Outpatient Parenteral Antimicrobial Therapy (OPAT) (IDSA 2004)

From IDWiki

Background

  • Most commonly used to treat soft-tissue infections and osteomyelitis
  • Not currently useful for treating community-acquired pneumonia

Evaluating patients for OPAT

  1. Are parenteral antimicrobials needed?
  2. Do the patient's care needs exceed what is available in the discharge destination?
  3. Is the discharge destination safe and able to support the care?
  4. Is the patient or their family willing and able to participate?
  5. Is it possible to communicate with and monitor the patient quickly and reliably?
  6. Is the patient or their family able to understand the benefits, risks, and economic consideration?
  7. Does informed consent need to be documented?

Requirements for successful OPAT programs

  • OPAT can be delivered in an infusion centre, skilling nursing facility, at home by a nurse, or at home self-administered

Team members and roles

  • Patient
  • ID specialist to direct antimicrobial therapy
    • Diagnosis, determination that OPAT is appropriate, selection of antimicrobials, monitoring side effects, monitoring effectiveness
    • Help to determine type of IV access
  • Primary care physician to participate in care
  • Nurse to provide IV therapy, maintain access devices
    • Help to determine type of IV access
    • Role varies by locationg of OPAT delivery
  • Pharmacist
    • Help with logistics of provision and delivery
  • Case manager and billing staff
  • Others, such as PT, dietitian, OT, and SW

Communication

  • An MD, RN, and pharmacist available 24 h daily
  • System for rapid communication between patient and team, and within team
  • Patient education regarding side effects and precautions

Policies and procedures

  • Outline the responsibilities of team members
  • Patient intake information
  • Patient selection criteria
  • Patient education materials

Monitoring

  • Patient response
  • Complications of disease, treatment, or program
  • Patient selection

Selection of antimicrobials

  • Choose an appropriate antimicrobial for the syndrome and organism
  • Once-daily dosing minimizes disruptions
  • Initial dose should be in a monitored setting, which could include hospital or clinic
  • Half-life determines frequency and therefore infusion system
  • Phlebotomy risk determines the vascluar access device that is needed
  • Temperature stability determines the logistics, including infusion system

Table 5: Properties of commonly prescribed antimicrobials

Drug Half-life
(h)
Risk of phlebitis Dilution
(mg/mL)
Stability
–20C
Stability
5C
Stability
25C
Acyclovir* 2-3.5 low 5 ND 37 d >37 d
Amphotericin B 24-360 high 0.1 ND 35 d 5 d
Liposomal ampho B 24-360 moderate 4 ND 24 h 5 d
Ampicillin 1 moderate 30 ND 48 h 8 h
Amp-sulbactam 1 moderate 20 ND 48 h 8 h
Caspofungin >48 low 0.2-0.3 ND 24 h 1 d
Cefazolin 1-2 low 10-20 30 d 10 d 1 d
Ceftazidime 1.4-2 low 1-40 90 d 21 d 2 d
Ceftriaxone 5.4-10.9 low 10-40 180 d 10 d 3 d
Cefuroxime 1-2 low 5-10 30 d 180 d 1 d
Chloramphenicol 1.5-4 low 10-20 180 d 30 d 30 d
Clindamycin 2-3 low 6-12 56 d 32 d 16 d
Doxycycline** 22-24 moderate 0.1-1 56 d 48 h 3 d
Erythromycin 1.5-2 high 0.1-0.2 30 d 14 d 1 d
Ertapenem 4 moderate 20 ND 24 h 6 h
Ganciclovir 2.5-3.6 low 5 364 d 35 d 5 d
Gentamicin 2-3 low 0.6-1 30 d 30 d 30 d
Imipenem-cilastatin 0.8-1.3 moderate 2.5-5 ND 2 d 10 h
Linezolid 4.5 low 2 ND ND ND
Meropenem 1.5 low 5-20 ND 24 h 4 h
Nafcillin 0.5-1.5 high 2-40 90 d 3 d 1 d
Oxacillin 0.3-0.8 moderate 10-100 30 d 7 d 1 d
Penicillin G*** 0.4-0.9 moderate 0.2 84 d 14 d 2 d
Quinupristin-dalfopristin 3/1 high 2 ND 54 h 5 h
TMP-SMZ* 8-11/10-13 moderate 8 ND ND 6 h
Tobramycin 2-3 low 0.2-3.2 30 d 4 d 2 d
Vancomycin 4-6 moderate 5 63 d 63 d 7 d

