Optimizing skin and skin structure infection outcomes: considerations of cost of care.

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.

Hepatitis B reactivation and rituximab: a new boxed warning and considerations for solid organ transplantation.

Use of rituximab, a chimeric monoclonal antibody directed at the CD20 antigen, continues to increase in solid organ transplantation (SOT) for several off-label uses. In September 2013, the United States Food and Drug Administration (FDA) issued a Drug Safety Communication to oncology, rheumatology and pharmacy communities outlining a new Boxed Warning for rituximab. Citing 109 cases of fatal hepatitis B virus (HBV) reactivation in persons receiving rituximab therapy with previous or chronic HBV infection documented in their Adverse Event Reporting System (AERS), the FDA recommends screening for HBV serologies in all patients planned to receive rituximab and antiviral prophylaxis in any patient with a positive history of HBV infection. There is a lack of data pertaining to this topic in the SOT population despite an increase in off-label indications. Previous reports suggest patients receiving rituximab, on average, were administered six doses prior to HBV reactivation. Recommendations on prophylaxis, treatment and re-challenging patients with therapy after resolution of reactivation remain unclear. Based on data from the FDA AERS and multiple analyses in oncology, SOT providers utilizing rituximab should adhere to the FDA warnings and recommendations regarding HBV reactivation until further data are available in the SOT population.

Susceptibility profile of vaginal isolates of Candida albicans prior to and following fluconazole introduction - impact of two decades.

Current treatment options for vulvovaginal candidiasis due to Candida albicans include over-the-counter and prescription antifungal agents. Fluconazole has been used extensively with an unknown impact on susceptibility. To investigate antifungal susceptibility trends in clinical vaginal isolates of C. albicans from 1986 to 2008, microdilution susceptibility was performed on randomly selected single isolates. Minimum inhibitory concentrations (MICs) were determined for: fluconazole, clotrimazole, miconazole, ketoconazole, itraconazole, voriconazole, flucytosine and amphotericin B. The MIC(90) for each drug was then calculated for the time periods: 1986-1989, 1992-1996 and 2005-2007. A total of 250 C. albicans vaginal isolates were included. The MIC(90) (mcg ml(-1) ) for fluconazole was 0.25, 0.5 and 0.5 mcg ml(-1) for each grouping, respectively. The corresponding MIC(90) for flucytosine was 1, 2 and 8 mcg ml(-1) , respectively. The MIC(90) for the remaining agents remained unchanged across time periods mentioned. Of note, the percentage of isolates with MIC ≥1 and ≥2 mcg ml(-1) for fluconazole increased from 3% to 9% over the study period. Although the C. albicans MIC(90) to fluconazole in vaginal isolates has not shown a clinically significant increase since 1986, there is an increasing number of isolates with elevated MICs. The implications of this increase are unknown, but given the achievable vaginal concentrations of fluconazole, reduced susceptibility may have clinical relevance.