Outpatient Parenteral Antibiotic Therapy in Older Adults: Nora T. Oliver,, Marion J. Skalweit

O u t p a t i e n t P a ren t e r a l
Antibiotic Therapy i n O lder

Adults
a, b
Nora T. Oliver, MD MPH *, Marion J. Skalweit, MD PhD
KEYWORDS
Outpatient parenteral antibiotic therapy Older adults Intravenous antibiotics
Adverse drug events
KEY POINTS
Older age is not a contraindication to participating in outpatient parenteral antibiotic ther-
apy (OPAT) when candidates are carefully vetted, and patient safety is a forefront
consideration.
OPAT in the home setting is preferred over OPAT given at skilled nursing facilities or infu-
sion clinic because it optimizes patient comfort, satisfaction, and autonomy while mini-
mizing health-care exposure amid the ongoing COVID-19 pandemic.
Older persons have more comorbidities and are at risk for polypharmacy and drug–drug
interactions that should be considered when selecting antibiotic and individualizing moni-
toring plans for the patient.
Innovations in OPAT such as use of long-acting lipoglycopeptides and the use of telemed-
icine further increase patient-centered care and reduce health-care exposure.
INTRODUCTION
Outpatient parenteral antimicrobial therapy (OPAT) is the process of delivering and

administering parenteral antibiotic medications of at least 2 doses to patients in the
outpatient setting without the need for intervening acute hospitalization.1 This is often
done in the comfort of the patient’s home or in other settings such as a skilled nursing
facility (SNF), hemodialysis (HD) unit, or outpatient infusion clinic, and has taken place
for more than 4 decades in the United States. It is a complex process that involves
multiple stakeholders and care coordination to accomplish, but when properly
executed, OPAT is a useful and patient-centered tool that has many opportunities
for treatment of complicated infections, improved patient satisfaction, and reduced
a
Section of Infectious Diseases, Atlanta VA Medical Center, 1670 Clairmont Road, RIM 111,
Decatur, GA 30033, USA; b Department of Medicine and Biochemistry, Case Western Reserve
University School of Medicine, 11100 Euclid Avenue, Cleveland OH 44106, USA
* Corresponding author.
E-mail address: [email protected]
Infect Dis Clin N Am 37 (2023) 123–137

https://doi.org/10.1016/j.idc.2022.09.002 id.theclinics.com
0891-5520/23/ª 2022 Elsevier Inc. All rights reserved.
Descargado para Anonymous User (n/a) en National Autonomous University of Mexico de

ClinicalKey.es por Elsevier en enero 09, 2024. Para uso personal exclusivamente. No se permiten
otros usos sin autorización. Copyright ©2024. Elsevier Inc. Todos los derechos reservados.
124 Oliver & Skalweit
health-care costs by avoiding or reducing acute care resources. In the era of the
COVID-19 pandemic, OPAT has played an essential role in freeing acute care hospital
resources and reducing the risk of nosocomial SARS-CoV-2 spread. For older adults,
the acute care hospital setting can incur risks such as hospital-acquired infections and
nosocomial SARS-CoV-2 transmission. With the background of the COVID-19
pandemic, the number of home infusion therapy (HIT) visits for antibiotics in the United
States remains high; from April 2020 through March 2021, antibiotic HIT represented
about 11% of all HIT service visits, which has tripled in number since 2019.2
Outpatient receipt of parenteral antibiotics is generally considered a safe and well-
tolerated practice for the patients who appropriately qualify for this type of service.
Home administration of parenteral antibiotics confers the most independence for
the patient and relies on the patient and/or support of a caregiver to administer the
medication to the patient with limited, weekly home nursing support. Settings with
more intensive nursing support such as infusion clinics, HD units, and SNFs allow
for direct supervision and administration of the antimicrobial agent by a health-care
professional. These types of settings may be more applicable to OPAT candidates
in which home safety is a concern or additional care cannot be rendered easily at
home or autonomously. Determining which OPAT environment is best suited for the
individual patient considers a variety of factors, ultimately centered around the safety
of the patient.
With the growing number of OPAT use in older adults, there are key issues and chal-
lenges this population faces regarding successful participation and completion of
OPAT. These include host-related factors, infection-related treatment decisions, and
environmental and psychosocial factors. Host-specific factors may include cognitive
ability, dexterity, mobility, and personal comfort or willingness to administer parenteral
antibiotics. Other individual factors such as comorbidities, polypharmacy, and need for
complex care (eg, wound care, physical therapy) may also affect decisions on antibiotic
selection and how and where OPAT is delivered. Antibiotic treatment courses are highly
variable, depending on underlying infection, and can span from days to weeks. Deci-
sions about length of therapy, coadministration, or substitution with oral antibiotics all
play a role in OPAT candidacy and location. Finally, home environmental and psycho-
social barriers influence antibiotic selection and OPAT candidacy because administra-
tion of parenteral antibiotics and maintenance of venous access demands a safe and
clean environment. Successful OPAT also demands participation at some level in the
transaction of medications and their administration in exchange for adherence with
said medications and accompanying ancillary supportive care.
This article herein reviews the types of infections affecting older adults that may indi-
cate the use of OPAT. We will also discuss the nuanced process of OPAT candidate
and location selection for the treatment of those infections. Determining which patient
will be successful in the OPAT process is sometimes difficult to clearly define at the
start of an OPAT course; success in OPAT hinges on the host, environmental, and
disease-specific variables at the time of inpatient discharge or in the outpatient
setting. Finally, the COVID-19 pandemic also has had impact on the use of OPAT
as a valuable tool to avoid unnecessary acute-care bed utilization as well as keeping
vulnerable patients away from health-care settings that could increase the risk of
nosocomial COVID-19. OPAT provides many opportunities to deliver the needed
care with a patient-centered approach.
Infections Indicating Use of Outpatient Parenteral Antimicrobial Therapy

Intravenous (IV) antimicrobial therapy is often given for severe infections, infections
with multidrug-resistant organisms (MDRO), or deep-seated infections with or without

