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LoVecchio F, McCarthy MW, Ye X, Henry AD, Doan QV, Lock JL, Riccobene T, Lyles RD, Talan DA. Single Intravenous Dose Dalbavancin Pathway for the Treatment of Acute Bacterial Skin and Skin Structure Infections: Considerations for Emergency Department Implementation and Cost Savings. J Emerg Med 2024; 67:e217-e229. [PMID: 38825531 DOI: 10.1016/j.jemermed.2024.03.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Revised: 01/03/2024] [Accepted: 03/06/2024] [Indexed: 06/04/2024]
Abstract
BACKGROUND A pathway for the treatment of acute bacterial skin and skin structure infections (ABSSSI) with a single intravenous (IV) dose of dalbavancin was previously shown to reduce hospital admissions and shorten inpatient length of stay (LOS). OBJECTIVES To describe pathway implementation at the emergency department (ED) and evaluate cost-effectiveness of a single-dose dalbavancin administered to ED patients who would otherwise be hospitalized to receive usual care with multidose IV antibiotics. METHODS The dalbavancin pathway was previously implemented at 11 U.S. EDs (doi:10.1111/acem.14258). Patients with ABSSSI, without an unstable comorbidity or infection complication requiring complex management, were treated with a single dose of dalbavancin. At the emergency physicians' discretion, patients were either discharged and received outpatient follow-up or were hospitalized for continued management. A decision analytic cost-effectiveness model was developed from the U.S. healthcare's perspective to evaluate costs associated with the dalbavancin pathway compared with inpatient usual care. Costs (2021 USD) were modeled over a 14-day horizon and included ED visits, drug costs, inpatient stay, and physician visits. One-way and probabilistic sensitivity analyses examined input parameter uncertainty. RESULTS Driven largely by the per diem inpatient cost and LOS for usual care, the dalbavancin pathway was associated with savings of $5133.20 per patient and $1211.57 per hospitalization day avoided, compared with inpatient usual care. The results remained robust in sensitivity and scenario analyses. CONCLUSION The new single-dose dalbavancin ED pathway for ABSSSI treatment, which was previously implemented at 11 U.S. EDs, offers robust cost savings compared to inpatient usual care.
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Affiliation(s)
- Frank LoVecchio
- College of Health Solutions, Arizona State University, Phoenix, Arizona
| | - Matthew W McCarthy
- Cornell University and New York Presbyterian Hospital, New York, New York
| | | | | | | | | | | | | | - David A Talan
- Ronald Reagan UCLA Medical Center, University of California at Los Angeles, Los Angeles, California
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Carbonara S. The efficacy of dalbavancin and impact on hospitalization and treatment costs in patients with ABSSSI. GLOBAL & REGIONAL HEALTH TECHNOLOGY ASSESSMENT 2024; 11:13-17. [PMID: 39100524 PMCID: PMC11292618 DOI: 10.33393/grhta.2024.3045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2024] [Accepted: 04/29/2024] [Indexed: 08/06/2024] Open
Abstract
Acute bacterial skin and skin structure infections (ABSSSIs) represent a common and costly healthcare burden, accounting for millions of annual infections and billions of dollars in healthcare expenditures. Dalbavancin is a long-acting glycopeptide antibiotic that has demonstrated efficacy and safety in the treatment of ABSSSIs. This review article will examine the efficacy of dalbavancin and focus on its impact on the hospital length of stay and costs associated with management of these infections.
