Skin and Soft Tissue Infections FINAL NEFSHP€¦ · SKIN AND SOFT TISSUE INFECTIONS OCTOBER 3-4, 2015 Steven Tran, PharmD NEFSHP Fall Meeting 2015 Disclosures • I have no financial

10/1/2015

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SKIN AND SOFT TISSUE INFECTIONSOCTOBER 3-4, 2015

Steven Tran, PharmD

NEFSHP Fall Meeting 2015

Disclosures

• I have no financial conflicts of interest to disclose or report.

Objectives for Pharmacists

Review the signs and symptoms of skin and soft tissue infections

Recommend evidence-based antibiotic regimens for the treatment of skin and soft tissue infections

Evaluate ongoing treatment regimens for appropriate continuation of therapy

Skin and Soft Tissue Infections (SSTI)

Impetigo/Ecthyma

Furuncles/Carbuncles/Abscesses

Cellulitis/Erysipelas

Wound Infections

Necrotizing Infections

Animal Bite Wounds

SSTI with Neutropenic Fever

Stevens DL, et al. Clin Infect Dis. 2014 June.

Skin and Soft Tissue Infections (SSTI)

Impetigo/Ecthyma

Furuncles/Carbuncles/Abscesses

Cellulitis/Erysipelas

Wound Infections

Necrotizing Infections

Animal Bite Wounds

SSTI with Neutropenic Fever


Scratching the Surface

Food and Drug Administration. Guidance for Industry. 2013 Oct.

Furuncles/Carbuncles/Abscesses Collection of pus within dermis or deeper

with redness, edema and/or induration

Cellulitis/Erysipelas Diffuse skin infection with spreading area

of redness, edema, and/or induration

Wound Infection Purulent drainage from wound with

surrounding redness, edema and/induration

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Scratching the Surface


Furuncles/Carbuncles/Abscesses Collection of pus within dermis or deeper

with redness, edema and/or induration

Cellulitis/Erysipelas Diffuse skin infection with spreading area

of redness, edema, and/or induration

Wound Infection Purulent drainage from wound with

surrounding redness, edema and/induration

Skin and Soft Tissue Infections: A Focus

• Common reason for medical attention

• Outpatient setting

• Physician offices

• Hospital outpatient departments

• Emergency room visits

• Inpatient setting

• Hospital admissions

• Surgical site complications

Suaya JA, et al. BMC Infectious Diseases. 2014 Jun.Dryden MS. Int J Antimicrob Agents. 2009 Jul.

0

0.5

1

1.5

2

2.5

3

3.5

4

ED Inpatient

Mil

lio

ns

1990s 2000s

The Bugs of Interest

• Nonpurulent SSTI - Cellulitis• Beta-hemolytic streptococci

• Purulent SSTI - Abscess• Staphylococcus aureus, methicillin-sensitive and resistant

• Hospital-acquired SSTI or Site/Wound Infection• S. aureus, p. aeruginosa, e. coli, enterococcus spp.

• SSTI with Recent Water Contact• Aeromonas hydrophila, Vibrio vulnificus

• Necrotizing fasciitis• S. pyogenes, S. aureus, enterobactericeae, klebsiella spp.,

pseudomonas spp., anaerobes

Rajan, S. Cleveland Clinic Journal of Medicine. 2012 Jan.Stevens DL, et al. Clin Infect Dis. 2014 June.

SENTRY: Complicated SSTIs

44.6

11.1 9.3 7.2 4.8 4.2 4.1

05

101520253035404550

% o

f Is

ola

tes

Rajan, S. Cleveland Clinic Journal of Medicine. 2012 Jan.

Bacteria on the Loose

• Methicillin-resistant S. aureus (MRSA)• Presence first detected in 1961

• Methicillin introduced 2 years earlier

• Major nosocomial pathogen • Hospital-acquired MRSA (HA-MRSA)

• Frequent isolate from positive cultures

• Blood stream and site infections

• Increasing community prevalence• Community-acquired MRSA (CA-MRSA)

• Respiratory and skin and soft tissue infections

Dryden MS. Int J Antimicrob Agents. 2009 Jul.Christensen KL, et. Clin Infect Dis. 2009 Oct.

Infectious Disease Society of America (IDSA) Guidelines

• 2014 Guidelines for SSTI

• Update and refine 2005 guidelines

• Organization and weighting of recommendations

• Recognize the emergent issue of MRSA for SSTIs

• Provide systematic management to providers for different classifications of SSTI

• Evidence-based treatment options

• Simple diagnostic algorithms for appropriate therapy


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Stevens DL, et al. Clin Infect Dis. 2014 June. Stevens DL, et al. Clin Infect Dis. 2014 June.