Outpatient Parenteral Antibiotic Therapy in Older Adults 125
source control. IV antimicrobial therapy is used to treat many complex acute and,
sometimes, chronic infections affecting older adults. Although this is not an exhaustive
review of infections indicating the use of OPAT, reviewed herein are infections with sig-
nificant impact in older adults: endovascular infections, bacteremias, bone and joint
infections, and complicated urinary tract infections (UTI).
Endovascular Infections
Endovascular infections include native valve and prosthetic valve endocarditis
(PVE),3,4 septic thrombophlebitis and endovascular device infections (lead-related
endocarditis,5 central venous catheters (CVCs), and nondriveline, left ventricular assist
device infections.6,7 Persons aged older than 60 years predominantly represent the
shifting epidemiology of infectious endocarditis in the past 20 years compared with
prior decades.7,8 Furthermore, older patients with complex cardiovascular disease
are more likely to receive implanted devices and prosthetic valves, making this group
particularly at the risk for infectious complications necessitating prolonged OPAT. Pa-
tients with PVE tend to be older and also incur greater in-hospital mortality compared
with native valve infective endocarditis.9
Typical pathogens of endovascular infections include skin and gastrointestinal flora
such Staphylococcus aureus, coagulase-negative staphylococci (CoNs, eg, Staphylo-
coccus epidermidis, Staphylococcus lugdunensis), beta-hemolytic streptococci, Viri-
dans group streptococci, and enterococci. Other organisms such as fastidious gram-
negative pathogens (eg, “HACEK” organisms) as well as more unusual pathogens
such as Abiotrophia and Gemella spp represent a smaller proportion of patho-
gens.7,8,10,11 Finally, culture negative endocarditis accounts for 15% to 19% of cases
in some studies.7,8,11,12 There is increasing resistance to antibiotics among CoNS,
enterococci, and gram-negative pathogens among Enterobacterales and Pseudomo-
nads, in particular, necessitating long courses of multiple antibiotics.
Bacteremias
Bacteremias are a common indication of OPAT in older adults. Whether bacteremia
occurs more frequently or presents differently in the older adult is still a question
but age seems to be a strong risk factor.13 For example, with each decade more
than 60 years, the incidence of Staphylococcus aureus bacteremia (SAB) increases
dramatically: 100/100,000 persons/y in the sixth decade to the 250/100,000 per-
sons/y in the eighth decade of life.14 Bacteremia can develop from several sources,
if known, including endovascular, odontogenic, gastrointestinal, genitourinary (GU),
or respiratory infections. Skin and skin structure infections also account a smaller,
but not insignificant proportion of bacteremia, less than 10%.15
Bacteremia in older individuals is most commonly related to respiratory and GU
sources.13 Comorbid conditions such as poor dentition, structural lung disease, ma-
lignancy, diverticular disease, choledocholithiasis, urinary tract dysfunction (eg,
bladder prolapse, neurogenic bladder, benign prostatic hyperplasia), and diabetic
foot ulcers all lead to an increased risk of infection and subsequent bacteremia.
Occult infections may lead to bacteremia and can be more difficult to diagnose in
an older patient with fewer signs or symptoms to guide the clinician. Gram-positive
bacteremias with S aureus, Enterococcal species, oral streptococci, and fungemias
are typically treated with OPAT for extended durations (2–8 weeks) dependent on
source and source control and resistance profile of the indicated pathogen. More
recent evidence has helped shorten OPAT lengths in uncomplicated gram-negative
bacteremia.16,17

Musculoskeletal Infections
One of the most common type of infections involves the musculoskeletal system,
including septic arthritis of native joints as well as prosthetic joint infections (PJI).
The older population is more likely to experience PJI due to the increased likelihood
of joint replacement with up to an 8% risk of mortality.18 Although rare, infections
are a feared complication of joint replacement, often requiring source control with
explantation of the prosthetic material, and in some cases, prolonged immobilization
and OPAT.
The sequelae of chronic diabetes and peripheral vascular disease may manifest as
serious bone infections in older adults requiring revascularization, debridement,
amputation, and OPAT.19 Typical bone and joint pathogens include skin flora (S
aureus, CoNS, beta-hemolytic streptococci, Cutibacterium acnes), oral streptococci,
and less commonly, enteric gram-negative bacteria and enterococci. OPAT can be
prolonged, in addition to the other morbidities associated with treatment, for example,
deep venous thrombosis, skin and soft tissue infections from prolonged immobiliza-
tion, and poor tissue healing.
Complicated Urinary Tract Infections

UTI are common in older persons with incidence ranging from 0.05 to 0.13 infections
per person year in older men and women.20 This can be attributed to changes in GU
anatomy related to aging such as urinary tract dysfunction secondary to menopause,
bladder prolapse, neurogenic bladder, and benign prostatic hyperplasia. Because of
these anatomic changes leading to obstruction or poor urine flow, in addition to an in-
crease in immunocompromised states, virtually all UTI in older adults are complicated
in nature.21 In addition, many older persons develop asymptomatic bacteriuria and
colonization that beget unnecessary treatment, and consequently MDRO (eg,
extended spectrum beta-lactamase [ESBL] producing Enterobacterales, Pseudo-
monas, and Acinetobacter spp, MRSA, MDR Enterococcus spp). Other risks for infec-
tion with MDRO include residence in a long-term care facility.22 Interestingly, a
multivariate study of older men versus younger men with complicated UTI did not
show a difference in risk of MDRO associated with age.23 Bacteremia and sepsis
associated with GU infections, as well as infections involving the prostate or with
nephrolithiasis will typically require OPAT of some duration. Infections with ESBL pro-
ducing organisms will also usually necessitate use of OPAT due to limited oral options;
however, the length of treatment need not be increased due to the presence of these
pathogens.24
Outpatient Parenteral Antimicrobial Therapy Candidacy in Older Adults

One of the most critical aspects in a successful OPAT experience is selecting which
OPAT setting is most appropriate for each patient, which may include either a SNF,
infusion center, home, or HD center in some cases. Many factors must be considered
to assure a safe transition to the outpatient environment. Age alone should not be a
limiting factor in deciding OPAT eligibility; however, it should be considered in the
greater context of the patient’s own psychosocial competence and physical ability
to participate in OPAT, environmental support, and ambulatory resources to success-
fully complete OPAT.1
Outpatient Parenteral Antimicrobial Therapy Environment

