Treatment of ABSSSI: Inpatient Versus Outpatient

Peter L. Salgo, MD; Bruce M. Jones, PharmD, BCPS; and Yoav Golan, MD, consider the value of treating acute bacterial skin and skin structure infections with IV antibiotics in nonhospital settings, such as wound care centers, walk-in clinics, and infusion centers.

Peter L. Salgo, MD: If we could bring people back to a nonhospital-admission observed setting—whether it’s to the ED for a 1-hour visit or a half-an-hour visit, an observation unit, or an outpatient infusion center—does this make sense? Is there an advantage to this?

Bruce M. Jones, PharmD, BCPS: I think there is. The key is selecting the right patient, deciding whether they truly need a parenteral, an IV antibiotic, and then looking at compliance/adherence and other factors. For certain patients, it’s an excellent option.

Yoav Golan, MD: Hospitals are great when you need them, but you have to remember, hospitals are very problematic when you don’t need them; and I’m not talking about cost now. I’m talking about the risk of getting infected with a hospital type of pathogen because you’re in a hospital. You may have a Foley catheter or a vascular line, and all of those serve as sources for infection. You may be in the hospital, where you lie in a bed. You’re not as active as you would be when you’re at home, so you may develop a deep vein thrombosis; you become confused; you vomit. We all know how it goes, and so hospitals are only good if you actually need. If you can avoid them, it would be the best for the patient, as well. We are entering an era in which we are trying to avoid hospitalization. Skin infections were one of the very first type of conditions, where people developed programs of hospital admission avoidance. This was actually started on the West Coast and disseminated throughout the country.

Bruce M. Jones, PharmD, BCPS: If you take that even further, look at patient satisfaction—it’s a very hot button topic these days.

Peter L. Salgo, MD: In the C-suite.

Bruce M. Jones, PharmD, BCPS: Oh yes, absolutely. If you look at these patients and you look at studies, acceptance of this is very high; patients love it. I’ve been up to our infusion center. Unfortunately, we have had to evacuate for hurricanes in Savannah, Georgia, the past 2 years. That’s where I go up and sleep. They have these leather chairs, they fold all the way back; you get a snack, you have a nice little flat-screen television.

Peter L. Salgo, MD: You have been a house officer in the past, far too long. You’re sleeping in an infusion center.

Bruce M. Jones, PharmD, BCPS: Whatever it takes, right? But they’re nice areas. That’s the key takeaway, that patient satisfaction with this is very high.

Peter L. Salgo, MD: Could it be not a cost center but a revenue center for a hospital? What do you think reimbursement would be like for coming to a brief visit to an ED or an outpatient infusion center, getting your antibiotics, and going home?

Bruce M. Jones, PharmD, BCPS: That’s the big difference. If it’s an outpatient, whether it’s ED or whether it’s an infusion center type setting, you can now bill for the drug and you can bill for the visit. There are cost-generation sides of it from looking at that.

Peter L. Salgo, MD: Far from being a DRG sink, if you have this facility where you bring people back, you can make money on this.

Yoav Golan, MD: Absolutely—in fact, this is the business of a lot of infectious disease doctors. When you shift inpatient into the outpatient setting, you provide new opportunities. One of them is, as you know, unlike in an inpatient setting, where we don’t get reimbursed for antibiotics that we infuse, you would actually get reimbursed for antibiotics, and you would also get reimbursed for the administration of those antibiotics. There are opportunities for care providers, as well, by doing the right thing, which is providing treatments that do not need to be given in a hospital out of the hospital setting.

Peter L. Salgo, MD: It also occurs to me that if patients have to come back and you say, “Please come back; we’re going to see you,” and if they miss an appointment, then compliance is better, and that has to be better for society.

Bruce M. Jones, PharmD, BCPS: Absolutely. That’s a big part of—especially with some of the newer agents—being able to know they received their full dose of an antibiotic in one setting and taking compliance and adherence out of the picture.