Infection Control & Hospital Epidemiology (2018), 39, 947–954 doi:10.1017/ice.2018.107
Original Article
A retrospective analysis of adverse events among patients receiving daptomycin versus vancomycin during outpatient parenteral antimicrobial therapy
Gregory M. Schrank MD1,3, Sharon B. Wright MD, MPH1,3, Westyn Branch-Elliman MD, MMSc2,3,a and Mary T. LaSalvia MD, MPH1,3,a
1Beth Israel Deaconess Medical Center, Divisions of Infectious Diseases and Infection Control/Hospital Epidemiology, Boston, Massachusetts, 2Veterans Affairs Boston Healthcare System, Boston, Massachusetts and 3Harvard Medical School, Boston, Massachusetts
Abstract
Objective: Outpatient parenteral antimicrobial therapy (OPAT) is a safe and effective alternative to prolonged inpatient stays for patients requiring long-term intravenous antimicrobials, but antimicrobial-associated adverse events remain a significant challenge. Thus, we sought to measure the association between choice of antimicrobial agent (vancomycin vs daptomycin) and incidence of adverse drug events (ADEs). Methods: Patients receiving OPAT treatment with vancomycin or daptomycin for skin and soft-tissue infections, bone and joint infections, endocarditis, and bacteremia or endovascular infections during the period from July 1, 2013, through September 30, 2016, were included. Demographic and clinical data were abstracted from the medical record. Logistic regression was used to compare ADEs requiring a change in or early discontinuation of therapy, hospital readmission, and emergency room visits between groups. Time from OPAT enrollment to ADE was compared using the log-rank test. Results: In total, 417 patients were included: 312 (74.8%) received vancomycin and 105 (25.2%) received daptomycin. After adjusting for age, Charlson comorbidity index, location of OPAT treatment, receipt of combination therapy with either β-lactam or fluoroquinolone, renal function, and availability of safety labs, patients receiving vancomycin had significantly higher incidence of ADEs (adjusted odds ratio [aOR], 3.71; 95% CI, 1.64–8.40). ADEs occurred later in the treatment course for patients treated with daptomycin (P<.01). Rates of readmission and emergency room visits were similar. Conclusions: In the OPAT setting, vancomycin use was associated with higher incidence of ADEs than daptomycin use. This finding is an important policy consideration for programs aiming to optimize outcomes and minimize cost. Careful selection of gram-positive agents for prolonged treatment is necessary to limit toxicity.
(Received 7 February 2018; accepted 17 April 2018; electronically published June 12, 2018)
Outpatient parenteral antibiotic therapy (OPAT) is a safe, effec- tive, and cost-saving alternative to prolonged inpatient hospita- lization for patients who require long durations of intravenous antimicrobial therapy.1–6 OPAT enables earlier transitions out of the acute-care setting, reduces the duration of hospitalization, and is associated with high levels of patient satisfaction.2–4 Although the benefits of OPAT are well recognized, long-term
intravenous antimicrobial treatment carries substantial risk of antimicrobial toxicity and complications of intravenous catheters.
Author for correspondence: Gregory Schrank, MD, Beth Israel Deaconess Medical
Center, 330 Brookline Ave, SL-431, Boston,MA, 02215. E-mail:
gschrank@bidmc.harvard.edu PREVIOUS PRESENTATION: Preliminary results of this analysis were presented as
an abstract at the SHEA Spring Conference on March 31, 2017, in St Louis, Missouri: Schrank GM, Branch-Elliman W, Wright SB, LaSalvia MT. Adverse Events Associated with Vancomycin vs. Daptomycin in Outpatient Parenteral Antibiotic Therapy (abstract
#9050) a Authors of equal contribution. Cite this article: Schrank GM, et al. (2018). A retrospective analysis of adverse events
among patients receiving daptomycin versus vancomycin during outpatient parenteral antimicrobial therapy. Infection Control & Hospital Epidemiology 2018, 39, 947–954. doi:10.1017/ice.2018.107
© 2018 by The Society for Healthcare Epidemiology of America. All rights reserved.
Multiple studies report rates of adverse events during a typical OPAT course ranging from 6% to 44%; the most common unde- sirable outcomes include adverse drug events (ADEs) and vascular access complications.1,7–13 These complications cause harm to patients, increase healthcare utilization, and diminish the benefits that OPAT programs offer patients and health systems. Minimiz- ing patient risk requires substantial clinical and administrative infrastructure to ensure that treatment is safe and effective.14–20 The adverse effects caused by antimicrobial therapy are well established. Among hospitalized patients, antibiotic-associated ADEs are common during treatment and when used for pro- phylaxis around surgery, with a linear relationship between the duration of therapy and the risk of ADEs.21,22 Vancomycin is associated with increased rates of ADEs, including nephrotoxicity, when compared to other gram-positive agents.8,21 Nephrotoxicity risk is compounded when vancomycin is administered in com- bination with β-lactam antibiotics, which commonly occurs in the OPAT setting if a patient is diagnosed with a polymicrobial infection or if no specific organism is isolated.22–25 Recent studies suggest that daptomycin may offer a safe and effective alternative
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