The selection of the OPAT setting is a key aspect of patient-centered care. The home
setting is the most independent OPAT location, which thereby requires the most

participation by patient or caregiver(s) in the daily OPAT process. Home OPAT typi-
cally relies on the patient self-infusing and performing daily care for the venous access
in a clean and safe environment. The home must be safe and conducive for receiving
weekly home nursing visits for laboratory monitoring and venous catheter care.
Despite the onus on the patient, home OPAT is generally very user friendly with the
use of elastomeric drug-delivery devices and small, portable infusion pumps, and
the selection of medications that be given as an IV push. Patients are often able to
carry on with their regular activity inside and outside the home, which lends this to be-
ing a highly satisfactory way to receive OPAT compared with receiving OPAT at an
SNF or infusion clinic.25,26
For older patients who are unable to administer OPAT at home, other alternatives
with supervision include infusion clinics and placement at SNFs. Infusion clinics are
ambulatory centers where IV antibiotics can be administered by health-care profes-
sionals; however, limitations include daily transportation, daily versus multidose anti-
biotic regimens, and weekend/holiday administration. In our experience, placement at
SNF is the least preferred venue for OPAT due to the lack of autonomy and indepen-
dence available through home or infusion clinic OPAT. Patient satisfaction with quality
of services and overall patient happiness while on therapy are lower without any sig-
nificant return on improved tolerability or fewer problems while on antimicrobial ther-
apy.25 SNFs are necessary, although, for some older patients who require
complicated antimicrobial regimen not amenable for home infusion or circumstances
when patients are either unwilling to perform OPAT due to discomfort or fear of self-
infusing or are not candidates due to poor psychosocial or physical competency.
For those patients with end-stage renal disease (ESRD) requiring HD, receipt of
OPAT at the HD unit is preferred for several reasons, namely convenience. The ability
to infuse renally dosed antibiotics using the patient’s HD access in a supervised
setting, thus, obviates any additional central access. Placing additional CVCs in pa-
tients with chronic kidney disease or ESRD should generally be avoided to preserve
venous access for future HD needs.1 However, there may be issues in receiving
certain, less common antibiotics that may require special ordering in advance or spe-
cific administration by the HD center, which adds to the cost and inconvenience for the
patient.
Psycho-Social and Physical Competence

Especially in the older patient, gaining a sense of the patient’s competence is impor-
tant in assessing success of OPAT at home. Aside from the obvious use of cognitive
testing to assure competence, the prescribing provider must assess whether the pa-
tient understands the nature of their infection, therapeutic plan, and willingness to self-
administer antibiotics at home. If a patient is not able to perform these functions, then
a reliable caregiver who will be overseeing and providing the OPAT should undergo the
same competency assessment. The patient or caregiver must be teachable. Use of
techniques such as “teach back” are helpful tools in illuminating a patient’s under-
standing and ability to retain knowledge before embarking in OPAT.27 This assess-
ment is similar for older patients with active mental health disorders that may
impede full participation in OPAT at home.
For those individuals who will truly be self-administering antibiotics in the home, vi-
sual acuity and manual dexterity can be assessed through teach back, and if neces-
sary, physical therapy and occupational therapy can be consulted to offer assistance
and techniques to improve dexterity. Devices such as elastomeric devices and IV line
extenders may also be useful in aiding the older patient. Finally, early and frequent
engagement of caregiver support in the OPAT process is critical.

Substance Use Disorder

OPAT in individuals with substance use disorder (SUD) can be challenging to admin-
ister, yet SUD remains a risk factor for severe infections such as bacteremia and endo-
vascular infections that predicate prolonged IV antimicrobial therapy. Historically,
patients with SUD have conferred bias in health-care providers away from using stan-
dard home OPAT for the completion of therapy, rather opting for supervised settings
such as prolonged acute care hospitalization, SNF placement, or off-label use of oral
therapy or long-acting, extended-interval IV infusions. These medical decisions for
alternative, sometimes second-line therapies have been based on provider fear of pa-
tient nonadherence with OPAT or misuse of CVC and related medicolegal repercus-
sions.28,29 A recent literature review of OPAT outcomes in persons who inject drugs
(PWID) showed rates of OPAT completion in PWID are high (72%–100%) and no dif-
ference in rates of treatment failure, infection relapse, or hospital readmission. PWID
also had lower complication rates and greater use of after-hour nursing assistance,
suggesting that PWID can independently manage OPAT and seek care when
needed.29 Adverse events related to CVC such as thrombosis and infection were
low and similar to persons without injection drug use. Misuse of CVC has also been
shown to be infrequent.29,30
For those persons with SUD, OPAT and the opportunity for SUD treatment often
intersect. OPAT can be an opportunity to engage patients in SUD, mental health,
and social services. Administration of opioid partial agonist buprenorphine/naloxone
or methadone treatment combined with receipt of OPAT can also be an effective
means of increasing adherence and successful treatment of infections in this vulner-
able population. This can empower a patient to regain autonomy, avoid stigma,
reenter into society, and recover from SUD.31 Infectious disease clinic teams staffed
with nurses, ID pharmacists, social workers, and psychologists are an important
resource and advocates for the patient.
Outpatient Parenteral Antimicrobial Therapy Safety in Older Adults

Per the Infectious Disease Society of America (IDSA) OPAT guidelines, there are
“many descriptive studies in the adult and pediatric literature documenting the suc-
cessful administration of OPAT medications at home by patients or family members,
with few complications.”1 With respect to age as a risk factor in OPAT, based on 11
observational studies, the IDSA strongly endorsed OPAT for older patients, although
it was based on weak evidence using the GRADE analytical approach.32 Since the
publication of these guidelines, 10 additional observational studies including older pa-
tient groups have emerged looking at a variety of outcomes in OPAT.33–42 Most of
these studies did not look at age specifically as a risk factor but the subjects ranged
in age from 50 to 90s.33–35,37,40 Five studies looked at age as a risk factor and 2 found
worse outcomes in older persons—treatment amendment occurred more frequently in
persons aged older than 64.5 years, and increased admissions to adjust OPAT (1.18
RR per decade).36,38,39,41,42 Overall, careful patient selection, assurance of support in
the home setting, laboratory monitoring and oversight by an infectious diseases physi-
cian or nurse/pharmacist were factors that assured a favorable outcome.
Duration of Therapy
In most instances, OPAT is administered during several weeks of therapy depending
on the clinical syndrome being treated. Per the 2018 IDSA OPAT guidelines, the dura-
tion of antimicrobial treatment correlates with increased incidence of adverse drug
events (ADE) in both pediatric and adult OPAT.1,43–45 Complications of OPAT may

be directly linked to the duration of therapy (OPAT > 30 days) but these data can also
be conflicting (worse outcomes with shorter duration <14 days).32,35,45 Studies
showing worse outcomes associated with shorter length of therapy are possibly
confounded by subjects whose OPAT was truncated due to complications versus
subjects receiving shorter courses of therapy, for example, cellulitis or UTI. Using
an appropriate length of therapy can protect against complications. Opportunities
to switch to oral therapies earlier in treatment course or use of long-acting lipoglyco-
peptide (LA LGP) antibiotics in lieu of daily administration are options to reduce com-
plications relating to length of OPAT.46
Adverse Events and Complications

