2018 Infectious Diseases Society of America Clinical Practice Guideline for the Management of Outpatient Parenteral Antimicrobial Therapy

Implementing the First Outpatient Parenteral Antimicrobial Therapy (OPAT) Program to Utilize Disposable Elastomeric Pumps in the Gulf Region: Results From a Tertiary Teaching Hospital in the Kingdom of Saudi Arabia

Objectives To describe the implementation process, safety, and efficacy outcomes, as well as cost-effectiveness, of the first outpatient parenteral antimicrobial therapy (OPAT) program to utilize disposable elastomeric pumps in the Kingdom of Saudi Arabia and the entire Gulf region. Methods This OPAT program was initiated in May 2018 and was administered through a multidisciplinary team that included the home medicine department, pharmacy department, nursing department, and the infectious diseases service. The device used was the Intermate® (Baxter, Deerfield, Illinois) elastomeric pump. After consultation with an infectious diseases physician, eligible patients were discharged home to complete the remainder of their antimicrobial treatment, which was self-administered via the elastomeric devices. Results From May 2018 to December 2019, 47 patients received 55 courses of OPAT via the new program. A total of 2,869 pumps were used during that period to provide 927 days of antimicrobial therapy in the home setting. Most patients completed the program successfully with no reported significant OPAT-related complications such as catheter-related infections. Four patients were re-admitted for relapse of infections and one patient was re-admitted for colistin-induced nephrotoxicity. No mortality was reported for any patient during OPAT treatment and 30 days after program completion. Conclusions The implementation of this novel OPAT program was safe, effective, and offered significant cost-savings to our institution. The entire process was very dynamic and was centered around proper patient selection and education as well as excellent communication between patients and the entire multidisciplinary team involved in the program. We hope that these results will encourage other institutions in the region to implement similar OPAT programs to alleviate the existing bed crisis due to the ongoing COVID-19 pandemic.

Current and future options for treating complicated skin and soft tissue infections: focus on fluoroquinolones and long-acting lipoglycopeptide antibiotics

Bacterial skin and soft tissue infections are among the most common bacterial infections and constitute a major burden for patients and healthcare systems. Care is complicated by the variety of potential pathogens, some with resistance to previously effective antimicrobial agents, the wide spectrum of clinical presentations and the risk of progression to life-threatening forms. More-efficient care pathways are needed that can reduce hospital admissions and length of stay, while maintaining a high quality of care and adhering to antimicrobial stewardship principles. Several agents approved recently for treating acute bacterial skin and skin structure infections have characteristics that meet these requirements. We address the clinical and pharmacological characteristics of the fourth-generation fluoroquinolone delafloxacin, and the long-acting lipoglycopeptide agents dalbavancin and oritavancin.

Recent Updates in Antimicrobial Stewardship in Outpatient Parenteral Antimicrobial Therapy

Purpose of Review

Antimicrobial stewardship within acute care is common and has been expanding to outpatient areas. Some inpatient antimicrobial stewardship tactics apply to outpatient parenteral antimicrobial therapy (OPAT) and complex outpatient antimicrobial therapy (COpAT) management, but differences do exist.

Recent Findings

OPAT/COpAT is a growing area of practice and research with its own unique considerations for antimicrobial stewardship. Potential ideas for antimicrobial stewardship in the OPAT/COpAT setting include redesigning the regimen to COpAT instead of OPAT, ensuring the use of the shortest effective duration of antimicrobial therapy; using antimicrobials dosed less frequently, such as long-acting glycopeptides; optimizing antimicrobial susceptibility testing reporting for common OPAT/COpAT drugs; and establishing routine laboratory and safety monitoring. Future consensus is needed to determine validated OPAT program metrics and outcomes.

Summary

As more focus is placed on outpatient antimicrobial stewardship, clinicians practicing in OPAT should publish more data regarding OPAT program methods and outcomes as they relate to antimicrobial stewardship. These can involve patient clinical outcomes, OPAT readmission rates, OPAT therapy completion, and central line-related complications.

Stability of Ampicillin in Normal Saline Following Refrigerated Storage and 24-Hour Pump Recirculation

Objective

Use of ampicillin in outpatient parenteral antimicrobial therapy (OPAT) has historically been complicated by frequent dosing and limited stability. The purpose of this study was to evaluate stability of ampicillin using high-pressure liquid chromatography (HPLC) in an OPAT dosing model using continuous infusion at room temperature over 24 hours immediately following preparation compared with batches stored under refrigeration for 24 hours, 72 hours, and 7 days.

Methods

An HPLC method was developed and validated as stability indicating using guidance in USP general Chapter <1225>. Four ampicillin batches were prepared for each experimental condition (immediate use and refrigerated storage for 24 hours, 72 hours, and 7 days). A pump was used to recirculate the solutions through medical-grade tubing for 24 hours. Triplicate 1-mL aliquots were removed from each batch at time 0, 4, 8, 12, and 24 hours and analyzed for ampicillin concentration.

Results

Each batch was assayed for initial concentration (20.34-21.50 mg/mL), and percent recovery compared with that concentration thereafter. For the duration of infusion, the average recoveries were 96.4%, 95.8%, 94.6%, and 90.3% for immediate use, 24-hour storage, 72-hour storage, and 7-day storage, respectively. The recovery remained above 90% for all batches and time points, except for 7-day storage, which fell below 90% after 4 hours of circulation.

Conclusion

Ampicillin can be prepared and stored in a refrigerator for up to 72 hours prior to continuously infusing at room temperature over 24 hours with less than a 10% loss of potency over the dosing period. This model supports twice weekly OPAT delivery of ampicillin.

Association of a Substance Use Disorder with Infectious Diseases among Adult Home Healthcare Patients with a Venous Access Device

Substance use disorders (SUDs) and high incidence of infectious diseases are both critical public health issues. Among patients who use a venous access device (VAD) in home care settings, SUDs may play a role in increasing their risk of having a concurrent infectious disease. This study examined the association of SUD with infectious diseases among adult home healthcare patients with a VAD. We identified adult patients with an existing VAD who were admitted to a home healthcare agency August 1, 2017-July 31, 2018 from the electronic health records of a large Medicare-certified agency. Four serious infectious diseases (endocarditis, epidural abscess, septic arthritis, and osteomyelitis) and SUD related to injectable drugs were identified using relevant ICD-10 codes. Multiple logistic regression was performed to examine the association. Of 416 patients with a VAD, 12% (n = 50) had at least one diagnosis of a serious infectious disease. The percentage of patients who had a serious infectious disease was 40% among those with SUDs, compared with only 11% among those without SUDs. After adjusting for age and sex, the odds of having a serious infectious disease was 3.52 times greater for those with SUDs compared with those without (odds ratio [95% confidence interval], 4.52 [1.48-13.79], n = .008). Our findings suggest that home healthcare patients with a VAD and a documented SUD diagnosis may have an increased risk of having a concurrent serious infectious disease. Therefore, patients with an SUD and a VAD would need more attention from home healthcare providers to prevent a serious infectious disease. Further research is suggested on modalities of care for individuals with an SUD and VAD to reduce the incidence of infectious diseases so that care can be delivered safely and efficiently in a home healthcare setting.

