A Review of Outpatient Parenteral Antimicrobial Therapy Practices: DISCUSSION part 2
Guidelines often recommend that when outpatient therapy is prescribed, a physician with OPAT experience, such as an infectious disease specialist, should be involved. In this study, the infectious disease service was involved in the care of 61% of the patients, including all patients with endocarditis and two-thirds of those with osteomyelitis. Neither the report from the Manitoba program nor that from the Hopital Enfant-Jesus (Quebec City, Quebec) mention involvement of infectious disease specialists in the delivery of OPAT. Although the report from the Hopital Charles LeMoyne (Greenfield Park, Quebec) mentioned involvement of infectious disease specialists in the initial organization of the program, the extent of such involvement in direct patient care was not reported. However, specialist involvement was an integral part of the programs in Calgary, Vancouver and Hamilton. Complex and/or less common infections and infections requiring long-term treatment are examples of situations in which involvement of infectious disease specialists would be particularly valuable. In the study reported here, 2 patients with osteomyelitis were not seen by an infectious disease specialist, and in both cases, OPAT failed. Although involvement of infectious disease specialists does not guarantee a successful outcome, these physicians may have more experience recognizing the early signs and symptoms of toxic effects, treatment failure, and complications and can make adjustments as needed. In addition, the possibility of replacing OPAT with oral therapy could perhaps be more readily recognized by someone with more experience in treating infectious diseases.
Complications were reported for 29% of the patients in this sample, the majority attributed to the IV access. We documented adverse effects attributable to the antimicrobial agent in 7 (11%) of the patients, a proportion similar to that observed in the Hamilton and Vancouver programs (close to 14% in both studies). Although complications were reported for the studies from Manitoba and Calgary, the overall incidence of adverse events was not provided. In contrast to the Jefferson Hospital Home Infusion Program in Pennsylvania15 but similar to the situation in Vancouver, a higher proportion of adverse events in the current study were related to IV access than to the antimicrobial agent. Slightly more than half of the access-related complications involved PICC lines. Unlike the Jefferson Hospital, where infection was the most common complication associated with venous access, no line- related infections were documented in the current study. However, the patients in the Jefferson program15 had a longer median duration of OPAT than the Ottawa patients (40 and 20.5 days, respectively). Three of the patients in the current study (5%) required a change in the originally prescribed antimicrobial regimen because of an adverse reaction, which coincides with the premature discontinuation rate reported by the OPAT Outcomes Registry (3% to 10%). In the Ottawa patients, however, outpatient management was continued.
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We observed a tendency toward less extensive monitoring of therapy for patients receiving OPAT than is usually the case for the inpatient population at The Ottawa Hospital and the University of Ottawa Heart Institute. Given this apparent lack of monitoring and documentation, some adverse events might have been missed. We are particularly concerned about the possibility of less common and more severe adverse events, such as aminoglycoside-related nephrotoxicity or ototoxicity. Clinical and laboratory monitoring by a health care professional experienced in antimicrobial therapy (e.g., an infectious disease specialist or pharmacist) is especially important for antimicrobials such as aminoglycosides and amphotericin B, because of the greater potential for serious adverse events. Four of the 6 patients discharged on gentamicin had requisitions for hematological and/or biochemical laboratory tests, whereas only 2 had requisitions for determination of serum gentamicin concentration. However, the extent and adequacy of patient monitoring, including laboratory testing, after hospital discharge was difficult to accurately assess. Of the 12 patients with monitoring plans explicitly stated in the health record, the results were either not available or not documented in the charts. Furthermore, it was not evident which physician (family physician, infectious disease specialist, or admitting physician) was responsible for outpatient care and monitoring. The IDSA guidelines include suggestions for the monitoring of laboratory parameters for specific antimicrobials, and the frequency at which these tests should be performed. We could not determine if these recommendations were followed.
Overall, 85% of the patients in this study completed their course of antimicrobial therapy, although 16 of these patients experienced a complication during therapy. The success rate of the Vancouver OPAT program was similar (86%). In Manitoba, the overall failure rate was 8% (15% in the current study); however, the definitions of failure differed, so these results cannot be directly compared. Cialis Jelly
Two limitations of the current study were its small sample size and retrospective nature. The charts of about one-third of the patients discharged on OPAT from The Ottawa Hospital and the University of Ottawa Heart Institute were reviewed. Although these patients should constitute a representative sample, the distribution of infections, the choice of antimicrobial regimen, and the identification of complications might have been different if more patients had been reviewed. Also, if the study had been performed prospectively, more detailed information about reasons for changes to the antimicrobial regimen, laboratory results, adverse effects, and complications might have been available.
This study provided the opportunity to describe our experience with OPAT in patients treated at The Ottawa Hospital and the University of Ottawa Heart Institute and thus to understand and appraise current practices at these institutions. This review indicates that, as in other programs, the majority of patients were successfully managed with OPAT, and the rate of complications was similar to those reported elsewhere. Nevertheless, a formalized OPAT program with defined policies and procedures and good systems for recording patient information may result in improvements in documentation, coordination of patient care, communication among health care professionals, and identification and management of adverse events and complications. We believe that such a program would reduce costs of care and reduce risk to patients. By providing timely, comprehensive care through an organized multidisciplinary program, the quality of care for patients receiving OPAT would be continuously assessed and promoted.
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