Adverse events are to be anticipated during OPAT treatment in all patients but espe-
cially in older patients with increased comorbidities and polypharmacy and for those
with severe infections, infections with MDRO, or intensive or prolonged antimicrobial
regimens.36,47 Adverse events including ADE, laboratory abnormalities, noninfectious
or non-OPAT-related complications, clinical failure, or disease progression can lead to
hospitalization and death. Several studies have tried to assess risk factors for such
complications, and one such study interestingly showed older adults were less likely
to have adverse outcomes (aOR 0.55) compared with younger patients.47 Another
study looking at nonagenarians compared with controls in the sixth decade of life
showed no association with increased risk of OPAT-related admission, emergency
room visit, or ADE. However, they had higher risk of death overall from non-OPAT
complications.42 Varying results were seen regarding age but the general consensus
is that adverse events are not increased in older adults on OPAT.36,47,48
ADE include delayed type hypersensitivity allergic reactions (itching, rash) that can
occur with any antibiotic during therapy. Hematologic ADEs include neutropenia,
other leukopenias, and thrombocytopenia.49 Neuropsychiatric complications with en-
cephalopathy and seizures can occur with certain antibiotics such as carbapenems,
cefepime, and IV acyclovir. In a review of cefepime included neurotoxicity, neurotoxic
side effects have been mostly present in patients aged older than 60 years and also in
the setting of underlying renal dysfunction and severe illness.50 Gastrointestinal ADEs
are common and include nausea, vomiting, dysgeusia, diarrhea, Clostridioides diffi-
cile-associated diarrhea (CDAD), acalculous cholecystitis, liver toxicity, and pancrea-
titis. Regarding CDAD, older patients especially those in the extreme of age,
significantly represent more CDAD-related hospitalization and death.51 Interestingly,
the occurrence of CDAD among OPAT recipients is quite uncommon and has been
reported in about less than 1% of patients on OPAT.52,53
Renal complications may occur more frequently with certain IV antibiotics or com-
binations thereof, such as vancomycin, nafcillin, and piperacillin-tazobactam, and
must be monitored closely especially in older adults with underlying chronic medical
renal disease. Common renal ADE includes acute kidney injury, reduction in tubular
secretion of creatinine, and hyperkalemia. One major study in 2017 showed hospital-
ized patients receiving the combination of vancomycin and piperacillin-tazobactam
had an increased risk of AKI (Hazard ratio [HR] 4, P < .0001) compared with those
receiving vancomycin and cefepime.54 Patient aged older than 60 years receiving
OPAT are more likely to have nephrotoxicity compared with those aged younger
than 60 years, probably for a variety of reasons—greater presence of chronic kidney
disease, use of nephrotoxic antibiotics, for example.55
The IDSA guidelines recommend laboratory monitoring during OPAT but there are
insufficient data to recommend specific testing.1 Laboratory testing should be tailored
to the specific side effects of therapy, as well as monitoring drug levels where

indicated. Given the high rate of ADEs and DDIs for older patients receiving OPAT, lab-
oratory monitoring is especially important in the outpatient setting.
Drug–Drug Interactions (DDI)/Polypharmacy

Older individuals tend to have increased comorbidities and often are taking a large
number of medications in addition to the OPAT regimen. On average, persons aged
older than 65 years taking more than 5 drugs is about 44%.56 Many of these medica-
tions are well-known inhibitors or inducers of cytochrome P450 (CYP) 3A4 and other
important cytochrome P450 enzymes that mediate drug metabolism. There are also in-
dividuals that have particular cytochrome polymorphisms in CYP 219 that can affect
individual drug metabolism, for example, hypermetabolizers or low metabolizers of vor-
iconazole.57 The most common types of medications that interact with antimicrobials
are HMG CoA reductase inhibitors (statins), psychiatric medications (eg, selective se-
rotonin reuptake inhibitors), antiarrhythmic medications, direct oral anticoagulants, and
warfarin.58 Particular antibiotics that have increased DDIs are agents in the following
classes: fluoroquinolones, macrolides, linezolid, rifamycins, and azoles.58,59
Cardiotoxicity is another area of concern in the older patients experiencing poly-
pharmacy with the addition of oral and IV antibiotics during OPAT. This older but
very large observational study of nearly 5 million outpatients receiving prescriptions
involving medications that influenced QTc showed 22% who filled overlapping pre-
scriptions were aged 65 years or older.60 As many OPAT regimens often contain a
combination of oral antibiotics such as fluoroquinolones or azoles, careful electrocar-
diogram monitoring may be indicated in some patients with underlying cardiovascular
disease or baseline dysrhythmias.
Peripherally Inserted Central Catheter (PICC)/CVC Events

One of the most common issues faced by patients receiving OPAT is malfunction of
the CVC. It is estimated that central line thrombosis occurs in 6% to 8% of PICC lines
in use or 2.9 to 7/events per 1000 line-days, which increases as a function of time after
placement with odds ratio (OR) of 1.25/wk.33,61–64 Female gender (OR 2.4), number of
lumens (2 vs 1; OR 11) and administration of penicillin G (OR 11.6), but not age, were
factors related to PICC complications.65 Other studies also found an association be-
tween type of antibiotics administered (eg, penicillins, cephalosporins, and carbape-
nems) and thrombosis.66 Administration of thrombolytics in the field to reestablish
PICC function is routine practice; however, it must be approached cautiously in the
older patient who may be on other blood-thinning agents.
PICC and CVC-associated blood stream infections are also concerns and with
increased risk the longer the catheter remains in place.65–67 Contamination of lines
may occur more frequently in individuals with reduced skin compliance and integrity,
manual dexterity or cognitive ability if managing infusions alone.47 A small observa-
tional study has shown worse outcomes with midline catheters but a recent large
meta-analysis with nearly 11,000 patients suggested that midline catheters have a
lower risk of occlusion (2.1 vs 7%) and blood stream infection (0.4% vs 1.6%) when
compared with PICC lines.63 In our experience, midline catheters are suitable options
for OPAT use especially when duration of antimicrobial is short (eg, < 2 weeks).
Hospitalization/Readmission
Risk factors for readmission in OPAT include age (1.18 aOR per decade), higher num-
ber of comorbidities, endovascular infections, and receipt of OPAT in an SNF.1,41,68
Studies that looked at readmission rates for self-administered OPAT versus SNF
OPAT demonstrate that self-administered OPAT was associated with a lower rate of

readmission compared with SNF OPAT.69 Safety concerns with OPAT in older adults
often lead to readmission for adjustment or alteration of antibiotics and monitoring for
resolution of complications. It is estimated that 1% to 26% of patients require rehospi-
talization due to a safety concern with OPAT, with higher percentages of older patients
being readmitted.69 Careful screening of patients’ psychosocial risks, comorbidities,
administration of test doses of antimicrobials and establishing safety and efficacy in
the individual patient are critical in avoiding complications and readmission.70 Clinic
follow-up for older patients is also a helpful practice to prevent 30 day-readmission
(OR 0.06, P < .0001).71
Outpatient Parenteral Antimicrobial Therapy During the COVID-19 Pandemic