Characteristics, safety and cost-effectiveness analysis of self-administered outpatient parenteral antibiotic therapy via a disposable elastomeric continuous infusion pump at two county hospitals in Houston, Texas, United States

WHAT IS KNOWN AND OBJECTIVE

Outpatient parenteral antibiotic therapy (OPAT) is an attractive option for patients who require parenteral antimicrobials as outpatients. Few OPAT studies have assessed the impact of IV antibiotic therapy via elastomeric continuous pumps, with most having been conducted outside the United States and few in county hospitals. The OPAT program in Harris Health system, the county hospital system of Houston, Texas, United States, has implemented a disposable elastomeric continuous infusion pump (eCIP) for self-administered intravenous antibiotics (s-OPAT) since December 2018. Our goal was to describe the clinical characteristics of patients discharged with an eCIP, as well as the safety and cost-effectiveness of this pump.

METHODS

We retrospectively analysed patients discharged from Harris Health hospitals between 12/2018 and 02/2021 with s-OPAT via eCIP at home. We extracted various patient characteristics and outcomes related to OPAT.

RESULTS AND DISCUSSION

Among 481 OPAT patients during the study period, 91 patients received s-OPAT via eCIP. A total of 1925 days of s-OPAT were administered at home, with a median duration of 12 days. Eighty-three patients (93.4%) achieved a cure from infection, six patients (6.6%) had side effects, and nine patients (9.9%) experienced 30-day hospital readmission. Twenty-two patients (24.2%) presented to the ED during s-OPAT, with 13 patients (14.3%) presenting with PICC line concerns. We estimated that s-OPAT via eCIP saved $2,360,500 to $3,503,900 compared to inpatient-only therapy.

WHAT IS NEW AND CONCLUSION

Our study showed that patients with s-OPAT via eCIP had a high cure rate with a relatively low incidence of side effects and 30-day hospital readmission. ED visits during therapy were relatively high, which indicates the necessity of close patient monitoring via the OPAT program. eCIP appears to be a good option to facilitate an early disposition of patients in county hospitals.

The impact of an outpatient parenteral antibiotic therapy (OPAT) clinic for adults with cellulitis: an interrupted time series study

Emergency department (ED) patients with cellulitis requiring intravenous antibiotics may be eligible for outpatient parenteral antibiotic therapy (OPAT). The primary objective was to determine whether implementation of an OPAT clinic results in decreased hospitalizations and return ED visits for patients receiving OPAT. We conducted an interrupted time series study involving adults with cellulitis presenting to two EDs and treated with intravenous antibiotics. The intervention was the OPAT clinic, which involved follow up at 48-96 h with an infectious disease physician to determine the need for ongoing intravenous antibiotics (implemented January 1, 2014). The primary outcomes were hospital admission and return ED visits within 14 days. Secondary outcomes were treatment failure (admission after initiating OPAT) and adverse peripheral line or antibiotic events. We used an interrupted time series design with segmented regression analysis over one-year pre-intervention and one-year post-intervention. 1666 patients were included. At the end of the study period, there was a non-significant 12% absolute increase in hospital admissions (95% CI - 1.6 to 25.5%; p = 0.084) relative to what would have been expected in the absence of the intervention, but a significant 40.7% absolute reduction in return ED visits (95% CI 25.6-55.9%; p < 0.001). Treatment failure rates were < 2% and adverse events were < 6% in both groups. Implementation of an OPAT clinic significantly reduced return ED visits for cellulitis, but did not reduce hospital admission rates. An ED-to-OPAT clinic model is safe, and has a low rate of treatment failures.

Improving the safety of outpatient parenteral antimicrobial therapy for patients with solid tumors

Background and objectives

Outpatient parenteral antimicrobial therapy (OPAT) for infections has been in use for nearly 40 years, and although it has been found safe and efficacious, its use has been studied primarily among otherwise healthy patients. We aimed to develop and evaluate an OPAT program for patients with cancer, particularly solid tumors.

Methods

We implemented multiple quality improvement interventions between June 2018 and January 2020. We retrospectively and prospectively collected data on demographics, the completeness of infectious diseases (ID) physician consultation notes, rates of laboratory test result monitoring, ID clinic follow-up, and 30-day outcomes, including unplanned OPAT-related readmissions, OPAT-related emergency center visits, and deaths.

Results

Completeness of ID provider notes improved from a baseline of 77 to 100% (p < .0001) for antimicrobial recommendations, 75 to 97% (p < .0001) for follow-up recommendations, and 19 to 98% (p < .0001) for laboratory test result monitoring recommendations. Completion of laboratory tests increased from a baseline rate of 24 to 56% (p = .027). Thirty-day unplanned OPAT-related readmission, ID clinic follow-up, 30-day emergency center visit, and death rates improved without reaching statistical significance.

Conclusions

Sustained efforts, multiple interventions, and multidisciplinary engagement can improve laboratory test result monitoring among solid tumor patients discharged with OPAT. Although demonstrating a decrease in unplanned readmissions through institution of a formal OPAT program among patients with solid malignancies may be more difficult compared with the general population, the program may still result in improved safety.

Guidelines for the hospital role of the clinical nurse in antimicrobial stewardship: A scoping review

Background

Antimicrobial stewardship aims to optimise the use of antimicrobial medicines to preserve the efficacy of these medicines and to contain antimicrobial resistance where possible. Nurses constitute the largest group of healthcare workers; however, the role played by nurses within current antimicrobial stewardship strategies is largely unacknowledged despite nurses being at point-of-care at the hospital bedside.

Objectives

To identify recommendations for the antimicrobial stewardship role of the bedside nurse in key global antimicrobial stewardship guidelines.

Methods

Scoping review methodology was used to systematically search published and 'grey' literature in PubMed, EBSCOhost, Google Scholar, government websites, and websites of professional societies and organisations. Search dates were 1990 to 2020. Inclusion criteria were English language antimicrobial stewardship guidelines for hospitals. Screening was conducted in two stages for title and abstract and then full text relevancy and documented according to the PRISMA Extension for Scoping Reviews.

Results

Of the 1 824 articles that were retrieved, only 43 met the inclusion criteria. Inclusion of the bedside nurse on the antimicrobial stewardship team occurred in 13.9% (n=6) of the papers. A role for the bedside nurse was recommended in antibiotic stewardship (32.5%; n=14), infection prevention and control (23.2%; n=10), and administration of antimicrobial medicines (20.9%; n=9) of reviewed documents. Other recommendations included the use of evidence-based antimicrobial stewardship (20.9%; n=9), collaboration with other healthcare staff (11.6%; n=5), facilitation of transition of care (18.6%; n=8), and nurse prescription of antibiotics (4.6%; n=2).

Conclusion

This scoping review highlights a slow but incremental increase in recognition of the role of the bedside nurse within the operational hub of antimicrobial stewardship strategies.

Contributions of the study

The present study was undertaken to fill the gap in the literature on clinical nurses' contribution in antimicrobial stewardship. The findings of the review largely demonstrate that multidisciplinary antimicrobial stewardship guidelines fail to view the bedside nurse as a contributor within antimicrobial stewardship strategies.

Comparing peripherally inserted central catheter-related practices across hospitals with different insertion models: a multisite qualitative study

BACKGROUND

Peripherally inserted central catheters (PICCs) provide reliable intravenous access for delivery of parenteral therapy. Yet, little is known about PICC care practices or how they vary across hospitals. We compared PICC-related processes across hospitals with different insertion delivery models.

