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