An ongoing dialogue on HIV/AIDS, infectious diseases,
August 20th, 2017
Two Quick Thoughts Inspired by Inpatient ID Consults, and An Inspirational Baseball Poster
A couple of quick thoughts for those of us doing inpatient care these days:
Thought One: Is daptomycin now preferred over vancomycin in most clinical settings?
It’s taken a while, but we’re getting there — close to that Gladwelllian “tipping point”. Allow this recap of vancomycin’s problems:
- The growing recognition that higher drug levels — the levels we want — bring with them more side effects.
- The extraordinary hassle and imprecision of monitoring vancomycin levels.
- The enormous variability in dosing due to differences in clearance from patient-to-patient.
- The lengthy vancomycin infusion time (at least 60 minutes/dose) which, if you have a patient on every 8 hour dosing, means they are spending many of their waking hours receiving vancomycin.
If you add to these issues the substantial decrease in daptomycin’s cost since it went generic, it’s hard to justify using vancomycin over daptomycin for many non-pneumonia indications these days.
Daptomycin is far from perfect, but if it replaces vancomycin there will be few tears shed on its behalf — vancomycin isn’t such a great drug either. Beta lactams are preferred over both of them for susceptible organisms.
And for the next time there’s a lull in the conversation with your friends, here are some fun facts about daptomycin, including how it was discovered on Mount Ararat in Turkey.
Thought Two: Outpatient parenteral antimicrobial therapy (OPAT) should be avoided whenever possible.
Two recent studies highlight the hazards associated with sending patients out of the hospital with intravenous lines to complete antibiotic therapy:
- Out of 339 patients prospectively studied from two academic medical centers, 18% experienced a significant adverse drug event, most commonly during the first two weeks after discharge. Note that most retrospective analyses have even higher rates, probably because many are discharged without being in an organized OPAT program.
- In people who inject drugs — a particularly challenging patient population who increasingly have “indications” for OPAT — a whopping 61% failed their OPAT course.
Aside from the medical challenges of OPAT, there’s also the clinical service side — which is dismal. Since payers typically do not reimburse providers for monitoring OPAT, this gives us ID doctors two terrible choices — provide the service for free because it’s good for patients or, alternatively, refuse to do it and document (leverage) the suboptimal care to get institutional funding.
The former is an example of our being “too nice”; the latter just makes me uncomfortable, but is increasingly required.
Bottom line: we should strive to give oral over IV antibiotics at discharge for all patients, except when the data strongly support parenteral therapy. Oral treatment is safer, cheaper, and usually just as effective.
Finally, given the current political climate, isn’t this poster just awesome?
It’s a subway poster from 1950, published by the Institute for American Democracy.
And as a baseball-crazy ID doctor, of course I love it!