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Affiliation(s)
- Sergio Carbonara
- Unità Operativa Complessa di Malattie Infettive, Ospedale Vittorio Emanuele II, Bisceglie - Italy
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Durante-Mangoni E, Riccardi A, Guarino M, Cesaro F, Lugarà M, Mascolo S, Morelli L, Natale V, Andreoni M. Emergency department care of ABSSSI with dalbavancin infusion, direct discharge, and outpatient telemedicine follow up: a study protocol. J Chemother 2023; 35:397-403. [PMID: 36264157 DOI: 10.1080/1120009x.2022.2134616] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2021] [Revised: 08/05/2022] [Accepted: 10/06/2022] [Indexed: 10/24/2022]
Abstract
Novel therapeutic strategies such as the long-acting lipoglycopeptide antibiotics allow for the treatment and discharge of selected emergency department (ED) patients with Acute Bacterial Skin and Skin Structure Infections (ABSSSI), who require intravenous antibiotics and would otherwise be hospitalized. The COVID-19 pandemic highlighted the need to develop strategies that may reduce hospitalization. The telehealth approach has shown success in remote management of cellulitis patients and could aid in the remote follow up of overall ABSSSI patients. This article describes a study protocol for the telemedicine follow up of patients diagnosed with ABSSSI in the ED, requiring intravenous treatment, receiving a single dalbavancin dose, and directly discharged. A telehealth system for remote follow up is evaluated as well as the possible inclusion of point-of-care ultrasound for the appropriate diagnosis of ABSSSI. The study will be conducted in compliance with regulatory requirements; and all collected data will be kept strictly confidential and in accordance with all relevant legislation on the control and protection of personal information. Dissemination of the study protocol may help increasing knowledge and awareness on this topic, with the aim of optimizing patient management, reducing hospitalization and lower the impact on healthcare associated costs.
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Affiliation(s)
- Emanuele Durante-Mangoni
- Department of Precision Medicine, University of Campania "Luigi Vanvitelli" and Unit of Infectious & Transplant Medicine, A.O.R.N. Ospedali dei Colli - Ospedale Monaldi, Napoli, Italy
| | | | - Mario Guarino
- Unit of Emergency Medicine, Ospedale CTO, A.O.R.N. Ospedali dei Colli, Napoli, Italy
| | - Flavio Cesaro
- Unit of Emergency Medicine, Ospedale CTO, A.O.R.N. Ospedali dei Colli, Napoli, Italy
| | - Marina Lugarà
- Unit of General Medicine, Ospedale del Mare, ASL Napoli 1 Centro, Napoli, Italy
| | - Silvia Mascolo
- Unit of Immunodeficiency and Gender Infectious Diseases, A.O.R.N. Ospedali dei Colli - Ospedale Cotugno, Napoli, Italy
| | - Lucia Morelli
- Unit of Emergency Medicine, Ospedale San Paolo, ASL Napoli 1 Centro, Napoli, Italy
| | - Vincenzo Natale
- Unit of Emergency Medicine, ASP Vibo Valenzia, and SIMEU Calabria, Vibo Valentia, Italy
| | - Massimo Andreoni
- Department of Systems Medicine, University of Rome "Tor Vergata", Rome, Italy
- Infectious Diseases Unit, University Hospital "Tor Vergata", Roma, Italy
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Weant KA, Gregory H. The Potential Utility of Single-Dose Long-Acting Intravenous Antibiotics for Acute Bacterial Skin and Skin-Structure Infections in the Emergency Department. Adv Emerg Nurs J 2023; 45:177-186. [PMID: 37501267 DOI: 10.1097/tme.0000000000000467] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/29/2023]
Abstract
Acute bacterial skin and skin-structure infections (ABSSSIs) are frequent clinical presentations to emergency departments (EDs) across the nation that can require substantial resources to treat due to several factors. These include an increasing prevalence of methicillin-resistant Staphylococcus aureus (MRSA) as the causative organism, limited availability of oral antibiotics that treat ABSSSIs secondary to MRSA, absorption and pharmacodynamic concerns with oral therapy, and regimen adherence. In patients who are unable to tolerate oral therapy, or are unable to adhere to prescribed antibiotics, inpatient admission for intravenous (IV) antibiotics may be necessary. Although inpatient IV antibiotics used to treat MRSA, such as vancomycin, are relatively inexpensive, hospital admission itself incurs significant associated costs. The introduction of the long-acting lipoglycopeptides, dalbavancin and oritavancin, has many potential advantages for the treatment of ABSSSIs including one- or two-dose regimens, allowing patients to receive their dose in the ED or infusion center and avoid inpatient admission altogether. Existing data have borne out these results, demonstrating that these agents can significantly reduce the length of hospital stay and the overall treatment cost of ABSSSIs. However, as these agents have nontraditional therapeutic regimens compared with alternative IV and oral agents that require consistent dosing, it is imperative to have decision support tools in place to ensure that this therapy is utilized in appropriate patients with ABSSSIs and that its true benefits can be realized for both the patient and the health care system.
