Outpatient Parenteral Antimicrobial Therapy (OPAT) Practices at a Veterans Affairs Hospital: Potential for Pharmacist Impact

Abstract Background The Infectious Diseases Society of America (IDSA) OPAT Practice Guidelines and Handbook recommend multidisciplinary team involvement as a key element to the success of OPAT. Studies have demonstrated that OPAT pharmacist oversight can improve monitoring of intravenous (IV) antibiotics and achieve clinical cure in 77% of patients. Pharmacists at the Veterans Affairs Palo Alto Health Care System are currently not routinely involved with the management of OPAT patients. Methods A retrospective analysis was performed to determine the rate of adherence to IDSA recommendations on antibiotic laboratory and clinical monitoring in veterans discharged with OPAT between July 1, 2015 and June 30, 2016. Secondary outcomes assessed were rates of clinical cure, treatment failure, readmission, and OPAT complications. Data was analyzed using descriptive statistics. Results Of 83 patients evaluated, 91 IV antibiotics were administered and 70 patients completed OPAT. The most common infections were osteomyelitis (n = 33, 40%), bacteremia (n = 13, 13%), and skin and soft-tissue infection (n = 9, 11%). Cephalosporins (n = 41, 45%) were most commonly used, followed by vancomycin (n = 18, 20%) and penicillins (n = 12, 13%). Appropriate monitoring of complete blood count, basic metabolic panel, and liver function occurred 45%, 45%, and 25% of the time, respectively, based on IDSA guidance. An increase in treatment failure was observed when less than 25% of weekly lab monitoring was conducted. Twenty-six patients (31%) met the IDSA recommendation for follow-up visits within 7–14 days of discharge and 51 patients (61%) received follow-up visits upon OPAT completion. Clinical cure was achieved in 52 patients (63%). There were more 90-day readmissions related to infection, adverse drug reactions, catheter-related complications, and C. difficile infections reported in the treatment failure group compared with the clinical cure group. Conclusion In most cases, IDSA recommendations on OPAT management were not appropriately followed and lack of monitoring was associated with treatment failure. Fewer patients achieved clinical cure compared with rates documented in the literature, strongly suggesting the need for an OPAT pharmacist to achieve optimal monitoring and follow-up. Disclosures All authors: No reported disclosures.

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613. Clinical Outcomes Following Dalbavancin Administration during Outpatient Parenteral Antimicrobial Therapy

Open Forum Infectious Diseases ◽

10.1093/ofid/ofab466.811 ◽

2021 ◽

Vol 8 (Supplement_1) ◽

pp. S410-S410

Author(s):

Jessica Tuan ◽

Jehanzeb Kayani ◽

Ann Fisher ◽

Brian Kotansky ◽

Louise Dembry ◽

...

Keyword(s):

