Practice Guidelines for Outpatient Parenteral Antimicrobial Therapy
These guidelines were formulated to assist physicians and other health care professionals with various aspects of the administration of outpatient parenteral antimicrobial therapy (OPAT). Although there are many reassuring retrospective studies on the efficacy and safety of OPAT, few prospective studies have been conducted to compare the risks and outcomes for patients who receive treatment as outpatients rather than as inpatients. Because truly evidence-based studies are lacking, the present guidelines are formulated from the collective experience of the committee members and advisors from related organizations. Important aspects of OPAT are described in the text and tables and include the following: The literature supports the effectiveness of OPAT for a wide variety of infections (table 1 and the Appendix). Infections treated with outpatient parenteral antimicrobial therapy (OPAT) and the antibiotics used in 4 studies or sites. A thorough assessment of the patient's general medical condition, the infectious process, and the home situation is necessary before starting therapy (table 2) Specific considerations in evaluating patients for outpatient parenteral antimicrobial therapy (OPAT). Prescribing physicians should be aware of a number of aspects of OPAT which distinguish it from other forms of therapy. These include the required teamwork, communication, monitoring, and outcome measurements (tables 3 and 4). Key elements required for an outpatient parenteral antimicrobial therapy (OPAT) program. Key elements required for evaluating an outpatient parenteral antimicrobial therapy (OPAT) program when the patient is to be referred. The physician has a unique role on the OPAT team, which may also include nursing, pharmacy, and social services. These responsibilities include establishing a diagnosis, prescribing treatment, determining the appropriate site of care, monitoring during therapy, and assuring the overall quality of care. Antimicrobial selection for OPAT is different from that for therapy in the hospital. Once-daily drug administration has many advantages. Potential for adverse effects and the stability of an antimicrobial once it is mixed must be considered (tables 5–7). Properties of commonly prescribed antimicrobials at various temperatures. Suggestions for laboratory parameters that should be monitored weekly during outpatient parenteral antimicrobial therapy (OPAT). The importance of administering the first dose of an antibiotic in a supervised setting is emphasized. Regular clinical and laboratory monitoring of patients receiving OPAT is essential and varies with the antimicrobial chosen (table 8). Outcome measures for outpatient parenteral antimicrobial therapy (OPAT). Outcomes measures should be an integral part of any OPAT program, to assure the effectiveness and quality of care (table 9). Internet resources with information on outpatient parenteral antimicrobial therapy (OPAT). Children receiving OPAT must be considered differently because of their special needs. The practice of administering intravenous antimicrobial therapy in the home and in alternate care settings has grown rapidly since it was first described in 1974 by Rucker and Harrison [1]. The most common infections treated and antimicrobials used by a variety of programs are shown in table 1. In the United States, OPAT is estimated to be a multibillion-dollar-a-year industry and is provided to 1 in 1000 Americans each year [10]. The growth of OPAT has been fueled by a variety of factors including the push for cost containment, the development of antimicrobial agents that can be administered once daily, technological advances in vascular access and infusion devices, increased acceptance of such therapy by both patients and health care personnel, and the availability of reliable and skilled services for OPAT in the community. Although OPAT has become widely accepted as a form of medical therapy (see Appendix), more information is needed regarding its benefits, safety, and limitations. This is especially true with the economic incentives for early discharge that exist for payors. These guidelines update those written in 1997 [11] and are intended to ensure successful implementation of parenteral antimicrobial services for patients in varied community settings, including the home and outpatient facilities, such as physicians' offices, hospital clinics, ambulatory-care centers, day hospitals, and skilled nursing facilities. They have been formulated to incorporate the perspectives of the team of physicians, nurses, pharmacists and other health care professionals necessary for an effective and safe program [6, 8, 12]. Advice and participation were requested of the leading infusion-nurse, pharmacy, infection control, and to a on the The were formulated from the collective clinical experience of the of and from the organizations. In the of the and quality of in of OPAT is by a of prospective studies and a number of are The information can a for programs to the in their These guidelines are general and to be to many in each treatment Because of the on OPAT, the related of of therapy, when to to therapy, and infusion other than antimicrobials are In the is used in of parenteral because is the more commonly used is used to to the of parenteral antimicrobial therapy in at on different The is used to to the varied settings in which intravenous antimicrobial therapy can be provided an in a hospital. These include the offices, ambulatory-care clinics, infusion centers, skilled nursing or care facilities, and The and of to and to any or with the and to treatment and to and of OPAT that a physician that such therapy is needed to a that is needed to the and that alternate of drug are or to in patient and selection are in table The of outpatient therapy programs are to patients to treatment and in the of their home or outpatient site and to the and of OPAT is appropriate the patient's medical care be in the hospital. in selection of patients for OPAT should the patient's is for both and of A of patients for home therapy that a of may be patients for for therapy is for antimicrobial therapy may be Because of the risks of infections and for adverse physicians with in the of infectious or with experience and of OPAT should be in the of for therapy. of the of the patient's infection and any medical is a of the assessment The of OPAT the of medical assessment more The patient's of or in health should be OPAT may be appropriate for patients with the therapy to their quality of