- Email: [email protected]
Outpatient parenteral antibiotic therapy
,NTERN*TlORAL
,clURrf*L
OF
Antimicrobial Agents ELSEVIER
International Journal of Antimicrobial Agents 5 (1995) 9-12
Outpatient parenteral antibiotic therapy Donald M. Poretz* Infectious
Diseases, Infec!ious Diseases Physicians Inc., Fairfax Hospital, 3289 Woodburn Road, Suite 200, Annandale, VA 22003, USA
Received 21 March 1994; accepted 22 August 1994
Abstract
Clinical studies have shown that outpatient administration of parenteral antibiotics is safe, cost-effective and practical. The development of new antibiotics with prolonged half-lives, such as ceftriaxone or cefotetan, has facilitated outpatient parenteral antibiotic therapy (OPAT). Good OPAT management requires coordination of physicians, nurses, pharmacists and health care administrators, and the establishment of firm guidelines. A variety of infections can be treated through OPAT,including osteomyelitis
and soft tissue infections, chronic urinary tract infections, and ear, nose and throat infections. Keywords:
Outpatient parenteral antibiotic therapy (OPAT), guidelines, infections, side-effects
1. Introduction Treatment of a wide variety of infectious diseases, that had previously required hospitalization for up to several weeks in order to administer parenteral antibiotics, has been shown to be safely administered on an outpatient basis. Numerous clinical studies have demonstrated that the administration of intravenous (i.v.) antibiotics on an outpatient basis to selected patients is safe, cost-effective and practical, and can reduce overall health-care expenditure. The first study of i.v. antibiotic therapy in an outpatient setting was publishead in 1978, and involved 13 patients who self-administered parenteral antibiotics, primarily for osteomyelitis [I]. A significant cost saving was noted compared with a control group of similar patients treated in hospital. Several other publications subsequently appeared in the medical literature, all of which demonstrated the safety, efficacy, and cost savings of outpatient i.v. antibiotic therapy [2-111. Most of the original studies focused on bone and joint infections but, as experience grew, it was shown that a wide variety of other infectious processes were amenable to outpatient i.v. antibiotic therapy. The development of newer /3-lactam antibiotics with prolonged half-lives, in particular,
*Tel. (+l-703) 560 7900; Fax (+l-703) 560 8408. 0924-8579/95/$29.000 1995 Elsevier Science B.V. All rights reserved SSDZ 0924-8579(94)00041-7
has helped facilitate the spread of outpatient parenteral antibiotic therapy.
2. Multidisciplinary approach Management of outpatient parenteral therapy requires a multidisciplinary approach that makes use of physicians, nurses, pharmacists, and health care administrators. A physician with training in internal medicine and infectious diseases often assumes the lead role in such programmes and will be ultimately responsible for the care of each patient. The physician will follow the patient clinically, looking at all aspects of the particular infection being treated, correlating laboratory data, and communicating with other physicians involved in the care of the patient and with other members of the team. A registered nurse with specialized knowledge of vascular devices and vascular access is also vital to the success of an outpatient i.v. antibiotic programme. Guidelines for nurses involved with i.v. devices were established by the National Intravenous Therapy Association (NITA) in 1984 [12]. The nurse is responsible for training the patient or family member in the management of vascular access and medication delivery. Potential complications are explained by the nurse to patients and their families and the nurse is also responsible for demonstrating the daily care of the i.v. device and aseptic
10
D.M.
Poretzllnternational
Journal of Antimicrobial
practices to the patient. The first dose of any antibiotic should be witnessed by the nurse or physician to make sure that no untoward side-effects occur. A pharmacist is also an integral part of the outpatient iv. team, offering expertise in parenteral compounding and i.v. admixture services. The pharmacist will assist the nurse in the training of patients as well as in preparing medications. Involvement in the preparation of materials used for patient training, consultation with healthcare team members regarding medication, ordering supplies as necessary, and regularly inspecting equipment also form part of the pharmacist’s function. Pharmacists, nurses, and physicians must all work closely together, monitoring the patient’s condition and paying careful attention to potential adverse reactions and sideeffects. The administrator of an outpatient programme needs to be concerned with the logistics of finances, billing and insurance reimbursement.
