A retrospective analysis of adverse events among patients receiving daptomycin versus vancomycin during outpatient parenteral antimicrobial therapy

Put the Vanc Down, Flip It and Reverse It: Comparison of Vancomycin and Daptomycin Health Care Utilization and Cost in Outpatient Parenteral Antimicrobial Therapy

Vancomycin and daptomycin are frequently used in outpatient parenteral antimicrobial therapy (OPAT). We analyze health care utilization and cost to the health care system for vancomycin vs daptomycin in the outpatient setting and find that vancomycin results in significantly higher health care utilization and similar cost per course compared with daptomycin in OPAT.

Patient safety outcomes for continuous infusion vancomycin as outpatient parenteral antimicrobial therapy

BACKGROUND

Administration of vancomycin as a continuous infusion has been associated with reduced nephrotoxicity. Given limited published experience with continuous infusion vancomycin in outpatient parenteral antimicrobial therapy (OPAT) programs, we reviewed outcomes from our center.

METHODS

This was a retrospective, single-center study of adult patients receiving vancomycin OPAT as continuous or intermittent infusion for an intended treatment duration of at least 7 days. The primary outcome was time to nephrotoxicity with continuous versus intermittent infusion vancomycin while on OPAT; additional outcomes included time to any vancomycin-associated adverse event, time to 60-day death or readmission, and time to 60-day emergency department encounter. Proportional hazards modeling was used to identify variables independently associated with outcomes, as well as assess the strength of association of continuous infusion with each outcome.

RESULTS

Four-hundred ninety-two patients were included: 118 treated with continuous and 374 with intermittent vancomycin infusion. Continuous infusion was not associated with lower rates of nephrotoxicity compared to intermittent infusion (adjusted hazard ratio (aHR) 0.72, 95% CI: 0.35-1.50). There were no advantages of continuous over intermittent infusion in the rates of any adverse event (aHR 0.93, 95% CI: 0.56-1.53), 60-day death or readmission (aHR 1.04, 95% CI: 0.68-1.61), or 60-day emergency department encounter (aHR 1.17, 95% CI: 0.68-1.99). Vancomycin area under the concentration-time curve (AUC) at discharge was the only modifiable factor identified that was independently associated with patient safety outcomes.

CONCLUSION

There was no appreciable benefit of continuous infusion vancomycin on outpatient safety outcomes. AUC-centered dosing approaches warrant further investigation as strategies to improve vancomycin safety in OPAT programs.

First-Dose Antimicrobial Infusion Reactions in Patients Enrolled in Outpatient Parenteral Antimicrobial Therapy Services

After receiving a monitored first-dose antimicrobial infusion at an infusion center, 6 of 93 (6%) patients enrolled in outpatient parenteral antimicrobial therapy services experienced an immediate reaction, none of which were consistent with immunoglobulin E-mediated reactions. These findings suggest it would be reasonable to forgo monitoring for most patients receiving first-dose intravenous antimicrobials outpatient.

Factors associated with daptomycin consumption in French hospitals between 2019 and 2020: A nationwide surveillance study

OBJECTIVES

This study aimed to investigate factors associated with daptomycin consumption in French healthcare facilities (HCF) between 2019 and 2020.

METHODS

Antibiotic consumption expressed as number of defined daily doses (DDD) per 1,000 patient-days (PD) and antimicrobial resistance (AMR) expressed as incidence densities per 1,000PD were extracted each year from the nationwide surveillance network run by the SPARES project (Surveillance and Prevention of Antimicrobial RESistance in hospitals), collecting data at ward level among voluntary HCFs using standardized methodology and webtool. All HCF participating both in 2019 and 2020 were included. A multivariable linear regression was fitted.