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Affiliation(s)
- Kyle A Weant
- Department of Clinical Pharmacy and Outcomes Sciences, College of Pharmacy, University of South Carolina, Columbia (Dr Weant); and Department of Pharmacy Services, University of Florida Health Shands, Gainesville (Dr Gregory)
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McCarthy MW, Keyloun KR, Gillard P, Choi JJ, Pickell N, Copp R, Walsh TJ. Dalbavancin Reduces Hospital Stay and Improves Productivity for Patients with Acute Bacterial Skin and Skin Structure Infections: The ENHANCE Trial. Infect Dis Ther 2020; 9:53-67. [PMID: 31713130 PMCID: PMC7054506 DOI: 10.1007/s40121-019-00275-4] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2019] [Indexed: 11/15/2022] Open
Abstract
INTRODUCTION Admissions for acute bacterial skin and skin structure infections (ABSSSI) are often prolonged because of intravenous (IV) antibiotics. Use of a long-acting IV antibiotic may reduce length of stay (LOS) on a hospitalist service. The ENHANCE ABSSSI trial sought to determine the impact on LOS and work productivity in patients treated with a long-acting IV antibiotic, dalbavancin, vs. usual care at an urban tertiary-care center. METHODS A single-center, pre- vs. post-period pragmatic trial at Weill-Cornell Medical Center assessed usual care for consecutively enrolled admitted ABSSSI patients during an observational period (pre-period). Identification and treatment of eligible admitted ABSSSI patients with dalbavancin were implemented in the post-period. Those with life-threatening infections, requiring multiple antibiotics/intensive care, or with unstable comorbidities were excluded. Outcomes were assessed over a 44-day follow-up period. RESULTS Of 48 and 43 patients enrolled, respectively, in the pre- and post-periods, mean infection-related LOS was reduced in the post-period (3.2 days vs. 4.8 days; P = 0.003). Similar results were found in an adjusted LOS analysis. Work productivity and activity impairment outcomes significantly improved in the post-period (P ≤ 0.01). Complete response rates were similar: 50% (pre-period) and 57% (post-period). Among AEs identified, 17% (n = 7) were found to have possible causal relation to dalbavancin in the post-period. Few AEs were serious (n = 3; 7% post-period versus n = 1; 2% pre-period). CONCLUSION After implementing the ENHANCE ABSSSI pathway, LOS was significantly reduced by almost 2 days, with potential improvements in work productivity and ability to complete daily activities. TRIAL REGISTRATION ClinicalTrials.gov identifier, NCT03233438. FUNDING Allergan plc.
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Affiliation(s)
- Matthew W McCarthy
- Department of Medicine, Division of General Internal Medicine, Weill Cornell Medicine of Cornell University and New York Presbyterian Hospital, New York, NY, USA.