3. Identifying suitable patients A number of consensus criteria have been established for the evaluation of potential candidates for outpatient i.v. antibiotic therapy. Some of the most important are shown below: Medical stability
Patients entered for outpatient therapy should be medically stable, afebrile with the medical condition stable enough to be managed on an outpatient basis. Drainage from wounds should be easily containable by a bandage. Patients with a diagnosis of infective endocarditis should be free of embolic phenomena and not show indications of congestive heart failure. Compliance
The patient should be compliant with all aspects of i.v. administration of outpatient drugs. Capability
Patients unable to self-administer medication should have a nurse, family member or other designated individual available to assume this responsibility. All aspects of aseptic technique and i.v. access maintenance, as well as specific instructions regarding medication, must be explained carefully to the patient or care-giver. Maintainable venous access
An adequate venous access must be available and maintained without too much difficulty. Factors that would exclude patients from participating in an outpatient i.v. programme include current substance abuse, impaired vision, a home environment that would prohibit proper treatment due to a lack of electricity, running water or refrigeration, and unhygienic surroundings.
Agents 5 (1995) 9-12
4. Equipment
A vascular access device is essential for outpatient administration of i.v. antibiotics. This can be a simple 1.25-in. plastic radio-opaque catheter, or one of many long-term indwelling i.v. devices such as a BroviacTM, HickmanTM or GroshongTM, or a totally buried subcutaneous device [13-141. The so-called midline, long line or peripherally-inserted central catheters have become increasingly popular since an operation is not necessary to insert them. Although many of these catheters are expensive to insert and maintain, they may be left in place for many weeks or months without replacement. Potential complications of central line catheter placement include pneumothorax, brachial plexus injury, haemorrhage, air embolism, catheter thrombosis, catheter tip migration, and catheter sepsis. Patency of these catheters is maintained by heparinized saline, but sometimes thrombolytic agents are necessary to dissolve clots. A variety of infusion devices is available to ensure appropriate infusion times [ 151. These devices are significantly smaller than the ones used in a hospital setting and are quite accurate. Antibiotics are usually reconstituted in plastic infusion bags and, on occasion, can be mixed in advance and frozen until they are ready to be infused. Occasionally, patients have been taught to mix their own antibiotics under sterile conditions. Most antibiotics are stable in solution for at least 48 h and many are stable for several days. Outpatient parenteral antibiotics can be administered in a variety of settings. It is commonplace for infusions to be given in the home with the help of a family member or visiting nurse. So-called ‘infusion centres’ have also been developed where patients can be observed directly in a facility with medical personnel in attendance [16]. Such centres have the advantage that laboratory results can be obtained rapidly and medication changed if necessary. Additional sites for infusion therapy include hospitals or other outpatient clinics and physicians’ offices. While intramuscular therapy is occasionally used for outpatient administration, pain at the injection site may limit the total number of injections possible [17].
5. Infections Over the years, clinical experience has shown that a wide variety of infections requiring parenteral antibiotics can be successfully treated on an outpatient basis (Table 1) [18]. Osteomyelitis and soft tissue infections are the most common entities that have been treated on an outpatient basis [19,20]. Many of these infections are in individuals with diabetes, peripheral vascular or other underlying diseases, and often require several weeks of therapy before they resolve. Occasionally these patients will need to be rehospitalized for bridement of wounds
D.M. Poretzllnternational Journal of Antimicrobial Agents 5 (1995) 9-12
and other surgical manipulations. More recently, the development of fluoroquinolones has allowed the early institution of oral antibiotic therapy in some individuals previously requiring long courses of parenteral treatment
VI. Outpatient i.v. antibiotic therapy has also proved to be of value in individuals with chronic urinary tract infections who have had repeated courses of oral antibiotics to which bacteria have become resistant. Pelvic inflammatory disease; ear, nose and throat infections including sinusitis, mastoiditis and otitis; and pulmonary infections such as exacerbations of chronic lung disease, bronchiostasis and infections in patients with cystic fibrosis have been quite amenable to outpatient therapy [22-241. Treatment of infective endocarditis, particularly penicillin-sensitive streptococcal endocarditis, has been documented as safe and effective when patients are carefully selected [25,26]. Other endothelial surface infections, including infected vascular grafts, have likewise been treated on an outpa.tient basis. Infected prosthetic devices, often requiring prolonged i.v. therapy, can be safely treated on an outpatient basis. More recently, infections involving neutropenic cancer patients have been shown to be safely and effectively treated in outpatient clinics with appropriate close monitoring [27,28]. Infections in individuals with AIDS who require drugs such as acyclovir, ganciclovir, foscarnet, amphotericin B and pentamidine, are now commonly treated on an outpatient .basis. Of course, careful monitoring for potential side-effects, and biochemical and physiological abnormalities is mandatory.
