Outpatient Management of Acute Bacterial Skin and Skin Structure Infections - Episode 20
Establishing a Protocol for OPAT
Segment Description: Christian Sandrock, MD, MPH, FCCP, shares the existing protocols that have been established for outpatient parenteral antibiotic therapy in his hospital system for the treatment of acute bacterial skin and skin structure infections.
Christian Sandrock, MD, MPH, FCCP: At my hospital, we have an existing outpatient protocol for outpatient IV therapy. There are actually multiple different protocols. The main one where we looked at skin and soft tissue infections, is followed largely through the emergency department. Obviously, in our clinic and our clinic system, we use the same one and that has a couple different features. One is initially, to be enrolled, you have to have a lesion that’s at least moderately large, and we define that as 75 cm2 or larger Number 2, you have to have a systemic sign of infection. So, for example a fever, leukocytosis, tachycardia that would qualify. Number 3, is it has to be part of one of the major areas of infection; so an abscess, or cellulitis, or postoperative wound infection. And number 4, is you can’t have any what we call, hardware. So, there can’t be something like a pacemaker or a prosthetic knee, or a mesh, or any hardware or device. If you meet that criteria, that means you’re eligible for outpatient therapy with a long-acting agent like dalbavancin (Dalvance) through our ED. As long as you meet that, that’s your first initial step, and then we consider that.
Now, the other areas we will consider are a few folds on top of that. One is, you have to have a level of clinical stability, so again, normal blood pressure, normal lactate. If you meet SIRS criteria by an elevated white count, by tachycardia, by a fever, that’s okay as long as that resolves with a little bit of IV fluids. We’re not so worried about meeting SIRS criteria. It’s really the hypotension and the elevated lactate that play a role. If you don’t meet those criteria, and you otherwise just meet SIRS criteria and are stable, that’s perfect.
Again, it has to be a lesion that a surgeon is not going to do more advanced surgery on, or it doesn’t appear to be necrotizing fasciitis. If that’s the case, that’s another candidate that qualifies; stable comorbidities—so again, no active psychiatric disease, no raging diabetes, none of those. And then lastly, they have to have a place to go. Now, what I mean by that, is they do not have to go to a home, they don’t have to have a place that they live. They just have to have follow-up, where they can get their wound checked; which we have a system through our ED and through one of our clinics where that can happen. They have to have an ability to get their medication. In this case, we’re giving him dalbavancin, so they get their medication in the emergency department. And then ideally, we’d like to have them have a place to go, so we have a relationship with some of our homeless shelters. If they are homeless, we will actually give them a voucher. We also have a contract with Lyft, where we will provide them a ride from our hospital to whatever home or place that they need. That provides them that stability and we will offer that as well. They often will get follow-up in one of our wound clinics. They’ll get a ride, and we at least, at worst case, get them a voucher to stay for that period of time in a homeless shelter. So, if they meet all that criteria, that’s a perfect candidate for outpatient therapy.
Once they’re admitted, a candidate for outpatient therapy, if we are going to send them home with IV access, they can’t actively be using drugs, they have to be in an area where they can receive medications, and then be able to actually administer the medication at home. That’s often not the case. If they’re admitted like some of our patients and we decide to give them a dose of dalbavancin and send them home, the same criteria from the emergency department applies.