METHODS

We used a descriptive qualitative methodology and a naturalist philosophy, with site visits to conduct semistructured interviews completed between August 2018 and January 2019. Study sites included five Veterans Affairs Medical Centres, two with vascular access teams (VATs), two with PICC insertion primarily by interventional radiology (IR) and one without on-site PICC insertion capability. Interview participants were healthcare personnel (n=56), including physicians, bedside and vascular access nurses, and IR clinicians. Data collection focused on four PICC domains: use and decision-making process, insertion, in-hospital management and patient discharge education. We used rapid analysis and a summary matrix to compare practices across sites within each domain.

RESULTS

Our findings highlight the benefits of dedicated VATs across all PICC-related process domains, including implementation of criteria to guide PICC placement decisions, timely PICC insertion, more robust management practices and well-defined patient discharge education. We also found areas with potential for improvement, such as clinician awareness of PICC appropriateness criteria and alternative devices, deployment of VATs and patient discharge education.

CONCLUSION

Vascular access nurses play critical roles in all aspects of PICC-related care. There is variation in PICC decision-making, care and maintenance, and patient education across hospitals. Quality and safety improvement opportunities to reduce this variation are highlighted.

Efficacy and cost-effectivity analysis of outpatient parenteral antimicrobial therapy unit in infectious disease clinical practices: Turkey perspective

BACKGROUND

Outpatient parenteral antimicrobial treatment (OPAT) has become a common treatment modality in developed countries. OPAT units are not widespread in Turkey, and their cost-effectivity analysis has not been studied, yet.

AIMS

To analyze the clinical efficacy and cost-effectiveness of the OPAT unit, based on a 1000-bed teaching hospital.

METHODS

The records of patients, who were treated between October 2013 and December 2017, in an OPAT unit of a tertiary hospital in Ankara, were obtained retrospectively. The cost that would arise if the patients were hospitalized for the same treatment period with the same diagnosis was calculated and compared with the actual treatment cost of the patients in the OPAT unit.

RESULTS

A total of 594 patients who received antimicrobial treatment at the OPAT unit were enrolled. The mean age of the patients was 55.39 ± 16.37 years and 313 (52.7%) were males. Based on the end-of-treatment goals, 98.5% of the patients reached the treatment goal. An indirect cost analysis revealed that the OPAT unit was 487.625 94 TL/129.008 78 $ less costly than inpatient parenteral antibiotic treatment. In other words, OPAT cost was 75% of the equivalent inpatient costs. It was also determined that a total of 7078 bed days and 11.9 bed days per person were saved.

CONCLUSIONS

OPAT units should be expanded increasingly in Turkey. The evaluation together with the health care system conditions in Turkey revealed that the OPAT program is safe, effective, and cost-efficient.

Evaluation of Bundled Interventions for Patients With Opioid Use Disorder Experiencing Homelessness Receiving Extended Antibiotics for Severe Infection

Hospitalizations for serious infections in patients with opioid use disorder (OUD) experiencing homelessness are common. Patients receiving 4 interventions (infectious disease consultation, addiction consultation, case management, and medications for OUD [MOUD]) had higher odds of clinical cure (unadjusted odds ratio [OR], 3.15; P = .03; adjusted OR, 3.03; P = .049) and successful retention in addiction care at 30 days (unadjusted OR, 5.46; P = .01; adjusted OR, 6.36; P = .003).

Policy Statement: Antibiotic Stewardship in Pediatrics

Antibiotic overuse contributes to antibiotic resistance, which is a threat to public health. Antibiotic stewardship is a practice dedicated to prescribing antibiotics only when necessary and, when antibiotics are considered necessary, promoting the use of the appropriate agent(s), dose, duration, and route of therapy to optimize clinical outcomes while minimizing the unintended consequences of antibiotic use. Because there are differences in common infectious conditions, drug-specific considerations, and the evidence surrounding treatment recommendations (eg, first-line therapy and duration of therapy) between children and adults, this statement provides specific guidance for the pediatric population. This policy statement discusses the rationale for inpatient and outpatient antibiotic stewardship programs (ASPs); essential personnel, infrastructure, and activities required; approaches to evaluating their effectiveness; and gaps in knowledge that require further investigation. Key guidance for both inpatient and outpatient ASPs are provided.

Real-World Clinical Use and Outcomes of Telavancin for the Treatment of Bone and Joint Infections: Results from the Telavancin Observational Use Registry (TOUR™)

Background

Additional antibiotic options are needed to treat bone and joint infections caused by penicillin-resistant Gram-positive pathogens.

Objective

This subanalysis of the Telavancin Observational Use Registry (TOUR™) aimed to record real-world telavancin usage patterns in patients with bone and joint infections treated with telavancin.

Methods

TOUR was a multicenter observational-use registry study conducted at 45 US sites between January 2015 and March 2017. Patient characteristics, infection type, infecting pathogen(s), previous treatment, telavancin dosing and duration, clinical response, and adverse event data were collected by retrospective medical chart reviews. As such, inclusion/exclusion criteria were limited, and any patient receiving at least one dose of telavancin at the discretion of the treating physician was eligible. Patients were assessed as either positive clinical response, failed treatment, or indeterminate outcome.

Results

Of the 1063 patients enrolled in TOUR, 27.4% (291/1063) were patients with bone and joint infections including osteomyelitis (with or without prosthetic material), acute septic arthritis, and prosthetic joint infections. Most of these patients had osteomyelitis without prosthetic material (191/291; 66.0%). Among patients assessed at the end of treatment, 211/268 (78.7%) achieved a positive clinical response, 26/268 (9.7%) failed treatment, and 31/268 (11.6%) had an indeterminate outcome. The most frequent pathogen was methicillin-resistant Staphylococcus aureus (110/291; 37.8%). The median (interquartile range [IQR as Q1, Q3]) telavancin dose was 750.0 mg (IQR, 750, 750 mg) or 8.2 mg/kg (IQR, 6.8, 9.7 mg/kg) administered for a median of 26 days (IQR, 12, 42 days). These assessments were recorded in the registry ≥ 30 days after the last dose of telavancin was administered.

Conclusions

Real-world data from the TOUR study show that clinicians are using once-daily telavancin with positive clinical outcomes for the treatment of bone and joint infections caused by Gram-positive pathogens.

Clinical Trial Registration

This trial was registered with ClinicalTrials.gov (NCT02288234) on 11 November, 2014.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40801-021-00255-6.

Experience with Liposomal Amphotericin B in Outpatient Parenteral Antimicrobial Therapy

Outpatient parenteral antimicrobial therapy (OPAT) is a safe, effective, and convenient treatment strategy for patients receiving intravenous antimicrobials in the outpatient setting; however, data are limited describing the use and safety of liposomal amphotericin B (L-AMB). Records of patients receiving L-AMB OPAT between 1/1/2015 and 7/31/2018 were retrospectively reviewed. The primary objective was to describe the OPAT patient population discharged on L-AMB and evaluate factors associated with readmission and adverse events (AEs). Analysis was performed to evaluate for predictors of worse outcomes. Forty-two patients (67% male, median age 50 years) were identified, most of whom were treated for histoplasmosis. The most common doses of L-AMB were 3 mg/kg (n = 16, 38%) or 5 mg/kg (n = 14, 33%) based on actual body weight. Twenty-six (62%) patients completed their anticipated course of L-AMB. Twenty-two (52%) patients were readmitted within 30 days of discharge; median time to readmission was 11 days (interquartile range [IQR] 5 to 18). While hypokalemia and acute kidney injury (AKI) were common, occurring in 26 (62%) and 20 (48%) patients, respectively, only 5 (12%) were readmitted to the hospital due to L-AMB-associated AEs. Ninety percent of patients achieved at least partial renal recovery within 30 days after L-AMB discontinuation. Factors significantly associated with AKI include higher L-AMB dose, lower serum potassium levels after therapy initiation, and receipt of potassium supplementation at discharge. L-AMB is associated with significant AEs; however, these results suggest that treatment is feasible in the outpatient setting with close monitoring, as the majority of AEs were managed effectively in an outpatient without long-term sequelae.

