Segment Description: Christian Sandrock, MD, MPH, FCCP, discusses the barriers to establish a successful protocol for outpatient parenteral antibiotic therapy in hospital systems where one does not currently exist, and provides an outlook on the future of long-acting lipoglycopeptides in the treatment of acute bacterial skin and skin structure infections.
Christian Sandrock, MD, MPH, FCCP: The barriers to developing outpatient, or OPAT protocols, are relatively complex. I think the first is developing an infrastructure at your hospital or a health system. If you don’t have one already, you need some infrastructure to provide that. That may mean that you have a relationship with home health and home pharmacy, where they can provide the actual care at the house, and they can provide the medication for the patient. Generally, that also involves having discharge planning and social work, where they can get that patient everything that they need to involve that. In cases where you’re just going to administer it in the emergency department, such as dalbavancin, and send them home, you need an ability to set up their follow-up and establish that follow-up for them.
If they have a skin and soft tissue infection or any other infection, they’re gouging to go home, you want to make sure they have adequate follow-up. Sometimes their main physician may not be in your health system. It’s a little harder at 2 o’clock in the morning to get an appointment for them, so you need to be able to make sure that they have a back-up, and a way to come back and be evaluated; whether it’s at your hospital or another facility, or if they do see somebody in your health care system, you make sure you have that appointment available for them before outpatient therapy. Having that infrastructure of good follow-up, good discharge planning, and then possible home health if they’re going home, really is paramount.
Secondly, then you need administrative buy-in and that includes 2 processes. One is administration, so they know that your goal is to get these patients home and not have them admitted. And number 2; that’s the physician and pharmacy side, which means that pharmacy and therapeutics, or antibiotic subcommittee, whoever may be in charge of that, knows the right antibiotics, knows the subgroup to use them in, and is able to actually feel comfortable using them. So that’s the next stage. Very often that’s the stage where you see most of the conflict. Some facilities, particularly rural facilities, don’t have the follow-up. That may be the case, but mostly in suburban and urban areas, you have discharge planning—all the appropriate follow-up and home health. It becomes a battle between what physicians may want to do and what administration wants to do.
For example, some hospitals, they don’t get a flat-rate, or a DRG, for skin and soft tissue infections. They get paid for every hospital day. So, their incentive is to admit that patient and keep them as long as possible. But you as a physician, want to do what’s best for that patient, and you may want to send them home on hospital day 1 or 2, or straight from the ED. Hospital administration may push back a little bit, or they may have an infusion center where they prefer to send the patient every day to the infusion center because that brings some revenue in for the health care system, even though that’s difficult for the patient and they prefer to be at home. That conflict between what’s best for the patient and what the physician and pharmacy wants to do, what administration and finance wants to do, can be in conflict, and that’s often where most of those battles occur.
Overall, I think outpatient therapy for skin and soft tissue infections is the future direction of where we’re going. I know that focusing on oral therapy, particularly with some of the generics like trimethoprim/sulfamethoxazole, doxycycline, was where we were about 15 years ago, and those are still the mainstay of treating skin and soft tissue infections as an outpatient. But there is a subset of patients in the gray zone, where they do have signs of systemic illness or they have a large lesion, greater than 75 cm2, where routinely those patients are admitted, and we’re now learning that many of those patients can transition to home either directly from the ED or shortly after admission. Getting used to that way of treating patients is different. I think in the future I’m looking forward to that being more stabilized.
The data came out on some of these long-acting lipoglycopeptides, and then you see a patient with a large lesion, 75, 80 cm2 and with a fever and a white count; it feels weird to give them a single dose of an antibiotic and send them home. We’re not used to that as physicians. We’re used to writing a pen mark around the area of erythema, we’re used to admitting them, we’re used to seeing that fever go away, that erythema regress, then we send them home when we know they’ve gotten better. This is that trust in giving a single dose of antibiotic, sending them out, and having them get better. It’s just uncomfortable, and we learned at my institution that for many of us, that felt very odd. It’s a different way of practicing medicine, particularly with skin and soft tissue infections. So, it took a little time for us to really say, “OK, we have clinical trial data that suggests these patients are going to be OK.” Now we have to feel OK with it at the bedside, and that took a little bit of time and it’s still a big work in progress for us.
I think we’re moving forward, taking those patients who normally we would admit for a very short admission and transition them to outpatients. I think that’s actually the big change, and it’s just a comfort level for us as practitioners and as physicians. I think that will take some time, but I look forward to the growth of that and the expansion of other diseases around that. Looking at bacteremia, and osteomyelitis, and other areas where we can support outpatient therapy quickly.