Site-of-Care Considerations for Managing ABSSSI

Considerations are provided regarding how site of care can influence the cost of managing acute bacterial skin and skin structure infections (ABSSSIs).

Tom Lodise, PharmD, PhD: I think Joe did a really nice job summarizing. When we think about the costs associated with skin and soft tissue infection, they’re largely derived from hospital cost, and most of that is due just to room and board. So one of the single-most-important things we can do for a patient, particularly those who present to the emergency department [ED], is deciding whether to admit them as an inpatient or treat them in the outpatient with or without observational unit care. So when we think about triaging these patients, there are really 3 things to consider: whether it’s a purulent or nonpurulent infection, how many systemic signs and symptoms the patient is manifesting—are they slightly or critically ill?—and an assessment of their comorbidities if they have any. And if they do, are they controlled or uncontrolled?

So patients with limited signs and symptoms of infection, few or no comorbidities that are controlled, could ideally be treated in the outpatient setting. However, what we’re finding is a lot of patients who get admitted to the hospital do not fit these criteria. Rather, these are patients with limited comorbidities and no signs and symptoms of infection. And as proof to that, there have been a number of surveys of ED docs. And what we find is you ask them, “Well, why did you admit the patient?” they say, “For administration of IV [intravenous] antibiotics.”

So really, I think there’s a conditioning of patients, particularly in the ED, to admit patients when they present with a demonstrable skin and soft tissue infection. So when I think about community-acquired pneumonia, we have well-defined criteria for whether or not to admit a patient. So I think one of the most well-known ones is the Pneumonia Severity Index score. We’re lacking that in patients who present with skin infections. So we see variable admissions.

And as proof to that, we did a study a few years ago looking at data from the Premier Research database. What we found is over a year for about 25% of hospitals throughout the United States, of around 700,000 patients admitted to the ED, around 125,000 were admitted, so that 1-in-5 rule. And among those admitted, over 70% had 0 or 1 comorbidity and no systemic signs and symptoms of infection. So again, I think when we think about skin, there’s a real opportunity, particularly from stewardship. I call it stewardship 2.0, thinking about not only proper drug selection but also initial site of care.

Joe Reilly, PharmD, BS, BCGP: Yes. And, as Tom said, when you think about those patients who are admitted, we try to break it down. Do they have systemic signs and symptoms, or are they tachypneic and such? But in many cases, the ED provider will see a patient who comes to the ED with a skin infection and they make an assessment of, Will this patient take their oral antibiotics? If somebody comes in and they seem like they would be a compliant patient, it’s hard. How do you determine that? It’s a clinical judgment that’s made at the time by the provider.

So a patient shows up in the ED with a skin infection at 2 in the morning. You might be thinking, "Why are they here at this time? Why didn’t they go to their primary care doctor? Is this patient truly a candidate for outpatient oral antibiotics?" They may not be compliant. And they just admit them because they needed an IV drip, not because of disease severity, not because they’re unstable. These are hemodynamically stable patients. They may not even have a fever. The wound could be managed in the outpatient setting, but they admit them because they assume that they won’t be compliant. And, as Tom said, there are data to support that patients won’t be compliant with their antibiotic therapy in the outpatient setting. So they’re often just admitted to admit them, and, hopefully, they get sorted out, and as we know, it may not be the best place to be when you have an infection, sitting in the hospital, especially if you’re stable.