RESULTS

Among 622 HCFs, we analyzed daptomycin consumption and AMR data in 1,637 clinical wards. Incidence densities of methicillin-resistant Staphylococcus aureus (MRSA) and methicillin-resistant coagulase-negative staphylococci (MRCNS) were the highest in intensive care unit wards (0.54 and 6.83 respectively in 2020). On the most adjusted model, the year 2020 was correlated with a higher daptomycin consumption (1.53; p = 0.01). A greater number of inpatient beds (0.01; p < 0.001), the presence of orthopedic surgery activity in the HCF (1.66; p < 0.02), MRSA (4.38; p < 0.001) and MRCNS (0.61; p < 0.001) incidence densities were associated with a higher daptomycin use. The final model explained 18% of the observed variance.

CONCLUSIONS

This study showed that daptomycin consumption was correlated to MRSA and MRCNS incidence densities, to the year 2020 and to non-modifiable HCF-related factors. Prevention of coagulase-negative staphylococci infections should be considered by antimicrobial stewardship teams when daptomycin use is going up in HCF.

Decreased hospital readmissions after programmatic strengthening of an outpatient parenteral antimicrobial therapy (OPAT) program

OBJECTIVE

To determine whether a structured OPAT program supervised by an infectious disease physician and led by an OPAT nurse decreased hospital readmission rates and OPAT-related complications and whether it affected clinical cure. We also evaluated predictors of readmission while receiving OPAT.

PATIENTS

A convenience sample of 428 patients admitted to a tertiary-care hospital in Chicago, Illinois, with infections requiring intravenous antibiotic therapy after hospital discharge.

METHODS

In this retrospective, quasi-experimental study, we compared patients discharged on intravenous antimicrobials from an OPAT program before and after implementation of a structured ID physician and nurse-led OPAT program. The preintervention group consisted of patients discharged on OPAT managed by individual physicians without central program oversight or nurse care coordination. All-cause and OPAT-related readmissions were compared using the χ² test. Factors associated with readmission for OPAT-related problems at a significance level of P < .10 in univariate analysis were eligible for testing in a forward, stepwise, multinomial, logistic regression to identify independent predictors of readmission.

RESULTS

In total, 428 patients were included in the study. Unplanned OPAT-related hospital readmissions decreased significantly after implementation of the structured OPAT program (17.8% vs 7%; P = .003). OPAT-related readmission reasons included infection recurrence or progression (53%), adverse drug reaction (26%), or line-associated issues (21%). Independent predictors of hospital readmission due to OPAT-related events included vancomycin administration and longer length of outpatient therapy. Clinical cure increased from 69.8% before the intervention to 94.9% after the intervention (P < .001).

CONCLUSION

A structured ID physician and nurse-led OPAT program was associated with a decrease in OPAT-related readmissions and improved clinical cure.

Usefulness of Routine Laboratory Tests for Follow up of Patients Receiving Outpatient Parenteral Antimicrobial Therapy Run by Infectious Diseases Fellows

BACKGROUND

The infectious disease society of America (IDSA) recommends routine laboratory tests for all patients receiving outpatient parenteral antimicrobial therapy (OPAT) to monitor for adverse events. There are no data to support how often patients should take monitoring laboratory tests. In addition, the relevance of different laboratory tests commonly used for OPAT follow up is not clearly known.

METHODS

We conducted a retrospective observational cohort study over a 7-year study interval (1 January 2014 to 31 December 2021). Clinical data were obtained to identify the risk factors associated with abnormal laboratory tests and determine if abnormal laboratory tests led to antibiotic change or hospital readmission.

RESULTS

Two hundred and forty-six patients met the inclusion criteria for this study. In our multivariate analysis, the Charlson comorbidity index (CCI) of 0-4 (aOR 0.39, 95%Cl 0.18-0.86), the use of ceftriaxone without vancomycin (aOR 0.47, 95%Cl 0.24-0.91) and an OPAT duration of 2-4 weeks (aOR 0.47, 95%Cl 0.24-0.91) were associated with a lower risk of OPAT complications. A CCI of 5 or more (aOR 2.5, 95%Cl (1.1-5.7)) and an OPAT duration of 5 or more weeks (aOR 2.7, 95% Cl 1.3-5.6) were associated with a higher risk of OPAT complications. An abnormal complete metabolic panel or vancomycin levels, but not an abnormal complete blood count, were associated with antibiotic change or readmission.