| | - Katelyn R Keyloun
- Global Health Economics and Outcomes Research, Allergan plc, Irvine, CA, USA
| | - Patrick Gillard
- Global Health Economics and Outcomes Research, Allergan plc, Irvine, CA, USA
| | - Justin J Choi
- Department of Medicine, Division of General Internal Medicine, Weill Cornell Medicine of Cornell University and New York Presbyterian Hospital, New York, NY, USA
| | - Nicholas Pickell
- Department of Medicine, Infectious Diseases, Weill Cornell Medicine of Cornell University and New York Presbyterian Hospital, New York, NY, USA
| | | | - Thomas J Walsh
- Departments of Medicine, Pediatrics, and Microbiology and Immunology, Weill Cornell Medicine of Cornell University and New York Presbyterian Hospital, New York, NY, USA
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Use of a telehealth follow-up system to facilitate treatment and discharge of emergency department patients with severe cellulitis. Am J Emerg Med 2020; 41:184-189. [PMID: 32081554 DOI: 10.1016/j.ajem.2020.01.061] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2019] [Revised: 01/30/2020] [Accepted: 01/31/2020] [Indexed: 11/21/2022] Open
Abstract
INTRODUCTION Novel long-acting lipoglycopeptide antibiotics allow for the treatment and discharge of selected emergency department (ED) patients with cellulitis who require intravenous antibiotics. Telehealth systems have shown success in remote management of dermatologic conditions; we implemented a telehealth follow-up program for patients diagnosed with cellulitis in the ED, treated with single-dose dalbavancin, and discharged. METHODS This was a prospective, multi-center observational study. Patients were included based on clinical criteria and ability to complete follow-up using a smartphone and enroll in an online care portal. We examined the rate of successful telehealth follow-up at 24- and 72-hour intervals from discharge. We also examined the ED return rate within 14 days, reviewed any visits to determine cause of return, and for admission. RESULTS 55 patients were enrolled. 54/55 patients completed at least one telehealth follow up encounter (98.2%). 13 patients (23.6%) had a return ED visit within 14 days; no patients required admission for worsening cellulitis. Patient engagement in the telehealth program decreased over time; there was an approximately 11% decrease in engagement between the 24 and 72-hour follow-up call, and a 15% decrease in engagement between the 24 and 72-hour image upload. Patients over 65 had a lower rate of image upload (31%) than younger patients (80.6%). DISCUSSION A telehealth follow-up system for discharged emergency department patients with cellulitis demonstrated high rates of engagement. In these patients who -may have otherwise required admission for intravenous antibiotics, telehealth-facilitated outpatient management resulted in a low ED return rate and no inpatient admissions for cellulitis.
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Chapman ALN, Patel S, Horner C, Green H, Guleri A, Hedderwick S, Snape S, Statham J, Wilson E, Gilchrist M, Seaton RA. Updated good practice recommendations for outpatient parenteral antimicrobial therapy (OPAT) in adults and children in the UK. JAC Antimicrob Resist 2019; 1:dlz026. [PMID: 34222901 PMCID: PMC8209972 DOI: 10.1093/jacamr/dlz026] [Citation(s) in RCA: 56] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
UK good practice recommendations for outpatient parenteral antimicrobial therapy (OPAT) were published in 2012 and 2015 for adult and paediatric patients, respectively. Here we update the initial good practice recommendations in a combined document based on a further review of the OPAT literature and an extensive consultation process. As with the previous good practice recommendations, these updated recommendations are intended to provide pragmatic guidance for new and established OPAT services across a range of settings and to act as a set of quality indicators for service evaluation and quality improvement.
