Outpatient Management of Acute Bacterial Skin and Skin Structure Infections - Episode 11

ABSSSI Case Scenarios for OPAT

Segment description: Peter L. Salgo, MD; Yoav Golan, MD; and Bruce M. Jones, PharmD, BCPS, share clinical case scenarios as examples of evaluation of patients who present with acute bacterial skin and skin structure infections in an emergency department.

Peter L. Salgo, MD: Doctors love clinical scenarios; let’s play the scenario game. Patient walks in and presents to you, saying, “Doctor, I have this rash, and I’m not feeling well.” What do you say? What do you do, and then what’s your next move?

Yoav Golan, MD: Well, a typical patient will come in and say they have a rash, which may be cellulitis, for example. The patient will say, “Well, I failed; I had a small skin cut, and then I developed this redness that now covers my entire leg.” That’s clearly far more than 75 square centimeters, which we said is about the size of a baseball. The patient says, “It’s painful, and I haven’t been feeling well. I’m fatigued, I have diabetes, and I started to have a fever in the past 2 days. I went to my primary care physician, who gave me Bactrim (trimethoprim/sulfamethoxazole), and it continues to expand despite the Bactrim.” Now the patient is in the emergency department and asks what you can do better than their primary care physician. The evaluation would include whether the patient is septic, whether the patient is hemodynamically stable. This patient is diabetic, so we make sure his diabetes is not out of control. We ask whether someone can make some food at home for them over the next 2 days, and if the answer is yes for all of those, you could basically treat the patient with IV antibiotics. That would be a typical patient who I would say 90 times of 100 would be admitted for IV vancomycin and could be discharged 90 times of 100 just because of their presentation. That could be 1 patient.

Bruce M. Jones, PharmD, BCPS: You go down to the emergency department, and the 1 person you don’t want to see is that 30-year-old male who is obese because you look at them, they have a skin infection, and you cannot give them enough vancomycin to get them to a therapeutic level. If you are, you’re giving it 3 times a day, 4 times a day; you’re going upward of 1500 mg, 2000 mg. It’s not going to be something that’s transferrable to an outpatient. If you have certain candidates, certain patients, that’s always an ideal one for me.

Peter L. Salgo, MD: So, those are the good candidates.

Yoav Golan, MD: Another group that is very, very attractive for those antibiotics is some IV drug users, and we see a lot of skin infections in IV drug users. As you know, IV drug use requires needles, and those needles can cause infections at the site. There is a particular issue with this patient population, that we are very limited with PICC lines and mid-lines. Very often, these are young people who are otherwise healthy, and they don’t want to be in the hospital. For them, being able to infuse them once, and get rid of the entire course of antibiotics, is very successful. Sometimes we actually will do that also among inpatients because we have inpatients who require 10 days of therapy. They’ve been there for 3 days, they are fine, they could be discharged, but they need 7 more days. We can’t do it through the PICC lines, so we can send them to our infusion center or wound center the next day and give them an infusion. By that, we benefit them because we shorten their time in the hospital, and they get that adequate therapy.

Bruce M. Jones, PharmD, BCPS: That’s always one of our top targets. You look at those IV drug abusers; if they are admitted to your hospital, what do they do? They sit. The nightmare is to try to get out of the hospital, so it’s a great target in that population.

Peter L. Salgo, MD: You were both being very gentle about this, but I’ll be a little less. Who wants to send an IV drug abuser home with an IV line?

Yoav Golan, MD: That’s definitely a problem. Most hospitals will not do that, from a risk management perspective, because those lines can be used for many different purposes, and you don’t want them to be used in a way that’s going to risk the patient’s life.

Peter L. Salgo, MD: Hospitals just don’t want to be seen as a portal of entry for illegal drugs, right?

Bruce M. Jones, PharmD, BCPS: We don’t do it. You walk by that patient’s room, and they’re sitting there with their legs crossed, watching television most days. They don’t really have another reason to remain as an inpatient.

Peter L. Salgo, MD: You can get the IV line out. There’s no temptation here to use that IV line for illicit purposes; you give them 1 dose, and go. Also, it seems to me that in my experience anyway, the IV drug abusers have terrible veins. You find 1 vein, you use it once, and we’re done.

Yoav Golan, MD: That is absolutely the case.

Peter L. Salgo, MD: Speaking as an inner-city doctor, I would say that’s one of the things I would think of.

Yoav Golan, MD: Again, bottom line is, that benefits them the best because they find themselves locked in the hospital. Maybe they are watching TV, but locked in a hospital for an infection that could otherwise be treated out of the hospital if they were not IV drug users. There’s no reason why they would get differential.

Peter L. Salgo, MD: Why not have a win-win, better for the hospital and better for the patient, whether the patient is an IVDA (intravenous drug abuser) or not?

Bruce M. Jones, PharmD, BCPS: Absolutely.

Peter L. Salgo, MD: Great new drugs, great ideas, and now quite as complicated as what we were discussing earlier about having a whole center and bringing people back for periodic readministration. I had no idea you could give it just once for 2 weeks. That’s really impressive.