Antimicrobial Therapy ◽

Clinical Cure ◽

Veterans Affairs ◽

Short Term ◽

Gram Positive ◽

Outpatient Parenteral Antimicrobial Therapy ◽

All Cause Mortality ◽

Antibiotic Duration ◽

Staphylococcus Spp ◽

Median Hospital

Abstract Background Dalbavancin, a lipoglycopeptide with prolonged half-life targeting Gram-positive organisms, is approved for treatment of acute bacterial skin and soft tissue infection. It reduces hospital duration in patients with barriers to short-term rehabilitation or outpatient parenteral antimicrobial therapy (OPAT). Increasing evidence supports the off-label use of dalbavancin to treat other types of infection. We conducted a quality improvement study to evaluate outcomes following dalbavancin administration. Methods We performed a cohort study of recipients of ≥1 dose of dalbavancin from 1/31/2016-1/31/2021 at the Veterans Affairs Connecticut Healthcare System. Demographic, comorbidity, microbiological, antibiotic duration prior to dalbavancin, indication for dalbavancin, and type of infection data were collected. Outcomes included 1) lab abnormalities: hepatotoxicity within 2 weeks of dalbavancin; 2) clinical cure: resolution of symptoms of infection within 90 days; 3) all-cause readmission within 90 days; and 4) all-cause mortality within 90 days. Results 42 patients met criteria. Median age was 69 years (range, 32-91), 100% were male, 55% (n=23) had diabetes, 31% (n=13) had liver disease, 36% (n=15) had other immunosuppressive conditions, and 12% (n=5) had substance use disorder (SUD). All received their first dose as inpatients. Median hospital duration was 8 days (range, 1-32). 4 (10%) required critical care. Median antibiotic duration prior to dalbavancin was 7 days (range, 1-42). Indications included ineligibility for OPAT (n=21, 50%), pharmacologic reasons (n=10, 24%), ineligibility for peripherally inserted central catheter (n=6, 14%), or SUD (n=5, 12%). Common microorganisms were Staphylococcus spp. (n=22, 52%), polymicrobial (n=13, 31%), and Corynebacterium spp. (n=10, 24%). 93% (n=39) had clinical cure of infection; readmissions and mortality were rare (Table 1). Conclusion Dalbavancin was associated with clinical cure for diverse infections with low rates of adverse events, readmission and mortality in patients ineligible for traditional OPAT. Although confirmatory data are needed from larger studies, dalbavancin appears to be a versatile therapeutic agent for Gram-positive infections. Disclosures All Authors: No reported disclosures

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Risk Factors for Failure in Conservatively Treated Osteoporotic Vertebral Fractures: A Systematic Review

Global Spine Journal ◽

10.1177/2192568220982279 ◽

2021 ◽

pp. 219256822098227

Author(s):

Max J. Scheyerer ◽

Ulrich J. A. Spiegl ◽

Sebastian Grueninger ◽

Frank Hartmann ◽

Sebastian Katscher ◽

...

Keyword(s):

Risk Factors ◽

Systematic Review ◽

Treatment Failure ◽

Patient Specific ◽

Mineral Density ◽

Radiographic Findings ◽

Specific Risk ◽

Fracture Development ◽

Predict Treatment Failure

Study Design: Systematic review. Objectives: Osteoporosis is one of the most common diseases of the elderly, whereby vertebral body fractures are in many cases the first manifestation. Even today, the consequences for patients are underestimated. Therefore, early identification of therapy failures is essential. In this context, the aim of the present systematic review was to evaluate the current literature with respect to clinical and radiographic findings that might predict treatment failure. Methods: We conducted a comprehensive, systematic review of the literature according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) checklist and algorithm. Results: After the literature search, 724 potentially eligible investigations were identified. In total, 24 studies with 3044 participants and a mean follow-up of 11 months (range 6-27.5 months) were included. Patient-specific risk factors were age >73 years, bone mineral density with a t-score <−2.95, BMI >23 and a modified frailty index >2.5. The following radiological and fracture-specific risk factors could be identified: involvement of the posterior wall, initial height loss, midportion type fracture, development of an intravertebral cleft, fracture at the thoracolumbar junction, fracture involvement of both endplates, different morphological types of fractures, and specific MRI findings. Further, a correlation between sagittal spinal imbalance and treatment failure could be demonstrated. Conclusion: In conclusion, this systematic review identified various factors that predict treatment failure in conservatively treated osteoporotic fractures. In these cases, additional treatment options and surgical treatment strategies should be considered in addition to follow-up examinations.

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CXCL13 concentration in latent syphilis patients with treatment failure

Open Medicine ◽

10.1515/med-2020-0204 ◽

2020 ◽

Vol 15 (1) ◽

pp. 635-643

Author(s):

Yan Zhang ◽

Jun Wang ◽

Yingnan Wei ◽

Huili Liu ◽

Chunli Wu ◽

...