6. Antimicrobial therapy A variety of antimicrobial agents has been successfully administered on an outp’atient basis. Of particular importance has been the development of antibiotics with prolonged half-lives that have allowed for once or twice daily administration. Ceftriaxone, cefoperazone and cefotetan have been particularly popular, though almost any antibiotic that can be administered in the hospital can also be given on an outpatient basis [29-311. Drugs Table 1 Types of infections treated
Bone and joint Skin/skin structure Respiratory Urinary tract Pelvic inflammatory disease Endocarditis Bacteraemia Miscellaneous Total
Number
%
1249 123 434 272 102 68 48 351 3247
38 22 13 8 3 2
1
11
with short half-lives requiring multiple administrations, however, are difficult to give on an outpatient basis. Medications that are veno-irritative and necessitate multiple changes of the i.v. device are also difficult for outpatient administration. Occasionally, it will be necessary to mix drugs together for ease of administration. Combinations of a cephalosporin and clindamycin or an aminoglycoside with clindamycin are compatible in solution and will decrease the total number of infusions required compared with giving these drugs separately. The most common side-effects noted during outpatient administration of parenteral antibiotics include gastrointestinal complaints, ranging from mild nausea to antibiotic-induced colitis secondary to infection with Clostridium dljjkile. The appearance of skin rashes as a manifestation of antibiotic allergy may lead to a need to discontinue the antibiotic and change to a drug of a different class. A disulfiram-like reaction may occur with cephalosporins containing a methylthiotetrazole sidechain (cephamandole, cefoperazone, moxalactam); patients must be warned not to take alcohol when they are taking one of these drugs. Additionally, bleeding exacerbations have been reported with these agents. Common haematological abnormalities include leukopenia, which is particularly common when p-lactam antibiotics are used but can also be seen with vancomycin and clindamycin. Most outpatient programmes obtain complete blood counts twice weekly. Renal function needs to be monitored twice weekly or as necessary depending on which antibiotic is used. Renal monitoring is especially important in the case of aminoglycosides. Diabetics and individuals with renal disease will obviously require more frequent monitoring in addition to obtaining antibiotic blood levels. Many antibiotics will cause nonspecific elevation of levels of liver enzymes; this usually does not require discontinuation of the drug. Particular attention needs to be paid to the possibility of interactions if the patient is receiving other medications.
7. Cost savings Home parenteral antibiotic therapy has been shown to save between 68% and 78% of the costs required for similar in-hospital care [32-341. While it costs us about $11 000 for a 3-6-week programme of i.v. antibiotic therapy in hospital, the same treatment at home has been found to cost approximately $4000. Many third-party payers have recognized the dramatic cost savings of home therapy and are routinely including this type of care in their policies. In addition, patients can often maintain normal lives and activities instead of having to stay in hospital for prolonged periods. The majority of adults are often able to return to work and children can attend school while they receive their outpatient antibiotics. In the future, it is anticipated that more care will be
12
D.M. Poretzllnternational
Journal of Antimicrobial Agents 5 (1995) 9-12
given in non-hospital settings, and medical personnel, particularly physicians with a special interest in infectious diseases, will need to be educated about aspects of outpatient care.