and the patient's participation is more on medical and factors other than the of infection 1 the more common infections and antimicrobials used at different OPAT most and infections are the most common with a or infections such as or should be for of parenteral antimicrobial therapy because of the that the patient's medical may or that may be their has many of patients may be to receive guidelines for that OPAT may be for patients by and OPAT can be more widely used for community resources are and physicians are aware of patients with are also for OPAT is a experience in on an outpatient with and patients with who have in or are at increased for that may be more and treated in the hospital. A care or outpatient during the first of therapy because of the increased of such as or and that patients with to be to receive OPAT 1 of drug or should be before therapy is who are to a vascular access are for OPAT A skilled nursing may be the most appropriate for care. or with of the may be appropriate for patients infusion can therapy and may the of The patient's to to the prescribed and the of vascular access therapy of the hospital setting is and a is and The of patients who receive OPAT and of their must be before are accepted the program. or their must be to for the the care of the vascular access and the care of the infusion and be to and such as or care of the of or and the those for treatment in a or infusion is an for patients with or or because of or receiving OPAT should have their and health by a in OPAT by patients with may be the of and infusion should be of the economic and the medical aspects of OPAT before the of therapy. should be regarding and to an before OPAT of with written information may be and physician is to the of must have of or and for physician and services. should be in such a that patient is with home or for home assessment and may be The health care team must also have of the patient's home to of This information is by a to the home before or at the of of therapy, assessment may Potential such as the of safety access to and social to be may also a to which should be OPAT program. The elements of OPAT programs are in table Although any physician can OPAT, physicians are in The physician should be infectious and OPAT that clinical or such as adverse drug and infusion and vascular access are or and In clinical settings, an infectious is required before a patient can be home to receive OPAT [6, have on to for physician and of home care Although there has been growth in home care services physician has because of of for or patient care in the home setting and pharmacists should also be and with OPAT, as should other members of the health care team, which may include social and The of has guidelines on the role in home care OPAT programs must have for nurses, physicians, and are required both for treatment and for monitoring of care. and has become it must with the and should have written and that the responsibilities of the team members and such as patient selection drug vascular laboratory monitoring, and of and and should information the program, a of a regarding and risks of OPAT, and when information the and the antimicrobials for quality and outcomes monitoring should also be OPAT and may be for an program or with of to OPAT The elements for OPAT programs to which a patient is are in table These to for programs that the prescribing physician the physician is for the patient's care and Specific in to those in table should be in Because prescribing physicians for clinical care it is for to the quality of care provided by the OPAT and to are considered for a patient should be treated as an outpatient and to assure the quality of care during OPAT In should their role with other in the patient's care physician or for an OPAT is for the of the program. This is to that of the medical for clinical and and A should have written regarding the of their the and the quality in The should be to information as as the for the of therapy. are an which can be for information safety, and and general The of a for administering OPAT varies with patient the program resources and the is to the of on the the patient's for and the for other medical services. The can be to the antimicrobial is administered in an infusion at a skilled nursing or at home by a or is In the antimicrobials are by the a or may in the at or any other by which therapy can be include infusion and a variety of administration that can be to the of the the and the drug This has the that it for the patient and a has that is in home may be in the home the of a may be administered by by or by intravenous infusion The number of nursing by the availability of infusion nurses, and other considerations may the of The has been in many including physician offices, outpatient centers, hospital outpatient clinics, an or care These the of access to medical and the patient to to the for nursing may parenteral antimicrobial therapy and have in patients are of have have medical are have for home therapy, or are to be care and for patients who skilled therapy infusion of antimicrobial effective OPAT program an team of professionals to patient care [6, The OPAT team of the a an infusion a In many a for the hospital or a are in the selection of patients and of therapy. members or other should in the and of of the hospital. are of such as selection of intravenous access devices, of the most appropriate site of care, and monitoring of laboratory physicians an infectious and other may be in which to the in care. OPAT to be patient selection and also and of care are of laboratory of patient and in are by or availability of most members of the care team is to the and safety of and experience in the of antimicrobial therapy and are required to outcomes and in OPAT Because OPAT is for physicians, nurses, or OPAT may be by a of The The role of the physician in OPAT has unique and of a diagnosis, of OPAT is selection of of monitoring and assessment at [6, The the infusion and the patient should the appropriate of vascular In with other members of the team, the physician the site of care. The physician is for the assessment of the patient's clinical to therapy, monitoring for drug of vascular access care of medical and of the of other members of the The OPAT physician should any in treatment including in or for administration of antimicrobial the physician and physician OPAT is to the that be or that be The of physician or to OPAT is The of a in home measurements of to the of OPAT are a of the The of the of in its for programs in infectious and of antimicrobial