Antibiotic Therapy

Certain concerns are especially pertinent for rural regions with a paucity of physicians. One CCAC respondent commented that physicians in the region overwhelmingly chose to have the patient sent to hospital rather than travelling to the patient’s home. The benefit derived from the presence of a physician instead of a trained nurse during an anaphylactic reaction is debatable. Hence, it could be more efficient and convenient for all parties involved if the constraint for physician supervision were waived.

Even if this change were made, a number of hurdles remain. Nursing agencies have their own stringent criteria for deciding whether to administer the first dose without medical supervision, and such criteria could override patient preferences by giving more weight to the potential for adverse medical and legal consequences. However, if standard policies were adopted, nursing agencies might be more willing to have nurses administer the first dose in the home. This conjecture lends support to the need for revisions to policies for home IV antibiotic therapy, as many existing CCAC policies date back to the early 1990s, when home IV programs were established.

As seen in the study by Dobson and others, the acquisition of epinephrine by patients can be problem­atic. In the study reported here, only one CCAC required the purchase of epinephrine as mandatory for patients receiving home IV antibiotic therapy. In both the CCAC and PSN surveys, the majority of respondents had a policy requiring the visiting nurse to carry epinephrine at all times. Such a policy avoids the inconvenience of patients acquiring their own supply. It is also a more logical choice, as the intent is for the visiting nurse to administer the epinephrine, if it is required. The proposed policy revision does not preclude prescribing epinephrine for patients if the physician deems it necessary. viagra plus

The problems related to the safe administration of first-dose IV antibiotic therapy in the outpatient setting could be addressed by different strategies. Infusion centres constitute a medically supervised setting for outpatient administration of antibiotics to patients who are physically able to attend such clinics. Maintenance of a home-based model for administration of IV antibiotic therapy requires an algorithm for determining the appropriateness of administering the first dose at home.

Such an algorithm was developed on the basis of the evidence gathered in this study. The proposed guideline (Figure 1) reflects the authors’ interpretation of current data and is in keeping with McNutty’s 1993 conclusion that “first-dose antimicrobial therapy can be administered safely in the home” with approval by the patient’s physician and appropriate planning. McNutty also recommended that drugs with a high frequency of allergic reactions, such as penicillin, be first administered in hospital, at a slow infusion rate for the first 5 to 10 minutes, and that complete anaphylaxis kits be carried by the nurses. Before the algorithm developed in the current study is applied to any patient population, it should be piloted by the home care agencies and physicians to determine its practicability and compliance and to address any concerns that arise. As with any medical treatment, IV antibiotic therapy carries inherent risk. Informed consent should be obtained before administration of the first dose of IV antibiotics in the home.
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Figure1. Algorithm for determining

Figure 1. Algorithm for determining the site for IV administration of first dose of antibiotic.

Although the response rate to the CCAC survey was fair, it was far from ideal, as the survey was intended to gather statistics on CCAC policies (i.e., not an opinion poll). Another approach to gathering these data would be to ask all CCAC managers to submit their respective policies regarding home IV therapy, if such documents exist. It is unclear whether the CCACs that failed to respond did not provide outpatient antibiotic therapy or did not have formal policies on home IV therapy, or whether the lack of response was due to lack of time or availability to find and provide the necessary information.

Although limited by low response rates, the CIDS and PSN surveys collated information on policies for first dosing of IV antibiotics on a national basis. The low response rate may be attributed to the surveys being sent by e-mail to listservs, where messages may be numerous, read infrequently, or even treated as junk mail. These surveys were not resent, as they were entirely voluntary, and respondents who were interested in replying would probably have responded to the first request. In certain regions, there may be a small number of infectious disease specialists serving a large population; even if they responded, the results might not be representative. Use of a formal survey with validated questions may increase response rates. A validated survey could also delineate the current standard of care in Canada, for example, to answer whether there are differences between provinces or between rural and urban centres. eriacta tablets

The results of this study emphasize not only the need for revisions to current policies governing home IV antibiotic therapy, but also the utility of developing standard protocols that balance available evidence with best practice. Further investigations such as a formal survey to demarcate standard of care will help to develop standard protocols. The proposed algorithm for first-dose home IV antibiotic treatment is a first step toward addressing 2 pertinent issues that have both clinical and economic impact: the location of first-dose administration and the prescription of epinephrine for each patient. Although the algorithm should be piloted before it is implemented as standard practice, the proposed guideline may allow for more efficient delivery of home IV antibiotic therapy and reduce patient inconvenience and costs associated with visits to clinics and physicians’ offices, while maintaining patient safety as the priority.