References PI Antoniskis A, Anderson BC, Van Volkinburg EJ, Jackson JM, Gilbert DN. Feasibility of outpatient self-administration of parenteral antibiotics. West J Med 1978;128:203-206. PI Stiver HG, Telford GO, Mossey GM et al. Intravenous antibiotic therapy at home. Ann Int Med 1978;89(1):690-693. [31 Stiver HG, Trosky SK, Cote DD, Oruck JL. Selfadministration of intravenous antibiotics: an efficient, cost-effective home care program. Can Med Assoc J 1982;127:207-211. [41 Kind AC, Williams DN, Parsons G, Gibson J. Intravenous antibiotic therapy at home. Arch Intern Med 1979;139:413-415. 151Rehm SJ, Weinstein AJ. Home intravenous antibiotic therapy: a team approach. Ann Int Med 1983;99:388-392. WI Poretz DM, Eron LJ, Goldenberg RI et al. Intravenous antibiotic therapy in an outpatient setting. JAMA 1982;248(3):336339. [71 Eisenberg JM, Kitz DS. Savings from outpatient antibiotic therapy for osteomyelitis. Economic analysis of a therapeutic strategy. JAMA 1986;255(12):158&1588. PI Poretz DM. Home management of intravenous antibiotic therapy. Bull N.Y. Acad Med 1988;64(6):57&576. [91 Smego RA Jr. Home intravenous antibiotic therapy. Arch Intern Med 1985;145(6):1001-1002. [lOI Williams DN, Kind AC, Gibson JA, Person G. Outpatient intravenous antibiotic experience with 65 patients. Am J IV Ther Clin Nutr 1982;9:3340. [ill Powell KR, Mawhorter SD. Outpatient treatment of serious infections in infants and children with ceftriaxone. J Ped 1987;107:898901. u21 Home I.V. therapy. NITA Journal 1984;8(2):93. t131 Hickman RO, Buckner CD, Clift RA, Sanders JE, Stewart P, Thomas ED. A modified right atria1 catheter for access to the venous system in marrow transplant recipients. Surgery, Gynecol Obstetr 1979;148:871-875. 1141August DA. Venous access in the outpatient: techniques and devices. Outpatient Ther Med 1987;2(4):1-7. [I51 Kwan JW. High technology I.V. infusion devices. Am J Hosp Pharm 1989;46:320-352. [I61 Poretz DM. The infusion center: a model for outpatient parenteral antibiotic therapy. Rev Infect Dis 1991;13(suppl 2):S142-146. [I71 Russo TA, Cook S, Gorbach SL. Intramuscular ceftriaxone in home parenteral therapy. Antimicrob Agents Chemother 1988;32(9):1439-1440.
[18] Remington J, Swartz M. Current clinical topics in infectious diseases. Blackwell Scientific Publications. [19] Eron LJ, Park CH, Hixon DL, Goldenberg RI, Poretz DM. Ceftriaxone therapy of bone and soft tissue infections in hospital and outpatient settings. Antimicrob Agents Chemother 1983;23(5):731-737. [20] Ingram C, Eron LJ, Goldenberg RI et al. Antibiotic therapy of osteomyelitis in outpatients. Medical Clinics of North America 1988;72:723-738. [21] Neu H. Medical Clinics of North America. Chapter on Quinolones, May 1988;72(3):623-636. [22] Winter RJD, George RJD, Deacock SJ et al. Self-administered home intravenous antibiotic therapy in bronchiectasis and adult cystic fibrosis. Lancet 1984;1:1338-1339. [23] Strandvik LH, Malmborg AS, Widen B. Home intravenous antibiotic treatment of patients with cystic fibrosis. Acta Paediatr 1992;81:340-344. [24] Gilbert J, Robinson T, Littlewood JM. Home intravenous antibiotic treatment in cystic fibrosis. Arch Dis Child 1988;63:512517. ~251Francioli P, Etienne J, Hoigne R. Treatment of streptococcal endocarditis with a single daily dose of ceftriaxone sodium for 4 weeks. JAMA 1992;267(2):26&267. WI Stamboulian D, Bonvehi Anevalo C et al. Antibiotic management of outpatients with endocarditis due to penicillin-susceptible streptococci. Rev Infect Dis 1991;13(suppl 2):S160-163. v71 Talcott JA, Whalen A, Clark J et al. Home antibiotic therapy for low-risk cancer patients with fever and neutropenia: a pilot study of 30 patients based on a validated prediction rule. J Clin One 1994;12(1):107-114. PI Rubenstein EB, Rolston K, Benjamin RS. Outpatient treatment of febrile episodes in low-risk neutropenic patients with cancer. Cancer 1993;71(11):364&3646. ~291Eron LJ, Goldenberg RI, Poretz DM. Combined ceftriaxone and surgical therapy for osteomyelitis in hospital and outpatient settings. Am J Surg 1984;148(4A):14. 