Outpatient Management of Acute Bacterial Skin and Skin Structure Infections - Episode 10

Gram-Positive ABSSSI: Early Identification and Follow-Up

Segment description: Peter L. Salgo, MD; Yoav Golan, MD; and Bruce M. Jones, PharmD, BCPS, highlight the importance of early recognition and identification of appropriate candidates for dalbavancin and oritavancin and of ensuring proper follow-up and post-treatment monitoring for patients with acute bacterial skin and skin structure infection.

Peter L. Salgo, MD: What I wanted to circle back with is, we had spent a fair amount of time talking about how to set up your hospital’s infrastructure to bring patients back for repeat intravenous therapy for skin infections and antibiotics, and you just blew it all up. They don’t have to come back; give them a dose, send them home, and say, “Have a nice life.”

Yoav Golan, MD: That’s right, but I still think that there are several different ways to use those antibiotics in a hospital setting. Hospitals would prefer to use them as outpatients because the hospital will get reimbursed for their use, if used as an outpatient. Most hospitals that do use those 2 antibiotics use them mostly as outpatient, and as an outpatient, it can be in the emergency department or in a wound center or in an outpatient clinic. Particularly for the emergency department, it’s important to provide the ability for follow-up in a hospital setting. If you come up with this wonderful program for the emergency department doctor and you train them, but then they call for a follow-up because they’re concerned about the patient, and they give the entire dose, but the patient doesn’t have a primary care physician, they call the wound center or they call the outpatient clinic and get an appointment in 3 or 4 weeks. But they’re going to be concerned they may not do that, and they may admit the patient. You need to take care of the infusion, and you have to take care of the follow-up. Now, most patients don’t need to be followed in a hospital; they can be followed with their primary care physician.

Bruce M. Jones, PharmD, BCPS: I think it really comes down to 3 things. It’s finding the right patient, whether they have failed outpatient oral therapy, allergy is an issue, history of MRSA, early recognitions, being able to find them in time before they’re admitted. If they are admitted, finding them and getting them out of the hospital earlier. And then ensuring proper monitoring and follow-up.

Peter L. Salgo, MD: Again, I’m not saying lose them to follow-up, but I am saying that you don’t have to bring them back, put them in a chair, and hook up another IV for another intravenous administration in 3 days. You give the antibiotic, and you’re done. It would be very nice if you followed up and made sure it worked, right?

Bruce M. Jones, PharmD, BCPS: Absolutely, and we’ve seen great success rates with both agents, to the point where we feel very comfortable using it for that reason, where you don’t have to necessarily always bring them back. We can say, “Come back. Call us if you have issues.”

Peter L. Salgo, MD: Give me a typical case.

Yoav Golan, MD: By the way, what you said, you may think it’s a compromise.

Peter L. Salgo, MD: No, I don’t, but go ahead.

Yoav Golan, MD: When you give 1 dose, versus admitting someone to get 10 days of twice-a-day vancomycin, you may think it’s a compromise. In fact, each of those has a half-life that’s so long that it will go well beyond the 10 days of vancomycin. So, in fact, this is a much longer course than the long course of vancomycin, or what have you.

Peter L. Salgo, MD: Even your heretical comment about stopping antibiotics early evaporates because this thing, with 1 dose, just hangs in there.

Yoav Golan, MD: That’s right.