Nonpurulent SSTIs


Nonpurulent SSTIs Pallin et al. (2013) Uncomplicated Cellulitis

Background Multicenter from 2007 to 2011

Design Randomized, double-blind, placebo controlled trial

Participants Inclusion

• Emergency room

• Uncomplicated cellulitis

Intervention Cephalexin + placebo versus

Cephalexin + trimethoprim/sulfamethoxazole

Outcome Primary: Risk difference for cure at 1 month• Follow-up at 2 weeks and 1 month

Pallin et al. Clin Infect Dis. 2013 June.

Exclusion• Symptoms > 1

week

• Diabetes• Abscess > 3 mm

• Purulence > 1 cc

Pallin et al. (2013) Uncomplicated Cellulitis

Statistics • Intention-to-treat

Results • 153 (146) patients

• Control: previous antibiotic use, crowded contact, spider bite

• Intervention: healthcare worker, MRSA contact, cellulitis with edema

• Clinical cure

• Control: 60/73 (82%)

• Intervention: 62/73 (85%)

• 2.7% (95% CI, -9.3% to 15%)

• Subsequent per-protocol analysis

• 4 non-cellulitis patients

• 4.2 (95% CI, -7.4 to 16%)

Pallin et al. Clin Infect Dis. 2013 June.

Pallin et al. (2013) Uncomplicated Cellulitis

Discussion • No benefit from trimethoprim-sulfamethoxazole

• IDSA guidelines

• Non-purulent cellulitis

• Microbiological data?

• CA-MRSA exotoxin?

• Diabetics excluded

• CA-MRSA risk factors

• Epidemiological correlations

• Duration of therapy

• Effectiveness versus efficacy

Implications • First evidence-based trial for IDSA guideline

• 2 ongoing trials

Pallin et al. Clin Infect Dis. 2013 June.Stevens DL, et al. Clin Infect Dis. 2005 Nov.

Ruhe et al. Clin Infect Dis 2007 June.Genestier, et al. J Clint Invest. 2005 May.

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Nonpurulent SSTIs


Nonpurulent SSTIs


Nonpurulent SSTIs


Purulent SSTIs

Schmitz et al. (2010) Uncomplicated Abscess

Background Role of CA-MRSA coverage after incision and drainage (I/D) of uncomplicated skin abscesses

Design Multi-center, double-blind, randomized placebo controlled trial

Participants • Inclusion• ED patients >16yo

• Abscess with I/D

Intervention Trimethoprim-sulfamethoxazole 160/800 mg BID for 7 days post-I/D versus placebo

Outcome Primary: Treatment failure within 7 days

Secondary: Development of new lesions, abscess, or pustule within 30 days

Schmitz GR et al. Ann Emerg Med. 2010 Sep.

• Exclusion• Immunocompromised

• Fever/systemic signs

• Previous antibiotics

• Deeper structure abscess


Results • 220 patients enrolled

• 96 TMP-SMX, 116 placebo

• Culture results

• Primary outcome

Placebo TMP-SMX

MRSA 47/100 (47%) 50/84 (60%)

MSSA 22/100 (22%) 13/84 (15%)

S. viridans 5/100 (5%) 2/84 (2%)

Coag neg staph 10/100 (10%) 1/84 (1%)

Placebo (n=102)

TMP-SMX(n=88)

P value

Treatment failureat 7 days

27 (26%)

15 (17%)

0.12

Schmitz GR et al. Ann Emerg Med. 2010 Sep.

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Results • 139 patients at 30-day follow-up

Discussion • Similar rates of CA-MRSA

• Loss to follow-up for secondary outcome

• Previous trials

• Cephalexin post-I/D

• TMP-SMX in pediatrics

• Addition of TMP-SMX to I/D does not decrease failure rate

Placebo (n=50)

TMP-SMX(n=46)

P value

New lesion within 30 days

14 (28%)

4 (9%)

0.02

Schmitz GR et al. Ann Emerg Med. 2010 Sep. Stevens DL, et al. Clin Infect Dis. 2014 June.