ND = no data; * should not be refrigerated; ** protect from sunlight; *** degradation products can form after a few hours

Choice of vascular access device

  • Peripheral IVs
    • Appropriate if they have good veins and will receive <2 weeks for adults (<1 week for children) with an antimicrobial that has low risk of phlebitis
  • Midline catheters may help for patients with more difficult access
  • Peripherally inserted central catheters (PICCs)
    • Appropriate for longer therapy (>1-2 weeks)
    • Can be used with programmable pumps
    • Need to record length of device on insertion and removal
    • CXR to confirm placement
  • Tunneled and nontunneled central catheters
    • May be preferred for patients who are active

Monitoring and follow-up

  • Patient must be monitored for response as well as adverse events
  • Should be followed by the MD one or twice each week, possibly daily
    • More frequent with potentially life-threatening infections like IE and meningitis
  • 3-10% of courses are stopped for adverse events

Table 6: Frequency of adverse effects

Adverse effect Cfz Ctz Ctrx Cm Gm Oxa Naf Van Total
Rash 1.92 2.19 1.39 5.43 0.61 3.55 4.51 2.29 2.05
Diarrhea 0.38 0.00 0.45 0.90 0.00 0.63 0.38 0.07 0.33
Nausea 0.77 0.22 0.36 0.90 0.92 1.88 1.50 0.24 0.50
Renal 0.13 0.22 0.00 0.00 2.75 0.21 0.75 0.42 0.50
Leukopenia 0.26 0.22 0.09 0.23 0.00 0.42 2.26 0.21 0.21
Urticaria 0.51 0.00 0.19 0.45 0.00 0.21 0.00 0.49 0.29
Fever 0.00 0.44 0.41 0.45 0.00 0.42 0.75 1.18 0.59
Vestibular 0.00 0.00 0.00 0.00 3.06 0.00 0.00 0.10 0.13
Hepatic 0.13 0.00 0.04 0.00 0.00 1.04 0.38 0.00 0.09
Anaphylaxis 0.26 0.00 0.04 0.00 0.31 0.21 0.00 0.14 0.10
Anaphylactoid 0.26 0.00 0.02 0.00 0.00 0.00 0.00 0.07 0.05
Anemia 0.00 0.22 0.00 0.00 0.00 0.21 0.75 0.00 0.04
  • Cm clindamycin, Ctrx ceftriaxome, Ctz ceftazidime, Cfz cefazolin, Gm gentamicin, Naf nafcillin, Oxa oxacillin, Van vancomycin
  • Only recorded events necessitating stopping therapy

Table 7: Suggested laboratory monitoring

Antimicrobial CBC Cr K LFTs Other
Aminoglycosides Weekly Twice weekly Clinical monitoring for vestibular dysfunction and hearing loss, and serum levels measured as indicated
Beta-lactams Weekly Weekly
Antipseudomonal beta-lactams Weekly Weekly Weekly
Fluoroquinolones Weekly
Clindamycin Weekly Weekly Weekly
Daptomycin Weekly Weekly Weekly CK at least weekly
Linezolid Weekly
Pentamidine Twice weekly Twice weekly Twice weekly Blood sugars daily, chem panel twice weekly
Quinu-dalfo Weekly
Septra Weekly Weekly Weekly
Vanco Weekly Weekly Serum levels as indicated
Ampho B formulations Weekly Twice weekly Twice weekly Weekly Magnesium weekly
Azoles Weekly Weekly Weekly
Caspofungin Weekly
Ganciclovir Twice weekly Weekly
Acyclovir Weekly Weekly Magnesium weekly
Foscarnet Weekly Twice weekly Twice weekly Weekly Chem panel with Ca/Mg weekly
Cidofovir Weekly Weekly Weekly Urinalysis and chem panel weekly
  • For aminoglycosides, follow a peak and trough around the third dose after any dose change
    • Can monitor for vestibular dysfunction with "dynamic illegible E test"
  • Unclear if monitoring serum vancomycin levels is helpful
    • Recommend peak and trough levels