Treatment Challenges Remain as ABSSSI Incidence Continues to Grow

Yoav Golan, MD, attending physician at Tufts Medical Center in Boston, Massachusetts, discusses trends in the incidence of acute bacterial skin and skin structure infections, standard protocols for treatment, and the challenges clinicians continue to face.

Interview Transcript (modified slightly for readability):

“One of the trends with ABSSSIs and the risk factors or the drivers of it, no question, we’ve seen a huge increase in skin infections both in the community and in the emergency department and admissions related to skin infections over the past 15 to 20 years. I think that there were 2 main drivers for that. One is that the bacteria that caused that particular Staphylococcus aureus [or] the type of clones of Staph aureus; [for example], 1 clone in particular that’s known as USA-300—and it circulates now to the communities and hospitals in the United States—is known to be more virulent than other Staph aureus that we used to see in the past. In other words, many people are colonized, on average, about one-third of adults are colonized with this bacteria but the likelihood of infection if you are colonized with this particular bacteria is higher, and so, that’s one driver of the increased frequency of those infections. The other is obviously the fact that we see people who get older—life expectancy is going up, and more people have diabetes and other risk factors for skin infections, [such as being] overweight, [having a] sedentary lifestyle—and become more vulnerable to develop skin infections. And so, both on the treatment side and the risk factors for the infection we see an increase and I think the expectation is that skin infections will continue to increase with the aging population.

What are the standard protocols for treating those infections and challenges? Standard protocols involved antibiotic use and follow-up in drainage of an abscess. The skin infections that we see typically are divided into redness, painful redness, infected redness— which is usually cellulitis or erysipelas—or an abscess, and those abscesses need to be drained, with or without antibiotics, depending on their size, or wounds that got infected, for example, trauma wounds or surgical wounds that get infected.

Of course, the main step is choosing the right antibiotic because those infections are almost, almost always caused by gram-positive bacteria, such as Streptococcus and Staph; these are the bacteria you want to cover. And because methicillin-resistant Staph aureus (MRSA), which is the more antibiotic-resistant variant of Staph aureus, is now so prevalent everywhere, including communities, you need to make sure that at least in patients who are sick you want to cover MRSA, as well. One of the challenges is for that many of the patients, we don’t actually have any guidance coming from the microlab because there are no cultures when you have cellulitis or erysipelas and you have to treat based on your understanding of what types of pathogens cause this and what is their susceptibility.

Challenges are the resistance, of course. It was much easier to treat skin infections 10, 20 years ago, particularly in the community because they would be responsive to many of our narrow-spectrum, best antibiotics like cephalosporins and the penicillins like oxacillin, dicloxacillin, [or] cephalexin, antibiotics that are not just very active but also very safe. And with increasing resistance we have lost most of the antibiotics that could be used for skin infections and the ones that we have [now] are not as good as the ones that we did have. So, you have 2 issues here, 1 is that you may give a patient an antibiotic for which the bacteria that is causing his infection is resistant to and even if the bacteria is susceptible, the response may not be as good as it used to be in the past, and this is, of course, a major challenge.

Another challenge is that many people do not have health insurance and skin infections are seen very often, in particular they’re seen in some populations more often than other populations, like people with the heavy drug use and so forth. Some of those people don’t have good insurance, and so, they don’t have good access to care and very often they find themselves in the emergency department as their first stop for care and that has been a major challenge as well.”