Monitoring patients receiving ambulatory antimicrobial therapy
Regular monitoring is required for all patients receiving ambulatory antimicrobial therapy. Studies have shown in patients receiving ambulatory antimicrobial therapy:
- up to 25% develop adverse reactions or intravenous access device complications
- 5 to 10% require hospital readmission
- around 5% request urgent telephone advice or unscheduled home visits, most commonly for infusion device or intravenous access problemsChapman, 2019Sriskandarajah, 2020.
Accordingly, a member of the managing team should be available for contact by the patient or carer 24 hours a day, 7 days a week, and there should be a process for arranging rapid review of the patient. The patient should have written contact information and education material on common problems and adverse events (see Information for patients receiving ambulatory antimicrobial therapy).
Patients receiving ambulatory antimicrobial therapy must have regular medical review; usually, this should be at least weekly. The purpose of medical review is toChapman, 2019:
- monitor response to treatment
- monitor for antimicrobial adverse effects (eg peripheral neuropathy [for patients treated with linezolid], raised creatinine kinase plasma concentration [for patients treated with daptomycin]) and other complications, including device-related complications
- review the results of investigations (including kidney and liver function monitoring)
- consider if the duration of antimicrobial therapy should be revised, including whether an earlier switch to oral therapy is appropriate
- discuss the patient’s experience of treatment.
Specialist ambulatory antimicrobial therapy staff may visit the patient daily, or other clinical staff may see the patient in the community periodically; the frequency will depend on the model of care employed. In some services, suitable patients (or carers) are trained to manage their own treatment (including line care and recognising complications or deterioration) so staff visits are less frequent.
Patients should have blood tests at least once a week (eg full blood count, urea and electrolytes, liver biochemistry). More frequent testing may be required. Plasma concentration and other relevant clinical monitoring are required for some antimicrobials, for example vancomycin (see vancomycin plasma concentration monitoring and dosage adjustment in adults or young infants and children) and aminoglycosides (see Monitoring aminoglycoside plasma concentrations). Patients on aminoglycosides must be carefully monitored for nephrotoxicity as well as vestibular and auditory toxicity (see Clinical monitoring for aminoglycoside toxicity).
Patients being treated with ambulatory antimicrobial therapy may be complex; vigilance is required when checking the results of blood tests, including those for plasma concentration monitoring. Additionally, the patient’s diet, fluid intake, level of activity and home environment can increase the risks of dehydration, drug toxicity, hypoglycaemia and other complications. Monitoring of kidney function, plasma drug concentrations and other relevant parameters is particularly important.
Fever in a patient receiving ambulatory parenteral antimicrobial therapy should prompt early review of the intravenous access device. Patients with an unexplained fever may require readmission to hospital for further investigation and management. Collect blood for culture from the intravenous access device and peripherally. If the patient has signs of sepsis or haemodynamic compromise, or if the area around the access site is inflamed, see Overview of infections associated with intravenous catheters.