Disclosure. Objectives. Transitions in Care: Inpatient to Outpatient Parenteral Antibiotic Therapy 2/16/2017

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1 Transitions in Care: Inpatient to Outpatient Parenteral Antibiotic Therapy Juan E. Villanueva, PharmD, BCPS PGY2 Infectious Diseases University of Arizona Banner University Medical Center Tucson Disclosure I have nothing to disclose concerning possible financial or personal relationship with commercial entities that may have a direct or indirect interest in the subject matter of this presentation Objectives List several barriers to discharge on parenteral antibiotic therapy Discuss medication characteristics that can complicate outpatient parenteral antibiotic therapy Evaluate the therapy options in a given scenario when parenteral antibiotic therapy has been ordered 1

2 Self-Assessment Questions True or False. A patient s socioeconomic status should be completed prior to discharge on OPAT. Which of the following antibiotics would be appropriate for administration via continuous infusion? A. Cefazolin B. Ceftriaxone C. Gentamicin D. Ertapenem True or False. Successful discharge on OPAT requires coordination using an interdisciplinary approach. Outpatient Parenteral Antimicrobial Therapy (OPAT) What is OPAT? Administration of parenteral antibiotics in an alternate, outpatient setting Growth of OPAT Cost containment Once daily administration of antibiotics Technological advances Increased acceptance Availability of resources Goal: Complete treatment safely and effectively CID. 2004;38:

3 Infections Treated with OPAT Skin and soft tissue Bacteremia Septic arthritis Osteomyelitis Pyelonephritis Pneumonia CID. 2004;38: Coordination Required Infectious Disease Physician Patient Case Managers Home Infusion Pharmacy Selecting Patients for OPAT Is parenteral antimicrobial therapy truly necessary with no suitable alternatives? Is patient fully aware of risks and benefits of OPAT? Is patient willing and capable of performing OPAT for duration of course? Safe environment with adequate support? Reasons to remain in hospital? 3

4 Poor Candidates for OPAT Septic Meningitis Endocarditis Septic arthritis Severe pneumonia - Clinical condition may worsen - Need for hospital-based procedures Unstable home environment (e.g. homeless) Injection drug use Lack access to transportation and/or phone CID. 2004;38: Ther Clin Risk Manag. 2014;10: Options for OPAT delivery Outpatient infusion center Staff to administer Wound care Laboratory monitoring Home Comfort and independence Self-care Education, education, education Vascular Access Peripheral Type Placement Common Use Comments Peripheral venous catheter Dorsum of hand Antecubital fossa Short-term access Replace every 3 to 4 days Not appropriate for OPAT Peripherally inserted midline catheter Into basillic, cephalic, or brachial vein at axilla Mid-term access Replace every 28 to 30 days Mid-term for OPAT Crow S. J Intraven Nurs. 1996;19(4): Ann Inter Med. 1995;123(11):841. 4

5 Vascular Access Central Type Placement Common Use Comments Central venous catheter (nontunneled) Peripherally inserted central catheter (PICC) (tunneled) Implantable port (tunneled) Internal jugular Subclavian Femoral (into SVC) Antecubital fossa (into SVC) Chest wall (into SVC) Short-term access Remain for few days Not appropriate for OPAT Long-term access Commonly used central device for OPAT Weeks to months Long-term access (semi-permanent) Not typically placed exclusively for OPAT Can Fam Physician. 2009;55(5): Antimicrobial Selection for OPAT Factors to Consider Probable infecting organism Pharmacokinetic/Pharmacodynamics Drug stability Duration of therapy Physician preference CID. 2004;38: CID. 2010;51:S198-S208 Once-daily Parenteral Antimicrobial Regimens β-lactams Ceftriaxone Ertapenem Aminoglycosides Gentamicin, Tobramycin, Amikacin Lipopeptide/Lipoglycopeptide Daptomycin Telavancin 5

6 Single-administration Parenteral Antimicrobial Regimens Dalbavancin* Oritavancin Clinical and Laboratory Monitoring Follow up visits with supervising physician Nursing visits Laboratory monitoring OPAT Outcomes Registry 3% - 10% stopped due to adverse reaction Vascular Access Device care Ther Clin Risk Manag. 2014;10: Aminoglycoside Monitoring Renal function at least weekly Trough and peak serum concentration Otologic symptoms Antimicrob Agents Chemother ;43(5):

7 Vancomycin Monitoring Renal function at least weekly Trough serum concentrations Minimal toxicity alone Leukopenia Clin Biochem Rev. 2010;31(1): OPAT Scheme OPAT Patient Selection OPAT Selection Patient Education Outcomes Measure Monitoring Care Transition Patient Cases 7