1301Kunkel MJ, Iannini PB. Cefonicid in a once-daily regimen for treatment of osteomyelitis in an ambulatory setting. Rev Infect Dis 1984;4:S865-S869. [311 Eron LJ, Goldenberg RI, Poretz DM. Outpatient cefoperazone therapy. In: Ishigiami J, ed. Recent Advances in Chemotherapy. University of Tokyo Press, Tokyo 1985;1040-1041. [321 Poretz DM, Wooldard D, Eron LJ, Goldenberg RI, Rising J, Sparks S. Outpatient use of ceftriaxone: a cost-benefit analysis. Am J Med 1984;77(4C):77-83. 1331Jacobs J, Wyant S. Economic examination of cefoperazone therapy. Drug Intel1 Clin Pharm 1987;21:373-379. 1341Balinsky W, Nesbitt S. Cost-effectiveness of cefoperazone parenteral antibiotics: a review ofthe literature. Am J Med 1989;87:301305.
,clURrf*L
OF
Antimicrobial Agents ELSEVIER
International Journal of Antimicrobial Agents 5 (1995) 9-12
Outpatient parenteral antibiotic therapy Donald M. Poretz* Infectious
Diseases, Infec!ious Diseases Physicians Inc., Fairfax Hospital, 3289 Woodburn Road, Suite 200, Annandale, VA 22003, USA
Received 21 March 1994; accepted 22 August 1994
Abstract
Clinical studies have shown that outpatient administration of parenteral antibiotics is safe, cost-effective and practical. The development of new antibiotics with prolonged half-lives, such as ceftriaxone or cefotetan, has facilitated outpatient parenteral antibiotic therapy (OPAT). Good OPAT management requires coordination of physicians, nurses, pharmacists and health care administrators, and the establishment of firm guidelines. A variety of infections can be treated through OPAT,including osteomyelitis
and soft tissue infections, chronic urinary tract infections, and ear, nose and throat infections. Keywords:
Outpatient parenteral antibiotic therapy (OPAT), guidelines, infections, side-effects
1. Introduction Treatment of a wide variety of infectious diseases, that had previously required hospitalization for up to several weeks in order to administer parenteral antibiotics, has been shown to be safely administered on an outpatient basis. Numerous clinical studies have demonstrated that the administration of intravenous (i.v.) antibiotics on an outpatient basis to selected patients is safe, cost-effective and practical, and can reduce overall health-care expenditure. The first study of i.v. antibiotic therapy in an outpatient setting was publishead in 1978, and involved 13 patients who self-administered parenteral antibiotics, primarily for osteomyelitis [I]. A significant cost saving was noted compared with a control group of similar patients treated in hospital. Several other publications subsequently appeared in the medical literature, all of which demonstrated the safety, efficacy, and cost savings of outpatient i.v. antibiotic therapy [2-111. Most of the original studies focused on bone and joint infections but, as experience grew, it was shown that a wide variety of other infectious processes were amenable to outpatient i.v. antibiotic therapy. The development of newer /3-lactam antibiotics with prolonged half-lives, in particular,
*Tel. (+l-703) 560 7900; Fax (+l-703) 560 8408. 0924-8579/95/$29.000 1995 Elsevier Science B.V. All rights reserved SSDZ 0924-8579(94)00041-7
has helped facilitate the spread of outpatient parenteral antibiotic therapy.