agents in a variety of clinical settings, including the practice and the as a The infusion The role of the infusion varies with the OPAT and the site of care the of patient as to the patient's for parenteral therapy of the hospital. They the role in for the of to be and in the care of the infusion and monitoring the of of the infusion as patients receive OPAT at can a home They may the antimicrobial or to care. They may also for the team and a role in of care. may in infusion therapy the the of the which has for in care settings The The on the team is for the and of the as as for monitoring for adverse and drug The of that pharmacists a assessment and that patients the antimicrobial and effects The of and care has guidelines for pharmacists in setting The patient and the The of the patient and in OPAT must be both should a part in the OPAT program and the treatment communication, and outcome is responsibilities of the patient and the are than for and their to therapy is and are to be in their care and with a of and in their The safety of the medical should also be especially with home and in on and with to safety and should be as with outpatient care than with care a and a the risks are than in a hospital of administration is an antimicrobial for OPAT, factors must be including the the and of and drug The antimicrobials used for OPAT are in table 1. Although any antimicrobial can be with to be with the patient the diagnosis, the of therapy, and physician of agents that can be administered once of and the for The of antimicrobials for OPAT to be as agents may administered and antimicrobial is an The dose of an intravenous should be administered in a supervised such as a care or the before a patient's discharge to home care. in and appropriate should be patients with there is that administration of an intravenous antimicrobial may outcomes with to and the of hospital of a parenteral antibiotic in the before may also outcomes the parameters of antimicrobials that are used for The of a drug the with which it can be The that the the of information is for determining a drug must be mixed and it can be The of administration must also be monitored especially with and Although push administration has been for of the it has been and may The and of a drug to be considered with of intravenous regarding and factors has the of antimicrobial agents which and a a on growth antibiotic therapy may be in a a may and may also the of and the of therapy by and patients has been Once-daily for patients with or should be used with The because of their and with a be by infusion such as that have and that are at may to be mixed and administered as as 4 on and have to the for most for and can be once has been used in outpatient settings because of its and the of infections to is administration is for patients with and for patients The regarding and the of has the of to Although many are both at and when the of of and in are of These are in at for should be administered by infusion therapy. in more drug to antibiotics is to with a before A number of are for and factors to be when of a and the of infusion chosen must be to be considered include the patient's overall clinical and the vascular antimicrobials prescribed and their of for a infusion and the of therapy are appropriate for patients with who receive a of therapy for and for with an that has for or in are also for patients with access or treatment is to A wide of are for of therapy and are when the of a infusion is are commonly used for OPAT in The of has increased since the OPAT guidelines were These are appropriate in many in which the for than vascular access is present and the risks of or of other of is are also appropriate for with a is the should be and when it is A should be to the of the especially or agents are to be used and are also widely used for access and for the infusion of They may be in patients who are or in and from it is necessary to patients who a may be more are The clinical aspects of OPAT a of patient care These include monitoring the patient for to treatment and adverse in to care of the at appropriate for the drug is required to laboratory during most of therapy. the of adverse effects to antimicrobial therapy, which to the drug administered of adverse effects to administered antimicrobials used for outpatient parenteral antimicrobial therapy (OPAT). The of patient with the physician to be when a patient a of In most patients the physician once or each patients to be by a especially at the of with or other infections may also more may be appropriate for patients with few and appropriate and and monitoring should for physician of to the or care may also be there are care may be with a should also be of OPAT to be have to therapy are and have adverse The of nursing with the patient's condition, and nursing may be needed at the of therapy for clinical monitoring and A number of patients and their are of with a in the number of nursing The guidelines in table the of monitoring for adverse and studies may be needed for of the to therapy. effects in patients receiving antimicrobial therapy are information from the OPAT Outcomes which that of antimicrobial are because of an adverse laboratory parameters an adverse the of laboratory monitoring should be in the may to be or its that adverse such as or and become more as the of therapy an infection is the for laboratory monitoring receiving therapy should have weekly monitoring may be considered for and are receiving of therapy should have an of the and the or dose and any of or should be considered for those patients receiving therapy as a to more of may be necessary may be drug and should be used to with the or an is patients and should be to by clinical such as the of the development of or a of in the should of an of therapy. The patient's of should be in the medical and should be to including the of an adverse drug in the written to receive OPAT that is at the of therapy. and should be considered for those to receive therapy of should be during each with the physician and may also be is in most The is an of for that can be in the is when are administered to as it has been to be of for or patients during therapy The of is in the literature to be related to of it when is with other or agents A and clinical outcomes has been in there is of a in an have been a number of to and for with Specific patient have been shown to have when are on parameters In and during the of treatment the of adverse drug and to assure effective it is that both and be studies of are are also that of including may the