Infection Control & Hospital Epidemiology
nursing facility and the primary outcome did not persist (P=.12), suggesting that unmeasured confounding may be driving this finding. Second, as a single-center analysis, this cohort and the clinical practices in our center may not be reflective of those in other OPAT clinics. In addition, anticipated OPAT duration of at least 14 days was a qualification for enrollment; shorter courses that are at lower risk of ADEs were not included. To ensure that only clinically significant ADEs were reflected in our results, we limited our primary outcome to ADEs that resulted in a therapy change or discontinuation. We also did not consider common adverse events, such as red man syndrome, that may negatively impact a patient’s quality of life without resulting in a change in therapy. There was a high rate of hospital readmission in this cohort as compared to other studies, potentially reflecting a sicker patient population, although a long follow up period—extended 30 days beyond the completion of OPAT therapy—mayalsohaveimpactedthis result.7,8,10,12,14,20 Our study is one of the few published analyses comparing
adverse events and healthcare utilization associated with 2 of the most commonly prescribed gram-positive agents in the OPAT setting, daptomycin and vancomycin. Other strengths include the size of the cohort included, the breadth of infectious diagnoses considered, and the completeness of the data with minimal missing covariates or outcomes. With an organized OPAT pro- gram involving physicians, nurses, and administrative staff, per- tinent clinical and demographic data for each patient was documented at the time of enrollment and clinical follow up, optimizing data capture. Pre-enrollment evaluation of patients with an infectious dis-
ease consultation and sufficient clinical support to ensure a complete care transition reduces adverse events and overall OPAT costs.17,19,20 Careful consideration is necessary when selecting an antibiotic agent for long-term therapy, including the risk of selection for antibiotic resistance, costs, ease of adminis- tration, need for monitoring, and the known risk of complica- tions, including ADEs. By defining the primary outcome as ADEs that required a change or discontinuation of therapy, the results of this study are more directly related to the choice of anti- microbial agent used for treatment, a programmatic decision for an OPAT clinic, rather than outcomes related to healthcare delivery, nursing care, or patient preferences. Our study informs inpatient clinicians and infectious disease OPAT providers regarding the risks of ADEs among recipients of vancomycin versus daptomycin. The perceived drawbacks of daptomycin—primarily cost and
broader spectrum of activity—must be weighed against the apparent challenges of long-term vancomycin: high rates of clinically sig- nificant ADEs and utilization of OPAT clinic resources. While our study did not include an economic analysis, our results suggest that vancomycin, although less expensive on a per-dose basis, is asso- ciated with complications that may render it more expensive when used for prolonged therapy in the outpatient setting. Notably, Medicare recipients (42.4% of this study’s cohort) without supple- mental insurance are often restricted in their long-term antibiotic options with regard to type of antimicrobial agent and site of ther- apy. As our analysis demonstrates, daptomycin is a safer alternative to vancomycin for gram-positive therapy in OPAT. Therefore, a Medicare recipient with a low burden of comorbidities and the ability to self-administer a once-daily medication may be better served receiving daptomycin home infusions. In addition to the direct medical costs associated with complications, vancomycin is
953
also associated with other societal costs attributable to lost time and work productivity. For example, vancomycin infusions last for 1– 2 hours, typically multiple times per day, compared to <30 minutes once daily for daptomycin. Prospective analysis to compare the rates of clinical success and ADEs would alleviate some of the con- founding challenges present in this study, and further cost- effectiveness analyses of these 2 medications would greatly inform the decisions of health systems beyond the wholesale price of the medication.
Supplementary material. To view supplementary material for this article, please visit
https://doi.org/10.1017/ice.2018.107
Acknowledgments. The authors acknowledge Linda Baldini, RN, the BIDMC InSIGHT Core, and the Center for Healthcare Delivery Science for their assistance with data retrieval.
Financial support. This study did not receive any funding and was con- ducted as part of our routine work. WBE is supported by a Veterans Inte- grated Service Network (VISN)-1 Career Development Award.
Conflicts of interest. All authors report no conflicts of interest relevant to this article.
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