CONCLUSION

Patients with fewer comorbidities, ceftriaxone and short OPAT durations are at lower risk for OPAT complications. These patients could be followed with less frequent laboratory monitoring.

The Incidence of Severe Hypercalcaemia-Induced Mental Status Changes in Patients Treated with Antibiotic-Loaded Calcium Sulphate Depot for Orthopaedic Infections

Local application of antibiotics with calcium-containing carrier materials (CCCM) might deliver large quantities of calcium, with some cases of hypercalcaemia reported. The incidence of symptomatic hypercalcaemia was estimated retrospectively in a consecutive, prospective series of patients treated between 10/2006 and 02/2019 with antibiotic-loaded CCCM for various orthopaedic infections. Risk factors were analysed. In the study period, 215 CCCM applications were performed. Two patients (0.9%) developed symptomatic hypercalcaemia. In one case, hypercalcaemia occurred 14 days after a second CCCM application during a staged septic hip revision. In the other case, hypercalcaemia became symptomatic six days after application of vancomycin-loaded CCCM in a component-retaining septic revision hip arthroplasty. In both cases, hypercalcemia was not imputable solely to the CCCM. Prolonged immobilization, renal impairment and other specific risk factors were present. Implantation of a CCCM for local application of antibiotics exposes the patient to large quantities of calcium during dissolution. This might induce symptomatic hypercalcaemia, a potentially life-threatening complication. The observed incidence of symptomatic hypercalcaemia remained rare (<1%). In some patients, compensatory mechanisms might be overwhelmed in the presence of other risk factors. Postoperative monitoring of calcaemia as well as elimination of risk factors is mandatory for all patients treated with CCCM.

Clinical Efficacy and Safety of Vancomycin Continuous Infusion in Patients Treated at Home in an Outpatient Parenteral Antimicrobial Therapy Program

Vancomycin is commonly used in outpatient parenteral antimicrobial therapy (OPAT) of Gram-positive infections. Therapeutic drug monitoring and adverse event monitoring pose a challenge. Outcome data of vancomycin in OPAT (vOPAT) are limited. The study aim was to report the safety and efficacy of a structured vOPAT program implemented in the University Hospitals Leuven. The program provides continuous elastomeric infusion of vancomycin at home with biweekly follow-up at the outpatient clinic. Demographics, clinical, biochemical and treatment parameters, target attainment parameters and clinical outcomes were recorded. An e-survey was conducted to assess patient satisfaction. Thirty-five vOPAT episodes in 32 patients were included. During 206 follow-up consultations, 203 plasma concentration measurements were registered with a median vancomycin plasma concentration of 22.5 mg/L (range 6.6–32.0). The majority of concentrations (68.5%) were within the therapeutic range (20.0–25.0 mg/L). Adverse event rates, including drug- (5.7%) and catheter-related (5.7%) events, were low. For 32 vOPAT episodes, a clinical cure rate of 100% was observed. All patients who completed the e-survey were satisfied with their vOPAT course. These findings show that a structured vOPAT program with rigorous follow-up provides safe and effective ambulatory treatment of patients with vancomycin in continuous infusion.

Inpatient Antibiotic Costs Associated With Switching From Vancomycin to Daptomycin for Outpatient Parenteral Antibiotic Therapy

