Infectious Disease Specialists Propose Clinical Pathway for ABSSI

Because patients with moderate to severe acute bacterial skin and skin structure infections (ABSSI) are difficult to categorize and require thoughtful care and management, clinicians often choose costly inpatient treatment and monitoring. This current treatment paradigm requires re-evaluation and reconfiguration in order to more closely align with the changing health care landscape, according to a group of hospital infectious disease clinical pharmacy specialists.

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John A Bosso, PharmD, Medical University of South Carolina (Charleston, SC), and colleagues participated in a roundtable discussion to consider the use of newer, single-dose, long-acting lipoglycopeptide antibiotics (eg, Orbactiv [oritavancin] and Dalvance [dalbavancin]), and integrate them into clinical pathways for the treatment of acute ABSSI. Oritavancin and dalbavancin received US Food and Drug Administration approval in 2014; these antibacterial drugs require fewer doses than all currently available therapies such as vancomycin. 

“The consensus treatment pathway is meant to act as a guide for individual facilities to develop their own internal pathways,” said the authors, who summarized the roundtable meeting in an article published in Hospital Practice. “As a result, hospitals and health systems must first consider their unique set of stakeholders, logistics, and resources before finding the right approach.” 

Defining the appropriate patient population to help identify patients who can be safely and effectively treated in the outpatient setting with long-acting lipoglycopeptide antibiotics is the first step in developing a clinical pathway. The roundtable participants established consensus criteria clinicians can use as a guide for selecting patients suitable for outpatient treatment with these antibiotics. Patient considerations include skin and skin structure infection with suspected Staphylococcus aureus; clinically stable and amenable to discharge; and failed therapy due to incorrect spectrum of coverage, need for multidrug regimen, nonadherence, and adverse events.

Once a patient is identified as a potential candidate for outpatient treatment, the pathway outlines the recommended steps for planning and administering the infusion, along with care coordination and follow-up. The roundtable participants said that a prospective antibiotic stewardship program review should be performed at the infusion planning stage, however, a formal infectious disease consult was not necessary. If the health care team agrees on the use of long-acting lipoglycopeptides, the therapy should be administered in a predetermined area (eg, observation unit, infusion center). 

After the infusion, clinicians should provide detailed discharge and follow-up planning, as well as consideration of an 8- to 48-hour observational stay. Additionally, the ABSSI clinical pathway recommends discharge and follow-up with a visit to either the primary care facility in 3 to 5 days, or an outpatient clinic/emergency department in 48 hours. Patient and family education should be a component of the discharge and follow-up planning and include the signs and symptoms which indicate further care is needed. The roundtable participants proposed hospital cases managers provide the post-treatment information to prevent patients from being lost in the follow-up.—Eileen Koutnik-Fotopoulos

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Bosso JA, Casapao AM, Edwards J, et al. Clinical pathway for moderate to severe acute bacterial skin and skin structure infections from a US perspective: a roundtable discussion [published online ahead of print September 15, 2016]. Hosp
Pract
. doi:10.1080/21548331.2016.1230466.