2. Multidisciplinary approach Management of outpatient parenteral therapy requires a multidisciplinary approach that makes use of physicians, nurses, pharmacists, and health care administrators. A physician with training in internal medicine and infectious diseases often assumes the lead role in such programmes and will be ultimately responsible for the care of each patient. The physician will follow the patient clinically, looking at all aspects of the particular infection being treated, correlating laboratory data, and communicating with other physicians involved in the care of the patient and with other members of the team. A registered nurse with specialized knowledge of vascular devices and vascular access is also vital to the success of an outpatient i.v. antibiotic programme. Guidelines for nurses involved with i.v. devices were established by the National Intravenous Therapy Association (NITA) in 1984 [12]. The nurse is responsible for training the patient or family member in the management of vascular access and medication delivery. Potential complications are explained by the nurse to patients and their families and the nurse is also responsible for demonstrating the daily care of the i.v. device and aseptic
10
D.M.
Poretzllnternational
Journal of Antimicrobial
practices to the patient. The first dose of any antibiotic should be witnessed by the nurse or physician to make sure that no untoward side-effects occur. A pharmacist is also an integral part of the outpatient iv. team, offering expertise in parenteral compounding and i.v. admixture services. The pharmacist will assist the nurse in the training of patients as well as in preparing medications. Involvement in the preparation of materials used for patient training, consultation with healthcare team members regarding medication, ordering supplies as necessary, and regularly inspecting equipment also form part of the pharmacist’s function. Pharmacists, nurses, and physicians must all work closely together, monitoring the patient’s condition and paying careful attention to potential adverse reactions and sideeffects. The administrator of an outpatient programme needs to be concerned with the logistics of finances, billing and insurance reimbursement.
3. Identifying suitable patients A number of consensus criteria have been established for the evaluation of potential candidates for outpatient i.v. antibiotic therapy. Some of the most important are shown below: Medical stability
Patients entered for outpatient therapy should be medically stable, afebrile with the medical condition stable enough to be managed on an outpatient basis. Drainage from wounds should be easily containable by a bandage. Patients with a diagnosis of infective endocarditis should be free of embolic phenomena and not show indications of congestive heart failure. Compliance
The patient should be compliant with all aspects of i.v. administration of outpatient drugs. Capability
Patients unable to self-administer medication should have a nurse, family member or other designated individual available to assume this responsibility. All aspects of aseptic technique and i.v. access maintenance, as well as specific instructions regarding medication, must be explained carefully to the patient or care-giver. Maintainable venous access
An adequate venous access must be available and maintained without too much difficulty. Factors that would exclude patients from participating in an outpatient i.v. programme include current substance abuse, impaired vision, a home environment that would prohibit proper treatment due to a lack of electricity, running water or refrigeration, and unhygienic surroundings.
Agents 5 (1995) 9-12
4. Equipment
A vascular access device is essential for outpatient administration of i.v. antibiotics. This can be a simple 1.25-in. plastic radio-opaque catheter, or one of many long-term indwelling i.v. devices such as a BroviacTM, HickmanTM or GroshongTM, or a totally buried subcutaneous device [13-141. The so-called midline, long line or peripherally-inserted central catheters have become increasingly popular since an operation is not necessary to insert them. Although many of these catheters are expensive to insert and maintain, they may be left in place for many weeks or months without replacement. Potential complications of central line catheter placement include pneumothorax, brachial plexus injury, haemorrhage, air embolism, catheter thrombosis, catheter tip migration, and catheter sepsis. Patency of these catheters is maintained by heparinized saline, but sometimes thrombolytic agents are necessary to dissolve clots. A variety of infusion devices is available to ensure appropriate infusion times [ 151. These devices are significantly smaller than the ones used in a hospital setting and are quite accurate. Antibiotics are usually reconstituted in plastic infusion bags and, on occasion, can be mixed in advance and frozen until they are ready to be infused. Occasionally, patients have been taught to mix their own antibiotics under sterile conditions. Most antibiotics are stable in solution for at least 48 h and many are stable for several days. Outpatient parenteral antibiotics can be administered in a variety of settings. It is commonplace for infusions to be given in the home with the help of a family member or visiting nurse. So-called ‘infusion centres’ have also been developed where patients can be observed directly in a facility with medical personnel in attendance [16]. Such centres have the advantage that laboratory results can be obtained rapidly and medication changed if necessary. Additional sites for infusion therapy include hospitals or other outpatient clinics and physicians’ offices. While intramuscular therapy is occasionally used for outpatient administration, pain at the injection site may limit the total number of injections possible [17].