Cefazolin versus Oxacillin/Nafcillin


Cefazolin versus Oxacillin/Nafcillin


Cefazolin versus Oxacillin

• Li et al. (2014)

• Complicated MSSA bacteremia• Tolerability

• Outcomes• Primary: rate of clinical cure at end of therapy

• Secondary: treatment failure, adverse events, discontinuation

• Results• 59 patients treated with cefazolin

• 93% received 6 grams daily

• 34 patients treated with oxacillin• 94% received 12 grams daily

• Clinical cure: 95% (C) versus 88% (O) (p = 0.25)Li J, et al. Antimicrob. Agents Chemother. 2014 June.

Cefazolin versus Oxacillin

24%

3% 3%

47%

30%

21%

0%

5%

10%

15%

20%

25%

30%

35%

40%

45%

50%

Treatment Failure ADEs Discontinuation

Cefazolin

Oxacillin

Li J, et al. Antimicrob. Agents Chemother. 2014 June.

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Cefazolin versus Nafcillin

Youngster I, et al. Clin Infect Dis. 2014 April.


6.7%4.2% 3.3%

1.6%

33.8%

13.9%11.4%

8.1%

0.0%

5.0%

10.0%

15.0%

20.0%

25.0%

30.0%

35.0%

40.0%

PAD Rash Renalimpairment

Liverabnormalities

Cefazolin

Nafcillin



6.7%4.2% 3.3%

1.6%

33.8%

13.9%11.4%

8.1%

0.0%

5.0%

10.0%

15.0%

20.0%

25.0%

30.0%

35.0%

40.0%

PAD Rash Renalimpairment

Liverabnormalities

Cefazolin

Nafcillin


Daily Cost

Cefazolin: $25

Nafcillin: $170

What About MRSA?


What About MRSA?


Linezolid vs Vancomycin vs Daptomcyin

• Retrospective cohort review• Acute SSTI for less than 2 weeks

• Linezolid, vancomycin, or daptomycin > 48 hours

• Outcome: hospital length of stay (LOS)

• Results:• 219 total patients

• Daptomycin: n = 84

• Linezolid: n = 45

• Vancomycin: n = 90

• Prolonged LOS: n = 30

Szczypniska E, et al. SpringerPlus. 2013 Dec.

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• No difference in length of stay for empiric treatment• Vancomycin: 87% of troughs > 10 mg/mL



MRSA Agent Daily Cost

Daptomycin (4 mg/kg) $340

Linezolid $222

Vancomycin (1g q12h) $7

Antibiotics and Healthcare

“Every antibiotic prescribed has a potential health system impact caused by creation of selective pressures for multi-drug resistant organisms.”

–Stan Deresinski, MD

CDC. Antibiotic Resistance Threat in the United States. 2013 April. Kanj SS et al. Mayo Clin Proc. 2011 Mar.

Resistance Timeline Narrow Spectrum of Approval

• Quantity of Antibiotic Use• Continuation of empiric

coverage with multiple agents

• New agents for MRSA and multi-drug resistant organisms

versus

• Quality of Antibiotic Use• Effective use of current

antibiotics

• Reserving newer therapies for resistant organisms

Spellberg N, et al. Clin Infect Dis.2008 Jan.Owens RC et al. Pharmacotherapy. May 2004.Arnold FW et al. J Manag Care Pharm. June 2004

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Food and Drug Administration (FDA) Guidance

• 2013: FDA and Industry• Guidance for Industry: Developing Drugs for Treatment

• Acute bacterial skin and skin structure infections (ABSSSI)• Resolution of signs and symptoms after completion of

therapy• Reliability of outcome measure?

• Previous research• Treatment effects at 48-72 hours

• Applicable to modern circumstances and standards?


Foundation for National Institutes of Health (FNIH): A Helping Hand

• Historical data suggests…• Antibacterial versus ultraviolet light

• Cessation of lesion spread for cellulitis: day 2

• Clinical cure at 7 days• Potential treatment response earlier in therapy?

• Effectiveness of modern agents vs. sulfonamides

Food and Drug Administration. Guidance for Industry. 2013 Oct.Snodgrass WR, Anderson T. BMJ. 1937 July.

Snodgrass WR, Anderson T. BMJ. 1937 Dec. Corwin P et al. BMJ. 2005 Dec.

• Interim Evaluation

• Analysis of modern trials for lesion size and control

• Tigecycline, daptomycin, ceftaroline

• Response 48-72 hours after randomization

• Success defined as control of infected lesion spread

• Concerns

• Lack of rigorous justification for biomarker

• Lesion spread as related to functional status

• Future direction

• Evaluate content validity and measurement properties of endpoints

• Third phase of review: new trials based on interim recommendations

Foundation for National Institutes of Health (FNIH): A Helping Hand

Talbot GH, et al. Clin Infect Dis. 2012 Oct.