Keyword(s):

Nervous System ◽

Treatment Failure ◽

Leukocyte Count ◽

Inflammatory Diseases ◽

Enzyme Linked Immunosorbent Assay ◽

Control Group ◽

System Control ◽

Failure Group ◽

Latent Syphilis ◽

Hiv Negative

AbstractWe aimed to investigate the CXCL13 concentration of the serum and cerebral spinal fluid (CSF) in human immunodeficiency virus (HIV)-negative latent syphilis patients with treatment failure and explore the change in CXCL13 after treatment. Sixty-eight latent syphilis patients with treatment failure (failure group), 68 syphilis patients with successful treatment (seroconversion group) and 18 patients with non-inflammatory diseases of the nervous system (control group) were included and serum and CSF were collected. Enzyme-linked immunosorbent assay was employed to detect the CXCL13 in the serum and CSF. Results showed that the serum CXCL13 concentration was comparable among three groups, and the CSF leukocyte count, IgG index and CXCL13 concentration in the failure group were significantly higher than those in the seroconversion group and control group (P < 0.05, P < 0.01). CSF CXCL13 concentration in the failure group was positively related to the CSF leukocyte count (r = 0.3594, P < 0.001). Of the 68 patients in the treatment failure group, neurosyphilis was found in 17 (25.0%). In conclusion, involvement of nervous system is one of the reasons for the treatment failure in patients with latent syphilis. Detection of CSF CXCL13 concentration is helpful for the diagnosis and therapeutic evaluation of HIV-negative latent syphilis patients with treatment failure and neurosyphilis.

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A case of hypereosinophilic syndrome with STAT5b N642H mutation

Oxford Medical Case Reports ◽

10.1093/omcr/omaa129 ◽

2021 ◽

Vol 2021 (1) ◽

Author(s):

Feihong Ding ◽

Chaoping Wu ◽

Yun Li ◽

Sudipto Mukherjee ◽

Subha Ghosh ◽

...

Keyword(s):

Complete Blood Count ◽

Hypereosinophilic Syndrome ◽

Organ Damage ◽

Myeloid Neoplasm ◽

Acute Eosinophilic Pneumonia ◽

Myeloid Neoplasms ◽

Somatic Signal ◽

Generation Sequencing

ABSTRACT Hypereosinophilia is defined as persistent eosinophilia (>1.5 × 109/L). Hypereosinophilic syndrome (HES) is a term used to describe a group of disorders characterized by sustained hypereosinophilia associated with end-organ damage. Based on underlying molecular mechanism of eosinophilia, there are different subtypes of HES. Diagnosis of HES subtype can be challenging, especially in the absence of overt lymphoid/myeloid neoplasms or discernable secondary causes. Long-term outpatient follow-up with periodic complete blood count and repeated bone marrow biopsy may be needed to monitor disease activity. Somatic signal transducer and activation transcription 5b (STAT5b) N642H mutation was recently found to be associated with myeloid neoplasms with eosinophilia. We report a case of HES who presented with pulmonary embolism and acute eosinophilic pneumonia, found to have recurrent STAT5b N642H mutation by next-generation sequencing, suggesting possible underlying myeloid neoplasm.

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Evaluating the Effectiveness of Diabetes Shared Medical Appointments (SMAs) as Implemented in Five Veterans Affairs Health Systems: a Multi-site Cluster Randomized Pragmatic Trial

Journal of General Internal Medicine ◽

10.1007/s11606-020-06570-y ◽

2021 ◽

Author(s):

Michele Heisler ◽

Jennifer Burgess ◽

Jeffrey Cass ◽

John F. Chardos ◽

Alexander B. Guirguis ◽

...

Keyword(s):

