Tricky Infusion Issues and Potential Solutions: OPAT Edition

Outpatient parenteral antimicrobial therapy (OPAT) can reduce hospital length of stay, improve cost-effectiveness, and enhance patient satisfaction.¹ Despite these benefits, over 20% of OPAT patients experience adverse events.^2,3 Several common issues can arise during and after OPAT transitions of care (TOC) which put patients at risk for adverse events and unplanned readmissions. Potential errors can occur during antibiotic regimen design, laboratory monitoring, and scheduling follow-up appointments. Addressing these issues may help improve health outcomes for OPAT patients.

One major OPAT-related issue is the potential for antimicrobial prescribing errors.⁴ These errors may appear during initial prescribing or readmissions. One study noted that 27% of patients experienced inappropriate antimicrobial therapy during readmissions.⁵ It is also important to recognize that prescribing recommendations intended to transition patients to home may run contrary to established stewardship practices, resulting in confusion amongst team members, as well as patient and caregivers.

For instance, regimens consisting of 1-2 infusions per day have been associated with higher treatment adherence rates.⁶ Examples of such practice is the use of broader-spectrum, less frequently dosed agents such as daptomycin or ertapenem, which are ideal given their once-daily dosing. Interestingly, use of daptomycin has been associated with other meaningful benefits, such as reduced toxicity.

Vancomycin therapy, when compared to daptomycin in OPAT, has been associated with a 4 to 5-fold higher increased risk of acute kidney injury and premature discontinuation, respectively.^7,8 Overall, daptomycin-treated patients were found to have reduced need for clinical interventions and phone calls, as well as higher OPAT satisfaction.^9,10

Adequate safety monitoring through frequent laboratory testing can also be an area of concern for OPAT patients and providers. Missing laboratory test information occurs in a significant portion of discharged patients and contributes to readmissions.¹¹ Multidisciplinary teams are recommended to closely monitor OPAT patients with clinical examination and weekly laboratory testing.¹² Processes that ensure post-discharge verification of appropriate lab orders, follow-up plan, and receipt of antimicrobials can lead to fewer antimicrobial errors, increased lab test receipt, and improved follow-up.²

Implementing dedicated TOC services can help to improve clinical outcomes and process measures in patients discharged on OPAT. For example, coordination with OPAT providers, patient and caregiver education, and evaluation for optimal patient disposition have been shown to reduce hospital readmissions by 10-13%.^13,14

Similarly, outpatient ID follow-up within two weeks of hospital discharge has been associated with lower risk of 30-day readmission (adjusted odds ratio, 0.33; P = .0001).³ Accurate and timely communication of key treatment information across the TOC can limit the possibility of error, and better facilitate transition to OPAT. Creation of standardized notes or information templates outlining such plans have been shown to improve adherence to lab plans, as well as increase clinic attendance.⁶ Such modifications to therapy need to be clearly communicated to the patient or caregiver, who should ultimately be given opportunity to participate, as well as the primary care team discharging the patient, and any post-discharge care partners (e.g., rehabilitation facility, visiting nurse group, and/or infusion center).

OPAT and antimicrobial stewardship programs should consider these issues and opportunities for improvements in communication, documentation, and education.

References

1.Shah. Handbook of outpatient parenteral antimicrobial therapy for infectious diseases [Internet]. 3rd ed. Tarrytown: CRG Publishing and Infectious Diseases Society of America; 2016 [cited 2021 Jun 22]. Available from: https://www.idsociety.org/globalassets/bb-complex-pages/idsa/opat-ehandbook/opat_epub_finalv2.pdf.

2.Keller SC, Ciuffetelli D, Bilker W, et al. The Impact of an Infectious Diseases Transition Service on the Care of Outpatients on Parenteral Antimicrobial Therapy. J Pharm Technol. 2013;29(5):205-214.

3. Saini E, Ali M, Du P, Crook T, Zurlo J. Early Infectious Disease Outpatient Follow-up of Outpatient Parenteral Antimicrobial Therapy Patients Reduces 30-Day Readmission. Clin Infect Dis. 2019;69(5):865-868.

4. Certain LK, Benefield RJ, Newman M, Zhang M, Thomas FO. A Quality Initiative to Improve Postdischarge Care for Patients on Outpatient Parenteral Antimicrobial Therapy. Open Forum Infect Dis. 2022;9(7):ofac199. Published 2022 Apr 15.

5. Britt RS, LaSalvia MT, Padival S, Patel P, McCoy C, Mahoney MV. Evaluation of Inpatient Antimicrobial Regimens for Readmitted Outpatient Parenteral Antimicrobial Therapy Patients Receiving Daptomycin or Ertapenem for Ease of Administration. Open Forum Infect Dis. 2019;6(12):ofz496. Published 2019 Nov 19.

6. Hamad Y, Dodda S, Frank A, et al. Perspectives of Patients on Outpatient Parenteral Antimicrobial Therapy: Experiences and Adherence. Open Forum Infect Dis. 2020;7(6):ofaa205. Published 2020 Jun 2. doi:10.1093/ofid/ofaa205

7. Schrank GM, Wright SB, Branch-Elliman W, LaSalvia MT. A retrospective analysis of adverse events among patients receiving daptomycin versus vancomycin during outpatient parenteral antimicrobial therapy. Infect Control Hosp Epidemiol. 2018;39(8):947-954.

8. Tuerff D, Nunez M. More Frequent Premature Antibiotic Discontinuations and Acute Kidney Injury in the Outpatient Setting With Vancomycin Compared to Daptomycin. J Clin Pharmacol. 2020;60(3):384-390. doi:10.1002/jcph.1536

9. Wu KH, Sakoulas G, Geriak M. Vancomycin or Daptomycin for Outpatient Parenteral Antibiotic Therapy: Does It Make a Difference in Patient Satisfaction? Open Forum Infect Dis. 2021;8(8):ofab418. Published 2021 Aug 30.

10. Nakarani M, Yu D, Sikka M, Lewis J, Douglass A, Mayer H, Young K, Streifel AC. Comparison of Vancomycin and Daptomycin Complications and Interventions in Outpatient Parenteral Antimicrobial Therapy [Session P-23; Poster Abstract] OFID 2020:7 (Suppl 1) • S361

11. Huck D, Ginsberg JP, Gordon SM, Nowacki AS, Rehm SJ, Shrestha NK. Association of laboratory test result availability and rehospitalizations in an outpatient parenteral antimicrobial therapy programme. Journal of Antimicrobial Chemotherapy. 2014;69(1):228-233.

12. Norris AH, Shrestha NK, Allison GM, et al. 2018 Infectious Diseases Society of America Clinical Practice Guideline for the Management of Outpatient Parenteral Antimicrobial Therapy. Clinical Infectious Diseases. 2019;68(1):e1-e35.

13. Agnihotri G, Gross AE, Seok M, et al. Decreased hospital readmissions after programmatic strengthening of an outpatient parenteral antimicrobial therapy (OPAT) program. Antimicrob Steward Healthc Epidemiol. 2023;3(1):e33.

14. Madaline T, Nori P, Mowrey W, et al. Bundle in the Bronx: Impact of a Transition-of-Care Outpatient Parenteral Antibiotic Therapy Bundle on All-Cause 30-Day Hospital Readmissions. Open Forum Infect Dis. 2017;4(2):ofx097.