IDSA issues new clinical practice guideline for outpatient parenteral antimicrobial therapy

An expert panel convened by the Infectious Diseases Society of America (IDSA) recently updated the organization's 2004 guideline on outpatient parenteral antimicrobial therapy, highlighting its safety and the importance of infectious diseases subspecialist involvement.

Since the previous guideline was published, three large studies have found no difference in the number of adverse events related to outpatient parenteral antimicrobial therapy compared to the more expensive hospital-administered IV antimicrobial therapy, according to the guideline. New research has also shown that review by an infectious diseases physician, nurse, or pharmacist before starting outpatient parenteral antimicrobial therapy is associated with a lower risk of hospital readmission.

The full guideline was published online on Nov. 13 by Clinical Infectious Diseases and includes the following recommendations:

• All patients should have an infectious diseases expert review their case prior to initiation of outpatient parenteral antimicrobial therapy (strong recommendation, very low-quality evidence).
• Patients or their caregivers should be allowed to self-administer outpatient parenteral antimicrobial therapy (strong recommendation, low-quality evidence). Self-administration at home without visiting nurse support may be allowed, provided that there is a system in place for effective monitoring for vascular access complications and antimicrobial adverse events (weak recommendation, low-quality evidence).
• Elderly patients should be allowed to be treated at home with outpatient parenteral antimicrobial therapy, assuming that potential challenges have been considered and that the patient or caregiver is able to communicate with the treatment team if necessary (strong recommendation, low-quality evidence).
• The first dose of a new parenteral antimicrobial agent may be administered at home in patients who have no history of allergy to antimicrobials in the same class and are under the supervision of a health care worker who can respond to anaphylactic reactions (weak recommendation, very low-quality evidence).
• Serial laboratory testing should be conducted in patients receiving outpatient parenteral antimicrobial therapy (strong recommendation, high-quality evidence). Data were insufficient to make recommendations about specific tests and frequency of monitoring for individual antimicrobials.
• Vancomycin blood levels should be measured regularly throughout the course of treatment (strong recommendation, very low-quality evidence). While the optimal frequency of measurement is undefined, the general practice for patients with stable renal function is once per week, the guideline said.
• For patients with advanced chronic kidney disease who require outpatient parenteral antimicrobial therapy, a tunneled central venous catheter is recommended rather than a peripherally inserted central catheter (strong recommendation, low-quality evidence).
• If a patient develops catheter-associated venous thromboembolism during treatment, it is not necessary to remove the vascular access device if the catheter remains well positioned and arm pain and swelling decrease with anticoagulation (weak recommendation, very low-quality evidence).

The guideline noted that there was not enough evidence to recommend a general frequency of outpatient follow-up. The treating physician should dictate the frequency of office visits after considering patient characteristics, individual social factors, the nature of the infection, and tolerance and response to therapy, according to the guideline.