development of is the to for in patients receiving or therapy is a common adverse with or therapy care. The care of the with the of of and site are for the In the for and guidelines for the of infection The has also practice for care, and to be especially for and to or of the and should be in the monitoring and care of the and should the A health care should and at and at The site should be for of and The development of of the or in with a or other should for a which of the should be for when used in with monitoring, a may be considered for patients receiving OPAT The of outcomes by an OPAT program is a part of the which to and assure the quality of their care and are chosen to the safety, and cost of the OPAT program The OPAT outcomes have been those related to cost and of outcomes may also be for and with payors. such as the for the of and the for outcomes measurements as a part of their the parameters or to The and of in or from therapy the for hospital discharge of the importance of monitoring outcomes to assure patient safety the 1997 OPAT guidelines were has been in the appropriate outcomes to and the for their are and prospective The in the the effectiveness of OPAT for many studies have been that the effectiveness of OPAT for patients with and with of in patients with at outcomes and patient with OPAT than hospital care studies to hospital can be patients receiving OPAT with the antimicrobial administered and the and of of the OPAT, as for antimicrobial therapy, adverse drug with to monitoring of to the antimicrobial used OPAT should have an program that can clinical and program are to for of a with a for The OPAT Outcomes is a that is that can compare a with that of an of with OPAT on outcomes for the patients and can its clinical This is in the of outcomes for infections treated with which are monitored in the OPAT Outcomes are in table safety and health infections are of with The home is for of hospital infection may be the of infection related to home care to be than the of infection and the of an from the home to be care are with a of many of are from infections safety with OPAT are to the hospital with adverse drug and from infusion and should be with to risks and be for health care safety and are to be the patient's of care in the outpatient setting Although many of guidelines to both and aspects of OPAT of in the care of and safety should be the most Although OPAT many it should be in or care can be to the with the or a of safety as provided by therapy. in are unique to assessment of in a with infections are more common in and and antimicrobial may be to and a other the must be of the necessary care. are unique to such as by on OPAT to is as as literature on the outpatient treatment of a number of on therapy and have been written for and and of OPAT in to the nursing of the In the of assessment to the to the infection and of the infection or experience and in the care of and the safety of the it is essential that the nursing be of a skilled assessment of the medical and to In most a should nursing care, rather than a or a nursing The of for the various of nursing, and the for nursing are to each should be aware of the of the nursing for assessment of in their A infusion exist the a related to nurses, and should have and with the unique antimicrobials and used for and to in or adverse drug The for home nursing in the of the guidelines as for in in which the clinical may be to and the of the infection are by home care may be include infections during the and infections for of any the of the for medical assessment of the and for the required number of nursing should be to discharge an OPAT program. with the medical of a may be required to the required for the safety of the or to in which a is to the of the or to and care for should be to may that from or who are of a medical care of the or infusion of The physician who and the as an outpatient has the for the intended of antimicrobials for the guidelines as those for parenteral therapy. the number of and and for is than those for because of of on efficacy and safety in with of the physician must the and most effective antimicrobials for the of with the is an as is the to the vascular access is essential before discharge as vascular access for an in the home with resources and from other medical may be on treatment of infections with agents is In antibiotics are to be during the of are used in because of The of used for antimicrobial infusion in is to are for The availability of vascular access by and is A variety of infusion are used in from of push to infusion that from or to infusion of the outcome parameters for patients are to those for the and used to the antibiotics and the infections and treated may be unique to the The and outcomes in program should be with those of rather than with of used for outcomes and in and OPAT is a part of medical practice in Although it is it is and especially for the who must a quality of care with OPAT as as that that be provided the patient is also a of of that the of and of services from physicians, nurses, and The for OPAT to be with and of effectiveness and patient are a number of by which information can be patient outcomes and the in different health care studies of OPAT are needed in to are access is of both with to selection and care. The safety of and in to for with OPAT has been for of and guidelines and have been by the and the that to These were from hospital studies and may be appropriate for of antibiotics by push may in OPAT, its safety has been The with of and the to early in the outpatient setting are of and the first dose of an intravenous antibiotic in the especially because of the for The to can be to and with the that in studies of therapy in on outcomes and patient safety can be of and with outcomes These can also be used to more the therapy for infectious and the agents used to The to guidelines considered be to their and of the guidelines or their in the various is In the Internet the to information and it to from other and to patient The for and the in of resources are the of the of information OPAT can be at the OPAT Outcomes site and at the of the in table The role of physicians in outpatient and home care is Although their role in the hospital and as to be their of services and home care has should be to the and needed to infections the hospital. from related who to guidelines include the following: of for for in and of and of of of has from and and has for and and to the of and is by of that the effectiveness outpatient parenteral antimicrobial therapy for various infectious