Outpatient Management of Acute Bacterial Skin and Skin Structure Infections - Episode 2

Understanding the Prevalence of ABSSSI in the Community

Peter L. Salgo, MD; Yoav Golan, MD; and Bruce M. Jones, PharmD, BCPS, discuss the prevalence of acute bacterial skin and skin structure infections, including MRSA, in the community, as well as risk factors, susceptibility, and increased resistance to oral antibiotics such as Keflex.

Peter L. Salgo, MD: I’m a hospitalist, if you will; I’m an intensivist. All my patients have already been admitted. I don’t even see those folks until they get so bad that they’re near death. But in the community, what’s going on with ABSSSI and MRSA? What’s happening here?

Bruce M. Jones, PharmD, BCPS: I think we’re starting to see a trend more toward inpatient. We have developed antibiograms specific to our emergency departments, and when you compare them with our inpatients, they’re starting to look more and more similar. You’re seeing higher rates of MRSA, and I think that’s causing a lot of the same concerns we’re seeing on the inpatient side.

Peter L. Salgo, MD: Are we seeing different bugs? Are we seeing a different profile of these patients? You said that it used to be more immunocompromised patients—not so much?

Yoav Golan, MD: In the past, you really needed to be special to be infected, particularly with MRSA. That was not very prevalent, but now it’s so prevalent in our communities that it doesn’t make you special—the fact that you are infected by MRSA. What happens is, you have such an infection, you go to your primary care physician, you may get an antibiotic such as Keflex (cephalexin) or doxycycline or one of those. It may or may not work, but many of those don’t work against MRSA, and just very few oral antibiotics are actually reliable. You end up not responding, and after a few days, you find yourself in the emergency department, when a few years ago this wouldn’t happen. Then all of a sudden, the emergency department is getting to see so many patients that they haven’t in the past.

Peter L. Salgo, MD: They’re getting overwhelmed.

Yoav Golan, MD: They definitely are. Also, they have to make very quick decisions as to what to do with those patients, knowing that they can’t keep them in the emergency department—and in many cases the perspective is that maybe they already failed or exhausted whatever we could do in the community.

Peter L. Salgo, MD: If you give somebody an oral antibiotic like Keflex, and you send them home and it fails, have you made it worse by ensuring that there’s increased resistance? What do you think?

Yoav Golan, MD: No, I wouldn’t say that. The main gram-positive bacteria are Streptococcus and Staphylococcus. Streptococcus would be susceptible to Keflex almost always and will not become resistant to Keflex if you started someone on Keflex. When it comes to Staphylococcus, it will never become resistant to Keflex if it was initially susceptible to Keflex.

Peter L. Salgo, MD: Got it.

Yoav Golan, MD: But, again, if it wasn’t susceptible, then Keflex is not going to work if the patient required some drainage of an abscess, for example. There are multiple reasons for failing therapy. I just wanted to mention 1 more thing. You talk about trends of skin infections. Another thing that I think we must take into consideration—and I think it’s a very strong call for action for us—is the fact that if you look at the risk factors for skin infections, they become more prevalent in our society. People are older, they are heavier, they have more diabetes, they become more susceptible to skin infections. That’s one of the reasons people develop ulcers, and that’s one of the reasons we’ve seen such an increase. The expectation is that this will continue to increase.

Peter L. Salgo, MD: It seems to be one of the counterintuitive issues with the wellness of the American public: We keep people alive longer. We keep people with chronic diseases going further. But on the other side of that, here comes MRSA, here comes susceptibility because of poor peripheral perfusion. Are you seeing that?

Bruce M. Jones, PharmD, BCPS: A little bit. Speaking back to his point before, I think it depends on the patient who presents and whether it’s a simple cellulitis picture. You start looking at systemic signs of infection, whether or not they’re febrile, and then comorbidities. That plays a big role regarding the type of patient we’re treating.

Peter L. Salgo, MD: When you talk about this sort of thing and emergency room visits and antibiotics and repeat infections—whenever you talk about this in terms of public health, we come back to money.

Bruce M. Jones, PharmD, BCPS: Absolutely.

Peter L. Salgo, MD: Right, because these tend to be expensive.