View source for Outpatient Parenteral Antimicrobial Therapy (OPAT) (IDSA 2004)

= Outpatient Parenteral Antimicrobial Therapy (OPAT) (IDSA 2004) =

== Background ==

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

== Evaluating patients for OPAT ==

# Are parenteral antimicrobials needed?
# Do the patient's care needs exceed what is available in the discharge destination?
# Is the discharge destination safe and able to support the care?
# Is the patient or their family willing and able to participate?
# Is it possible to communicate with and monitor the patient quickly and reliably?
# Is the patient or their family able to understand the benefits, risks, and economic consideration?
# 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<br/>(h)
! Risk of phlebitis
! Dilution<br/>(mg/mL)
! Stability<br/>–20C
! Stability<br/>5C
! Stability<br/>25C
|-
| Acyclovir*
| 2-3.5
| low
| 5
| ND
| 37 d
| &gt;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
| &gt;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 &lt;2 weeks for adults (&lt;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 (&gt;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 &quot;dynamic illegible E test&quot;
* Unclear if monitoring serum vancomycin levels is helpful
** Recommend peak and trough levels