Elsevier

Mayo Clinic Proceedings

Volume 87, Issue 1, January 2012, Pages 98-105
Mayo Clinic Proceedings

Symposium on antimicrobial therapy
Practical Considerations in the Use of Outpatient Antimicrobial Therapy for Musculoskeletal Infections

https://doi.org/10.1016/j.mayocp.2011.11.005Get rights and content

Abstract

Successful treatment of many musculoskeletal infections often requires an extended course of outpatient antimicrobial therapy, much of which is administered parenterally outside the hospital under the guidance of an infectious disease specialist. Delivery of outpatient parenteral antimicrobial therapy (OPAT) may occur in physicians' offices, ambulatory infusion centers, or hospital clinics but most frequently is done in patients' homes, often by the patients themselves. In this article, we outline the essential elements of outpatient antimicrobial therapy for musculoskeletal infections with particular emphasis on OPAT, including patient selection and evaluation; antimicrobial administration, including the route, duration, and complications of central venous access; and clinical and laboratory monitoring of antimicrobial therapy. We believe that primary care physicians, orthopedists, and infectious disease specialists caring for patients with musculoskeletal infections should become familiar with the use of, indications for, and complications of OPAT.

Section snippets

Patient Evaluation and Selection

Patients who are candidates for outpatient parenteral antimicrobial therapy (OPAT) can have a variety of musculoskeletal infectious syndromes such as osteomyelitis, prosthetic joint infections, diabetes-related foot infections, and soft tissue or surgical site infections. Available data from the medical literature and expert opinion support the effectiveness of prolonged, directed, systemic antimicrobial therapy (4-6 weeks or longer) for adults with many musculoskeletal infections.1, 2, 3, 4, 5

Oral Antimicrobial Therapy

In general, there is little difference between the oral and parenteral route as long as both routes provide adequate serum and bone concentrations. Traditionally, the parenteral route has been the preferred modality of administration for many musculoskeletal infections, particularly for treatment of osteomyelitis in adults and for prosthetic joint infections. However, if fully bioavailable (ie, quinolones, metronidazole, linezolid), antimicrobials can be administered orally.23, 24, 25, 26

Clinical and Laboratory Monitoring of Treatment Efficacy and Toxicity

Complications related to antimicrobials in an outpatient setting are similar to those in the inpatient setting. Common complications of antimicrobial therapy include rash, nausea, vomiting, diarrhea, Clostridium difficile–associated colitis, and oropharyngeal or vaginal candidiasis; more unusual complications include ototoxicity from vancomycin or aminoglycosides.8 Patients should be educated and counseled about possible antimicrobial adverse effects and toxicities and should be instructed to

Conclusion

The administration of outpatient parenteral antimicrobial therapy has been proved to be an efficacious, safe, practical, and cost-effective method. It allows patients to return to their daily activities with minimal discomfort or disruptions of their schedules. Outpatient intravenous antimicrobial therapy is a vital component of the medical treatment of many musculoskeletal infections. Oral therapy can be administered in selected circumstances. We have provided an overview of the process of

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