The on-going COVID-19 pandemic has caused increased strain on health-care sys-
tems globally. Especially during surge periods of infection, hospitalization rates rose
to record numbers. During the Delta surge of COVID in 2021, daily hospital admission
rate in the United States for patients with confirmed SARS CoV-2 infection exceeded
10,000 and increased to more than 20,000 in January 2022 during the Omicron
surge.72 The pandemic has presented several unique dilemmas in the crossroads of
patients requiring long-term antimicrobial therapy and hospital resource utilization.
Patients with serious illness but without COVID-19 illness often delayed seeking
care either in fear of getting SARS-CoV-2 infection or due to health-care resource
lockdowns.73 Similarly, patients with non-COVID-19 illnesses competed for hospital
resources with patients with severe COVID-19. SNFs that often house and provide
services for patients needing OPAT demonstrated efficient spread of SARS-CoV-2
within facilities between patients and staff, further lessening the appeal of using these
locations for OPAT of patients with and without COVID-19 illness, alike.74
Amid the COVID-19 pandemic and stretched hospital resources, necessity for
routine long-term antimicrobial therapy turned to opportunities within the OPAT world
to continue care for these patients and open hospital resources for patients with
COVID-19. One opportunity for growth includes increased use of telemedicine ser-
vices for OPAT initiation and treatment monitoring. Telemedicine for OPAT delivery
and monitoring burgeoned during COVID-19 pandemic but even before COVID, there
had been mounting evidence that telemedicine services are effective in managing
OPAT care. Prior studies have shown clinical success, minimal drug-related adverse
events and few unplanned readmissions, comparable to conventional, nontelemedi-
cine OPAT care.75,76 Infectious disease (ID)-led OPAT management and follow-up
have previously been shown to have lower odds of hospitalization after the initial infec-
tion event compared with non-ID-led OPAT (OR 0.661) and lower odds of emergency
department admission (OR 0.449). If coupled with telemedicine, ID-led OPAT manage-
ment not only has the potential to reduce health-care utilization but has also shown
promise to reduce health-care costs.77
Another area with increased interest is the use of medications that have dosing in-
tervals of greater than 24 hours, such as LA LGP oritavancin and dalbavancin. Further-
more, medications with longer half-lives, may also lend the opportunity to space out
therapeutic drug monitoring to longer intervals and avoid CVC insertion all together.
LA LGPs have the major advantage of single dose infusions with pharmacokinetic pro-
files that can extend lengthy periods. For example, 2, once-weekly infusions of dalba-
vancin can cover an entire course (5–8 weeks) of antimicrobial therapy for common
OPAT-indicated infections such as S aureus osteomyelitis.78 Although these medica-
tions carry Food and Drug Administration indication for skin and soft tissue infections,
there is growing evidence for the successful use of LA LGP in off-label situations such
as bone and joint infections and SAB. The largest study to date looking at real-world

data of 134 patients treated with oritavancin for acute osteomyelitis showed majority
achieved clinical success with few cases of relapse or persistence of infection
(9.7%).79 Furthermore, a more recent retrospective study comparing dalbavancin
with standard of care for SAB showed no difference in clinical failure rate; however,
it was able to show much less use of CVC, shorter length of index hospitalization,
and thus fewer hospital-acquired infections.80
Anecdotally, in our experience, expansion of telemedicine services and increased
use of LA LGP at our local institution has provided significant direct and indirect ben-
efits to patients in need of long-term antibiotics for infections. These approaches are
patient-centered and work to reduce travel time for the older individuals and time
physically spent in health-care settings where they can be exposed to other
hospital-acquired infections such as COVID-19 itself. LA LGP has the potential to
reduce side effects, pill-burden, and central-venous catheter complications for older
adults with complex infections. Finally, these strategies also help to expand home
OPAT services to overlooked candidates such as PWID. These approaches are all
to reduce health-care exposure and utilization while maintaining safe and successful
outcomes of serious infections.
SUMMARY
OPAT can be conducted effectively and safely for older adults with the appropriate sup-
portive care. Age should not be an exclusionary factor for OPAT but rather prompt the
OPAT provider to do a thorough candidacy evaluation to ensure the patient will be suc-
cessful in OPAT regardless of location. Care must be taken in monitoring and evaluating
adverse reactions and minimizing DDIs in older adults with underlying polypharmacy.
New innovations in OPAT including the use of LA LGP and telemedicine will help bridge
OPAT care into a more patient-centered, thoughtful practice. Especially as the COVID-
pandemic is among us for the foreseeable future, protecting our older patients from un-
necessary health-care exposure and thus health care-associated infections is critical.
CLINICS CARE POINTS
Older adults with multiple cormorbidities are at risk of severe infections that may require
prolonged courses of antibiotics. If intravenous antibiotics are indicated, OPAT is a safe
and effective way to deliver the antibiotic course.
OPAT, especially when given at home, promotes a patient-centered therapeutic plan that
fosters patient autonomy and satisfaction.
The COVID-19 pandemic has spotlighted the role and potential of OPAT as an alternative to
delivering antimicrobial therapy outside of the acute care setting. This benefit is two fold –
reduce the burden of acute care utilization and avoid unnecessary health care exposure for
older patients.
DISCLOSURES
The authors have nothing to disclose.
REFERENCES
1. 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. Clin Infect Dis 2019;68(1):e1–35.