FNIH and FDA: Development of Endpoints

• Bridge Recommendations• Cellulitis/erysipelas, major cutaneous abscesses,

wound infections• >75 cm2 lesion size

• <30% trial population: abscess

• Clinical Trials• Non-inferiority design

• Primary outcome: lesion response at 48-72 hours

• Secondary outcome: resolution of ABSSSI 7-14 days after therapy

Food and Drug Administration. Guidance for Industry. 2013 Oct.Talbot GH et al. Clin Infect Dis. 2012 Oct.

Tedizolid Dalbavancin Oritavancin

Approval June 2014 May 2014 August 2014

Indication

ABSSSI• MSSA/MRSA• Strep. spp.• E. faecalis

ABSSSI• MSSA/MRSA• Strep. spp.

ABSSSI• MSSA/MRSA• Strep. spp.• E. faecalis

Dose200 mg IV or PO

daily x 6 days1000 mg IV x 1, then

500 mg IV 1 week later1200 mg IV infusion

x1

Adverse Effects

Nausea, vomiting, diarrhea

Nausea, rash, Red-Man Syndrome

Nausea, vomiting, SSTI abscess

formation

Half-life 12 hours 204 hours 393 hours

Arsenal of New Antimicrobials

Prokocimer P et al. JAMA. 2013 Feb. Moran GJ et al. Lancet Infect Dis. 2014 Aug.Boucher HW. N Engl J Med. 2014 Jun. Corey GR et al. Clin Infect Dis. 2014 Oct.

ESTABLISH-1 ESTABLISH-2Group • >18 yo

• ABSSSI with local or systemic signs of infection

• >12 yo

• ABSSSI with local or systemic signs of infection

Intervention • 200 mg PO tedizolid daily x 6 days

• 600 mg PO linezolid BID x 10 days

• 200 mg IV tedizolid x daily 6 days

• 600 mg IV linezolid x BID 10 days

Outcome • Early response

• Sustained response

• Clinical success

• Early response

• Sustained response

• Clinical success

Results • 667 patients

Early response

• 0.1% [-6.1-6.2%]

Sustained response

• 69.3% vs 71.9%

Clinical success

• 85.5% vs 86.0%

• 666 patients

Early response

• 2.6% [-3.0-8.2%]

Sustained response

• 87% vs 88%

Clinical success

• 92% vs 96%

Prokocimer P et al. JAMA. 2013 Feb. Moran GJ et al. Lancet Infect Dis. 2014 Aug.

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DISCOVER-1/2 SOLO-1/2Group • ABSSSI with 1 systemic and 2

local signs• IV tx for at least 3 days

• ABSSSI with 1 systemic and 2 local signs

• IV tx for at least 7 days

Intervention • Dalbavancin 1 g IV on day 1, then 500 mg IV on day 8

• Vancomycin 1g or 15 mg/kg IV q12h x 3-14 days

• Oritavancin 1200 mg IV x 1 over 3 hours



• Lesion reduction

• PTE clinical response

• Early response



Results • 659 DALBA, 653 VANCOEarly response• 79.7% vs 79.8%Lesion reduction• 88.6% vs 88.1%PTE clinical response• 96.0% vs 96.7%

• 978 ORITA, 981 VANCOEarly response• 81.2% vs 80.9%Lesion reduction• 86.4% vs 84.1%PTE clinical response• 81.2% vs 80.2%

Corey R, et al. Pennsylvania Convention Center. 2014 Oct. Boucher HW. N Engl J Med. 2014 Jun. Corey GR et al. Clin Infect Dis. 2014 Oct.

Corey GR et al. N Engl J Med. 2014 Jun.

DISCOVER-1/2 SOLO-1/2Group • ABSSSI with 1 systemic and 2

local signs• IV tx for at least 3 days

• ABSSSI with 1 systemic and 2 local signs

• IV tx for at least 7 days

Intervention • Dalbavancin 1 g IV on day 1, then 500 mg IV on day 8


• Oritavancin 1200 mg IV x 1 over 3 hours





• Early response



Results • 659 DALBA, 653 VANCOEarly response• 79.7% vs 79.8%Lesion reduction• 88.6% vs 88.1%PTE clinical response• 96.0% vs 96.7%

• 978 ORITA, 981 VANCOEarly response• 81.2% vs 80.9%Lesion reduction• 86.4% vs 84.1%PTE clinical response• 81.2% vs 80.2%

Corey R, et al. Pennsylvania Convention Center. 2014 Oct. Boucher HW. N Engl J Med. 2014 Jun. Corey GR et al. Clin Infect Dis. 2014 Oct.