Failure modes and effects analysis to improve transitions of care in patients discharged on outpatient parenteral antimicrobial therapy

PURPOSE

To identify barriers to safe and effective completion of outpatient parenteral antimicrobial therapy (OPAT) in patients discharged from an academic medical center and to develop targeted solutions to potentially resolve or improve the identified barriers.

SUMMARY

A failure modes and effects analysis (FMEA) was conducted by a multidisciplinary OPAT task force to evaluate the processes for patients discharged on OPAT to 2 postdischarge dispositions: (1) home and (2) skilled nursing facility (SNF). The task force created 2 process maps and identified potential failure modes, or barriers, to the successful completion of each step. Thirteen and 10 barriers were identified in the home and SNF process maps, respectively. Task force members created 5 subgroups, each developing solutions for a group of related barriers. The 5 areas of focus included (1) the OPAT electronic order set, (2) critical tasks to be performed before patient discharge, (3) patient education, (4) patient follow-up and laboratory monitoring, and (5) SNF communication. Interventions involved working with information technology to update the electronic order set, bridging communication and ensuring completion of critical tasks by creating an inpatient electronic discharge checklist, developing patient education resources, planning a central OPAT outpatient database within the electronic medical record, and creating a pharmacist on-call pager for SNFs.

CONCLUSION

The FMEA approach was helpful in identifying perceived barriers to successful transitions of care in patients discharged on OPAT and in developing targeted interventions. Healthcare organizations may reproduce this strategy when completing quality improvement planning for this high-risk process.

Applying the Infectious Diseases Literature to People who Inject Drugs

People who inject drugs (PWID) presenting with injection drug use-associated infections are an understudied population excluded from most prospective infectious disease (ID) clinical trials. Careful application of the existing ID literature to PWID must consider their unique medical, psychological, and social challenges. Identification and treatment of the underlying substance use disorder are key underpinnings to any successful ID intervention.

Outpatient Antimicrobial Treatment for People Who Inject Drugs

This article reviews the changing epidemiology of infections associated with injection drug use, perceived barriers to care, features of successful programs for outpatient antimicrobial treatment, models of shared decision making at the time of discharge, and linkage to preventative care after antimicrobial completion. In the search for patient-centered care associated with a rising substance use epidemic, one must continue to strive for novel collaborative approaches to ensure that each person is treated in the best way possible to successfully complete antimicrobial therapy, and then linked to a path of lifelong health care.

Nine Seasons of a Bronchiolitis Observation Unit and Home Oxygen Therapy Protocol

BACKGROUND

We implemented an observation unit and home oxygen therapy (OU-HOT) protocol at our children's hospital during the 2010-2011 winter season to facilitate earlier discharge of children hospitalized with bronchiolitis. An earlier study demonstrated substantial reductions in inpatient length of stay and costs in the first year after implementation.

OBJECTIVE

Evaluate long-term reductions in length of stay and cost.

DESIGN, SETTING, AND PARTICIPANTS

Interrupted time-series analysis, adjusting for patient demographic factors and disease severity. Participants were children aged 3 to 24 months and hospitalized with bronchiolitis from 2007 to 2019.

INTERVENTION

OU-HOT protocol implementation.

MAIN OUTCOME AND MEASURES

Hospital length of stay. Process measures were the percentage of patients discharged from the OU; percentage of patients discharged with HOT. Balancing measures were 7-day hospital revisit rates; annual per-population bronchiolitis admission rates. Secondary outcomes were inflation-adjusted cost per episode of care and discharges within 24 hours.

RESULTS

A total of 7,116 patients met inclusion criteria. The OU-HOT protocol was associated with immediate decreases in mean length of stay (-30.6 hours; 95% CI, -37.1 to -24.2 hours) and mean cost per episode of care (-$4,181; 95% CI, -$4,829 to -$3,533). These findings were sustained for 9 years after implementation. Hospital revisit rates did not increase immediately (-1.1% immediate change; 95% CI, -1.8% to -0.4%), but a small increase in revisits was observed over time (change in slope 0.4% per season, 95% CI, 0.1%-0.8%).

CONCLUSION

The OU-HOT protocol was associated with sustained reductions in length of stay and cost, representing a promising strategy to reduce the inpatient burden of bronchiolitis.

Outpatient therapy with piperacillin/tazobactam using elastomeric pumps in patients with Pseudomonas aeruginosa infection

The aim of this study was to evaluate the efficacy and safety of outpatient antimicrobial therapy with piperacillin-tazobactam in continuous infusion using elastomeric pumps and to evaluate the economic impact compared with conventional hospital treatment in patients with Pseudomonas aeruginosa (PA) infections. This is an observational study. Patients with PA infection treated with continuous piperacillin-tazobactam infusion using elastomeric pumps in our hospital between January 2015 and December 2017 were included. Primary outcomes were mortality during antibiotic treatment and mortality at 30 days. Secondary outcomes were reinfection or relapse at 30 days and clinical cure rate. The cost of each episode was compared with theoretical cost of the same treatment using conventional hospitalization. 35 patients were included. One patient (2.9%) died during the treatment. Overall 30-day mortality was 5.7%. No death was related to infection by PA. One patient (2.9%) had a reinfection at 30 days. Cure was achieved in 93% of patients at the end of treatment. There were no severe complications related to elastomeric pumps. Treatment cost with outpatient antimicrobial therapy was 67% lower than theoretical cost with conventional hospital treatment. Oupatient antimicrobial therapy with piperacillin-tazobactam in continuous infusion using elastomeric pumps in patients with PA infections is safe and effective with lower costs.

Comparison of linezolid step-down therapy to standard parenteral therapy in methicillin-resistant Staphylococcus aureus bloodstream infections

Data supporting oral step-down therapy in methicillin-resistant Staphylococcus aureus (MRSA) bloodstream infection (BSI) are sparse; linezolid offers potential in this setting. This study aimed to determine the effectiveness and safety of oral step-down linezolid compared with standard parenteral therapy (SPT) in MRSA-BSI. This was a retrospective cohort performed in adults receiving step-down/outpatient linezolid or SPT (vancomycin, daptomycin) for MRSA-BSI from 2011-2019. Primary outcome was 90-day infection-related re-admission (IRR) from clinical worsening/relapse or infection recurrence. 215 patients included (54 linezolid, 161 SPT). Infection sources were skin (34%), bone/joint (15%), endocarditis (13%), other (32%), multiple (6%). Patients receiving SPT more commonly had complicated bacteraemia (72% vs. 41%; P < 0.0001) and metastatic foci (45% vs. 20%; P = 0.001). 90-day IRR occurred in 17% and 26% of linezolid and SPT groups, respectively (P = 0.159). When accounting for disease severity, linezolid use was not independently associated with 90-day IRR (adjOR, 1.0, 95% CI 0.24-4.3; P = 0.986). There were no differences in all-cause 90-day mortality (4% vs. 6%, P = 0.487) or overall incidence of drug-related adverse events (AEs) (17% vs. 16%; P = 0.843) between the groups. More patients in the SPT group developed an AE requiring re-hospitalisation (12% vs. 2%; P = 0.024), most commonly line-related complications. Oral step-down linezolid demonstrated similar clinical and safety outcomes compared with SPT for MRSA-BSI, except linezolid was associated with fewer AEs requiring re-hospitalisation. Additional research is needed exploring step-down linezolid in MRSA-BSI, particularly in patients requiring shorter durations of outpatient therapy.

