Outpatient Parenteral Antimicrobial Therapy (OPAT) (IDSA 2018)
From IDWiki
Anne H Norris, Nabin K Shrestha, Genève M Allison, Sara C Keller, Kavita P Bhavan, John J Zurlo, Adam L Hersh, Lisa A Gorski, John A Bosso, Mobeen H Rathore, Antonio Arrieta, Russell M Petrak, Akshay Shah, Richard B Brown, Shandra L Knight, Craig A Umscheid, 2018 Infectious Diseases Society of America Clinical Practice Guideline for the Management of Outpatient Parenteral Antimicrobial Therapy, Clinical Infectious Diseases, Volume 68, Issue 1, 1 January 2019, Pages e1–e35, https://doi.org/10.1093/cid/ciy745
| Antiinfective | Oral Bioavailability, %a | Doses per dayb | Infusion Time | Delivery Devicec | Monitoring Frequency (Weekly) | Most Common Potentially Serious ADRs | Torsades de Pointes Riske | Other Comments | ||
|---|---|---|---|---|---|---|---|---|---|---|
| CBC-diff | BMP: including K, Cr, BUN | Liver profile:
ALT, AST, ALK, Tbil | ||||||||
| Antibiotics | ||||||||||
| Amikacin | NA | 1–3 | 30–60 min depending on dose | Grav, Elas | 1 | 2 | … | Nephrotoxicity; ototoxicity | See aminoglycoside monitoringf | |
| Ampicillin | 50 | 4–6 | 3–5 min push or 10–15 min infusion | Grav, EID, IVP | 1 | 1 | 1 | Hypersensitivity including anaphylaxis | Stable once reconstituted for only 3 days; see stability footnoteg | |
| Ampicillin-sulbactam | NA | 3–4 | 10–15 min push or 15–30 min infusion | Grav, EID, Elas, IVP | 1 | 1 | 1 | Hypersensitivity including anaphylaxis | Stable once reconstituted for only 3 days; see stability footnoteg | |
| Azithromycin | 28–52 | 1 | 60 min | Grav | 1 | … | … | Known | Consider change to po | |
| Aztreonam | NA | 2–4 | 3–5 min push or 20–60 min infusion | Grav, EID, Elas, IVP | 1 | 1 | 1 | Rare cross-allergenicity with other beta-lactams | ||
| Cefazolin | NA | 3–4 | 3–5 min push or 30–60 min infusion | Grav, Elas, IVP | 1 | 1 | … | Hypersensitivity including anaphylaxis | Dialysis-only dosing possible | |
| Cefepime | NA | 2–3 | 5 min push or 30 min infusion | Grav, Elas, IVP | 1 | 1 | … | Hypersensitivity including anaphylaxis | Dialysis-only dosing possible | |
| Cefoxitin | NA | 3–4 | 3–5 min push or 20–30 min infusion | Grav, Elas, IVP | 1 | 1 | … | Hypersensitivity including anaphylaxis | ||
| Ceftaroline | NA | 2–3 | 5 min push or
5–60 min |
Grav, IVP | 1 | 1 | … | Hypersensitivity including anaphylaxis | ||
| Ceftazidime | NA | 3 | 3–5 min push or 15–30 min infusion | Grav, Elas, IVP | 1 | 1 | … | Hypersensitivity including anaphylaxis | NA | Dialysis-only dosing possible |
| Ceftazidime-avibactam | NA | 3 | 120 min | Grav, EID | 1 | 1 | … | Hypersensitivity including anaphylaxis | … | |
| Ceftolozane-tazobactam | NA | 3 | 60 min | Grav, EID | 1 | 1 | … | Hypersensitivity including anaphylaxis | … | |
| Ceftriaxone | NA | 1–2 | 1–4 min push or 30 min infusion | Grav, Elas, IVP | 1 | 1 | 1 | Hypersensitivity including anaphylaxis | See monitoring footnoted | |
| Ciprofloxacin | 50–85 | 2–3 | 60 min | Grav, Elas | … | … | … | Tendonitis/tendon rupture; peripheral neuropathy | Known | Consider change to po; see monitoring footnoted |
| Clindamycin | 90 | 3–4 | 10–60 min (not to exceed 30 mg/min) | Grav, Elas | 1 | 1 | 1 | Consider change to po; see monitoring footnotef | ||
| Colistin | NA | 2–4 | 3–5 min IVP; 30 min for infusion | Grav, IVP | 1 | 2 | … | Nephro- and neurotoxicity | Inhaled colistin may be an option for respiratory tract infections | |