Corey GR et al. N Engl J Med. 2014 Jun.

Roles of New Agents

• Tedizolid• Shortened duration of therapy

• Less side effects

• Dalbavancin• Convenient dosing

• Long half-life

• Oritavancin• Convenient dosing

• Long half-life

• But how do they compare?

Prokocimer P et al. JAMA. 2013 Feb. Moran GJ et al. Lancet Infect Dis. 2014 Aug.Boucher HW. N Engl J Med. 2014 Jun. Corey GR et al. Clin Infect Dis. 2014 Oct.

Thom H et al. (2015)

ABSSSI: Systemic Review and Meta-Analysis

Background Previous meta-analyses did not include newer agents and excluded the presence of indirect evidence for treatments

Design and Criteria

Systematic literature review and network meta-analysis

• Adult patients with ABSSSI treated with:

• Vancomycin

• Linezolid

• Daptomycin

• Tigecycline

• Clindamycin

• Study data and outcomes must have conformed to new FDA guidelines on ABSSSI

• Exclusions: medical conditions affecting interpretation of early clinical response (ECR) e.g. neutropenia

• Intention to treat (ITT) and clinically evaluable (CE) patients

Thom H et al. Curr Med Res Opin. 2015 Aug.

• Telavancin

• Dalbavancin

• Oritavancin

• Tedizolid



Outcome Focus

• Clinical response

• Test-of-cure (TOC)

• Early clinical response (ECR)

Results • 52 trials identified

• 26 trials included for TOC outcome

• 10 trials included enough data for ECR comparison

• Clindamycin/telavancin excluded due to lack of relationship data




Treatment TOC ITT* TOC CE*

Ceftaroline 1.07 (0.77-1.51) 2.29 (0.21-2.48)

Dalbavancin 1.01 (0.24-4.41) 1.16 (0.47-2.35)

Daptomycin 2.18 (0.90-5.42) N/A

Linezolid 1.55 (0.91-2.57) 1.65 (0.68-3.53)

Oritavancin 1.06 (0.80-1.43) 1.24 (0.41-2.26)

Tedizolid 1.51 (0.82-2.73) N/A

Tigecycline 0.87 (0.61-1.26) 0.90 (0.31-1.79)


*Treatment effects are presented as odds ratio versus vancomycin. Ratios >1 indicate superior outcome for the comparator.

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Discussion • No statistically significant difference among approved agents for ABSSSI for TOC

• Limited ECR data suggests same results

• Previous two meta-analyses suggests superiority of linezolid over vancomycin

• No inclusion of indirect effects of treatment comparators

Limitations • Unable to assess MRSA or MSSA confirmed subgroups due to lack of data

• Several studies lacked information to assess ECR

Conclusion • Suggestion of equivalence for current use of agents for ABSSSI

• More ABSSSI studies are needed that confirm to recent FDA guidelines

Thom H et al. Curr Med Res Opin. 2015 Aug. Stevens DL, et al. Clin Infect Dis. 2014 June.

Narrowing Coverage to Suspected Pathogens


De-escalation to Defined Therapy


Antimicrobial Stewardship

Right Drug

Right Dose

Right Duration

Appropriate De-escalation

Right Route of Delivery

Dellit TH, et al. Clin Infect Dis. 2007 Jan.

Antimicrobial Stewardship Program• Principles of Stewardship

• Appropriate selection, dosing, route, and duration of antimicrobial therapy

• Optimize clinical outcomes

• Minimize unintended consequences of antimicrobial use:

Drug toxicity

Selection of pathogenic organisms

Emergence of resistance

• Ensure quality assurance and patient safety

Dellit TH, et al. Clin Infect Dis. 2007 Jan.

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Pasquale TR, et al. Am J Health Syst Pharm. 2014 Jul.