Injection Drug Use-Associated Candidemia: Incidence, Clinical Features, and Outcomes, East Tennessee, 2014-2018

BACKGROUND

Injection drug use (IDU) is an established but uncommon risk factor for candidemia. Surveillance for candidemia is conducted in East Tennessee, an area heavily impacted by the opioid crisis and IDU. We evaluated IDU-associated candidemia to characterize the epidemiology and estimate the burden.

METHODS

We assessed the proportion of candidemia cases related to IDU during January 1, 2014-September 30, 2018, estimated candidemia incidence in the overall population and among persons who inject drugs (PWID), and reviewed medical records to compare clinical features and outcomes among IDU-associated and non-IDU candidemia cases.

RESULTS

The proportion of IDU-associated candidemia cases in East Tennessee increased from 6.1% in 2014 to 14.5% in 2018. Overall candidemia incidence in East Tennessee was 13.5/100 000, and incidence among PWID was 402-1895/100 000. Injection drug use-associated cases were younger (median age, 34.5 vs 60 years) and more frequently had endocarditis (39% vs 3%). All-cause 30-day mortality was 8% among IDU-associated cases versus 25% among non-IDU cases.

CONCLUSIONS

A growing proportion of candidemia in East Tennessee is associated with IDU, posing an additional burden from the opioid crisis. The lower mortality among IDU-associated cases likely reflects in part the younger demographic; however, Candida endocarditis seen among approximately 40% underscores the seriousness of the infection and need for prevention.

Low Use of Outpatient Parenteral Antimicrobial Therapy for Drug Use-Associated Infective Endocarditis in an Urban Hospital System

Background

The opioid crisis in the United States has led to increasing hospitalizations for drug use-associated infective endocarditis (DUA-IE). Outpatient parenteral antimicrobial therapy (OPAT), the preferred modality for intravenous antibiotics for infective endocarditis, has demonstrated similar outcomes among patients with DUA-IE versus non-DUA-IE, but current studies suffer selection bias. The utilization of OPAT for DUA-IE more generally is not well studied.

Methods

This retrospective cohort study compared OPAT use for DUA-IE versus non-DUA-IE in adults hospitalized between January 1, 2015 and September 1, 2019 at 3 urban hospitals. We used multivariable regression analysis to assess the association between DUA-IE and discharge with OPAT, adjusting for clinically significant covariables.

Results

The cohort included 518 patients (126 DUA-IE, 392 non-DUA-IE). Compared to those with non-DUA-IE, DUA-IE patients were younger (53.0 vs 68.2 years, P < .001) and more commonly undomiciled (9.5% vs 0.3%, P < .01). Patients with DUA-IE had a significantly lower odds of discharge with OPAT than non-DUA-IE patients (adjusted odds ratio [aOR] = 0.20; 95% confidence interval [CI], 0.10–0.39). Odds of discharge with OPAT remained lower for patients with DUA-IE after excluding undomiciled patients (aOR = 0.22; 95% CI, 0.11–0.43) and those with patient-directed discharges (aOR = 0.27; 95% CI, 0.14–0.52).

Conclusions

Significantly fewer patients with DUA-IE were discharged with OPAT compared to those with non-DUA-IE, and undomiciled patients or patient-directed discharges did not fully account for this difference. Efforts to increase OPAT utilization among patients with DUA-IE could have important benefits for patients and the healthcare system.

Home intravenous antibiotherapy and the proper use of elastomeric pumps: Systematic review of the literature and proposals for improved use

Over several decades, the economic situation and consideration of patient quality of life have been responsible for increased outpatient treatment. It is in this context that outpatient antimicrobial treatment (OPAT) has rapidly developed. The availability of elastomeric infusion pumps has permitted prolonged or continuous antibiotic administration by dint of a mechanical device necessitating neither gravity nor a source of electricity. In numerous situations, its utilization optimizes administration of time-dependent antibiotics while freeing the patient from the constraints associated with infusion by gravity, volumetric pump or electrical syringe pump and, more often than not, limiting the number of nurse interventions to one or two a day. That much said, the installation of these pumps, which is not systematically justified, entails markedly increased OPAT costs and is liable to expose the patient to a risk of therapeutic failure or adverse effects due to the instability of the molecules utilized in a non-controlled environment, instability that necessitates close monitoring of their use. More precisely, a prescriber must take into consideration the stability parameters of each molecule (infusion duration, concentration following dilution, nature of the diluent and pump temperature). The objective of this work is to evaluate the different means of utilization of elastomeric infusion pumps in intravenous antibiotic administration outside of hospital. Following a review of the literature, we will present a tool for optimized antibiotic prescription, in a town setting by means of an infusion device.

Costs and Outcomes of 1-year post-discharge care trajectories of patients admitted with infection due to antibiotic-resistant bacteria

BACKGROUND

The impact of antibiotic resistance (AMR) on initial hospital management has been extensively studied but its consequences after hospital discharge remain largely unknown. We aimed to analyze hospital care trajectories, cumulative length of hospital stays (c-LOS) and associated costs of care over a 1-year period after hospitalization with incident AMR infection.

METHOD

All incident bacterial infection-related hospitalizations occurring from January 1, 2015, to December 31, 2015 and recorded in the French national health data information system were extracted. Bacterial resistance ICD-10 codes determined six infection status. Inpatient and outpatient care consumption and associated costs were studied. The impact of resistance on c-LOS was estimated using a Poisson regression. A sequence analysis through optimal matching method was conducted to identify hospital trajectories along with an extrapolation.

FINDING

Of the 73,244 patients selected, 15.9% had AMR infection, thus providing 58,286 incident AMR infections after extrapolation. c-LOS was significantly longer for infections with resistant bacteria, reaching 20.4 days and 2.9 additional days IC95%[2.6; 3.2] for skin and soft tissue infections. An estimated 29,793 (51.1%) patients had hospital readmission within the following year, for a total cost of €675 million. Five post-discharge trajectories were identified: Post-hospitalization mainly at home (68.4% of patients); Transition to home from rehabilitation care (12.3%); Early death (<3 months) (9.7%); Late death (7.4%), and Long-term hospitalization (2.2%).

INTERPRETATION

AMR has an impact on patients' c-LOS stay beyond the initial hospitalization. Half of patients hospitalized due to AMR are readmitted to hospital within the ensuing year, along five different trajectories.

FUNDING

French Ministry of health.

