123Antimicrobial drug administration is the most common home infusion therapy and is used to treat infections in both adult and pediatric patient populations. Given a safe home setting, an appropriate vascular access device (VAD), and a clinically stable patient responding to therapy, most antimicrobial drugs can be safely administered at home. Most often patients or their caregivers are taught how to independently administer their infusions. Studies suggest that there is no evidence of higher rates of VAD complications or worse clinical outcomes for those who self-administer as compared to when health care providers (usually nurses) administer the infusions (Barr, Semple, & Seaton, 2012; Bhavan, Brown, & Haley, 2015). A wide range of infectious diseases may be treated at home. Common diagnoses include cellulitis, osteomylelitis, bacterial endocarditis, infections associated with cystic fibrosis, and central nervous system–related infections. Increasingly, patients are treated at home without prior hospitalization.

After reading this chapter, the reader will be able to:

124PATIENT SELECTION CONSIDERATIONS

■  The patient and family are motivated and willing and capable of participating in self-infusion management.

       In general, the goal in home administration of antimicrobial medications is patient/caregiver independence with self-infusion.

       For patients who require a relatively short course of IV therapy or if there are functional or cognitive limitations that impact ability to learn infusion procedures, the home care nurse may provide the home infusions depending upon available reimbursement. Other options for infusion delivery include outpatient facilities, physician offices, ambulatory infusion centers, or long-term care facilities.

■  The patient is clinically stable.

       The patient’s infectious disease is responding to antimicrobial treatment.

       The patient is tolerating the antimicrobial drug without significant reactions or reactions are managed with adjunctive treatments (e.g., amphotericin B–related chills and fever managed with premedication with acetaminophen and diphenhydramine).

       First dose issues: When possible, first doses are best administered in a controlled environment with access to emergency medical equipment and medications. Guidelines from the United Kingdom state that the first doses may be administered in the patient’s home if administered by a person competent and equipped to identify and manage anaphylaxis (Chapman et al., 2012). There were no anaphylactic reactions in a study of 770 patients who received antimicrobials at home with 25 different medications including first doses (Dobson, Boyle, & Loewenthal, 2004). The Infusion Nurses Society (Gorski, Hadaway, Hagle, McGoldrick, Meyer, & Orr, 2016) provides guidance for first doses in the home setting as follows:

           The home care agency has a first dose protocol.

           There is reasonable access to emergency services should a severe reaction occur.

           Patient is alert, cooperative, and able to respond appropriately.

           Informed consent—patient understands the potential risks of a first dose.

           125Medications are available in the home and there are orders for their use in the treatment of anaphylaxis/severe drug reaction.

       An example of an adult anaphylaxis protocol is 0.2 to 0.5 mL of 1:1,000 epinephrine intramuscularly (IM) and 50 mg diphenhydramine IV in the event of signs/symptoms.

           The patient has no history of severe allergic reactions.

           The nurse administers the first dose and observes the patient for a minimum of 30 minutes after infusion completion.

■  An appropriate VAD is in place to administer antimicrobial therapy.

       Short peripheral IV catheters, midline peripheral catheters, or peripherally inserted central catheters (PICCs) are common VADs for antimicrobial administration. The decision is based upon a number of factors including anticipated duration of therapy, infusate characteristics, and the patient’s vascular access as discussed in Chapters 4 and 5.

■  The home environment is safe, clean, with adequate refrigeration space, and the patient has ready access to a telephone.

       Antimicrobial drugs and related supplies are generally delivered to patient homes on a weekly basis. Many antimicrobial drugs require storage in the refrigerator.

■  Reimbursement is verified.

       Private third-party payers vary in coverage.

       Certain antimicrobial drugs may be covered under the durable medical equipment benefit for external infusion pumps under Part B of the Medicare program. These include acyclovir, foscarnet, ganciclovir, and amphotericin B.

ANTIMICROBIAL MEDICATIONS

Antimicrobial medications include the use of antibacterial, antiviral, antifungal, and antiprotozoal drugs. Antibacterial drug selection is based on attaining bacteriostatic (slowing down bacterial growth) or bacteriocidal (destroying bacteria) activity at the site of the infection. Antiviral drugs, such as ganciclovir and acyclovir, slow down viral multiplication by incorporating into the virus’ DNA.

Antibiotic medications are classified based upon the similarity of their chemical structures and mechanisms of action. A helpful summary of antibiotic classifications is found in a clinical article by Percival (2017). Because antibiotics are so commonly administered, home care nurses must have a sound understanding of indications, expected dosage, and adverse reactions. Antibiotics are classified as follows:

126■  Beta-lactams, which include the subgroups of penicillins, cephalosporins, and the carbapenems (e.g., imipenem, meropenum, ertapenum).

■  Glycopeptides, which include only vancomycin in the United States. Vancomycin is commonly home administered, used to treat gram-positive organisms including methicillin resistant staphyloccoccus aureus (MRSA), has a narrow therapeutic index, requires serum concentration monitoring, and is nephrotoxic.

■  Cyclic lipopeptides, which include only daptomycin, which is also commonly administered at home. It is also used to treat gram-positive organisms such as MRSA and vancomycin-resistant enterococci (VRE). Myopathy is an adverse effect with weekly monitoring of creatine phosphokinase (CPK) levels recommended.

■  Lipoglycopeptides are the newest class of gram-positive antibiotics. They include telavancin, dalbavancin, and oritavancin.

■  Aminoglycosides include gentamicin, tobramycin, and amikacin and are used to treat gram-negative bacteria. Because of their narrow therapeutic index, serum concentrations must be carefully monitored. Toxicities include nephro- and ototoxicity.

(Percival, 2017)

In a recent descriptive study of 1,461 courses of outpatient antimicrobial therapy (OPAT) in the home, the most common antimicrobials administered were vancomycin (36%), piperacillin/tazobactam (13%), ceftriaxone, ertapenem, and daptomycin (Shrestha et al., 2016).

Antimicrobial Lock Technique

For patients who require long-term infusion therapy, the CVAD becomes the patient’s “lifeline.” Efforts are aimed at CVAD preservation whenever possible. In patients who experience repeated episodes of catheter-related bloodstream infection (CR-BSI), antimicrobial lock technique has been used to successfully eradicate infections and avoid 127catheter removal. Antimicrobial locking solutions may be used for both infection prophylaxis and for treatment of CVAD-related infection. The technique includes the use of a highly concentrated antibiotic or an antiseptic agent instilled into the internal lumen of a central venous access device and is allowed to dwell for a prescribed duration of time (e.g., 12 hours per day in between intermittent infusions). Antiseptic solutions include ethanol, taurolidine, and citrate among others. The catheter manufacturer’s directions for use of ethanol should be reviewed as ethanol can cause damage to CVADs made of polyurethane. Antimicrobial locking is used in patients with long-term CVADs, patients with a history of multiple CR-BSIs, and high-risk populations (Gorski, Hadaway, Hagle, McGoldrick, Orr, & Doellman, 2016, p. S79). The procedure includes instillation of the antimicrobial solution in a volume approximately equal to the catheter lumen and allowing it to dwell for the prescribed duration of time. It is important that the antimicrobial locking solution is aspirated at the end of the locking period to reduce the risk of adverse effects including development of antimicrobial resistance (Gorski, Hadaway, Hagle, McGoldrick, Orr, & Doellman, 2016, p. S79). Antimicrobial lock technique may be administered in conjunction with systemic IV antibiotic therapy.

COMPREHENSIVE CARE, ASSESSMENT, AND MONITORING

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