5. Infections Over the years, clinical experience has shown that a wide variety of infections requiring parenteral antibiotics can be successfully treated on an outpatient basis (Table 1) [18]. Osteomyelitis and soft tissue infections are the most common entities that have been treated on an outpatient basis [19,20]. Many of these infections are in individuals with diabetes, peripheral vascular or other underlying diseases, and often require several weeks of therapy before they resolve. Occasionally these patients will need to be rehospitalized for bridement of wounds
D.M. Poretzllnternational Journal of Antimicrobial Agents 5 (1995) 9-12
and other surgical manipulations. More recently, the development of fluoroquinolones has allowed the early institution of oral antibiotic therapy in some individuals previously requiring long courses of parenteral treatment
VI. Outpatient i.v. antibiotic therapy has also proved to be of value in individuals with chronic urinary tract infections who have had repeated courses of oral antibiotics to which bacteria have become resistant. Pelvic inflammatory disease; ear, nose and throat infections including sinusitis, mastoiditis and otitis; and pulmonary infections such as exacerbations of chronic lung disease, bronchiostasis and infections in patients with cystic fibrosis have been quite amenable to outpatient therapy [22-241. Treatment of infective endocarditis, particularly penicillin-sensitive streptococcal endocarditis, has been documented as safe and effective when patients are carefully selected [25,26]. Other endothelial surface infections, including infected vascular grafts, have likewise been treated on an outpa.tient basis. Infected prosthetic devices, often requiring prolonged i.v. therapy, can be safely treated on an outpatient basis. More recently, infections involving neutropenic cancer patients have been shown to be safely and effectively treated in outpatient clinics with appropriate close monitoring [27,28]. Infections in individuals with AIDS who require drugs such as acyclovir, ganciclovir, foscarnet, amphotericin B and pentamidine, are now commonly treated on an outpatient .basis. Of course, careful monitoring for potential side-effects, and biochemical and physiological abnormalities is mandatory.
6. Antimicrobial therapy A variety of antimicrobial agents has been successfully administered on an outp’atient basis. Of particular importance has been the development of antibiotics with prolonged half-lives that have allowed for once or twice daily administration. Ceftriaxone, cefoperazone and cefotetan have been particularly popular, though almost any antibiotic that can be administered in the hospital can also be given on an outpatient basis [29-311. Drugs Table 1 Types of infections treated
Bone and joint Skin/skin structure Respiratory Urinary tract Pelvic inflammatory disease Endocarditis Bacteraemia Miscellaneous Total
Number
%
1249 123 434 272 102 68 48 351 3247
38 22 13 8 3 2
1
11
with short half-lives requiring multiple administrations, however, are difficult to give on an outpatient basis. Medications that are veno-irritative and necessitate multiple changes of the i.v. device are also difficult for outpatient administration. Occasionally, it will be necessary to mix drugs together for ease of administration. Combinations of a cephalosporin and clindamycin or an aminoglycoside with clindamycin are compatible in solution and will decrease the total number of infusions required compared with giving these drugs separately. The most common side-effects noted during outpatient administration of parenteral antibiotics include gastrointestinal complaints, ranging from mild nausea to antibiotic-induced colitis secondary to infection with Clostridium dljjkile. The appearance of skin rashes as a manifestation of antibiotic allergy may lead to a need to discontinue the antibiotic and change to a drug of a different class. A disulfiram-like reaction may occur with cephalosporins containing a methylthiotetrazole sidechain (cephamandole, cefoperazone, moxalactam); patients must be warned not to take alcohol when they are taking one of these drugs. Additionally, bleeding exacerbations have been reported with these agents. Common haematological abnormalities include leukopenia, which is particularly common when p-lactam antibiotics are used but can also be seen with vancomycin and clindamycin. Most outpatient programmes obtain complete blood counts twice weekly. Renal function needs to be monitored twice weekly or as necessary depending on which antibiotic is used. Renal monitoring is especially important in the case of aminoglycosides. Diabetics and individuals with renal disease will obviously require more frequent monitoring in addition to obtaining antibiotic blood levels. Many antibiotics will cause nonspecific elevation of levels of liver enzymes; this usually does not require discontinuation of the drug. Particular attention needs to be paid to the possibility of interactions if the patient is receiving other medications.