Clinical Practice ◽

Usual Care ◽

Health Systems ◽

Pragmatic Trial ◽

Veterans Affairs ◽

Control Group ◽

Shared Medical Appointments ◽

Site Cluster ◽

Cluster Randomized

Abstract Objective To examine whether diabetes shared medical appointments (SMAs) implemented as part of usual clinical practice in diverse health systems are more effective than usual care in improving and sustaining A1c improvements. Research Design and Methods A multi-site cluster randomized pragmatic trial examining implementation in clinical practice of diabetes SMAs in five Veterans Affairs (VA) health systems was conducted from 2016 to 2020 among 1537 adults with type 2 diabetes and elevated A1cs. Eligible patients were randomly assigned to either: (1) invitation to participate in a series of SMAs totaling 8–9 h; or (2) continuation of usual care. Relative change in A1c (primary outcome) and in systolic blood pressure, insulin starts, statin starts, and anti-hypertensive medication classes (secondary outcomes) were measured as part of usual clinical care at baseline, at 6 months and at 12 months (~7 months after conclusion of the final SMA in four of five sites). We examined outcomes in three samples of SMA participants: all those scheduled for a SMA, those attending at least one SMA, and those attending at least half of SMAs. Results Baseline mean A1c was 9.0%. Participants scheduled for an SMA achieved A1c reductions 0.35% points greater than the control group between baseline and 6-months follow up (p = .001). Those who attended at least one SMA achieved reductions 0.42 % points greater (p < .001), and those who attended at least half of scheduled SMAs achieved reductions 0.53 % points greater (p < .001) than the control group. At 12-month follow-up, the three SMA analysis samples achieved reductions from baseline ranging from 0.16 % points (p = 0.12) to 0.29 % points (p = .06) greater than the control group. Conclusions Diabetes SMAs as implemented in real-life diverse clinical practices improve glycemic control more than usual care immediately after the SMAs, but relative gains are not maintained. Our findings suggest the need for further study of whether a longer term SMA model or other follow-up strategies would sustain relative clinical improvements associated with this intervention. Trial Registration ClinicalTrials.gov ID NCT02132676

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Histologic Remission Is Associated With Lower Risk of Treatment Failure in Patients With Crohn Disease in Endoscopic Remission

Inflammatory Bowel Diseases ◽

10.1093/ibd/izaa301 ◽

2020 ◽

Author(s):

Hyuk Yoon ◽

Sushrut Jangi ◽

Parambir S Dulai ◽

Brigid S Boland ◽

Vipul Jairath ◽

...

Keyword(s):

Treatment Failure ◽

Crohn Disease ◽

Lower Risk ◽

Hazard Analysis ◽

Cumulative Risk ◽

Treatment Optimization ◽

Cox Proportional Hazard ◽

Endoscopic Remission ◽

Risk Of Treatment

Abstract Background Although achieving histologic remission in ulcerative colitis is established, the incremental benefit of achieving histologic remission in patients with Crohn disease (CD) treated to a target of endoscopic remission is unclear. We evaluated the risk of treatment failure in patients with CD in clinical and endoscopic remission by histologic activity status. Methods In a single-center retrospective cohort study, we identified adults with active CD who achieved clinical and endoscopic remission through treatment optimization. We evaluated the risk of treatment failure (composite of clinical flare requiring treatment modification, hospitalization, and/or surgery) in patients who achieved histologic remission vs persistent histologic activity through Cox proportional hazard analysis. Results Of 470 patients with active CD, 260 (55%) achieved clinical and endoscopic remission with treatment optimization; 215 patients with histology were included (median age, 33 years; 46% males). Overall, 132 patients (61%) achieved histologic remission. No baseline demographic, disease, or treatment factor was associated with achieving histologic remission. Over a 2-year follow-up, patients with CD in clinical and endoscopic remission who achieved histologic remission experienced a 43% lower risk of treatment failure (1-year cumulative risk: 12.9% vs 18.2%; adjusted hazard ratio, 0.57 [95% confidence interval, 0.35-0.94]) as compared with persistent histologic activity. Conclusions Approximately 61% of patients with active CD who achieved clinical and endoscopic remission with treatment optimization simultaneously achieved histologic remission, which was associated with a lower risk of treatment failure. Whether histologic remission should be a treatment target in CD requires evaluation in randomized trials.

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Debridement, Antibiotics, and Implant Retention Is a Viable Treatment Option for Early Periprosthetic Joint Infection Presenting More Than 4 Weeks After Index Arthroplasty

Clinical Infectious Diseases ◽

10.1093/cid/ciz867 ◽

2019 ◽

Vol 71 (3) ◽

pp. 630-636 ◽

Cited By ~ 3

Author(s):

Claudia A M Löwik ◽

Javad Parvizi ◽

Paul C Jutte ◽

Wierd P Zijlstra ◽

Bas A S Knobben ◽

...

