When to switch to an oral treatment and/or to discharge a patient with skin and soft tissue infections

Phenolics Profiling by HPLC-DAD-ESI/MSn of the Scientific Unknown Polygonum hydropiperoides Michx. and Its Antioxidant and Anti-Methicillin-Resistant Staphylococcus aureus Activities

Polygonum hydropiperoides Michx. is an Asian native plant species that is also widely distributed in the Americas. Despite its traditional uses, P. hydropiperoides is scarcely scientifically exploited. This study aimed to chemically characterize and investigate the antioxidant and antibacterial activities of hexane (HE-Ph), ethyl acetate (EAE-Ph), and ethanolic (EE-Ph) extracts from aerial parts of P. hydropiperoides. The chemical characterization was performed through HPLC-DAD-ESI/MSⁿ. The antioxidant activity was assessed by the phosphomolybdenum reducing power, nitric oxide inhibition, and the β-carotene bleaching assays. The antibacterial activity was determined by the minimal inhibitory concentration (MIC) and the minimal bactericidal concentration followed by the classification of the antibacterial effect. Chemical characterization revealed the expressive presence of phenolic acids and flavonoids in EAE-Ph. An increased antioxidant capacity was revealed in EAE-Ph. Regarding antibacterial activity, EAE-Ph showed weak to moderate property against 13 strains tested with MIC values ranging from 625 to 5000 µg/mL, with bactericidal or bacteriostatic effects. Glucogallin and gallic acid stand out as the most relevant bioactive compounds. These results suggest that P. hydropiperoides is a natural source of active substances, supporting this species' traditional use.

Current international and national guidelines for managing skin and soft tissue infections

PURPOSE OF REVIEW

Skin and soft tissue infections account for a significant percentage of both community and nosocomial infections. Several nosological entities are included in this concept. However, there is a very scarce body of doctrine for their treatment based on randomised trials. Therefore, we considered it necessary to review current treatment guidelines to bring new recommendations and improvements to our colleagues. In this review of recent literature, we identified updated guidelines in this area by searching the databases PubMed, evidence-based medicine online, York University reviewers group, Cochrane, MBE-Trip and Sumsearch using the terms: soft tissue infection, therapy, guideline.

RECENT FINDINGS

Developments focus on using new antimicrobials and on the prescription of shorter antibiotic treatment courses.

SUMMARY

With the development of new drugs and the current evidence of their use, there is a need to refine the appropriate drug's decision-making. Drugs with a long half-life, which allows weekly administration, can reduce hospital admission and length of stay with fewer healthcare resources. Shorter courses of antibiotics are recommended. The role of stewardship programmes will continue to expand. The surgical indication and its value are evident in many patients. Therefore, management should rely on a collaborative group with experience in this disease.

Antimicrobial Management of Complicated Skin and Soft Tissue Infections in an Era of Emerging Multi-Drug Resistance: Perspectives from 5 Gulf Countries

The number of complicated skin and soft tissue infections (cSSTIs) in the Arabian Gulf region has risen in recent years, particularly those caused by multi-drug resistant (MDR) pathogens. The high prevalence of diabetes, obesity, and associated cardio-metabolic comorbidities in the region renders medical and surgical management of cSSTI patients with MDR infections challenging. An experienced panel of international and regional cSSTI experts (consensus group on cSSTIs) was convened to discuss clinical considerations for MDR infections from societal, antimicrobial stewardship, and cost perspectives, to develop best practice recommendations. This article discusses antibiotic therapies suitable for treating MDR cSSTIs in patients from the Gulf region and recommends that these should be tailored according to the local bacterial ecology by country and region. The article highlights the need for a comprehensive patient treatment pathway and defined roles of each of the multidisciplinary teams involved with managing patients with MDR cSSTIs. Aligned and inclusive definitions of cSSTIs for clinical and research purposes, thorough and updated epidemiological data on cSSTIs and methicillin-resistant <i>Staphylococcus aureus</i> in the region, clearcut indications of novel agents and comprehensive assessment of comparative data should be factored into decision-making are necessary.

Potential role of new-generation antibiotics in acute bacterial skin and skin structure infections

PURPOSE OF REVIEW

To summarize the available results of primary analyses from high-quality randomized studies of either recently approved or possible future agents for the treatment of acute bacterial skin and skin structure infections (ABSSSI).

