ABSSSI: Understanding Current Gaps in Care

Given data of newer agents, Joe Reilly, PharmD, BS, BCGP, and Tom Lodise, PharmD, PhD, elucidate the pitfalls of other agents used to manage acute bacterial skin and skin structure infections.

Tom Lodise, PharmD, PhD: There’s another thing I want to mention, Joe. We talked a lot about noncompliance, but think about the agents we’re using, right? So think about our older oral generics, and let’s just talk about the ones with MRSA [methicillin-resistant Staphylococcus aureus] coverage. You have clindamycin, you have Bactrim, and you have doxycycline. So with Bactrim, you have questions about bioavailability and adverse effects, and there are gaps in coverage. Bactrim and clindamycin are not good strep [Streptococcus] drugs. And their activity against MRSA is not as good as some of our newer agents. Also, we think about clindamycin, C difficile [Clostridium difficile] infections. And even for the tetracyclines, we just don’t have a lot of experience using it in this capacity.

In addition to noncompliance, I think another issue is even when they do take these drugs, we don’t really have any landmark clinical trials to hang our hats on to say that these drugs are good. The one thing I do know is anytime Bactrim is compared with vancomycin, which we all know is a drug that is probably not the most efficacious, it always has lower response rates anytime you put it in a trial in patients with severe staph [Staphylococcus] disease. So I think in addition to some of the compliance issues you mentioned, I just think when we think about these older generics, we’re just dealing with inferior agents.

Joe Reilly, PharmD, BS, BCGP: Yes. And, as Tom had said, there are also adverse effects associated with these medications. Those who take Bactrim get an upset stomach or a rash. Clindamycin requires multiple daily dosing, and these things aren’t very favorable with patients who may not be good candidates for oral antibiotics in the outpatient setting. Sometimes other antibiotics like linezolid or tedizolid are used in this patient population. If they take all their medication, it can be successful, but a lot of times, providers are concerned about drug interactions with these medications as well.

Tom Lodise, PharmD, PhD: Yes. I think the oxycodones are great drugs. They actually have superiority. If you look at its clinical trial data compared with vancomycin, there’s a signaling of superiority across its noninferiority trials, particularly those with MRSA-documented infections. So there it’s not a matter of efficacy but safety. Serotonin toxicity, suppression of platelets, which occurs with more than 5 days of use. So, again, there are great drugs, but no drug is perfect, and I think with those, it’s more of the safety concerns that have providers a bit concerned.