Segment Description: Christian Sandrock, MD, MPH, FCCP, shares the standard protocol in his personal institution for the treatment and admission of patients with acute bacterial skin and skin structure infections.
Christian Sandrock, MD, MPH, FCCP: Our hospital has a number of different incentives to treat skin and soft tissue infections, and other protocolized infections, obviously. First and foremost, and which is probably the biggest for us, is that we are just overwhelmed as far as census. So, on any given day, our hospital is usually over 100% full. We have many patients waiting in the emergency department, in the PACU (postanesthesia care unit). It’s not unusual to have elective surgeries canceled or delayed in order to wait for a bed that’s available. So, this is a big incentive for us to not admit patients; not only infectious diseases patients such as skin and soft tissue infections, but really any patients. By protocolizing them and focusing on reducing admissions, maximizing outpatient therapy, even IV antibiotic therapy, and having early discharge, becomes a big priority for us. So that’s usually the big incentive for many of them.
Now, with skin and soft tissue infections, the thing that’s difficult is the patient population, at least here in California where I work, is a difficult patient population. They often live outdoors or are homeless and don’t have a home. They’re often very mobile and not very stable. If you choose to do oral antibacterial therapy, compliance is a big issue. If you want to do outpatient IV therapy, many of them don’t have a home so you can’t send them home. And, if you do have a home, we have a very high rate of methamphetamine and drug abuse. So, sending them home with an indwelling venous catheter is almost impossible. That subgroup of patients can be very difficult, and we found from our own internal evaluations that these patients stay significantly longer than average in the literature. They certainly outstay what is called our DRG (diagnosis-related group), or our billing. So, we know that for most of these patients, unfortunately our hospital loses money. That’s not why we do it, but, obviously, when they lose money and they stay much longer—and they certainly are much more difficult to manage—any time we can maximize that therapy as an outpatient and impact our census, it becomes important.
We have multiple protocols for skin infections in our hospital. The first is on the emergency department and outpatient side. We look, for example, at patients in defining diseases where oral therapy should be the standard of care. This, for example, a small thing such as 1- to 2-cm abscesses, carbuncles, furuncles, cellulitis that’s less than 75 cm2—this would be classic outpatient oral therapy. That would be a guideline.
If they obviously have larger disease, larger abscess, systemic signs of infection like a fever, tachycardia, SIRS (systemic inflammatory response syndrome) symptoms, some of those patients may get admitted, some of them may be warranted for home therapy or outpatient therapy with, maybe, the long-acting lipoglycopeptides like dalbavancin (Dalvance) or oritavancin (Orbactiv), where that provides us a single dose, where we can send them home and have long outpatient therapy. We use dalbavancin for that case. And, on average, we probably capture about 20% to 25% of the patients that are candidates. We can certainly do better, but, again, sometimes it’s difficult to hit all of those.
Lastly when they do get admitted, obviously, we like to maximize ways to get them home or out of the hospital. Examples of that would be if they can tolerate home IV therapy, we transition to that as quickly as possible. There might be some options for early oral therapy. We did, for example, in our hospital provide free oral therapy for our patients. Our inpatient hospital pharmacy just filled doxycycline or trimethoprim/sulfamethoxazole. We carried it up to the patient, gave it to them for free to improve compliance, or we may actually give them a dose of a lipoglycopeptide like dalbavancin, send them home a few days early which allows us to free up a bed, optimizes therapy for the patient, and is able to transition therapy much more quickly as an outpatient.
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