2. HIT Monitoring Report. Center for Medicare and Medicaid Services. Available
from: www.cms.gov/files/document/hit-monitoring-report-january-2022.pdf. Ac-
cessed 25 July, 2022.
3. Chambers HF, Bayer AS. Native-Valve Infective Endocarditis. N Engl J Med 2020;
383(6):567–76.
4. Ivanovic B, Trifunovic D, Petrovic MS, et al. Prosthetic valve endocarditis - A
trouble or a challenge? J Cardiol 2019;73(2):126–33.
5. Mohammedzein A, Mozumder A, Milton S. Cardiac implantable electronic device
infections-decision-making process in complex patients: report of 3 cases.
J Investig Med High Impact Case Rep 2019;7. 2324709619831320.
6. Skalweit MJ. Left Ventricular Assist Device Infections. In: Firstenberg MS, editor.
Advanced Concepts in Endocarditis. London: Intech Open; 2018.
7. Hill EH, Herijgers P, Claus P, et al. Infective endocarditis: changing epidemiology
and predictors of 6-month mortality: a prospective cohort study. Eur Heart J 2007;
28(2):196–203.
8. Castillo FJ, Anguita M, Castillo JC, et al. Changes in Clinical Profile, Epidemiology
and Prognosis of Left-sided Native-valve Infective Endocarditis Without Predis-
posing Heart Conditions. Rev Esp Cardiol (Engl Ed 2015;68(5):445–8.
9. Wang A, Athan E, Pappas PA, et al. Contemporary clinical profile and outcome of
prosthetic valve endocarditis. JAMA 2007;297(12):1354–61.
10. Coll PP, Lindsay A, Meng J, et al. The Prevention of Infections in Older Adults:
Oral Health. J Am Geriatr Soc 2020;68(2):411–6.
11. Murdoch DR, Corey GR, Hoen B, et al. Clinical presentation, etiology, and
outcome of infective endocarditis in the 21st century: the International Collabora-
tion on Endocarditis-Prospective Cohort Study. Arch Intern Med 2009;169(5):
463–73.
12. Skalweit MJ. Culture Negative Endocarditis: Advances in Diagnosis and Treat-
ment. In: Firstenberg MS, editor. Contemporary challenges in endocarditis. Lon-
don: Intech Open; 2016.
13. Leibovici-Weissman Y, Tau N, Yahav D. Bloodstream infections in the elderly:
what is the real goal? Aging Clin Exp Res 2021;33(4):1101–12.
14. Laupland KB, Lyytikainen O, Sogaard M, et al. The changing epidemiology of
Staphylococcus aureus bloodstream infection: a multinational population-based
surveillance study. Clin Microbiol Infect 2013;19(5):465–71.
15. Gunderson CG, Martinello RA. A systematic review of bacteremias in cellulitis
and erysipelas. J Infect 2012;64(2):148–55.
16. Yahav D, Franceschini E, Koppel F, et al. Seven Versus 14 Days of Antibiotic Ther-
apy for Uncomplicated Gram-negative Bacteremia: A Noninferiority Randomized
Controlled Trial. Clin Infect Dis 2019;69(7):1091–8.
17. Swamy S, Sharma R. Duration of Treatment of Gram-Negative BacteremiaAre
Shorter Courses of Antimicrobial Therapy Feasible? Infect Dis Clin Pract 2016;
24(3):155–60.
18. De Angelis G, Mutters NT, Minkley L, et al. Prosthetic joint infections in the elderly.
Infection 2015;43(6):629–37.
19. Uckay I, Holy D, Betz M, et al. Osteoarticular infections: a specific program for
older patients? Aging Clin Exp Res 2021;33(3):703–10.
20. Rowe TA, Juthani-Mehta M. Urinary tract infection in older adults. Aging Health
2013;9(5):75–89.
21. Wagenlehner FME, Bjerklund Johansen TE, Cai T, et al. Epidemiology, definition
and treatment of complicated urinary tract infections. Nat Rev Urol 2020;17(10):
586–600.

22. Jump RL, Crnich CJ, Mody L, et al. Infectious Diseases in Older Adults of Long-
Term Care Facilities: Update on Approach to Diagnosis and Management. J Am
Geriatr Soc 2018;66(4):789–803.
23. Smithson A, Ramos J, Niño E, et al. Characteristics of febrile urinary tract infec-
tions in older male adults. BMC Geriatr 2019;19(1):334.
24. Fink DL, Collins S, Barret R, et al. Shortening duration of ertapenem in outpatient
parenteral antimicrobial therapy for complicated urinary tract infections: A retro-
spective study. PLoS One 2019;14(9):e0223130.
25. Mansour O, Arbaje AI, Townsend JL. Patient Experiences With Outpatient Paren-
teral Antibiotic Therapy: Results of a Patient Survey Comparing Skilled Nursing
Facilities and Home Infusion. Open Forum Infect Dis 2019;6(12):ofz471.
26. Saillen L, Arensdorff L, Moulin E, et al. Patient satisfaction in an outpatient paren-
teral antimicrobial therapy (OPAT) unit practising predominantly self-
administration of antibiotics with elastomeric pumps. Eur J Clin Microbiol Infect
Dis 2017;36(8):1387–92.
27. Yen PH, Leasure AR. Use and Effectiveness of the Teach-Back Method in Patient
Education and Health Outcomes. Fed Pract 2019;36(6):284–9.
28. Cortes-Penfield N, Cawcutt K, Alexander BT, et al. A Proposal for Addiction and
Infectious Diseases Specialist Collaboration to Improve Care for Patients With
Opioid Use Disorder and Injection Drug Use-Associated Infective Endocarditis.
J Addict Med 2022;16(4):392–5.
29. Suzuki J, Johnson J, Montgomery M, et al. Outpatient Parenteral Antimicrobial
Therapy Among People Who Inject Drugs: A Review of the Literature. Open
Forum Infect Dis 2018;5(9):ofy194.
30. Ho J, Archuleta S, Sulaiman Z, et al. Safe and successful treatment of intravenous
drug users with a peripherally inserted central catheter in an outpatient parenteral
antibiotic treatment service. J Antimicrob Chemother 2010;65(12):2641–4.
31. Serota DP, Chueng TA, Schechter MC. Applying the Infectious Diseases Litera-
ture to People who Inject Drugs. Infect Dis Clin North Am 2020;34(3):539–58.
32. Guyatt GH, Oxman AD, Vist GE, et al. GRADE: an emerging consensus on rating
quality of evidence and strength of recommendations. BMJ 2008;336(7650):
924–6.
33. Briquet C, Cornu O, Servais V, et al. Clinical characteristics and outcomes of pa-
tients receiving outpatient parenteral antibiotic therapy in a Belgian setting: a
single-center pilot study. Acta Clin Belg 2020;75(4):275–83.
34. Burnett YJ, Spec A, Ahmed MM, et al. Experience with Liposomal Amphotericin B
in Outpatient Parenteral Antimicrobial Therapy. Antimicrob Agents Chemother
2021;65(6):e01876–920.
35. Chambers ST, Basevi A, Gllagher K, et al. Outpatient parenteral antimicrobial
therapy (OPAT) in Christchurch: 18 years on. N Z Med J 2019;132(1501):21–32.
36. Keller SC, Williams D, Gavgani M, et al. Rates of and Risk Factors for Adverse
Drug Events in Outpatient Parenteral Antimicrobial Therapy. Clin Infect Dis
2018;66(1):11–9.
37. Miron-Rubio M, Gonzalez-Ramallo V, Estrada-Cuxart O, et al. Intravenous antimi-
crobial therapy in the hospital-at-home setting: data from the Spanish Outpatient
Parenteral Antimicrobial Therapy Registry. Future Microbiol 2016;11(3):375–90.
38. Ponce Gonzalez MA, Miron-Rubio M, Mujal Martinez A, et al. Effectiveness and
safety of outpatient parenteral antimicrobial therapy in acute exacerbation of
chronic obstructive pulmonary disease. Int J Clin Pract 2017;71(12).
39. Quirke M, Curran EM, O’Kelly P, et al. Risk factors for amendment in type, dura-
tion and setting of prescribed outpatient parenteral antimicrobial therapy (OPAT)

