly needs to be there.

 I think it depends on the setting. We are more of a tertiary care, so we see very complicated patients. The more you move into community settings, there is a bigger proportion of patients who could be treated as outpatients.

 Not specifically you or your setting; I’m at a quaternary care hospital, as well, but our ED treats a catchment area, and that catchment area is all-comers, not necessarily referred in. Again, my sense of what you told me is that it’s a lot less than half that have to come in. I think I’m going to side with this guy. It sounds like a much smaller group, but the caveat is that you have to be set up to take care of them.

 In other words, if you don’t have an outpatient treatment center, you don’t have an ED that’s ready to do this, and you don’t have some sort of infusion center, then you’re out of luck. You have to bring them in, because what else are you going to do?

 You need 2 capabilities, that’s all. You need the ability to infuse without being an inpatient—which every ED has, by the way&mdash;and you need the ability to follow-up. You already have resources for follow-up, because many patients have primary care physicians, they come from institutions, and so forth. You have outpatient clinics, walk-in clinics, and so forth. These are the 2 components that are required in order to not admit a patient in a way that’s not going to concern the ED doctor, and he’s going to participate in it.

 We struggle, too, with one of the things we see, and that is a fairly large indigent population, where they’re using the ED physician as their primary care provider—so making sure to take care of especially that subset of patients.

 Again, that may cut 2 ways; it’s expensive, yes, but also because if you are their physician, you see them. Maybe that’s a good thing in terms of this specific entity.

Determining the Severity of ABSSSI

 Peter L. Salgo, MD; Yoav Golan, MD; and Bruce M. Jones, PharmD, BCPS, review the advantages and disadvantages of newer long-acting lipoglycopeptide antibiotics, such as dalbavancin and oritavancin, compared with the standard treatment of vancomycin.

 Now, you did mention that we had some new agents coming up, and I promised we’d get to them. There are at least 2; let’s take a look at these. There’s dalbavancin and oritavancin, right? What’s so special about these drugs that we’re talking about them today in this setting?

 What makes them special is that they both have activity against the relevant pathogens that are the most common causes of skin infections, which are gram-positives: 

). Their spectrum of activity is very relevant to skin infections, and both are indicated for acute bacterial skin and skin structure infections.

 That’s right. They are like, in a sense, a new-generation vancomycin with some additional properties. Of course, what makes them unique is their very long half-life, which allows the entire course to be given in 1 infusion.

 The entire course in 1 infusion. What does that mean?

 Well, it means that once you are done infusing the antibiotic, you take away the need for IV antibiotic, as an indication for anything. We just had a long discussion about the fact that many patients get admitted from the emergency department for the sole reason of requiring IV antibiotics. Once you give them the last drop of one of those 2, oritavancin or dalbavancin, by that, you have taken away the IV antibiotics. You took away the 1 indication for admitting them, and now there’s no reason to admit them. That’s only 1 example for that; another example is, if you compare them with a long course of a multiple-times-a-day antibiotic like vancomycin, for example, their effectiveness is equivalent.

 Let me be sure I’m hearing this correctly; maybe I’m not. Their half-life is such that if you give them 1 dose, they don’t have to come back ever again for more antibiotics, or 1 dose is good for the day? What are you saying?

 It’s 1 dose, and then they don’t have to come back. You gave them all the antibiotics that they needed, and they don’t have to get any additional antibiotic therapy.

 Well, try to imagine we have a 1-dose antibiotic for any type of infection.

 I’m just flabbergasted; this is wonderful. Now we have these 2 agents. First of all, activity against gram-positive and gram-negative. What are the advantages and disadvantages here in terms of resistant species? What does all of this look like?

 Activity specifically against gram-positives—a very similar profile to that of vancomycin&mdash;you’re not going to have the gram-negative coverage. Outside that, as he mentioned, being able to give a full course of therapy at one time. Very similar profile between oritavancin and dalbavancin, but there are some unique properties that distinguish them. If you look at a cost standpoint, there’s a little bit of a difference, but specifically, infusion time as an example. Dalbavancin, 30-minute infusion versus a 3-hour infusion for oritavancin. Some of the other things that get lost in there, too, are also minimum volume. Dalbavancin can go in as little as 300 mL, where you have to put oritavancin in a liter. If you look at mechanism of action, dalbavancin has one mechanism of action, very similar to vancomycin. Oritavancin has 2, maybe 3; so multiple mechanisms of action. If you look at profile, we touched on a little bit about gram-positive coverage. I will say, too, especially with enterococci species that are vancomycin-resistant, I would have a lot more confidence in oritavancin. Overall, besides that, they have pretty similar properties.

 What about allergic responses, side effects of these drugs, downsides of either? Compare the 2.