| Daptomycin | NA | 1 | 2 min push or 30 min infusion | Grav, Elas, IVP | 1 | 1 | … | Myopathy; rhabdomyolysis | Baseline and weekly CK, discontinue if symptomatic and CK >1000 U/L (~5× ULN) or asymptomatic and CK >2000 U/L (~10× ULN);
dialysis-only dosing possible | |
| Dalbavancin | NA | Once per week | 30 min | Grav | … | … | … | Hypersensitivity including anaphylaxis | Red man syndrome more likely if infusion <30 min; monitoring requirements unknown for treatment duration greater than 2 weeks | |
| Ertapenem | NA | 1 | 30 min | Grav, Elas | 1 | 1 | 1 | Hypersensitivity including anaphylaxis | NA | See stability footnoteg |
| Gentamicin | NA | 1–3 | 30–120 min depending on dose | Grav, EID, Elas | 1 | 2 | … | Nephrotoxicity; ototoxicity | See aminoglycoside monitoringf | |
| Imipenem | NA | 3–4 | 20–60 min depending on dose | Grav | 1 | 1 | 1 | Hypersensitivity including anaphylaxis; seizures | See stability footnoteg | |
| Levofloxacin | 90 | 1 | 60–90 min depending on dose | Grav | … | … | … | Tendonitis/tendon rupture; cardiac arrhythmias; peripheral neuropathy | Known | Consider change to po; see monitoring footnote;d dialysis-only dosing possible |
| Linezolid | 100 | 2 | 30–120 min | Grav, EID | 1 | … | 1 | Thrombocytopenia; leukopenia; anemia;
peripheral neuropathy; optic neuritis |
Consider change to po; monitor for neuropathy, optic neuritis in prolonged use; see monitoring footnote;d potential for drug interactions | |
| Meropenem | NA | 3–4 | 30 min | Grav, Elas | 1 | 1 | 1 | Hypersensitivity including anaphylaxis | Dialysis-only dosing possible; see stability footnoteg | |
| Metronidazole | 100 | 2–4 | 30–60 min | Grav, EID, Elas | 1 | … | … | Peripheral neuropathy | Conditional | Consider change to po |
| Nafcillin | NA | 4–6 | 30–60 min | Grav, EID | 1 | 1 | 1 | Hypersensitivity including anaphylaxis | Central line commonly used because of concern for phlebitis risk | |
| Oritavancin | NA | Once | 180 min | Grav | … | … | … | Hypersensitivity including anaphylaxis; infusion related | Red man syndrome more likely if infusion <60 min; monitoring requirements unknown for treatment duration greater than a single dose | |
| Oxacillin | NA | 4–6 | 10–30 min | Grav, Elas | 1 | 1 | 1 | Hypersensitivity including anaphylaxis; hepatotoxicity | Central line commonly used because of concern for phlebitis risk | |
| Penicillin G | 25–73 | 4–6 | 15–30 min | Grav, EID | 1 | 1 | 1 | Hypersensitivity including anaphylaxis | Oral penicillin V K is not a substitute for IV treatment of most clinical conditions requiring IV penicillin, eg, syphilis | |
| Piperacillin-tazobactam | NA | 3–4 | 30–240 min (extended infusion) | Grav, EID | 1 | 1 | 1 | Hypersensitivity including anaphylaxis | ||
| Polymyxin B | NA | 1 | 60–90 min | Grav | 1 | 2 | … | Nephro- and neurotoxicity | Monitor for nephrotoxicity, neurotoxicity | |
| Rifampin | 70–90 | 1–3 | 30 min | Grav | 1 | 1 | 1 | Hepatitis; hypersensitivity | NA | Potential for drug–drug interactions; consider change to po |
| Tedizolid | 91 | 1 | 60 min | Grav | 1 | … | 1 | Thrombocytopenia; leukopenia; anemia; peripheral neuropathy; optic neuritis | Consider change to po; monitor for neuropathy, optic neuritis in prolonged use; potential for drug interactions; see monitoring footnoted | |