Facing multidrug-resistant pathogens in periprosthetic joint infections with self-administered outpatient parenteral antimicrobial therapy-A prospective cohort study

A key factor in the successful management of periprosthetic joint infection (PJI) besides the surgical regime is a consistent antimicrobial therapy. Recently, oral versus intravenous (IV) antibiotics for bone and joint infection trial demonstrated the noninferiority of oral antimicrobial therapy compared to IV, implying that an early transition to oral administration is reasonable. It is likely that the international consensus meeting of musculoskeletal Infections and the European Bone and Joint Infection Society will consider these findings. However, rising levels of antimicrobial resistance are challenging and recommendations for dealing with multidrug-resistant (MDR) pathogens resistant to oral antibiotics are lacking. This study focuses on establishing guidance towards their management in PJI. From December 2015 to June 2019, patients with MDR pathogens were included in a single-center prospective cohort study and treated with self-administered outpatient parenteral antimicrobial therapy (S-OPAT) based on a two-stage revision strategy. Demographics, pathogens, antimicrobial agents, and outcomes were recorded. A total of 1738 outpatient days in 26 patients were analyzed. The incidence of pathogens resistant to oral antibiotics in PJI was 4%, most frequently encountered were staphylococcus epidermidis. The Kaplan-Meier-estimated infection-free survival after 3 years was 90% (95% confidence interval, 84.6%-95.5%). We recorded adverse events in 6 of 54 (11%) S-OPAT episodes (3.45/1000 S-OPAT days). (i) S-OPAT in two-stage revision arthroplasty to counter increasing numbers of MDR pathogens resistant to oral agents can achieve a high infection eradication rate and (ii) should therefore be taken into account at the next society's consensus treatment updates.

A Case of Pediatric Subcutaneous Abscess Caused by Mycobacterium mageritense Infection

Soft tissue infections with Mycobacterium mageritense are uncommon. We report the case of a 5-year-old girl who developed a subcutaneous abscess in her right ankle caused by M. mageritense. She had a history of acute encephalopathy and adrenal insufficiency and was hospitalized for acute pancreatitis. During hospitalization, the patient developed fever and tachycardia. Blood culture was positive for gram-positive bacilli. Although initial testing with matrix-assisted laser desorption/ionization-time of flight mass spectrometry (MALDI-TOF MS) reported a different organism, a repeat test identified M. mageritense. One month after the positive blood culture, she developed redness and swelling in the right ankle. The pus from the subcutaneous abscess after drainage grew M. mageritense, which was further confirmed by the sequencing of housekeeping genes. Based on sensitivity testing, the patient was treated with tosufloxacin and linezolid. The local inflammatory signs gradually improved on starting the treatment. The antibiotics were administered for 6 months, and she experienced no relapse during the 8 months of follow-up after the completion of therapy. This is the first case report of a pediatric M. mageritense infection, which also highlights an important potential pitfall of MALDI-TOF MS. Further, we observe that the choice of antimicrobials for the treatment of M. mageritense is more limited in children than in adults.

The Urgent Need for Medicare Reimbursement for Home Infusion Antibiotics Amidst a Pandemic

The Centers for Medicare and Medicaid Services should immediately update current policies to include reimbursement for Medicare patients receiving intravenous antibiotics at home. The majority of these patients are over the age of 65 and at increased risk for severe illness due to severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2). Requiring them to travel to an infusion center, stay in a skilled nursing facility or remain in the hospital longer than necessary to receive treatment results in avoidable risk of exposure amidst a pandemic. Current policy has significant implications for increased cost and harm to both these patients and the US healthcare system.

Evaluating the safety and effectiveness of a nurse-led outpatient virtual IV vancomycin monitoring clinic: a retrospective cohort study

Background

Outpatient parenteral antimicrobial therapy (OPAT) with vancomycin is a common treatment modality for certain Gram-positive infections. Data regarding the safety of various models of delivery are limited.

Objectives

To review outcomes of a nurse-led OPAT vancomycin monitoring service.

Methods

This was a retrospective cohort study of consecutive patients referred to a nurse-led OPAT vancomycin clinic from December 2015 to March 2018. Patients were administered IV vancomycin in the home with active laboratory monitoring of vancomycin trough levels, renal function and complete blood count using an integrated electronic database linked with community laboratories (virtual vancomycin clinic, VVC). Monitoring was coordinated by nurses with physician approval of recommended dosing changes. Data were extracted from the electronic medical record. Demographics; clinical indication; microbial aetiology; culture source; antimicrobial regimen(s); serum creatinine and vancomycin trough values; initiation, discharge and completion dates; hospitalizations; adverse events; and outcomes were all evaluated.

Results

Two hundred and seventy-five patients underwent a total of 301 courses of OPAT with vancomycin; 285 courses were completed. The rate of treatment discontinuation due to adverse effects was 33/301 (11.0%), with 15/33 (45.5%) being due to renal adverse effects (15/301 [5.0%] of episodes). Two of 15 (18.2%) patients developed stage 2 acute kidney injury (AKI), and no patients had stage 3 AKI or required haemodialysis. Nine of 301 (3.0%) required readmission for treatment failure. Nursing costs associated with monitoring were $63.93 CAD/patient ($48.43 USD).

Conclusions

A nurse-led VVC was a safe, effective and inexpensive modality for administering outpatient vancomycin.

Risk Factors for Adverse Events in Children Receiving Outpatient Parenteral Antibiotic Therapy

BACKGROUND

Outpatient parenteral antibiotic therapy (OPAT) can decrease length of hospital stay but is associated with adverse events (AEs). The purpose of this study was to quantify and identify risk factors for OPAT-associated AEs in children.

METHODS

Retrospective single-center study of children ≤21 years old discharged on OPAT from January 2016 to April 2019 with infectious diseases follow-up. Demographic and clinical factors and medication and central venous catheter (CVC)-associated AEs were assessed through chart review. Univariable and multivariable analyses were performed.

RESULTS

Among 181 OPAT courses, an AE occurred in 70 (39%). Medication AEs occurred in 30 of 181 courses (16.6%). Children residing in an urban area had a 4.5 times higher risk of having a medication-related AE compared with those in a rural area (odds ratio: 4.51; 95% confidence interval: 1.60-12.77; P = .005). CVC AEs occurred in 47 of 181 courses (26%). Every additional day of OPAT increased the odds of having a CVC-related AE by 4% (odds ratio: 1.04; 95% confidence interval: 1.01-1.07; P = .003). Twenty (11.1%) courses resulted in readmission to the hospital because of an AE.

CONCLUSIONS

In this cohort, 39% of children experienced an OPAT-associated AE, and CVC AEs were more common than medication AEs. Longer duration of intravenous therapy and urban residence were independently associated with OPAT-associated AEs, highlighting the importance of converting to oral antibiotic therapy as soon as feasible to reduce OPAT-associated AEs.

Quality Indicators for Appropriate Outpatient Parenteral Antimicrobial Therapy in Adults: A Systematic Review and RAND-modified Delphi Procedure

Background

Our aim in this study was to develop quality indicators (QIs) for outpatient parenteral antimicrobial therapy (OPAT) care that can be used as metrics for quality assessment and improvement.

Methods

A RAND-modified Delphi procedure was used to develop a set of QIs. Recommendations on appropriate OPAT care in adults were retrieved from the literature using a systematic review and translated into potential QIs. These QIs were appraised and prioritized by a multidisciplinary panel of international OPAT experts in 2 questionnaire rounds combined with a meeting between rounds.

Results

The procedure resulted in 33 OPAT-specific recommendations. The following QIs that describe recommended OPAT care were prioritized by the expert panel: the presence of a structured OPAT program, a formal OPAT care team, a policy on patient selection criteria, and a treatment and monitoring plan; assessment for OPAT should be performed by the OPAT team; patients and family should be informed about OPAT; there should be a mechanism in place for urgent discussion and review of emergent clinical problems, and a system in place for rapid communication; laboratory results should be delivered to physicians within 24 hours; and the OPAT team should document clinical response to antimicrobial management, document adverse events, and monitor QIs for OPAT care and make these data available.