8 Patient Case: S.A. 45 y/o male admitted for right sided chest pain found to have prolonged Staphylococcus aureus bacteremia Oxacillin MIC <=0.25 PMH: HTN, hyperlipidemia, eczema MRI spine no fluid collection identified TTE/TEE vegetation on mitral valve Patient Case: S.A. IV antibiotic started Infectious diseases team plan to continue outpatient Patient deemed appropriate for home Pertinent Patient Data Normal renal function Normal hepatic function Active lifestyle Family support What are possible IV antimicrobials suitable for this patient? Antistaphylococcal Antibacterials Length of IV infusion IV Push or Infusion Cefazolin Daptomycin IV Infusion Vancomycin Continuous Infusion Cefazolin Nafcillin/ Oxacillin Antibiotic Concentration, diluent Rate of Administration Osmolality (mosm/l) Cefazolin 1g/10 ml, SWFI 1-2 min 340 Daptomycin 500 mg/10 ml, SWFI 2 min 364 8

9 What was done? Cefazolin Intermittent IV infusion x 4 weeks Tolerated well inpatient Considerations Outpatient setting Pharmacokinetic/Pharmacodynamics Patient preference Patient Case: O.M. 54 y/o female admitted with a right diabetic foot ulcer PMH: poorly controlled DM, HTN, depression Imaging (MRI): multiple scattered abscesses and osteomyelitis of 5 th metatarsal Deep culture obtained in OR Patient Case: O.M. IV antibiotic therapy started ID team planned to continue at home Cleared by PT to discharge home Current IV access: two 20-gauge peripheral IVs Pertinent patient data Normal renal function Severe peripheral neuropathy in her hands Support system: daughter What are potential barriers for successful discharge on OPAT? 9

10 Potential Barriers to Discharge Duration Cost Antibiotic Stability Patient Willingness Physical Patient Limitations Education IV access Patient Case O.M. Culture and susceptibility results: Right soft tissue Staphylococcus aureus Methicillin susceptible (MSSA) Organism Susceptibility Results Cefepime Ciprofloxacin Piperacillin/ Meropenem Tazobactam Proteus mirabilis <=1 <=0.25 <=4 <=0.25 Pseudomonas aeruginosa 2 <=1 8 <=0.25 Abscess Osteomyeltitis: 5 th metatarsal and plantar surface Potential Treatment Options Patient Case: O.M. Cefepime + metronidazole Both 3 times daily Metronidazole: ADE - potential to exacerbate peripheral neuropathy Meropenem Single agent to cover all organisms Broad spectrum Pipercillin/ tazobactam Additional anaerobic coverage Continuous infusion possible 10

11 Optimal Option Patient Case: O.M. Piperacillin/tazobactam Extended infusion utilized while admitted Transitioned to continuous infusion for OPAT Considerations Pharmacokinetics/pharmacodynamics Stability Patient preference Quality of life Insurance coverage Discussion OPAT part of standard medical practice Quality of care must be provided with OPAT Complications associated with PICCs Prospective, randomized trials needed Question #1 A patient s socioeconomic status should be considered prior to discharge on OPAT. True 11

12 Question #2 Which of the following antibiotics would be appropriate for administration via continuous infusion? A. Cefazolin B. Ceftriaxone C. Gentamicin D. Ertapenem A. Cefazolin Question #3 Successful discharge on OPAT requires coordination using an interdisciplinary approach. True Acknowledgements Dr. Carol Rollins, MS, RD, CNSD, PharmD, BCNSP Dr. Kathryn Matthias, PharmD, BCPS (AQ-ID) 12

13 References Tice AD, Rehim SJ, Dalovisio JR, et al. Practice guidelines for outpatient parenteral antimicrobial therapy. CID. 2004;38: Lodise, TP, Lomaestro BM, Drusano GL. Application of antimicrobial pharmacodynamics concepts into clinical practice: Focus on β-lactam antibiotics. Pharmacotherapy 2006;26(9): Halilovic J, Christensen CL, Nguyen HH. Managing an outpatient parenteral antibiotic therapy team: challenges and solutions. Ther Clin Risk Manag. 2014;10: Paladino JA, Poretz D. Outpatient parenteral antimicrobial therapy today. CID. 2010;51:S198-S208. Crow S. Prevention of intravascular infections ways and means. J Intraven Nurs. 1996;19(4): Paule M, Leclercq M, Tulkens PM. Aminoglycosides: Nephrotoxicity. Antimicrob Agents Chemother ;43(5): Martin JH, Norris R, Barras M, et al. Therapeutic monitoring of vancomycin in adult patients; A consensus review in American society of health-systm pharmacist, the infectious diseases society of America, and the society of infectious diseases pharmacists. Clin Biochem Rev. 2010;31(1): Maki DG, Ringer M. Risk factors for infusion-related phlebitis with small peripheral venous catheters. A randomized controlled trial. Ann Intern Med. 1991;114(10):845. Mermel LA, Parenteau S, Tow SM. The risk of midline catheterization in hospitalized patients. A prospective study. Ann Inter Med. 1995;123(11):841. Cheung E, Baerlocher MO, Asch M, et al. Venous access. Can Fam Physician. 2009;55(5): Trissel LA. Trissel s Stability of Compounded Formulation 5 th Ed. Washington, DC. American Pharmacists Association Cubicin [Package insert]. Whitehouse Station, NJ. Merck & Co., Inc; Questions? Juan E. Villanueva, PharmD, BCPS PGY2 Infectious Diseases University of Arizona Banner University Medical Center Tucson villanueva@pharmacy.arizona.edu 13