Updated Guidelines Advise on Outpatient Parenteral Antimicrobial Therapy

An infectious diseases (ID) specialist should be consulted before patients receive intravenous (IV) antimicrobial infusion therapy outside of the hospital, suggest updated guidelines released by the Infectious Diseases Society of America (IDSA) and published in the journal Clinical Infectious Diseases. Once they begin receiving outpatient parenteral antimicrobial therapy (OPAT), patients should be monitored regularly, according to the guidelines.

Since previous guidelines were published in 2004, large studies have concluded that there is no difference in the number of adverse events related to OPAT compared to hospital-administered IV antimicrobial therapy. Additionally, recently-published research underscores the value of review by an ID physician, nurse, or pharmacist before starting OPAT, noting that it is associated with a lower risk of hospital readmission. In many cases a specialist will recommend an oral instead of an IV antimicrobial, and one study concluded that an ID specialist-led stewardship program reduced pediatric OPAT orders by 24%, without increasing readmissions.

Other recommendations in the guideline are:

• OPAT vancomycin should be monitored closely throughout the course of treatment for adverse events as one study found 42% of patients developed nephrotoxicity after 14 days on therapy. If nephrotoxicity develops, options include lowering the dose or stopping the vancomycin and switching to another medication such as daptomycin.
• In patients with no history of allergy to antimicrobials in the same class, the first dose of a new IV antimicrobial may be given at home under the supervision of a health care worker who is trained to manage an allergic reaction.
• In patients receiving OPAT antimicrobials for 2 weeks or less, it is acceptable to deliver the medication using a midline catheter in the arm rather than via a peripherally inserted central catheter (PICC) or central venous catheter.
• If a patient with a PICC develops a blood clot, it is not necessary to remove and replace the catheter if anticoagulation is started, the catheter is well-positioned and arm pain and swelling have decreased.

“Given the growing worldwide problem with antimicrobial overuse and resistance, any opportunity to de-escalate these drugs is critically important,” Anne H. Norris, MD, guidelines cochair and associate professor of clinical medicine at the Perelman School of Medicine at the University of Pennsylvania, Philadelphia said in a press release about the guidelines. “Not only does this [guideline] provide good stewardship of antimicrobials, but lowers costs and potentially improves patients’ well-being. It’s always better to avoid IV access if possible, and the narrower spectrum oral antimicrobials kill off fewer healthy bacteria than broader spectrum agents.”

References

1. Norris AH, Shrestha NN, Allisoin GM, et al. 2018 IDSA Clinical Practice Guideline for the Management of Outpatient Parenteral Antimicrobial Therapy. Clin Infect Dis. 2018; https://doi.org/10.1093/cid/ciy745.

2. ID Specialist input improves outcomes for outpatient parenteral antimicrobial therapy: New IDSA Guidelines [news release]. Arlington, Va. IDSA website. https://www.idsociety.org/news--publications-new/articles/2018/id-specialist-input-improves-outcomes-for--outpatient-parenteral-antimicrobial-therapy-new-idsa-guidelines/ Accessed November 13, 2018.