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Affiliation(s)
| | - Sanjay Patel
- Southampton Children’s Hospital, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Carolyne Horner
- The British Society for Antimicrobial Chemotherapy, Birmingham, UK
| | - Helen Green
- Southampton Children’s Hospital, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Achyut Guleri
- Blackpool Teaching Hospitals NHS Foundation Trust, Blackpool, UK
| | | | - Susan Snape
- Nottingham University Hospitals NHS Foundation Trust, Nottingham, UK
| | - Julie Statham
- South Warwickshire NHS Foundation Trust, Warwick, UK
| | | | | | - R Andrew Seaton
- Queen Elizabeth University Hospital, NHS Greater Glasgow and Clyde, Glasgow, UK
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Keyloun KR, Weber DJ, Gardstein BM, Berger A, Gillard P, Ganz ML. Economic burden of hospital admissions for patients with acute bacterial skin and skin structure infections in the United States. Hosp Pract (1995) 2018; 46:278-286. [PMID: 30067108 DOI: 10.1080/21548331.2018.1506673] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2018] [Accepted: 07/27/2018] [Indexed: 06/08/2023]
Abstract
Objectives: We estimated the total US hospital costs associated with acute bacterial skin and skin structure infection (ABSSSI) admissions as well as the admissions that may have been potential candidates for outpatient parenteral antimicrobial therapy (OPAT). Methods: We assessed inpatient admissions for ABSSSI from the Premier database (2011-2014), focusing on all admissions of adults with length of stay (LOS) ≥ 1 days and a primary diagnosis of erysipelas, cellulitis/abscess, or wound infection. We performed a detailed analysis of 2014 admissions for patient, treatment, hospital, and economic characteristic variables. Using published selection criteria, we identified a subset of patients admitted in 2014 who may have been potential candidates for OPAT. Results: We analyzed 277,971 admissions. In 2014, most admissions were for cellulitis without major complications or comorbidities; mean ± SD LOS was 4.0 ± 3.0 days, and total hospital cost per admission was $6400 ± $6874, 54% of which was attributable to room costs. Among 2014 admissions, 14% involved patients with clinical characteristics suggesting that they were consistent with guideline recommendations for exclusive treatment with OPAT. Compared with all admissions in the year, these admissions were of younger patients (aged 50 vs. 55 years), admitted more frequently for cellulitis (90% vs. 70%), with shorter LOS (2.8 ± 1.8 days), and lower mean total hospital cost per admission ($4080 ± $3066). Conclusions: Admissions for ABSSSI impose a substantial cost to US hospitals, with half of costs attributable to room costs. When extrapolated to all US patients admitted to the hospital for ABSSSI during 2014, had OPAT guidelines been universally followed, admissions may have been reduced by 14%, thereby saving US hospitals $161 million.
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Affiliation(s)
- Katelyn R Keyloun
- a Global Health Economics & Outcomes Research , Allergan plc , Irvine , CA , USA
| | - David J Weber
- b Infectious Diseases , University of North Carolina at Chapel Hill , Chapel Hill , NC , USA
| | | | - Ariel Berger
- c Real-World Evidence , Evidera , Waltham , MA , USA
| | - Patrick Gillard
- a Global Health Economics & Outcomes Research , Allergan plc , Irvine , CA , USA
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Koziatek C, Mohan S, Caspers C, Swaminathan A, Swartz J. Experience with dalbavancin for cellulitis in the emergency department and emergency observation unit. Am J Emerg Med 2018; 36:1312-1314. [DOI: 10.1016/j.ajem.2017.11.037] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2017] [Revised: 11/13/2017] [Accepted: 11/15/2017] [Indexed: 10/18/2022] Open
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Bookstaver PB, Jenkins TC, Stenehjem E, Doron S, Brown J, Goldwater SH, Lopes C, Haynes A, Udeze C, Mo Y, Gillard P, Liu Y, Keyloun K. Impact of Outpatient vs Inpatient ABSSSI Treatment on Outcomes: A Retrospective Observational Analysis of Medical Charts Across US Emergency Departments. Open Forum Infect Dis 2018; 5:ofy109. [PMID: 30581883 PMCID: PMC6299460 DOI: 10.1093/ofid/ofy109] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2018] [Accepted: 05/11/2018] [Indexed: 12/23/2022] Open
Abstract
Background The objective of this study was to characterize treatment of patients with acute bacterial skin and skin structure infections (ABSSSIs) and describe the association between hospital admission and emergency department (ED) visits or readmissions within 30 days after initial episode of care (IEC). Methods This was a retrospective, observational, cohort study of adults with ABSSSI who presented to an ED between July 1, 2012, and June 30, 2013. Patient, health care facility, and treatment characteristics, including unplanned ED visits or readmissions, were obtained through manual chart review and abstraction. Adjusted logistic regression analysis examined likelihood of all-cause unplanned ED visits or readmissions between admitted and nonadmitted patients. Results Records from 1527 ED visits for ABSSSI from 40 centers were reviewed (admitted, n = 578 [38%]; nonadmitted, n = 949 [62%]). Admitted patients were typically older (mean age, 52.2 years vs 43.0 years), more likely to be morbidly obese (body mass index > 40 kg/m2; 17.3% vs 9.1%), and had more comorbidities (Charlson Comorbidity Index ≥ 4; 24.4% vs 6.8%) compared with those not admitted. In the primary analysis, adjusted logistic regression, controlling for comorbidities and severity of illness, demonstrated that there was a similar likelihood of all-cause unplanned ED visits or readmissions between admitted and nonadmitted patients (odds ratio, 1.03; 95% confidence interval, 0.74–1.43; P = .87). Conclusions ABSSSI treatment pathways leveraging outpatient treatment vs hospital admission support similar likelihood of unplanned 30-day ED visits or readmissions, an important clinical outcome and quality metric at US hospitals. Further research regarding the decision criteria around hospital admission to avoid potentially unnecessary hospitalizations is warranted.