Purpose: The common practice of changing patients to daptomycin for outpatient parenteral antibiotic therapy (OPAT) can increase inpatient daptomycin use and impact inpatient pharmacy expenses. The purpose of this study was to quantify the additional inpatient antibiotic expenditures associated with changing patients from vancomycin to daptomycin for OPAT. Methods: This study examined patients who were discharged from January 1, 2018 to June 30, 2019. Patients were included if they were ≥18 years old, transitioned from vancomycin to daptomycin prior to discharge, and were cared for by the Infectious Diseases OPAT program. Patients switched to daptomycin for therapeutic reasons were excluded. A cost analysis evaluating the vancomycin regimen prior to changing to daptomycin and the daptomycin doses given prior to discharge and during readmissions for the first 6 weeks after discharge was performed using Wholesale Acquisition Costs. The primary outcome was the inpatient antibiotic expense associated with changing to daptomycin for OPAT. Results: Sixty-eight patients met study criteria. The mean number of inpatient doses of daptomycin administered prior to discharge was 4.3. Twelve patients were readmitted and received a mean of 5.3 additional doses. The estimated cost difference between the inpatient daptomycin doses and equivalent vancomycin therapy was $2647 per patient. Limiting patients to only 1 pre-discharge dose of daptomycin would reduce this cost difference to $926 per patient. Conclusion: Switching from vancomycin to daptomycin for OPAT can be associated with substantial inpatient pharmacy costs. These excessive costs can be mitigated if only 1 dose of daptomycin is given before discharge.

Safety of prolonged outpatient courses of intravenous antibiotics: a prospective cohort study

OBJECTIVES

The perceived need for prolonged intravenous antibiotic courses has become a major driver behind the growth of outpatient parenteral antimicrobial therapy (OPAT) services. Several recent randomised controlled trials demonstrate non-inferiority of early switch to oral therapy and highlight the need to accurately quantify harms associated with OPAT.

METHODS

We conducted a 10-year prospective cohort study in a tertiary hospital OPAT service. Adults admitted to the service between 1^st June 2009 and 30^th June 2019 who received an intravenous antimicrobial agent were included. Adverse events (AEs) attributable to intravenous antibiotics or intravenous access were recorded in a prospectively maintained database and analysed.

RESULTS

There were 4,160 admissions (median length of stay 20 days), and a total of 88,432 patient-days of observation. 135 (3.3% of admissions) experienced at least one major AE (1.54/1,000 patient days [95%CI: 1.29 to 1.82]). The risk of a major AE peaked in the second week of OPAT admission, with acute kidney injury (43/136, 32%) and severe cytopenia (42/136, 31%) being most common. At least one minor AE occurred in 38.3% (1,592/4,160) of admissions (26.4 per 1,000 patient days [95%CI: 25.4 to 27.5]), with central venous catheter related complications accounting for 71% (1658/2338).

CONCLUSIONS

The incidence of major adverse events during long courses of intravenous antibiotics is low, peaking in week two and tailing off thereafter. These results should inform decisions concerning the choice of intravenous versus oral antimicrobials.

Stability of Antimicrobials in Elastomeric Pumps: A Systematic Review

Outpatient parenteral antimicrobial therapy (OPAThttp) programs have become an important healthcare tool around the world. Portable elastomeric infusion pumps are functional devices for ambulatory delivery of antimicrobial drugs, and their stability is an essential point to guarantee an appropriate infusion administration. We conducted a systematic review to provide a synthesis and a critical evaluation of the current evidence regarding antimicrobial stability in elastomeric pumps. Data sources were PubMed, EMBASE, and Web of Sciences. The review protocol was registered on the Center for Open Science, and it was carried out following the PRISMA guidelines. Studies were eligible if the aim was the evaluation of the physicochemical stability of an antimicrobial agent stored in an elastomeric device. Of the 613 papers identified, 33 met the inclusion criteria. The most studied group of antimicrobials was penicillins, followed by cephalosporins and carbapenems. In general, the stability results of the antimicrobials that have been studied in more than one article agree with each other, with the exception of ampicillin, flucloxacillin, and ceftazidime. The antibiotics that displayed a longer stability were glycopeptides and clindamycin. Regarding the stability of antifungals and antivirals, only caspofungin, voriconazole, and ganciclovir have been investigated. The information provided in this article should be considered in patient treatments within the OPAT setting. Further stability studies are needed to confirm the appropriate use of the antimicrobials included in this program to ensure optimal patient outcomes.

Exploratory Cost-Effectiveness Analysis for Treatment of Methicillin-Resistant Staphylococcus aureus Bloodstream Infections: Is Linezolid or Daptomycin Favored Over Vancomycin?

