IDWeek 2019 News Network: The Challenges of Treating ABSSSI

Segment Description: George Sakoulas, MD, UC San Diego School of Medicine, discusses the issues involved with treating acute bacterial skin and skin structure infections, including compliance, duration of therapy, and areas of unmet need.

George Sakoulas, MD: Acute bacterial skin and skin structure infections (ABSSSI) can definitely be challenging to treat, in part actually for a good thing, because we have lots of options out there that treat infections and finding the right agent for the particular patient can be a little challenging. Weighing in what particular bacteria can cause the infection, as well as weighing in the patient's immunocompromised or non-immunocompromised state, comorbidities leave open lots of options and choices, and deciding whether to give someone oral antibiotics versus intravenous antibiotics, inpatient versus outpatient, there are a lot of factors that need to be weighed in when making such decisions and treating them.

Areas of unmet need for ABSSSI largely weigh in on pharmaco-economically balancing what's available, getting patients on the therapy that is most efficient, not just in terms of restoring them back to their life, back home, and back to their jobs, taking care of their children and so on…and minimizing stays in the hospital. Studying that and defining in a more black-and-white, more tangible fashion, I think is one of the largest unmet needs when trying to establish data for clinicians to make decisions for treating ABSSSI.

Compliance in patients with ABSSSI, it can definitely be a big problem. Largely because many of the patients are younger, they don't have a lot of medical problems. They don't take their health that seriously. They see the immediate need when they're very ill or when they have the immediate problem, and once their treatment has begun then they forget about it, it becomes less urgent and they're off to the routines of their lives, not worrying about what antibiotics you have to take and how often.

So clearly with that kind of scenario, the less doses a patient requires per day, the better it's going to be. It's a lot easier for someone to remember to take a medication once a day, as opposed to having to take something four times a day. For example, cephalexin, great drug on paper, covers [methicillin-sensitive Staphylococcus aureus (MSSA)] and [Streptococcus]. Bad news is, how often is someone going to remember to take cephalexin 4 times a day? The options of once-daily dosing, and now we actually have drugs that can be given once in an emergency room setting or outpatient urgent care setting where the patient can be given an IV dose that lasts a week and doesn't have to worry about taking any more doses.

The compliance factor is balanced by the fact that some patients only need 2 or 3 days of antibiotics. They take their course and many of them do fine. Unfortunately, there are some patients who do stop prematurely and they wind up having to come back to the hospital. So you're balancing the, “I'm done, not taking more than I need to take” versus “okay, well, I stopped too early” and then having to continue. So, obviously, if you're worried about compliance, less doses per day and even eliminating the need to take any antibiotics with a parenteral, one-time dose is one of the options we have available today.

Duration of therapy, it’s sort of a black box, not only for ABSSSI, but also for all infections. How long to treat a patient is really almost a case by case basis. We have guidance, 5 to 14 days or 7 to 14 days based on historical paradigms, but at the end of the day, some patients are better with 3 days of treatment and they don't need any more; some patients need longer. One of the variables that determines duration of treatment is the patient’s underlying immunosuppression and comorbidity state. Obviously, if you have a patient with more comorbidities, you're going to need to treat longer. If you have a patient who has a larger burden of infection, you're also going to need to treat longer. So, balancing the immunosuppression and infection burden of a particular patient is a moving target patient to patient, and very difficult to establish. With some clinical judgment, an experienced physician can decide, “Okay, you're a 5-day person versus a 10-day person” and hopefully make the right decisions and hopefully the patient can comply with that recommendation to minimize the relapses.

Unfortunately, one of the problems we also have with this situation is with Staph is that patients colonized with Staph frequently, you could treat them, they get through the acute period, but the mere colonization opens up an opportunity for another infection to happen. Not an issue of compliance or you didn't give them enough therapy, but the fact that they're colonized sets up an opportunity for a recurrent, not necessarily a relapse infection, but a recurrent infection a few weeks later and we in practice, see that all the time.