 Especially with these drugs, the biggest thing I would worry about if I’m giving one of these is that it is going to stay therapeutic for 2 weeks and going to stay in the body maybe even as long as a month. What happens if they have an allergic reaction or a side effect? When you have specifically some of those, like dalbavancin as an example, they have over 2500 patients in their phase II and phase III studies that they’ve looked at. They specifically looked at safety and tolerability, and what they found was that from a side effect standpoint, they were very similar to competitors—linezolid and vancomycin. Also, they looked at how long those adverse events last. They actually lasted shorter amounts of time, so good safety and tolerability.

 Even though the main drug antibacterial effect lasted longer, the side effects were not a bigger issue.

 There were a few additional advantages over vancomycin. We mentioned earlier that we push the trough levels of vancomycin high, and we now see more and more kidney toxicity.

 Well, that’s the reality of life. I think that the kidney toxicity is lower with dalbavancin. We don’t have to monitor levels, by the way, so it takes away this entire system of having to monitor levels and what do you do with the levels. The other thing is that you can infuse it relatively quickly, as you heard; 30 minutes. With vancomycin, we tend to start with an hour, and if someone has any type of itchiness or other side effect, we usually increase it to 2 hours. Despite that, infusion-related side effects that have been an issue with this class of antibiotics have actually been seen in far less than 2% of patients in the clinical trials, and there were quite a few people in the clinical trials. Both of those antibiotics are convenience antibiotics, and when you look at convenience, you also have to look at the convenience of the infusion itself. Part of the fact is that you can give an entire course in a half hour; another fact is that you don’t need a PICC (peripherally inserted central catheter) line or a mid-line, which is a procedure by itself. As you know, in many hospitals, you need to have special procedures to do that, and the cost is very, very high; it’s many hundreds of dollars. You don’t have to go with that stuck in your arm and having the risk of bacteremia and other infections related to the line. There are multiple advantages, and I’m not even mentioning all the advantages that have to do with the fact that if you get this, you don’t have to be admitted and all those risks of being admitted.

 That’s a very big point, too, that gets lost: the central line, the PICC line. You mentioned cost, over $1000 to get a PICC line in, especially if you start including adverse effects from having it, if you take an average. Being able to not have a central line in these patients. I can’t say for other institutions, but for us, we have a very low threshold in patients who are admitted, putting a PICC line in.

 There is 1 more difference; both antibiotics are terrific antibiotics that, for the very first time, expand our ability to treat patients and actually make us change a paradigm. We were talking about the paradigm change from admitting everyone for IV to maybe not admitting many of them and treating them in outpatient settings, with at least as effective a strategy, if not even better, in terms of safety and not having to be admitted to the hospital. Another difference between the 2 is the stability. Dalbavancin is stable for a longer period of time, and sometimes it doesn’t really mean much, but once you dispense the antibiotic in the emergency department, you really have to complete the infusion of oritavancin within 6 hours. Three of those 6 hours are the infusion time. Sometimes what happens in the ED, maybe more so than in the ward, is that the patient was just sent to the CAT scan or to have an X-ray, and by the time the patient comes back, it may be too late. When you talk about convenience, you have to look at all those factors that determine convenience, like the infusion time and stability and interference with blood tests for coagulation and so on.

 I’ll be the pharmacist in the room. That’s the great thing with dalbavancin: no drug interaction. We know oritavancin does have interactions with some of our routinely used anticoagulation tests, but besides that, from a drug interaction standpoint, these are great options.

 The INR (international normalized ratio) is the INR, the APTT (activated partial thromboplastin time) is the APTT?

 Let me ask some standard questions about any antibiotic. Platelets; any activity against platelets? Do you see platelet counts drop?

 It’s not a major problem for any of those 2.

 Well, red man syndrome, you can see with any glycopeptide, but it’s far less common with those long-acting ones, compared with vancomycin, and it’s far, far less common with dalbavancin. That’s the main reason why you can give it in a relatively quick infusion.

 I get it. So that, in fact, is one of the reasons that you can speed it up.

Outpatient Management of Acute Bacterial Skin and Skin Structure Infections

An Overview of ABSSSI

Understanding the Prevalence of ABSSSI in the Community

ABSSSI: Standard Protocol of Admission and Treatment

Cost Considerations of IV Antibiotics for ABSSSI

Oral Antibiotic Compliance for ABSSSI

Treatment of ABSSSI: Inpatient Versus Outpatient

ABSSSI: Outpatient Parenteral Antibiotic Therapy

Determining the Severity of ABSSSI

Lipoglycopeptide Therapies for Gram-Positive Infections

Gram-Positive ABSSSI: Early Identification and Follow-Up

ABSSSI Case Scenarios for OPAT

Trends of ABSSSI Incidence in the Community

Establishing Real-World Protocols for OPAT

OPAT Protocols: Navigating Challenges

Lipoglycopeptide Antibiotics for ABSSSI: Education

Standard Protocol for the Treatment of ABSSSI

Cost Considerations for the Treatment of ABSSSI

Risk Stratification for ABSSSI

Long-Acting Lipoglycopeptide Antibiotics for ABSSSI

Establishing a Protocol for OPAT

Future of OPAT for ABSSSI