for adult patients with cellulitis: a retrospective cohort study and CART analysis.
Postgrad Med J 2018;94(1107):25–31.
40. Suleyman G, Kenney R, Zervos MJ, et al. Safety and efficacy of outpatient paren-
teral antibiotic therapy in an academic infectious disease clinic. J Clin Pharm
Ther 2017;42(1):39–43.
41. Durojaiye OC, Morgan R, Chelaghma N, et al. External validity and clinical use-
fulness of a risk prediction model for 30 day unplanned hospitalization in patients
receiving outpatient parenteral antimicrobial therapy. J Antimicrob Chemother
2021;76(8):2204–12.
42. Shrestha NK, Blaskewicz C, Gordon SM, et al. Safety of Outpatient Parenteral
Antimicrobial Therapy in Nonagenarians. Open Forum Infect Dis 2020;7(10):
ofaa398.
43. Cunha CB, D’Agata EM. Implementing an antimicrobial stewardship program in
out-patient dialysis units. Curr Opin Nephrol Hypertens 2016;25(6):551–5.
44. Hoffman-Terry ML, Fraimow HS, Fox TR, et al. Adverse effects of outpatient
parenteral antibiotic therapy. Am J Med 1999;106(1):44–9.
45. Pulcini C, Couadau T, Bernard E, et al. Adverse effects of parenteral antimicrobial
therapy for chronic bone infections. Eur J Clin Microbiol Infect Dis 2008;27(12):
1227–32.
46. Krsak M, Morrisette T, Miller M, et al. Advantages of Outpatient Treatment with
Long-Acting Lipoglycopeptides for Serious Gram-Positive Infections: A Review.
Pharmacotherapy 2020;40(5):469–78.
47. Keller SC, Wang NY, Salinas A, et al. Which Patients Discharged to Home-Based
Outpatient Parenteral Antimicrobial Therapy Are at High Risk of Adverse Out-
comes? Open Forum Infect Dis 2020;7(6):ofaa178.
48. Keller SC, Williams D, Gavgani M, et al. Environmental Exposures and the Risk of
Central Venous Catheter Complications and Readmissions in Home Infusion
Therapy Patients. Infect Control Hosp Epidemiol. Infect Control Hosp Epidemiol
2017;38(1):68–75.
49. Cimino C, Allos BM, Phillips EJ. A Review of b-Lactam-Associated Neutropenia
and Implications for Cross-reactivity. Ann Pharmacother 2021;55(8):1037–49.
50. Payne LE, Gagnon DJ, Riker RR, et al. Cefepime-induced neurotoxicity: a sys-
tematic review. Crit Care 2017;21(1):276.
51. Jump RL. Clostridium difficile infection in older adults. Aging health 2013;9(4):
403–14.
52. Wong KK, Fraser TG, Shrestha NK, et al. Low incidence of Clostridium difficile
infection (CDI) in patients treated with outpatient parenteral antimicrobial therapy
(OPAT). Infect Control Hosp Epidemiol 2015;36(1):110–2.
53. Barr DA, Semple L, Seaton RA. Outpatient parenteral antimicrobial therapy
(OPAT) in a teaching hospital-based practice: a retrospective cohort study
describing experience and evolution over 10 years. Int J Antimicrob Agents
2012;39(5):407–13.
54. Navalkele B, Pogue JM, Karino S, et al. Risk of Acute Kidney Injury in Patients on
Concomitant Vancomycin and Piperacillin-Tazobactam Compared to Those on
Vancomycin and Cefepime. Clin Infect Dis 2017;64(2):116–23.
55. Cox AM, MAlani PN, Wiseman SW, et al. Home intravenous antimicrobial infusion
therapy: a viable option in older adults. J Am Geriatr Soc 2007;55(5):645–50.
56. Morin L, Johnell K, Laroche ML, et al. The epidemiology of polypharmacy in older
adults: register-based prospective cohort study. Clin Epidemiol 2018;10:289–98.