Pasquale et al. (2014) Antimicrobial Stewardship - ABSSSI

Background • Summa Health System

• Historical data from 2011

• ABSSSI average LOS: 6.2 days

• 30-day ABSSSI readmission rate: 6.2%

Design • Retrospective observational chart review

Participants • Emergency department admits with ABSSSI

• Reviewed within 24 hours

• Cellulitis, abscess, surgical site/wound infections

Intervention • Evaluation of patient by clinical pharmacist and ID physician

• Prospective chart review and recommendation

Outcome • Length of stay and 30-day ABSSSI readmission rate


Results • 62 patients• 22 (35%) diabetics

• 85 Interventions; 81 accepted

Dose change 27 (44%)

De-escalation 23 (37%)

Regimen change 20 (24%)

ID consult 6 (7%)

Other 9 (11%)

Cellulitis 47 (76%)

Major or deep abscess 16 (26%)

Surgical site infection 5 (8%)

Diabetic Wound 2 (3%)

Pasquale TR, et al. Am J Health Syst Pharm. 2014 Jul.


Results

Discussion • Specific for ABSSSI • Observational study

• Small patient size

Implications • Interventions are readily available in various forms

• Antimicrobial stewardship implementation and focus

ASP Group(n=62)

Historical Group

(n=1149)

P-value

Length of stay (days) 4.4 6.2 <0.001

30-day all-cause readmission rate 6.5% 16.71% 0.050

30-day ABSSSI readmission rate 3.33% 6.27% 0.483

Pasquale TR, et al. Am J Health Syst Pharm. 2014 Jul. Stevens DL, et al. Clin Infect Dis. 2014 June.

Intravenous to Oral AntibioticsCoverage IV Therapy PO Therapy

Streptococcus/ MSSA

• Cefazolin

• Oxacillin/ Naficillin

• Ceftriaxone

• Amoxicillin-clavulanate

• Cephalexin

• Clindamycin

MRSA • Vancomycin

• Linezolid

• Ceftaroline

• Daptomycin

• Doxycycline

• Minocycline

• TMP-SMX

• Clindamycin

Polymicrobial • Piperacillin/ tazobactam + vancomycin

• TMP-SMX + cephalexin or clindamycin


Future Directions

• Duration of Antibiotic Therapy for Cellulitis (DANCE)• Prospective, multicenter, non-inferiority trial in the

Netherlands

• Short versus standard duration of inpatient cellulitis therapy• Primary outcome: resolution of cellulitis at day 14 without

recurrence at day 28

• Flucloxacillin IV/PO for 10-14 days for all cellulitis cases

• Potential guidance for duration of therapy• Similar studies for respiratory tract infections, urinary tract

infections, and bacteremia

Cranendonk DR, et al. BMC Infect Dis. 2014 May.

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Future Directions• Omadacycline

• Oral/IV, once-daily tetracycline derivative• Gram (+), gram (-), atypical, anaerobic, MRSA

• ABSSSI, CABP, UTI undergoing phase 3 trials

• Iclaprim• IV dihydrofolate reductase inhibitor initially denied approval in 2008• Phase 3 trials approved on April 2015

• ABSSSI and HABP caused by gram (+) pathogens

• Other investigational antibiotics• BC-3781 – semisynthetic pleuromutilin derivative• CEM-102/Fusidic acid – oral agent with high dose regimen• JNJ-Q2/Avarofloxacin – targets topoisomerase II and IV• TD-1792/1607 – glycopetptide-cephalosporin heterodimers

Conclusion

Skin and soft tissue infections are common

High antibiotic exposure for patients

Appropriate empiric treatment with antibiotics, if indicated

Identification of most common pathogens for SSTI classification

Nonpurulent – Streptococcus spp., MSSA

Purulent – MSSA/MRSA

Bug-drug match

Consider local antibiogram

Conclusion

Antimicrobial stewardship is essential

Appropriate drug

Appropriate dose

Appropriate de-escalation of therapy

Refer to culture/susceptibility if present

Appropriate IV to PO conversion

Review resolution of leukocytosis, fever, PO intake

Appropriate duration of therapy

7-14 days inpatient, but reassess daily

Acknowledgements

• Florian Daragjati, PharmD, BCPS

• Michele Loudy, PharmD, BCPS

• Kevin Epps, PharmD, BCPS (AQ-ID), BCNSP

SKIN AND SOFT TISSUE INFECTIONSOCTOBER 3-4, 2015

Steven Tran, PharmD

NEFSHP Fall Meeting 2015

Skin and Soft Tissue Infections FINAL NEFSHP€¦ · SKIN AND SOFT TISSUE INFECTIONS OCTOBER 3-4, 2015 Steven Tran, PharmD NEFSHP Fall Meeting 2015 Disclosures • I have no financial

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