RECENT FINDINGS

In the last 2 decades, several novel agents have been approved for the treatment of ABSSSI, that are also active against methicillin-resistant Staphylococcus aureus (MRSA). In addition to already available agents, further molecules are in clinical development that could become available for treating ABSSSI in the forthcoming future.

SUMMARY

The current and future availability of several new-generation antibiotics will allow to modulate therapeutic choices not only on efficacy but also on other relevant factors such as the combination of the drug safety profile and the comorbidities of any given patient, the expected adherence to outpatient therapy, and the possibilities of early discharge or avoiding hospitalization by means of oral formulations, early switch from intravenous to oral therapy, or single-dose administration of long-acting intravenous agents. With the advent of new-generation antibiotics, all these factors are becoming increasingly essential for tailoring treatment to individual patients in line with the principles of personalized medicine, and for optimizing the use of healthcare resources.

Clinical and operational factors associated with treatment duration for cellulitis in outpatient parenteral antimicrobial therapy (OPAT)

This study aims to identify factors associated with duration of intravenous (IV) and follow-on oral antibiotic therapy for cellulitis in patients treated through outpatient parenteral antimicrobial therapy (OPAT). A retrospective review of episodes of cellulitis treated over a year (January 2018-January 2019) at a large teaching hospital in Sheffield, UK. Overall, 292 OPAT episodes of cellulitis were reviewed. The mean durations of IV therapy and follow-on oral antibiotics were 5.3 days (range 1-32 days) and 6.1 days (range 2-17 days), respectively. Age, peak C-reactive protein and frequency of medical assessments during OPAT were independently associated with longer duration of IV therapy. Senior clinicians were likely to prescribe shorter courses of follow-on oral antibiotics. IV to oral conversion was more likely to occur on the first day of the work week. Our findings suggest that clinical and OPAT-related factors can influence early conversion to oral antibiotic therapy.

Inpatient Observation After Transition From Intravenous to Oral Antibiotics

OBJECTIVES

Children hospitalized with infections are commonly transitioned from intravenous (IV) to enteral (per os [PO]) antibiotics before discharge, after which they may be observed in the hospital to ensure tolerance of PO therapy and continued clinical improvement. We sought to describe the frequency and predictors of in-hospital observation after transition from IV to PO antibiotics in children admitted for skin and soft tissue infections (SSTIs).

METHODS

We conducted a retrospective cohort study of children with SSTIs discharged between January 1, 2016, and June 30, 2018, using the Pediatric Health Information System database. Children were classified as observed if hospitalized ≥1 day after transitioning from IV to PO antibiotics. We calculated the proportion of observed patients and used logistic regression with random intercepts to identify predictors of in-hospital observation.

RESULTS

Overall, 15% (558 of 3704) of hospitalizations for SSTIs included observation for ≥1 hospital day after the transition from IV to PO antibiotics. The proportion of children observed differed significantly between hospitals (range of 4%-27%; P < .001). Observation after transition to PO antibiotics was less common in older children (adjusted odds ratio [aOR] = 0.69; 95% confidence interval [CI] 0.52-0.90; P = .045). Children initially prescribed vancomycin (aOR = 1.36; 95% CI 1.03-1.79; P = .032) or with infections located on the neck (aOR = 1.72; 95% CI 1.32-2.24; P < .001) were more likely to be observed.

CONCLUSIONS

Children hospitalized for SSTIs are frequently observed after transitioning from IV to PO antibiotics, and there is substantial variability in the observation rate between hospitals. Specific factors predict in-hospital observation and should be investigated as part of future studies aimed at improving the care of children hospitalized with SSTIs.

Current role of oxazolidinones and lipoglycopeptides in skin and soft tissue infections

PURPOSE OF REVIEW

An increase of skin and soft tissue infections involving Staphylococcus aureus has been reported in community and hospital settings. Methicillin resistance in S. aureus is associated with treatment failure and increased mortality. Recently, new antimicrobials with enhanced activity against methicillin-resistant Staph. aureus have been approved for the treatment of skin and soft tissue infections. Among these, novel oxazolidinones and lipoglycopeptides represent options with favorable pharmacokinetic characteristics and safety profiles.