7. Cost savings Home parenteral antibiotic therapy has been shown to save between 68% and 78% of the costs required for similar in-hospital care [32-341. While it costs us about $11 000 for a 3-6-week programme of i.v. antibiotic therapy in hospital, the same treatment at home has been found to cost approximately $4000. Many third-party payers have recognized the dramatic cost savings of home therapy and are routinely including this type of care in their policies. In addition, patients can often maintain normal lives and activities instead of having to stay in hospital for prolonged periods. The majority of adults are often able to return to work and children can attend school while they receive their outpatient antibiotics. In the future, it is anticipated that more care will be
12
D.M. Poretzllnternational
Journal of Antimicrobial Agents 5 (1995) 9-12
given in non-hospital settings, and medical personnel, particularly physicians with a special interest in infectious diseases, will need to be educated about aspects of outpatient care.
References PI Antoniskis A, Anderson BC, Van Volkinburg EJ, Jackson JM, Gilbert DN. Feasibility of outpatient self-administration of parenteral antibiotics. West J Med 1978;128:203-206. PI Stiver HG, Telford GO, Mossey GM et al. Intravenous antibiotic therapy at home. Ann Int Med 1978;89(1):690-693. [31 Stiver HG, Trosky SK, Cote DD, Oruck JL. Selfadministration of intravenous antibiotics: an efficient, cost-effective home care program. Can Med Assoc J 1982;127:207-211. [41 Kind AC, Williams DN, Parsons G, Gibson J. Intravenous antibiotic therapy at home. Arch Intern Med 1979;139:413-415. 151Rehm SJ, Weinstein AJ. Home intravenous antibiotic therapy: a team approach. Ann Int Med 1983;99:388-392. WI Poretz DM, Eron LJ, Goldenberg RI et al. Intravenous antibiotic therapy in an outpatient setting. JAMA 1982;248(3):336339. [71 Eisenberg JM, Kitz DS. Savings from outpatient antibiotic therapy for osteomyelitis. Economic analysis of a therapeutic strategy. JAMA 1986;255(12):158&1588. PI Poretz DM. Home management of intravenous antibiotic therapy. Bull N.Y. Acad Med 1988;64(6):57&576. [91 Smego RA Jr. Home intravenous antibiotic therapy. Arch Intern Med 1985;145(6):1001-1002. [lOI Williams DN, Kind AC, Gibson JA, Person G. Outpatient intravenous antibiotic experience with 65 patients. Am J IV Ther Clin Nutr 1982;9:3340. [ill Powell KR, Mawhorter SD. Outpatient treatment of serious infections in infants and children with ceftriaxone. J Ped 1987;107:898901. u21 Home I.V. therapy. NITA Journal 1984;8(2):93. t131 Hickman RO, Buckner CD, Clift RA, Sanders JE, Stewart P, Thomas ED. A modified right atria1 catheter for access to the venous system in marrow transplant recipients. Surgery, Gynecol Obstetr 1979;148:871-875. 1141August DA. Venous access in the outpatient: techniques and devices. Outpatient Ther Med 1987;2(4):1-7. [I51 Kwan JW. High technology I.V. infusion devices. Am J Hosp Pharm 1989;46:320-352. [I61 Poretz DM. The infusion center: a model for outpatient parenteral antibiotic therapy. Rev Infect Dis 1991;13(suppl 2):S142-146. [I71 Russo TA, Cook S, Gorbach SL. Intramuscular ceftriaxone in home parenteral therapy. Antimicrob Agents Chemother 1988;32(9):1439-1440.
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