Outpatient Management of Acute Bacterial Skin and Skin Structure Infections - Episode 15
Lipoglycopeptide Antibiotics for ABSSSI: Education
Segment description: Peter L. Salgo, MD; Yoav Golan, MD; and Bruce M. Jones, PharmD, BCPS, stress the importance of formal time-based follow-up with patients, as well as educating recurring patients and their primary care physicians on long-acting lipoglycopeptide antibiotics.
Peter L. Salgo, MD: Now, there is something in my brainstem talking to me that says I should be uncomfortable giving these drugs to somebody, sending them home, and saying, “Have a nice life,” without a formal time-based follow-up. In other words, “Please come back in a week. Please come back in 2 weeks.” Do you do that?
Yoav Golan, MD: You must have a follow-up plan, and the follow-up plan could be in 3 days or 4. “If the redness does not go away, see your primary care physician in 3 or 4 days or see your primary care physician in a week,” as you would say. Patients with pneumonia who come to the emergency department don’t come back to the emergency department for follow-up even though pneumonia is more deadly than a skin infection, on the average. You need to have a plan, and you have to educate the patient as well. You must tell the patient, “This is what I expect is going to happen. This is when I want you to see your primary care physician.” If you are very concerned, you can have them come back to the emergency department or the wound center. But you need to have a follow-up plan for the patient, so you feel just sure about your decision.
Bruce M. Jones, PharmD, BCPS: Education is paramount on these patients, especially if you have somebody that has these recurrent infections where they’re used to getting 7 to 14 days of treatment, whether it’s an IV antibiotic or an oral antibiotic, and to explain to them why they’re getting 1 dose and they’re done. A lot of times they get that dose and they’re like, “All right, where’s my prescription?” There is a big component of patient education, but then also going to that follow-up. If you are sending them out to their primary care physician, you are responsible, in my mind, for explaining a lot of times to the primary care physician. They’re not as familiar with these newer agents, especially if they’ve never prescribed them, so you must explain to them, as well, what should be done. Follow-up is a very big deal.
Peter L. Salgo, MD: It sounds to me like you have to get some buy-in and maybe some education to the local primary care community.
Bruce M. Jones, PharmD, BCPS: Absolutely.
Peter L. Salgo, MD: Do you reach out to them? Do you have educational seminars? What do you do?
Bruce M. Jones, PharmD, BCPS: We do. We’ve tried to reach out, especially if we identify patients. We’re always trying to include, within the documentation that we send to the primary care physician, “Your patient is following up in X days. Here’s what they received,” and a lot of times we’ll send information about the drug with them. So, there’s a big component of educating the physicians.
Yoav Golan, MD: In this case, it makes so much sense to give 1 dose as the entire course. From whatever perspective you’re looking at, there’s really no disadvantage as compared to giving multiple doses of similar, more toxic, more side-effects-type of antibiotic; it’s all about the feasibility. The education, usually a very small proportion of it, goes to, “Why should you do that?” and most of it is, “How are we going to do that? How are we going to put together the program?” Once you answer that, I don’t think it’s very difficult. We should also remember that in our hospital, for example, we use dalbavancin in the emergency department; we use more of it in our outpatient clinics, particularly in our wound clinic. It’s important to remember that at the end of the day, our goal is not to actually get those patients into the emergency department but to stop them before if they don’t need to get to the hospital at all. This is a slightly different protocol, but once you make it feasible, and wound centers see themselves as seeing patients with wounds that may need to be admitted, if there is some exacerbation, they try to prevent that from happening with all the care that they provide. This is just another component that fits very naturally into their work.
Peter L. Salgo, MD: You’re describing, however, a much bigger program. In other words, the limited program is, “I’m the ED in my hospital. Here’s a wound infection, I’ve got this new drug, let’s treat it.” You’re saying you don’t want to see these guys. You want those in the medical environment to be so attuned to it that maybe at one of these urgent care centers, they’ll just do it or maybe they’ll do it in the wound care center, distant from the ED.
Yoav Golan, MD: Or in a hospital that has one of those admission avoidance programs. People come to the ED, which triages the patients to an urgent care center in the hospital itself. They can get the infusion there, and they don’t even find themselves in the ED. If something happens, and they need to be admitted or sent to the ED at some point of time, that’s always possible.
Bruce M. Jones, PharmD, BCPS: Going back to educating those physicians: Because not only are you educating them on follow-up, but a lot of times these primary care physicians can send these patients to your infusion center to receive these drugs. Being able to help them identify patients, as well, that they would have otherwise sent to the emergency room.
Peter L. Salgo, MD: What comes to mind is a phrase which is politically volatile right now: the unfunded mandate. In my view, in medicine, the unfunded mandate is get them out faster, and do this better. But there’s no money for it, and there are no drugs to accomplish it, but they’re telling you to do it anyway. Here you have some agents that actually work. That’s different.
Yoav Golan, MD: Yes. For the very first time, we actually have the ability to take away the only indication for the admission, I would say at least half, and maybe more than half, once you complete the infusion. The minute you complete the infusion, the one indication for admission is gone. We talked about the statistics and how many admissions we have. How great would it be if we could invest this money in some other field of medicine and care and not in unnecessary admissions.