Conclusions

We systematically developed a set of 33 QIs for optimal OPAT care, of which 12 were prioritized by the expert panel. These QIs can be used to assess and improve the quality of care provided by OPAT teams.

Outpatient Parenteral Antimicrobial Therapy Plus Buprenorphine for Opioid Use Disorder and Severe Injection-related Infections

In a pilot randomized trial in persons with opioid use disorder hospitalized with injection-related infections, an innovative care model combining outpatient parenteral antimicrobial therapy with buprenorphine treatment had similar clinical and drug use outcomes to usual care (inpatient intravenous antibiotic completion) and shortened hospital length of stay by 23.5 days.

CLINICAL TRIALS REGISTRATION

NCT03048643.

Antibiotic Stewardship in Pediatrics

Antibiotic overuse contributes to antibiotic resistance, which is a threat to public health. Antibiotic stewardship is a practice dedicated to prescribing antibiotics only when necessary and, when antibiotics are considered necessary, promoting use of the appropriate agent(s), dose, duration, and route of therapy to optimize clinical outcomes while minimizing the unintended consequences of antibiotic use. Because there are differences in common infectious conditions, drug-specific considerations, and the evidence surrounding treatment recommendations (eg, first-line therapy, duration of therapy) between children and adults, this statement provides specific guidance for the pediatric population. This policy statement discusses the rationale for inpatient and outpatient antibiotic stewardship programs; essential personnel, infrastructure, and activities required; approaches to evaluating their effectiveness; and gaps in knowledge that require further investigation. Key guidance for both inpatient and outpatient antibiotic stewardship programs are provided.

Experiences in outpatient parenteral antimicrobial therapy (OPAT): Barriers and challenges from the front lines

Background:

Outpatient parenteral antimicrobial therapy (OPAT) is now the standard of care for managing patients who no longer need inpatient care but require prolonged intravenous antimicrobial therapy. OPAT increases patient satisfaction, reduces the lengths of hospital stay, lowers emergency department readmission rates, and decreases total healthcare spending.

Objective:

To investigate Virginia Commonwealth University Health System’s experience with OPAT and to highlight the obstacles patients and clinicians face when navigating and utilizing this program.

Design:

We conducted this descriptive study at a large, academic, tertiary-care hospital in Central Virginia.

Methods:

We performed manual reviews of electronic medical records of 602 patient, and we evaluated the records of those receiving OPAT between 2017 and 2020. Reviews included antimicrobial agents, diagnoses requiring OPAT, adverse effects related to antimicrobials, adverse effects related to peripherally inserted central catheters (PICC), readmission rate, discharge destination, and death. We evaluated our program with descriptive statistics.

Results:

Among 602 patients who received OPAT, most were diagnosed with bacteremia or musculoskeletal infections. Patients were either discharged home or to another healthcare facility, with the former comprising most of the rehospitalizations. Ertapenem and vancomycin were associated with the most adverse drug events among our cohort. Elevated transaminase levels were noted in 23% of patients. The rate of PICC-line adverse events in this study population was 0.05%.

Conclusions:

Our findings highlight the barriers and challenges that patients and providers face when receiving OPAT, and they can inform efforts to improve patient clinical outcomes.

Rate of broad-spectrum antibiotic overuse in patients receiving outpatient parenteral antibiotic therapy (OPAT)

Broad-spectrum antibiotics with once-daily dosing are often chosen for outpatient parenteral antibiotic therapy (OPAT) due to convenience even when narrower-spectrum antibiotics are appropriate. At our institution, up to 50% of select broad-spectrum OPAT regimens had potential to be narrowed, highlighting the need to re-evaluate regimens for de-escalation prior to discharge.

Outpatient Subcutaneous Antimicrobial Therapy (OSCAT) as a Measure to Improve the Quality and Efficiency of Healthcare Delivery for Patients With Serious Bacterial Infections

Since the 1970s, outpatient parenteral antimicrobial therapy (OPAT) has been a viable option for patients who require intravenous antibiotics when hospitalization is not warranted. While the benefits of OPAT as a measure to improve the efficiency of healthcare delivery (i.e., reduced hospital days) and patient satisfaction are well-documented, OPAT is associated with a number of challenges, including line complications and reliance on daily healthcare interactions in some cases at home or in a clinic. To minimize the continued need for intensive healthcare services in the outpatient setting, there is trend toward patients self-administering antibiotics at home without the presence of healthcare workers, after adequate training. In most cases, patients administer the antibiotics through an established intravenous catheter. While this OPAT practice is becoming more accepted as a standard of care, the potential for line complications still exists. Outpatient subcutaneous antimicrobial therapy (OSCAT) has become an increasingly accepted alternative route of administration of antibiotics to IV by French infectious diseases physicians and geriatricians; however, currently, no antibiotics are approved to be administered subcutaneously. Antibiotics with longer half-lives that are completely absorbed and have a favorable local tolerability profile are ideal candidates for OSCAT and have the potential to maximize the quality and efficiency of parenteral antibiotic delivery in the outpatient setting. The increasing development of wearable, on-body subcutaneous delivery systems make OSCAT even more viable as they increase patient independence while avoiding line complications and potentially removing the need for direct healthcare professional observation.

Continued Dosing of Oritavancin for Complicated Gram-Positive Infections

Several retrospective and cohort analyses have suggested that continued dosing of oritavancin is both safe and efficacious for complicated Gram-positive infections, such as methicillin-resistant Staphylococcus aureus and vancomycin-resistant enterococci.

Clinic- and Hospital-Based Home Care, Outpatient Parenteral Antimicrobial Therapy (OPAT) and the Evolving Clinical Responsibilities of the Pharmacist

Clinic- and hospital-based home care describes models of care where services commonly associated with hospital inpatient care are provided at the patient's home or in an outpatient or community-based clinic. Hospital in the Home (HITH), also termed Hospital at Home (HaH) in parts of Europe and America, is a common and important example of this type of care. Other examples include infusion centers, skilled nursing facilities (particularly in the USA), self-administration models (including home infusion services) and administration through outpatient or community clinics. Different models of HITH care are used internationally and these encompass a wide range of services. Medication administration, particularly outpatient parenteral antimicrobial therapy (OPAT), is an important element in many of these models of care. There is a key role for pharmacists since the provision of medication is integral in this model of patient care outside the hospital setting. Data on the growing importance of HITH and OPAT as well as the administration of medications suited to clinic- and hospital-based home care, including subcutaneous and intramuscular injectables, immunoglobulins and other blood fractions, cancer chemotherapy, total parenteral nutrition, biologicals/biosimilars, vasopressors and enzymes, using differing service models, are described. The pharmacist's role is evolving from that involved primarily with dose preparation and supply of medications. Their clinical expertise in medication management ensures that they are an integral member and leader in these models of care. Their role ensures the safe and quality use of medicines, particularly across transitions of care, with the pharmacist taking on the roles of educator and consultant to patients and health professional colleagues. Activities such as antimicrobial stewardship and ongoing monitoring of patients and outcomes is fundamental to ensure quality patient outcomes in these settings.

A Review of β-Lactam-Associated Neutropenia and Implications for Cross-reactivity

OBJECTIVE

To review the incidence, management, and current understanding of the pathophysiology of β-lactam-induced neutropenia and to critically evaluate the practicality and safety of direct substitution to an alternative β-lactam in the setting of this reaction.

DATA SOURCES

A literature analysis using the PubMed and Ovid search engines (July 1968 to October 2020) was performed using the search terms neutropenia, leukopenia, β-lactam, nonchemotherapy, agranulocytosis, and G-CSF (granulocyte colony-stimulating factor).