RECENT FINDINGS

Newly approved compounds include tedizolid, characterized by the availability of both oral and intravenous formulation and once daily administration and dalbavancin, a long-acting antimicrobial allowing for weekly administration. These new molecules present advantages, such as enhanced activity against multidrug-resistant Gram-positive bacteria and favorable safety profiles.

SUMMARY

We have reviewed the pharmacokinetic characteristics and the implications for use in skin and soft tissue infections of tedizolid and dalbavancin. Advantages associated with the use of these compounds include the possibility for early patient discharge, reduced hospital length of stay, and outpatient treatment, with potential impact on morbidity, mortality, and overall health-care costs.

Tedizolid phosphate for the treatment of acute bacterial skin and skin-structure infections: an evidence-based review of its place in therapy

Introduction

Tedizolid phosphate is an oxazolidinone approved for the treatment of acute bacterial skin and skin-structure infections (ABSSSIs) and active against methicillin-resistant Staphylococcus aureus.

Aims

The objective of this article was to review the evidence for the efficacy and safety of tedizolid phosphate for the treatment of ABSSSI.

Evidence review

Approval of tedizolid phosphate for the treatment of ABSSSI was based on the results of two phase III randomized controlled trials, ESTABLISH-1 (NCT01170221) and ESTABLISH-2 (NCT01421511), comparing 6-day once-daily tedizolid vs 10-day twice-daily linezolid. In ESTABLISH-1, noninferiority was met with early clinical response rates of 79.5% and 79.4% in tedizolid and linezolid groups, respectively (difference 0.1%, 95% CI –6.1% to 6.2%, with a 10% noninferiority margin). In ESTABLISH-2, noninferiority was met with 85% and 83% rates of early clinical response in tedizolid and linezolid groups, respectively (difference 2.6%, 95% CI –3.0% to 8.2%). Pooled data from ESTABLISH-1 and ESTABLISH-2 indicated a lower frequency of thrombocytopenia in tedizolid-treated than in linezolid-treated patients.

Conclusion

Tedizolid offers the option of an intravenous to oral switch, allows once-daily administration, and presents lower risk of myelotoxicity when a 6-day course is used for the treatment of ABSSSI. Greater economic cost associated with this antibiotic could be offset by its shorter treatment duration and possibility of oral administration in routine clinical practice, although either sponsored or nonsponsored postmarketing observational experience remains essential for ultimately confirming the effectiveness and tolerability of tedizolid outside clinical trials.

Efficacy and Safety of Tedizolid Phosphate versus Linezolid in a Randomized Phase 3 Trial in Patients with Acute Bacterial Skin and Skin Structure Infection

Tedizolid phosphate is approved for the treatment of acute bacterial skin and skin structure infection (ABSSSI) caused by Gram-positive bacteria in the United States, Europe, and other countries. In this multicenter, double-blind, phase 3 study, 598 adult ABSSSI patients in China, Taiwan, the Philippines, and the United States were randomized to receive 200 mg of tedizolid, intravenously (i.v.)/orally (p.o.), once daily for 6 days or 600 mg of linezolid, i.v./p.o.

Tedizolid phosphate is approved for the treatment of acute bacterial skin and skin structure infection (ABSSSI) caused by Gram-positive bacteria in the United States, Europe, and other countries. In this multicenter, double-blind, phase 3 study, 598 adult ABSSSI patients in China, Taiwan, the Philippines, and the United States were randomized to receive 200 mg of tedizolid, intravenously (i.v.)/orally (p.o.), once daily for 6 days or 600 mg of linezolid, i.v./p.o. twice daily for 10 days. The primary endpoint was early clinical response rate at 48 to 72 h. Secondary endpoints included programmatic and investigator-assessed outcomes at end-of-therapy (EOT) and posttherapy evaluation (PTE) visits. Safety was also evaluated. In the intent-to-treat (ITT) population, 75.3% of tedizolid-treated patients and 79.9% of linezolid-treated patients were early responders (treatment difference, –4.6%; 95% confidence interval [CI], –11.2, 2.2). After exclusion of patients who never received the study drug (tedizolid, n = 8; linezolid, n = 1; modified ITT), comparable early response rates were observed (tedizolid, 77.4%; linezolid, 80.1%; treatment difference, –2.7%; 95% CI, –9.4, 3.9). Secondary endpoints showed high and similar clinical success rates in the ITT and clinically evaluable (CE) populations at EOT and PTE visits (e.g., CE-PTE for tedizolid, 90.4%; for linezolid, 93.5%). Both drugs were well tolerated, and no death occurred. Eight patients experienced phlebitis with tedizolid while none did with linezolid; hence, drug-related treatment-emergent adverse events were reported in a slightly higher proportion in the tedizolid (20.9%) arm than in the linezolid arm (15.8%). The study demonstrated that tedizolid in a primarily Asian population was an efficacious and well-tolerated treatment option for ABSSSI patients. (This study has been registered at ClinicalTrials.gov under registration no. NCT02066402.)