Keyword(s):

Treatment Failure ◽

Periprosthetic Joint Infection ◽

Joint Infection ◽

Viable Option ◽

Time Intervals ◽

Implant Retention ◽

Time Point ◽

Viable Treatment

Abstract Background The success of debridement, antibiotics, and implant retention (DAIR) in early periprosthetic joint infection (PJI) largely depends on the presence of a mature biofilm. At what time point DAIR should be disrecommended is unknown. This multicenter study evaluated the outcome of DAIR in relation to the time after index arthroplasty. Methods We retrospectively evaluated PJIs occurring within 90 days after surgery and treated with DAIR. Patients with bacteremia, arthroscopic debridements, and a follow-up <1 year were excluded. Treatment failure was defined as (1) any further surgical procedure related to infection; (2) PJI-related death; or (3) use of long-term suppressive antibiotics. Results We included 769 patients. Treatment failure occurred in 294 patients (38%) and was similar between time intervals from index arthroplasty to DAIR: the failure rate for Week 1–2 was 42% (95/226), the rate for Week 3–4 was 38% (143/378), the rate for Week 5–6 was 29% (29/100), and the rate for Week 7–12 was 42% (27/65). An exchange of modular components was performed to a lesser extent in the early post-surgical course compared with the late course (41% vs 63%, respectively; P < .001). The causative microorganisms, comorbidities, and durations of symptoms were comparable between time intervals. Conclusions DAIR is a viable option in patients with early PJI presenting more than 4 weeks after index surgery, as long as DAIR is performed within at least 1 week after the onset of symptoms and modular components can be exchanged.

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Frequent Emergence of Resistance in Clostridium difficile during Treatment of C. difficile-Associated Diarrhea with Fusidic Acid

Antimicrobial Agents and Chemotherapy ◽

10.1128/aac.00019-06 ◽

2006 ◽

Vol 50 (9) ◽

pp. 3028-3032 ◽

Cited By ~ 39

Author(s):

T. Norén ◽

M. Wullt ◽

Thomas Åkerlund ◽

E. Bäck ◽

I. Odenholt ◽

...

Keyword(s):

Clostridium Difficile ◽

Treatment Failure ◽

Fusidic Acid ◽

Negative Impact ◽

Acid Resistance ◽

Clinical Recurrence ◽

Acid Therapy ◽

Emergence Of Resistance ◽

Culture Positive

ABSTRACT Samples from patients with Clostridium difficile-associated diarrhea (CDAD) that were randomized to fusidic acid (n = 59) or metronidazole (n = 55) therapy for 7 days were cultured for Clostridium difficile in feces on days 1, 8 to 13, and 35 to 40. Of the patients who were culture positive only before treatment, 77% (36/47) were permanently cured (no treatment failure and no clinical recurrence), compared to 54% (22/41) of those with persistence of C. difficile at one or both follow-ups (P = 0.03). A similar association between bacterial persistence and a worse outcome of therapy was seen in both treatment groups. Resistance to fusidic acid was found in 1 of 88 pretherapy isolates available, plus in at least 1 subsequent isolate from 55% (11/20) of patients who remained culture-positive after fusidic acid therapy. In 10 of these 11 patients, the resistant follow-up isolate(s) belonged to the same PCR ribotype as the susceptible day 1 isolate, confirming frequent emergence of resistance to fusidic acid during treatment. Despite this, 5 of these 11 patients were permanently cured with fusidic acid, relative to 5 of 9 patients with susceptible C. difficile at follow-up (P = 1.0). None of the 36 PCR ribotypes of C. difficile identified was associated with any particular clinical outcome or emergence of fusidic acid resistance. In conclusion, culture positivity for C. difficile was common after both fusidic acid and metronidazole therapy and was associated with treatment failure or recurrence of CDAD. Development of resistance in C. difficile was frequent in patients given fusidic acid, but it was without apparent negative impact on therapeutic efficacy in the actual CDAD episode.

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