STUDY SELECTION AND DATA EXTRACTION

The included English-language studies evaluated the incidence, mechanism, and/or management of β-lactam-induced neutropenia in pediatric or adult patients.

DATA SYNTHESIS

Drug-induced neutropenia is a well-documented adverse reaction of β-lactam antibiotics, with an incidence of approximately 10% following at least 2 weeks of intravenous therapy. However, multiple gaps in knowledge remain in the mechanism of pathophysiology and optimal management of this reaction. Both direct toxic and immune-mediated mechanisms have been implicated. Although the cornerstone of management includes cessation of the offending agent, controversy exists on the appropriateness of direct substitution or future use of an alternative β-lactam.

RELEVANCE TO PATIENT CARE AND CLINICAL PRACTICE

Given the frequency of use and superiority of β-lactams over alternative therapy for several infectious disease states, practical recommendations are needed on the management and safe use of β-lactams following β-lactam-induced neutropenia.

CONCLUSION

Future use of β-lactams with differing R1 side chains, particularly those from a separate class, should not be deemed contraindicated following β-lactam-induced neutropenia and may be considered when indicated, with close laboratory monitoring.

Comparison of dalbavancin to standard-of-care for outpatient treatment of invasive Gram-positive infections

OBJECTIVE

To assess the efficacy and safety of dalbavancin compared to standard-of-care (SOC) or vancomycin and daptomycin in invasive infections due to suspected or confirmed Gram-positive organisms.

METHODS

Retrospective cohort of adults who received dalbavancin or SOC on discharge or as an outpatient from 12/2016 to 11/2019. Indications were osteoarticular infection (OAI), infective endocarditis (IE), or other bloodstream infection (BSI). Primary endpoint was 90-day infection-related readmission (IRR); secondary endpoints included time-to-IRR, frequency of adverse drug events (ADEs), and all-cause readmission and mortality.

RESULTS

215 patients were included: 70 (33%) receiving dalbavancin, and 145 (67%) receiving SOC. Indications were OAI (47%), IE (27%), and other BSI (26%). OAI was more common in patients on dalbavancin compared with those receiving SOC (70% vs. 37%, P<0.001). Dalbavancin patients had shorter median (interquartile range [IQR]) length of stay (LOS) prior to drug initiation compared with those receiving SOC (10 [7-17] vs. 13 [9-19], P=0.021). IRR incidence was 17% for dalbavancin patients and 28% for SOC patients. Dalbavancin use was independently associated with lower IRR (adjusted odds ratio [adjOR], 0.10; 95% confidence interval [CI], 0.04-0.31). There was longer median (IQR) time-to-IRR in the dalbavancin group (43 [30-87] vs. 23 [11-63] days, P=0.039), but no differences in all-cause readmission or mortality. Treatment-related ADE incidence was 3% and 14% for the dalbavancin and SOC groups, respectively (P=0.013). Infusion reactions (1/2) and catheter-related complications (1/2) were the most common dalbavancin ADEs; catheter-related complications (14/21), nephrotoxicity (3/21), rhabdomyolysis (2/21), and rash (2/21) were the most common SOC ADEs.

CONCLUSIONS

Dalbavancin use was associated with lower 90-day IRR, a shorter hospital LOS prior to therapy, and longer time-to-IRR compared with SOC.

Safety of Outpatient Parenteral Antimicrobial Therapy in Nonagenarians

Background

Although widely accepted for adults, the safety of outpatient parenteral antimicrobial therapy (OPAT) in very old patients has not been examined.

Methods

Nonagenarians (age ≥90 years) discharged from the hospital on OPAT over a 5-year period were identified from the Cleveland Clinic OPAT Registry. Three matched controls (<90 years) were selected for each nonagenarian. Times to OPAT-related emergency department (ED) visit and OPAT-related readmission were compared across the 2 groups in multivariable subdistribution proportional hazards competing risks regression models. Incidence of adverse drug events and vascular access complications were compared using negative binomial regression.

Results

Of 126 nonagenarians and 378 controls, 7 were excluded for various reasons. Among the remaining 497 subjects, 306 (62%) were male, 311 (63%) were treated for cardiovascular or osteoarticular infections, and 363 (73%) were discharged to a residential health care facility. The mean (SD) ages of nonagenarians and controls were 92 (2) and 62 (16) years, respectively. Compared with matched controls, being a nonagenarian was not associated with increased risk of OPAT-related ED visit (hazard ratio [HR], 0.77; 95% CI, 0.33-1.80; P = .55), OPAT-related readmission (HR, 0.78; 95% CI, 0.28-2.16; P = .63), adverse drug event from OPAT medications (incidence rate ratio [IRR], 1.00; 95% CI, 0.43-2.17; P = .99), or vascular access complications (IRR, 0.66; 95% CI, 0.27-1.51; P = .32). Nonagenarians had a higher risk of death overall (HR, 2.64; 95% CI, 1.52-4.58; P < .001), but deaths were not from OPAT complications.

Conclusions

Compared with younger patients, OPAT in nonagenarians is not associated with higher risk of OPAT-related complications. OPAT can be provided as safely to nonagenarians as to younger patients.

Novel respiratory infectious diseases in Korea

Respiratory infections are very common and highly contagious. Respiratory infectious diseases affect not only the person infected but also the family members and the society. As medical sciences advance, several diseases have been conquered; however, the impact of novel infectious diseases on the society is enormous. As the clinical presentation of respiratory infections is similar regardless of the pathogen, the causative agent is not distinguishable by symptoms alone. Moreover, it is difficult to develop a cure because of the various viral mutations. Various respiratory infectious diseases ranging from influenza, which threaten the health of mankind globally, to the coronavirus disease 2019, which resulted in a pandemic, exist. Contrary to human expectations that development in health care and improvement in hygiene will conquer infectious diseases, humankind's health and social systems are threatened by novel infectious diseases. Owing to the development of transport and trading activity, the rate of spread of new infectious diseases is increasing. As respiratory infections can threaten the members of the global community at any time, investigations on preventing the transmission of these diseases as well as development of effective antivirals and vaccines are of utmost importance and require a worldwide effort.

Enterococcus faecalis Endocarditis and Outpatient Treatment: A Systematic Review of Current Alternatives

The selection of the best alternative for Enterococcus faecalis infective endocarditis (IE) continuation treatment in the outpatient setting is still challenging. Three databases were searched, reporting antibiotic therapies against E. faecalis IE in or suitable for the outpatient setting. Articles the results of which were identified by species and treatment regimen were included. The quality of the studies was assessed accordingly with the study design. Data were extracted and synthesized narratively. In total, 18 studies were included. The treatment regimens reported were classified regarding the main antibiotic used as regimen, based on Aminoglycosides, dual β-lactam, teicoplanin, daptomycin or dalbavancin or oral therapy. The regimens based on aminoglycosides and dual β-lactam combinations are the treatment alternatives which gather more evidence regarding their efficacy. Dual β-lactam is the preferred option for high level aminoglycoside resistance strains, and for to its reduced nephrotoxicity, while its adaptation to the outpatient setting has been poorly documented. Less evidence supports the remaining alternatives, but many of them have been successfully adapted to outpatient care. Teicoplanin and dalbavancin as well as oral therapy seem promising. Our work provides an extensive examination of the potential alternatives to E. faecalis IE useful for outpatient care. However, the insufficient evidence hampers the attempt to give a general recommendation.