Outpatient Management of Acute Bacterial Skin and Skin Structure Infections - Episode 3

ABSSSI: Standard Protocol of Admission and Treatment

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.

Peter L. Salgo, MD: So, how does a typical patient with ABSSSI present into the ED to begin with?

Yoav Golan, MD: 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.

Peter L. Salgo, MD: 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?

Bruce M. Jones, PharmD, BCPS: 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—adherence—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.

Peter L. Salgo, MD: 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.

Bruce M. Jones, PharmD, BCPS: Right, absolutely.

Peter L. Salgo, MD: 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?

Bruce M. Jones, PharmD, BCPS: 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.

Peter L. Salgo, MD: 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.

Bruce M. Jones, PharmD, BCPS: I think a lot of times, yes.

Peter L. Salgo, MD: Why? Why is that happening?

Bruce M. Jones, PharmD, BCPS: I think its concern over failure. Maybe it’s comorbidities—a lot of issues coming in—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—comorbidities, fever—anything that might push them over the edge just a little bit.

Yoav Golan, MD: 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?

Bruce M. Jones, PharmD, BCPS: 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.

Peter L. Salgo, MD: 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?

Yoav Golan, MD: 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.

Peter L. Salgo, MD: So, you drain them and let the T cells go to work?

Yoav Golan, MD: Exactly—T cells, B cells—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.

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

Bruce M. Jones, PharmD, BCPS: Yes, yes.

Peter L. Salgo, MD: Have we lost sight of that?

Bruce M. Jones, PharmD, BCPS: I think so, to an extent, yes.

Peter L. Salgo, MD: 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?

Bruce M. Jones, PharmD, BCPS: 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.

Peter L. Salgo, MD: Wait, tazobactam/vancomycin?

Bruce M. Jones, PharmD, BCPS: Oh, yes.

Peter L. Salgo, MD: That’s it?

Bruce M. Jones, PharmD, BCPS: 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.

Peter L. Salgo, MD: Antibiotic stewardship alone would say, “Whoa, wait a minute.”

Bruce M. Jones, PharmD, BCPS: Oh, absolutely, absolutely.

Yoav Golan, MD: 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.

Peter L. Salgo, MD: 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?

Yoav Golan, MD: 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.

Peter L. Salgo, MD: Nobody wants to back a dump truck of vancomycin up to a patient’s bed, right?

Yoav Golan, MD: Well, that’s what we do.

Peter L. Salgo, MD: I’m afraid to even think about this.

Yoav Golan, MD: 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.

Peter L. Salgo, MD: That’s a challenge.

Yoav Golan, MD: It’s definitely a challenge.