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Affiliation(s)
- P Brandon Bookstaver
- Department of Clinical Pharmacy and Outcomes Sciences, University of South Carolina College of Pharmacy and Palmetto Health Richland, Columbia, South Carolina
| | | | - Edward Stenehjem
- Division of Clinical Epidemiology and Infectious Diseases, Intermountain Medical Center, Murray, Utah
| | | | - Jack Brown
- Wegmans School of Pharmacy, St John Fisher College, Rochester, New York
| | | | | | | | | | - Yifan Mo
- Allergan plc, Madison, New Jersey
| | | | - Yan Liu
- Allergan plc, Madison, New Jersey
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Almarzoky Abuhussain SS, Goodlet KJ, Nailor MD, Nicolau DP. Optimizing skin and skin structure infection outcomes: considerations of cost of care. Expert Rev Pharmacoecon Outcomes Res 2018. [PMID: 29521147 DOI: 10.1080/14737167.2018.1450142] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
INTRODUCTION Skin and skin structure infections (SSSIs) refer to a collection of clinical infectious syndromes involving layers of skin and associated soft tissues. Although associated with less morbidity and mortality than other common skin infections, SSSIs represent a significant increasing source of healthcare expense, with a prevalence of 500 episodes per 10,000 patient-years in the United States resulting in burdening health care systems, of approximately $6 billion annually. AREAS COVERED Opportunities to reduce costs of care associated with SSSI are highlighted, including transitions of care and avoiding unnecessary hospital admissions. Moreover, we reviewed new antibiotics (e.g. single dose glycopeptides), and the impact of consulting specialists in the emergency department on SSSI treatment outcomes. EXPERT COMMENTARY New healthcare models and payment strategies combined with new therapeutics are challenging norms of care. Newer drugs to treat skin infections can move a substantive percent of patients previously admitted to hospital care to the outpatient setting. Additionally, patients can be managed with oral or one time intravenous regimens, improving the likelihood of patient adherence and satisfaction. These variables need to be weighed against added acquisition costs and the development of thoughtful algorithms is needed to direct care and optimize treatment, cost, and patient satisfaction.
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Affiliation(s)
- S S Almarzoky Abuhussain
- a Ctr. for Anti-Infective Res. & Dev. , Hartford Hospital , Hartford , CT , USA.,b Umm Al-Qura University, Collage of Pharmacy, Clinical Pharmacy Department , Makkah , Saudi Arabia
| | - K J Goodlet
- c Midwestern University, College of Pharmacy, Department of Pharmacy Practice , Glendale , AZ , USA
| | - M D Nailor
- d St. Joseph's Hospital and Medical Center, Department of Pharmacy Services , Phoenix , AZ , USA
| | - D P Nicolau
- a Ctr. for Anti-Infective Res. & Dev. , Hartford Hospital , Hartford , CT , USA
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