Outpatient Management of Acute Bacterial Skin and Skin Structure Infections - Episode 7

ABSSSI: Outpatient Parenteral Antibiotic Therapy

Segment description: 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.

Peter L. Salgo, MD: 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.

Yoav Golan, MD: 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.

Peter L. Salgo, MD: 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?

Yoav Golan, MD: 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.

Bruce M. Jones, PharmD, BCPS: 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.

Peter L. Salgo, MD: 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?

Yoav Golan, MD: 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.

Peter L. Salgo, MD: 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?

Bruce M. Jones, PharmD, BCPS: 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?

Peter L. Salgo, MD: 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?

Yoav Golan, MD: 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.

Peter L. Salgo, MD: 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.

Yoav Golan, MD: 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.

Bruce M. Jones, PharmD, BCPS: 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.

Peter L. Salgo, MD: 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.

Yoav Golan, MD: We already do that.

Peter L. Salgo, MD: Well, you do, yes.

Yoav Golan, MD: 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.

Peter L. Salgo, MD: We’re going to get to that, too.

Yoav Golan, MD: We are now creating the support for outpatients.