What Is New in the Management of Skin and Soft Tissue Infections in 2016?

Garyphallia Poulakou; Efthymia Giannitsioti; Sotirios Tsiodras

Disclosures

Curr Opin Infect Dis. 2017;30(2):158-171. 

In This Article

Novel Antimicrobial Therapy

Novel antibacterial agents against gram-positive bacteria causing ABSSTI (including MRSA strains) have been developed over the last few years in agents.[1,2,27] With currently available armamentarium, clinicians not only need to reevaluate their current treatment paradigms but moreover, using the new guidance can determine patient groups most suitable for early de-escalation or switch to oral therapy.[9,10,36] As inadequate treatment of MRSA infections may lead to recurrence,[16,71] newly launched antimicrobials such as oritavancin, dalbavancin and tedizolid may obviate this risk.[72,73]

Several benefits of some of the drugs currently under active investigation for ABSSSI exist. As compared to older agents, e.g. vancomycin, linezolid and daptomycin, the new agents have equal efficacy and are given for shorter intervals[74,75] or have a better safety profile[75–77] (Table 1). Single-dose regimens have been proven efficacious for oritavancin[76] and dalbavancin[78] with a favorable safety profile compared with vancomycin or linezolid.[30,75] Safety may become an important issue in selecting appropriate therapy in ABSSSI; whereas daptomycin use has been associated with very successful clinical outcomes,[79] monitoring for creatine phosphokinase elevations is necessary and in some instances eosinophilic pneumonia has developed.[80] Linezolid use may be limited by hematological side-effects.[81,82] The novel oxazolidinone tedizolid exhibits an excellent activity against most gram-positive pathogens associated with ABSSSI[30] including linezolid nonsusceptible strains[83] while exhibiting a much better hematological side-effect profile;[76] thus, it could serve as an alternative to linezolid.

Antibacterials may differ regarding their bactericidal activity against specific pathogens like MRSA or enterococci, especially resistant strains. In a very recent study, among new antibacterials used in ABSSSI, rapid bactericidal activity for MRSA isolates has been shown for dalbavancin and daptomycin irrespective of bacterial burden.[84]

In a study of cSSTIs, ceftaroline fosamil use was associated with lower length of stay, equivalent or lower in-hospital mortality rates and lower inpatient costs compared with usual practice (including linezolid).[85] Dosing concerns are under investigation suggesting that a t.i.d. administration can better achieve the pk/pd goals also for pediatric patients.[86–88] Hematological disturbances and skin rash were the common adverse reactions of ceftaroline in a recent evaluation, but without increased rates in β-lactam hypersensitive patients.[89]

Thus, the clinician should carefully evaluate the clinical scenario in order to reach the appropriate therapeutic decision especially in difficult infections due to resistant pathogens, taking into account accumulating evidence about particular antibiotic properties, safety and cost.[16,90]

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