Contagion: How soon do you assess into clinical care and what are you looking for when changing treatments or step-down?

Jones: Once we start seeing clinical stability in these patients, our approach varies based on case-specific factors. For example, if a patient’s infection source is a wound and we have pending cultures, we may initially go broad due to concerns about polymicrobial infection. This requires us to monitor culture results, consider de-escalation, and ultimately shift toward optimal therapy. If it’s MSSA, we aim to transition to cefazolin or an antistaphylococcal penicillin. For MRSA, we focus on MRSA-specific therapies. However, it’s also important to consider the broader picture and long-term treatment plans.

Another factor we assess is whether the patient has a history of injection drug use, which is relevant for patients in our region, Savannah, Georgia, where IV drug use is prevalent. Knowing if they have a history of drug injection affects decisions regarding OPAT, outpatient transitions, and discharge planning.

Contagion: In thinking about discharge, what are the factors you want to see in patients?

Jones: I think this is a good time to mention the SABATO trial, which examined switching some low-risk patients to oral therapy after 5 to 7 days of IV treatment, once they had stabilized. Implementing this approach has been challenging here, and I think that’s true for many places. It’s a significant change in practice, moving away from the comfort of 4- to 6-week IV therapy regimens that many of us are used to.

Patient disposition also plays a big role, and this is where a multidisciplinary approach, particularly case management, becomes essential. In our health system, we conduct daily multidisciplinary rounds that bring together case managers, attending physicians, pharmacists, and nursing staff. Case managers play a crucial role in determining the patient’s next steps and discharge plan. For us as pharmacists, knowing the patient’s destination helps us prepare appropriately for their treatment needs in that setting.

Contagion: For those patients who still need to receive outpatient therapy at an infusion center, does the treatment medication from inpatient to outpatient influence your initial therapy choice?

Jones: The best answer I can give is that it depends. Our primary goal is to get patients on the most effective and optimized treatment possible. However, once the patient is stable, we have to start considering their discharge plan. Where are they going? Will they be going to a nursing home, managing home infusions for IV antibiotics, or visiting an infusion center? We have an on-site infusion center, which influences our approach.

The choice of agent may depend on the discharge setting. For example, if the patient will be going to a location where only once-daily dosing is feasible, we may need to select a compatible agent. Cost is another factor, as the patient’s insurance coverage—or lack thereof—affects our options.

With an infusion center, one limitation we encounter is the need for once-daily (Q24) dosing, as more frequent schedules, like Q12, Q8, or Q6, aren’t always practical. One way to address this is by using certain agents, like beta-lactams, as continuous infusions, allowing us to maintain effective treatment with a once-daily dosing model.

The conversation was edited for grammar and clarity.