Outpatient Parenteral Antibiotic Therapy for Bone and Joint Infections: An Italian Multicenter Study

Abstract

In the early eighties, the advantages of outpatient parenteral antibiotic therapy (OPAT) (reduced costs, no hospitalization trauma in children, no immobilization syndrome in elderly, reduction in nosocomial infections by multiresistant organisms) were identified in the United States, and suitable therapeutic programs were established. Currently, more than 250,000 patients per year are treated according to an OPAT program. In order to understand the different ways of managing OPAT and its results, a National OPAT Registry was set up in 2003 in Italy. Analysis of data concerning osteomyelitis, septic arthritis, prosthetic joint infection and spondylodiskitis, allowed information to be acquired about 239 cases of bone and joint infections, with particular concern to demographics, therapeutic management, clinical response, and possible side effects. Combination therapy was the first-line choice in 66.9% of cases and frequently intravenous antibiotics were combined with oral ones. Teicoplanin (38%) and ceftriaxone (14.7%), whose pharmacokinetic/pharmacodynamic properties permit once-a-day administration, were the two top antibiotics chosen; fluoroquinolones (ciprofloxacin and levofloxacin) were the most frequently utilized oral drugs. Clinical success, as well as patients' and doctors' satisfaction with the OPAT regimen was high. Side-effects were mild and occurred in 11% of cases. These data confirm that the management of bone and joint infections in an outpatient setting is suitable, effective and safe.

Patients with Prosthetic Joint Infection on IV Antibiotics are at High Risk for Readmission

“…A recent multicenter study found outpatient parenteral antimicrobial therapy suitable, cost-effective, and safe in bone and joint infections [5]. However, most of the population in this study received intravenous antimicrobials in hospital infusion centers rather than the community setting.…”

The Community IntraVenous Antibiotic Study (CIVAS): a mixed-methods evaluation of patient preferences for and cost-effectiveness of different service models for delivering outpatient parenteral antimicrobial therapy

“…56 Of the remaining studies that considered acceptability in OPAT patients only, most involved multiple OPAT models (and did not differentiate between them in their findings), or did not specify the model(s) under study. In general, satisfaction with treatment was very high, 2,13,27,36,[67][68][69][70][71][72][73][74][75][76][77][78][79][80][81][82][83] including when patients had to have frequent attendance at hospital. 5,84 Commonly perceived advantages of OPAT included the ability to resume daily activities, 2,27,71,73 feelings of improved self-esteem or greater freedom and control, 67,71,73,85,86 and not having to remain in or attend hospital.…”

Italian Guidelines for the Diagnosis and Infectious Disease Management of Osteomyelitis and Prosthetic Joint Infections in Adults

“…For methicillinresistant S. aureus (MRSA) infections following surgery, continuous outpatient perfusion of vancomycin with steady-state plasma levels of approximately 25 mg/l for several months has been used with success [79]. Teicoplanin administered once daily for very prolonged periods also appears to be efficacious [68,80]. Quinopristin-dalfopristin is active against Enterococcus faecium [including vancomycin-resistant strains; (VRE)] and S. aureus (including MRSA), but not against E. faecalis.…”

“…To date, only ofloxacin and ciprofloxacin have been tested in combination with rifampin [60,61,67]. However, the antimicrobial spectrum of newer fluoroquinolones, such as levofloxacin (grading A-II) and moxifloxacin (grading A-III), is more promising for the treatment of staphylococcal infections [68][69][70][71][72]. In a prospective cohort study of patients with staphylococcusinfected orthopedic implants treated with a long-term oral combination of rifampin and levofloxacin, Barberan et al [73] reported an overall clinical and bacteriological success rate of 69.5% (48/69) and 80% (16/20), respectively.…”

“…Penicillin-susceptible streptococcal PJIs can be successfully treated with prosthesis retention and iv penicillin or with once-daily ceftriaxone followed by oral amoxicillin-rifampin [78]. PJIs caused by methicillin-resistant staphylococci are primarily treated by iv glycopeptides [68,77] (grading A-III). For methicillinresistant S. aureus (MRSA) infections following surgery, continuous outpatient perfusion of vancomycin with steady-state plasma levels of approximately 25 mg/l for several months has been used with success [79].…”