57. Zhang Y, Hao X, Hou Y, et al. Impact of cytochrome P450 2C19 polymorphisms
on the clinical efficacy and safety of voriconazole: an update systematic review
and meta-analysis. Pharmacogenet Genomics 2022;32(7):257–67.
58. Das B, Ramasubbu SK, Agnihotri A, et al. Leading 20 drug-drug interactions, pol-
ypharmacy, and analysis of the nature of risk factors due to QT interval prolong-
ing drug use and potentially inappropriate psychotropic use in elderly psychiatry
outpatients. Ther Adv Cardiovasc Dis 2021;15. 17539447211058892.
59. Hale CM, STeele JM, Seabury RW, et al. Characterization of Drug-Related Prob-
lems Occurring in Patients Receiving Outpatient Antimicrobial Therapy. J Pharm
Pract 2017;30(6):600–5.
60. Curtis LH, Truls Ostby, Sendersky V, et al. Prescription of QT-prolonging drugs in
a cohort of about 5 million outpatients. Am J Med 2003;114(2):135–41.
61. Quintens C, Steffens E, Jacobs K, et al. Efficacy and safety of a Belgian tertiary
care outpatient parenteral antimicrobial therapy (OPAT) program. Infection 2020;
48(3):357–66.
62. Seo H, Altshuler D, Dubrovskaya Y, et al. The Safety of Midline Catheters for Intra-
venous Therapy at a Large Academic Medical Center. Ann Pharmacother 2020;
54(3):232–8.
63. Swaminathan L, Flanders S, HOrowitz J, et al. Safety and Outcomes of Midline
Catheters vs Peripherally Inserted Central Catheters for Patients With Short-
term Indications: A Multicenter Study. JAMA Intern Med 2022;182(1):50–8.
64. Underwood J, Marks M, Collins S, et al. Intravenous catheter-related adverse
events exceed drug-related adverse events in outpatient parenteral antimicrobial
therapy. J Antimicrob Chemother 2019;74(3):787–90.
65. Lam PW, Graham C, Leis J, et al. Predictors of Peripherally Inserted Central Cath-
eter Occlusion in the Outpatient Parenteral Antimicrobial Therapy Setting. Antimi-
crob Agents Chemother 2018;62(9):e00900–18.
66. Barr DA, Semple L, Seaton RA. Self-administration of outpatient parenteral anti-
biotic therapy and risk of catheter-related adverse events: a retrospective cohort
study. Eur J Clin Microbiol Infect Dis 2012;31(10):2611–9.
67. Li W, Branley J, Sud A. Outpatient parenteral antibiotic therapy in a suburban ter-
tiary referral centre in Australia over 10 years. Infection 2018;46(3):349–55.
68. Huang V, Ruhe JJ, Lerner P, et al. Risk factors for readmission in patients dis-
charged with outpatient parenteral antimicrobial therapy: a retrospective cohort
study. BMC Pharmacol Toxicol 2018;19(1):50.
69. Sriskandarajah S, HObbs J, Roughhead E, et al. Safety and effectiveness of ’hos-
pital in the home’ and ’outpatient parenteral antimicrobial therapy’ in different age
groups: A systematic review of observational studies. Int J Clin Pract 2018;19:
e13216.
70. Barnes A, Nunez M. Diabetic Foot Infection and Select Comorbidities Drive Re-
admissions in Outpatient Parenteral Antimicrobial Therapy. Am J Med Sci 2021;
361(2):233–7.
71. Palms DL, Jacob JT. Close Patient Follow-up Among Patients Receiving Outpa-
tient Parenteral Antimicrobial Therapy. Clin Infect Dis 2020;70(1):67–74.
72. COVID Data Tracker Weekly Review. 2022. Available from: www.cdc.gov/
coronavirus/2019-ncov/covid-data/covidview/index.htm. Accessed 28 July, 2022.
73. Anderson KE, McGinty EE, Presskreischer R, et al. Reports of Forgone Medical
Care Among US Adults During the Initial Phase of the COVID-19 Pandemic.
JAMA Netw Open 2021;4(1):e2034882.
74. Barnett ML, Hu L, Martin T, et al. Mortality, Admissions, and Patient Census at
SNFs in 3 US Cities During the COVID-19 Pandemic. JAMA 2020;324(5):507–9.

75. Tan SJ, Ingram PR, Rothnie AJ, et al. Successful outpatient parenteral antibiotic
therapy delivery via telemedicine. J Antimicrob Chemother 2017;72(10):
2898–901.
76. Sheridan KR, Abdel-Massih R, Gupta N, et al. Tele-OPAT Outcomes at Two Com-
munity Hospitals. Open Forum Infect Dis 2020;7(Suppl 1):S373–4.
77. Shah A, Petrak R, Fliegelman R, et al. Infectious Diseases Specialty Intervention
Is Associated With Better Outcomes Among Privately Insured Individuals
Receiving Outpatient Parenteral Antimicrobial Therapy. Clin Infect Dis 2019;
68(7):1160–5.
78. Cojutti PG, Rinaldi M, Zamparini E, et al. Population pharmacokinetics of dalba-
vancin and dosing consideration for optimal treatment of adult patients with
staphylococcal osteoarticular infections. Antimicrob Agents Chemother 2021;
65(5):e02260–320.
79. Van Hise NW, Chundi V, Didwania V, et al. Treatment of Acute Osteomyelitis with
Once-Weekly Oritavancin: A Two-Year, Multicenter, Retrospective Study. Drugs
Real World Outcomes 2020;7(Suppl 1):41–5.
80. Molina KC, Lunow C, Lebin M, et al. Comparison of Sequential Dalbavancin With
Standard-of-Care Treatment for Staphylococcus aureus bloodstream infections.
Open Forum Infect Dis 2022;9(7):ofac335.


Outpatient Parenteral Antibiotic Therapy in Older Adults: Nora T. Oliver,, Marion J. Skalweit

Uploaded by

Copyright:

Available Formats

Outpatient Parenteral Antibiotic Therapy in Older Adults: Nora T. Oliver,, Marion J. Skalweit

Uploaded by

Document Information

Original Description:

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Outpatient Parenteral Antibiotic Therapy in Older Adults: Nora T. Oliver,, Marion J. Skalweit

Uploaded by

Copyright:

Available Formats

O u t p a t i e n t P a ren t e r a l

Antibiotic Therapy i n O lder

Outpatient parenteral antimicrobial therapy (OPAT) is the process of delivering and

Infect Dis Clin N Am 37 (2023) 123–137

Descargado para Anonymous User (n/a) en National Autonomous University of Mexico de

Infections Indicating Use of Outpatient Parenteral Antimicrobial Therapy

Descargado para Anonymous User (n/a) en National Autonomous University of Mexico de

Descargado para Anonymous User (n/a) en National Autonomous University of Mexico de

Complicated Urinary Tract Infections

Outpatient Parenteral Antimicrobial Therapy Candidacy in Older Adults

Outpatient Parenteral Antimicrobial Therapy Environment

Descargado para Anonymous User (n/a) en National Autonomous University of Mexico de

Psycho-Social and Physical Competence

Descargado para Anonymous User (n/a) en National Autonomous University of Mexico de

Substance Use Disorder

Outpatient Parenteral Antimicrobial Therapy Safety in Older Adults

Descargado para Anonymous User (n/a) en National Autonomous University of Mexico de

Adverse Events and Complications

Descargado para Anonymous User (n/a) en National Autonomous University of Mexico de

Drug–Drug Interactions (DDI)/Polypharmacy

Peripherally Inserted Central Catheter (PICC)/CVC Events

Descargado para Anonymous User (n/a) en National Autonomous University of Mexico de

Outpatient Parenteral Antimicrobial Therapy During the COVID-19 Pandemic

Descargado para Anonymous User (n/a) en National Autonomous University of Mexico de

CLINICS CARE POINTS

The authors have nothing to disclose.

Descargado para Anonymous User (n/a) en National Autonomous University of Mexico de

Descargado para Anonymous User (n/a) en National Autonomous University of Mexico de

Descargado para Anonymous User (n/a) en National Autonomous University of Mexico de

Descargado para Anonymous User (n/a) en National Autonomous University of Mexico de

Descargado para Anonymous User (n/a) en National Autonomous University of Mexico de

Descargado para Anonymous User (n/a) en National Autonomous University of Mexico de

You might also like