| Telavancin | NA | 1 | 60 min | Grav | 1 | 2 | … | Nephrotoxicity; hypersensitivity including anaphylaxis; infusion-related prolongation of QTc | Possible | High rate of renal injury in patients aged >65 years, with preexisting renal impairment or other nephrotoxins; red man syndrome more likely if infusion <60 min |
| Tigecycline | NA | 2 | 30–60 min | Grav | 1 | 1 | 1 | Nausea/ vomiting | ||
| Tobramycin | NA | 1–3 | 30–120 min depending on dose | Grav, EID, Elas | 1 | 2 | … | Nephrotoxicity; ototoxicity | See aminoglycoside monitoringf | |
| Trimethoprim/ sulfamethoxazole | 85 | 2–4 | 60–90 min | Grav | 1 | 1 | 1 | Hyperkalemia; rash; nephrotoxicity; Stevens Johnson syndrome | Special | Consider change to po; potential for drug–drug interactions; high fluid requirement; spurious increase in serum creatinine |
| Vancomycin | NA | 1–2 | 60–120 min depending on dose | Grav, EID, Elas | 1 | 1 | … | Nephrotoxicity; infusion-related reactions | Dialysis-only dosing possible; vancomycin trough levels or area under the curve/minimum inhibitory concentration weekly and with dose changes;
red man syndrome more likely if infusion <60 min | |
| Antifungals | ||||||||||
| Amphotericin B | NA | 1 | Liposomal: 2 hours Deoxycholate: 2–4 hours | EID (including pole pump)
Elas |
1 | 2 | 1 | Rates >10%; hypotension, rigors, nausea, vomiting, diarrhea, anemia, thrombocytopenia,
electrolyte abnormalities (K, Mg, Ca), renal failure, hypoglycemia, LFT abnormalities |
Conditional | Sodium loading recommended; chemistry 10 preferredf |
| Anidulafungin | NA | 1 | 1.5 hours | Grav | 1 | 1 | 1 | |||
| Caspofungin | NA | 1 | 1 hour | Grav, EID, Elas | 1 | 1 | 1 | |||
| Fluconazole | ≥90 | 1 | 1–2 hours (not to exceed 200 mg/h) | Grav, Elas | … | … | 1 | Known | Consider change to po; watch for drug-drug interactions | |
| Isavuconazole | 98 | 1–3 | ≥1 hour | Grav (with pump) | … | … | 1 | Consider change to po; watch for drug–drug interactions | ||
| Micafungin | NA | 1 | 1 hour | Grav | 1 | 1 | 1 | |||
| Posaconazole | Highly dependent on gastric pH | 1–2 | 90 min with in-line filter | Grav | 1 | 1 | 1 | Conditional | Consider change to po; watch for drug–drug interactions | |
| Voriconazole | 96 | 2 | 1–2 hours | Grav | 1 | 1 | 1 | Hallucinations; auditory/ visual disturbances; skin changes; fluorosis with prolonged use | Conditional | Consider change to po; watch for drug–drug interactions; monitor plasma concentrations; avoid intravenous formulations if CrCl <50 unless benefits clearly outweigh risks (accumulation of cyclodextrin vehicle) |
| Antivirals | ||||||||||
| Acyclovir | 10–30 | 3 | 1 hour | Grav, Elas | 1 | 1 | … | Crystalluria; acute renal injury | Hydration critical in preventing nephrotoxicity;
consider change to po valacyclovir, famciclovir, or acyclovir | |
| Cidofovir | NA | 1 | 1 hour | EID (including pole pump) | 1 | 2 | 1 | Rash; anemia; neutropenia; iritis; uveitis; decreased intraocular pressure; nephrotoxicity; metabolic acidosis | Hydrate with NS before and after dose; consider probenecid; urinalysis weekly; chemistry 10 preferredf | |
| Foscarnet | NA | 1–3 | 1–2 hours (not to exceed 1 mg/kg/ min) | EID, Elas | 1 | 2 | 1 | Nephro- and neurotoxicity; anemia; granulocytopenia; electrolyte disturbances | Hydrate with NS or D5W prior to first dose; chemistry 10 preferredf | |
| Ganciclovir | 5–10 | 1–2 | 1 hour | Grav, Elas | 2 | 1 | … | Dose-dependent myelosuppression | Consider change to po valganciclovir | |
