Clinical infectious diseases : an official publication of the Infectious Diseases Society of America
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Review
Update and overview of outpatient parenteral antimicrobial therapy regulations and reimbursement.
Outpatient care, including outpatient parenteral antimicrobial therapy (OPAT), is increasingly seen by both clinicians and insurers as a safe, effective, and economical adjunct or alternative to hospitalization. Despite this, perhaps the least understood reimbursement and regulatory policies for health care services are those that apply to OPAT. We present a brief review and update of current rules and regulations relating to OPAT, with emphasis on areas of special interest to physicians serving as medical directors of home or ambulatory infusion programs or providing OPAT as an extension of their office practices.
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Review
The unique issues of outpatient parenteral antimicrobial therapy in children and adolescents.
The decision to discharge a hospitalized child or adolescent to receive outpatient parenteral antimicrobial therapy (OPAT) is based on criteria very different from those concerning adults. Clinical studies of pediatric OPAT are sparse, as are pharmacokinetic data for antimicrobial agents in children. ⋯ The psychological disadvantage of hospitalization in children, compared with adults, is great, and both populations are equally vulnerable to nosocomial infection, increasingly augmented by multidrug-resistant organisms. Although the relatively few clinical studies involving OPAT in children attest to its efficacy and safety, well-designed prospective trials and comprehensive cost-benefit analyses are still needed.
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Although first identified just >4 decades ago, methicillin-resistant Staphylococcus aureus (MRSA) has undergone rapid evolutionary changes and epidemiologic expansion to become a major cause of nosocomial and community-acquired infections worldwide. Increasing resistance to vancomycin among MRSA strains in conjunction with availability of new antibiotics, including daptomycin and linezolid, have increased treatment choices but made clinical treatment decisions more challenging. This article describes the clinical features and management issues of 2 challenging-to-treat manifestations of MRSA infection, bacteremia and/or endocarditis and osteomyelitis. It also presents a brief review of community-associated MRSA infections and preventive strategies directed against MRSA.
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Booster vaccination against tetanus and diphtheria at 10-year intervals is commonly recommended. Reduced antigen content diphtheria and tetanus toxoids and acellular pertussis (dTpa) vaccines developed for booster vaccination of preschool children, adolescents, and adults are licensed for once-in-a-lifetime use in most countries. Objective. To evaluate decennial administration of a dTpa vaccine. Methods. Young adults vaccinated with dTpa or diphtheria and tetanus toxoids followed by acellular pertussis (DT+ap) 1 month later in a clinical trial 10 years previously received 1 dTpa dose. Blood samples were taken before and 1 month after vaccination. Antibody concentrations against vaccine antigens were measured by enzyme-linked immunosorbent assay. Solicited and unsolicited symptoms and serious adverse events were recorded. ⋯ A second dTpa booster was highly immunogenic and well tolerated in this population of young adults. This study supports the use of this vaccine as a decennial booster.
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Since its introduction in the 1970s, outpatient parenteral antimicrobial therapy (OPAT) has become a standard modality for patients with many infections requiring long-term intravenous antibiotic therapy. Delivery of OPAT may occur in physicians' offices, hospital clinics, specialized infusion centers, and currently most often, patient's homes, often self-administered. ⋯ An OPAT Outcomes Registry contains information from >11,000 antibiotic courses administered from 1997 through 2000. Although a number of studies are purported to analyze the economic impact of OPAT on health care, a comprehensive, clinical outcomes-based pharmacoeconomic analysis, as described here, has, to our knowledge, yet to be done.