Outpatient Management of Acute Bacterial Skin and Skin Structure Infections - Episode 5

Oral Antibiotic Compliance for ABSSSI

Peter L. Salgo, MD; Yoav Golan, MD; and Bruce M. Jones, PharmD, BCPS, emphasize the importance of patient education, patient compliance, oral antibiotic adherence, and managing expectations of prescriptions for acute bacterial skin and skin structure infections.

Peter L. Salgo, MD: Now, there is another cost factor that I haven’t seen really rolled into this, but it is important: nonadherence. You send somebody out early, and you say, “Please take your drugs,” and then they don’t—now all breaks loose, no?

Yoav Golan, MD: Well, compliance is a major issue, that’s for sure. People sometimes don’t take their medications because they can’t afford them. Sometimes they can’t afford them because they think they’re already fine. Sometimes they don’t take them because they have some side effect, or they have to take them 3 times a day, but maybe 2 times a day is just fine. So, compliance could be an issue for sure, and that’s an issue that’s typical to oral antibiotics, because usually we control the administration of intravenous antibiotics. On the other hand, I should say that we have a more modern definition of compliance, as compared with the past, when you were given the course of antibiotics, and you always had to follow the course of antibiotics. Talking about skin infections, if you have cellulitis and you received 10 days or 2 weeks of antibiotics, if after 6 days your cellulitis is gone, there are really no data that you must continue the antibiotics. While you need them, you have to take them as prescribed. That also means that if you have to take them on an empty stomach—as would be the case with dicloxacillin, for example, which is very important for skin infections—then you have to do it, because otherwise you are undertreated. You have to take it a number of times a day, and you have to take it until your symptoms are gone. But if your symptoms are gone, I suggest you call your doctor and say, “You gave me 10 days; my symptoms are gone after 5 days—should I continue the course?” Very often the answer is going to be no.

Bruce M. Jones, PharmD, BCPS: This extends to even beyond antibiotics. We’ve moved really within our “meds to beds” program, just trying to make sure these patients fill their prescriptions, even before they leave the hospital. They deliver them to the room before they walk out the door. With antibiotics, I think what ends up happening—as we discussed earlier with these patients who have failed—a lot of times, if you really speak to them, they never even filled the antibiotic, but they get lumped into a group of failures.

Peter L. Salgo, MD: Well, I don’t want to blame patients here. To some degree—you’re laughing—but I think it’s true.

Bruce M. Jones, PharmD, BCPS: Yes, I agree.

Peter L. Salgo, MD: My view, for what it’s worth, is that regarding a patient who is noncompliant, we didn’t educate right. We didn’t somehow get that patient with the program. By the way, I didn’t miss the heretic alert here, which is “Well, maybe we don’t need 10 days; maybe 7 days is OK.” The problem is they’re not even taking them for 7 days! How do we do that?

Yoav Golan, MD: I agree with you. Again, I think the most important thing is explaining to your patient. Patients who are prescribed antibiotics, unlike many others…When you get the blood pressure pill, you don’t really have a very clear end point unless you measure your own blood pressure—or with diabetes, for example, you measure your glucose. Patients who are getting antibiotics should be educated as to what they should expect. “Why do I get this antibiotic, doctor? What do you expect this to do?” If you tell the patient, “Listen, you’re getting the antibiotic because you have an infection of your skin that presents itself as redness and is painful and maybe have some fever. When your fever is gone and the redness is gone, then you don’t need the antibiotic anymore.” Patients will understand that, but you must also explain to them that if they don’t take the antibiotic as prescribed, the likelihood of that happening or happening fast will decrease. That is important for patients to understand, as well.

Bruce M. Jones, PharmD, BCPS: I laugh because you can make the right diagnosis, you can choose the right antibiotic, but sometimes it’s that 5 minutes spent with the patient, explaining to them at the end. That is the most important.

Peter L. Salgo, MD: You hear “I’ve only got 7 minutes—that’s all they’re paying me for.” Well, it’s tricky, and out there in society, if people are partially treating infections—whether it’s pneumonitis, whether it’s cellulitis—aren’t we risking the spread of multiply resistant organisms?

Yoav Golan, MD: Yes—for some types of infections, particularly infections caused by gram-negative bacteria that have the ability to become resistant very quickly, absolutely. You don’t take the antibiotic the right way, you increase the likelihood of resistance. Your own infection may become resistant as you get the antibiotic, and your next infection will be more resistant.