BACKGROUND AND OBJECTIVE

Methicillin-resistant Staphylococcus aureus bloodstream infections (MRSAB) cause significant mortality, and often require extended antibiotic therapy. Vancomycin, the most common initial MRSAB treatment, carries significant monitoring burden and nephrotoxicity risks. Our objective was to compare the cost-effectiveness of vancomycin and other antibiotic regimens against MRSAB.

METHODS

We estimated the cost-effectiveness of intravenous antibiotics (vancomycin, daptomycin, linezolid, ceftaroline/daptomycin) for Veterans Health Administration patients with MRSAB using an exploratory decision-tree model. Primary effectiveness outcome was composite of microbiological failure at 7 days and adverse drug event (ADE)-related discontinuation after at least 7 days.

RESULTS

In base-case analyses, intravenous linezolid was the least expensive regimen at 4 and 6 weeks. Daptomycin was more expensive and more effective than linezolid, with an incremental cost-effectiveness ratio (ICER) of ~$13,000 (4 weeks) per composite failure avoided. With 6 weeks of treatment, daptomycin was more expensive and more effective than vancomycin (ICER ~$21,000 per composite failure avoided). Vancomycin and ceftaroline/daptomycin were dominated strategies at both 4 and 6 weeks. In one-way sensitivity analyses, vancomycin was favored when its microbiological failure risk was less than 20.1% (base-case: 27.2%), assuming a willingness to pay (WTP) threshold of $40,000/composite treatment failure avoided. In two-way sensitivity analyses, intravenous linezolid was favored if linezolid microbiological failure and ADE-related discontinuation rates were < 22.5% and < 17.3%, respectively. Daptomycin, vancomycin, and linezolid were favored in 50%, 31%, and 17% of 4-week probabilistic iterations, respectively, at $40,000 WTP.

CONCLUSION

Daptomycin is likely less expensive and more effective than vancomycin or other initial regimens for MRSAB. More data are needed on the safety of linezolid against MRSAB.

Vancomycin or Daptomycin for Outpatient Parenteral Antibiotic Therapy: Does It Make a Difference in Patient Satisfaction?

A 5-question telephone survey was administered to compare satisfaction between patients receiving vancomycin vs daptomycin outpatient parenteral antimicrobial therapy (OPAT). Twenty-seven patients completed the survey (40%). Vancomycin had higher daily interference score than daptomycin (P = .03). All patients receiving daptomycin reported a satisfaction score ≥8/10, as compared to 67% of patients who received vancomycin (P < .03). OPAT antibiotics with less cumbersome administration regimens may translate into higher patient satisfaction and quicker return to life normalcy.

Experiences in outpatient parenteral antimicrobial therapy (OPAT): Barriers and challenges from the front lines

Background:

Outpatient parenteral antimicrobial therapy (OPAT) is now the standard of care for managing patients who no longer need inpatient care but require prolonged intravenous antimicrobial therapy. OPAT increases patient satisfaction, reduces the lengths of hospital stay, lowers emergency department readmission rates, and decreases total healthcare spending.

Objective:

To investigate Virginia Commonwealth University Health System’s experience with OPAT and to highlight the obstacles patients and clinicians face when navigating and utilizing this program.

Design:

We conducted this descriptive study at a large, academic, tertiary-care hospital in Central Virginia.

Methods:

We performed manual reviews of electronic medical records of 602 patient, and we evaluated the records of those receiving OPAT between 2017 and 2020. Reviews included antimicrobial agents, diagnoses requiring OPAT, adverse effects related to antimicrobials, adverse effects related to peripherally inserted central catheters (PICC), readmission rate, discharge destination, and death. We evaluated our program with descriptive statistics.

Results:

Among 602 patients who received OPAT, most were diagnosed with bacteremia or musculoskeletal infections. Patients were either discharged home or to another healthcare facility, with the former comprising most of the rehospitalizations. Ertapenem and vancomycin were associated with the most adverse drug events among our cohort. Elevated transaminase levels were noted in 23% of patients. The rate of PICC-line adverse events in this study population was 0.05%.

