ABSSSI and OPAT: Key Messages

Segment description: Peter L. Salgo, MD; Bruce M. Jones, PharmD, BCPS; and Yoav Golan, MD, hypothesize on theoretical downsides of resistance development for gram-negative infections and reflect on the importance of implementing outpatient parenteral antibiotic therapy.

Peter L. Salgo, MD: In this case, it does seem to be interesting that here we can do something that saves money, makes patients better—that was your point—and gets them out of this, at least in inner cities, these combat zone emergency rooms that really aren’t set up to deal with this.

Bruce M. Jones, PharmD, BCPS: Absolutely.

Peter L. Salgo, MD: Where’s the downside here? Is there a downside?

Bruce M. Jones, PharmD, BCPS: I think there is a downside. When you think about giving an agent that is active this long in the body, are we going to start seeing more and more issues with resistance, and to a point where maybe they aren’t as good of agents down the road? I think the worry is, there is still a bit of an unknown to having a drug that is going to stay in the body that long.

Peter L. Salgo, MD: That notwithstanding, do you see any downsides?

Yoav Golan, MD: Well, yes, I think that’s a theoretical downside. As I mentioned earlier, I think that the risk of resistance development in gram-positives is slightly limited as compared to gram-negatives. But I think that this is one of the very first times that I can see where all interest groups are aligned, as we mentioned. For the community, it will be much better for society to pay for less admissions, for the patient to obviously stay at home rather than being admitted, and for the hospital to avoid an admission that’s unnecessary, particularly if it’s the type of admission that the hospital usually doesn’t get covered with the reimbursement. There’s really no reason why not to do that when you can. And you need to be responsible to put together a program to make it possible.

Peter L. Salgo, MD: This all sounds interesting to me, but I want to give you guys the last word because as is always the case in television, the clock sort of does run down. So, before we go, I’m going to give each of you some dedicated time, a silo of your very own. If there’s one message that you’d like our viewers to take away, now would be the time to deliver that. Dr. Golan, why don’t you go first?

Yoav Golan, MD: Well, I would say that when you care for a patient with a skin infection, traditionally you would consider an admission because of fever, leukocytosis, and so forth. Know that admission is not always the best choice for those patients. Now, we actually have the way to treat them in an outpatient setting and give them an admission-grade type of antibiotic course of therapy with the same success rate but, in a much safer and less costly way.

Peter L. Salgo, MD: All right. Dr. Jones, you’ve got the last word.

Bruce M. Jones, PharmD, BCPS: I really think it comes down to 3 points for me. The first one is, if you look at lipoglycopeptides and even some of these other new anti-MRSA agents, none are going to definitively replace vancomycin. I do think they all have a niche; they all have certain populations and a place in therapy. Going back to OPAT, specifically, whether it’s admission avoidance or discharging early, I think it’s a great option to decrease length of stay, to prevent admission. Finally, I think it all comes down to 3 things: selecting the right patients and selecting them early, having protocols and gatekeepers in place, and then finally assuring proper monitoring and follow-up.

Peter L. Salgo, MD: Well, this has been great. Thank both of you for being here. Every now and again if you stay in medicine long enough, you find something that sounds really good, that seems to work and makes really good sense. This is one of these times. Twenty years from now, will we be having a different conversation? Maybe other people will be having these conversations. But for now, getting people out of the hospital and treating them as outpatients, making them better, it all sounds great. This is interesting to me, so we’ll follow this and we’ll maybe have you back and discuss it some more. I want to thank you for joining us for this panel discussion as well. I’m Dr. Peter Salgo, and I’ll see you next time.