Early discharge criteria in patients with acute bacterial skin and skin structure infections in a large tertiary-care teaching hospital in Florence, Italy

The study is aimed at retrospectively estimating the percentage of inpatients with severe acute bacterial skin and skin structure infections (ABSSSI) who met the early discharged (ED) criteria adapted from Nathwani et al. (Int J Antimicrob Agents. 2016 Aug;48(2):127-36) and to calculate the number of hospitalization days that could be potentially saved. A retrospective study was conducted in a tertiary care hospital in Florence, Italy. We included all patients admitted for cellulitis and post-surgical infections from 2014 to 2017. Demographic and clinical data were obtained from electronic medical records. We a priori defined the following as a risk factor for non-adherence (RFNA): active or on methadone intravenous drug users, homeless, migrants without health care assistance, and patients who need a caregiver to take prescribed medications. One hundred sixty-two subjects were enrolled. Of them, 94 (58.0%) were male, and 113 (69.7%) had cellulitis/erysipelas. A microbiological isolate was obtained in 51 patients (31.4%); Staphylococcus aureus was the most frequent (47%). Eighty-four (51.8%) were ED suitable, with 258 (49.0%) patient days potentially saved. Among the 78 not ED suitable patients, the most common reason for prolonged length of stay (LOS) was having at least one RFNA (34.6%). Fourteen (18.0%) had one RFNA. Half of the patients admitted in our hospital met the ED criteria with a sparing close to 50% in terms of hospitalization days. Unstable social and personal factors were the most frequent causes for prolonged LOS. In this selected subset of patients, more recent and easier to administer treatments, including long-acting agents, could be proposed.

The safety of treatment options for acute bacterial skin and skin structure infections

INTRODUCTION

Acute bacterial skin and skin-structure infections (ABSSSI) may develop in both in-patients and out-patients, possibly with a severe clinical presentation. Since most phase 3 randomized clinical trials have shown non-inferiority in efficacy across different agents, considerations regarding their different safety profiles inevitably play a crucial role in the everyday choice about which of them should be employed for the treatment of ABSSSI.

AREAS COVERED

In this review, the authors discuss the safety profile of different treatment options for ABSSSI.

EXPERT OPINION

The spread of methicillin-resistant Staphylococcus aureus (MRSA) in the last decades has inevitably influenced the therapeutic approach to ABSSSI. Adequate knowledge of the peculiar toxicity profile of each drug active against MRSA is essential for guiding, monitoring and managing adverse events, in turn reducing any unfavorable impact of toxicity on patients' outcomes. In the next five years, potential toxicity will play a critical role in establishing the best available therapy for each specific patient, together with consideration regarding the possibility of avoiding hospitalization or allowing a switch from intravenous to oral therapy and early discharge.

2018 WSES/SIS-E consensus conference: recommendations for the management of skin and soft-tissue infections

Skin and soft-tissue infections (SSTIs) encompass a variety of pathological conditions that involve the skin and underlying subcutaneous tissue, fascia, or muscle, ranging from simple superficial infections to severe necrotizing infections. SSTIs are a frequent clinical problem in surgical departments. In order to clarify key issues in the management of SSTIs, a task force of experts met in Bertinoro, Italy, on June 28, 2018, for a specialist multidisciplinary consensus conference under the auspices of the World Society of Emergency Surgery (WSES) and the Surgical Infection Society Europe (SIS-E). The multifaceted nature of these infections has led to a collaboration among general and emergency surgeons, intensivists, and infectious disease specialists, who have shared these clinical practice recommendations.