Conclusions:

Our findings highlight the barriers and challenges that patients and providers face when receiving OPAT, and they can inform efforts to improve patient clinical outcomes.

Which Patients Discharged to Home-Based Outpatient Parenteral Antimicrobial Therapy Are at High Risk of Adverse Outcomes?

Background

Patients increasingly receive home-based outpatient parenteral antimicrobial therapy (OPAT). Understanding which patients might be at higher risk of complications is critical in effectively triaging resources upon and after hospital discharge.

Methods

A prospective cohort of patients discharged from 1 of 2 academic medical centers in Baltimore, Maryland, between March 2015 and December 2018 were consented and randomly divided into derivation and validation cohorts for development of a risk score for adverse OPAT outcomes. Data from the derivation cohort with the primary outcome of a serious adverse outcome (infection relapse, serious adverse drug event, serious catheter complication, readmission, or death) were analyzed to derive the risk score equation using logistic regression, which was then validated in the validation cohort for performance of predicting a serious adverse outcome.

Results

Of 664 patients in the total cohort, half (332) experienced a serious adverse outcome. The model predicting having a serious adverse outcome included type of catheter, time on OPAT, using a catheter for chemotherapy, using a catheter for home parenteral nutrition, being treated for septic arthritis, being on vancomycin, being treated for Enterococcus, being treated for a fungal infection, and being treated empirically. A score ≥2 on the serious adverse outcome score had a 94.0% and 90.9% sensitivity for having a serious adverse outcome in the derivation and validation cohorts, respectively.

Conclusions

A risk score can be implemented to detect who may be at high risk of serious adverse outcomes, but all patients on OPAT may require monitoring to prevent or detect adverse events.

Evaluation of Inpatient Antimicrobial Regimens for Readmitted Outpatient Parenteral Antimicrobial Therapy Patients Receiving Daptomycin or Ertapenem for Ease of Administration

Background

Outpatient parenteral antimicrobial therapy (OPAT) allows for long-course intravenous treatment of infections without lengthy hospital stays. Upon discharge, antimicrobial therapy may be broadened for “ease” of once-daily administration (EOA). Patients requiring subsequent readmission can be tailored to pre-OPAT regimens to minimize adverse effects. This study assessed continuation of EOA regimens upon hospital readmission during or immediately after OPAT.

Methods

This was a retrospective review of adults enrolled in OPAT and discharged on ertapenem or daptomycin for EOA, defined by the terms “convenience” or “EOA” in OPAT notes or by switching to ertapenem or daptomycin upon OPAT enrollment despite adequate therapy with narrower-spectrum agents. The primary outcome was the percentage of patients readmitted during or after their OPAT course and maintained on an EOA regimen. Secondary outcomes included inpatient therapy cost, rates of Clostridioides difficile infection, and adverse events.

Results

Of 188 patients receiving an OPAT EOA regimen, 71 were readmitted, representing 113 unique readmissions. Patients were mostly males (81%) aged 57 years. The EOA regimens were continued in 27% of hospital readmissions. The Infectious Diseases (ID) team was consulted in 48% of readmissions, and the Antimicrobial Stewardship Program (ASP) intervened in 26%. Combined, this resulted in de-escalation in 28% of cases. Clostridioides difficile infections and adverse events occurred in 7% and 12% of readmissions, respectively. The median acquisition cost of inpatient EOA regimens was $150 per readmission.

Conclusions

The OPAT EOA regimens were continued in 27% of hospital readmissions indicating a role for improved indication documentation and collaboration between ID services, ASPs, and OPAT teams.

More Frequent Premature Antibiotic Discontinuations and Acute Kidney Injury in the Outpatient Setting With Vancomycin Compared to Daptomycin

Vancomycin and daptomycin are often used in outpatient parenteral antimicrobial therapy for gram-positive coverage. Vancomycin's narrow therapeutic window poses challenges. We retrospectively assessed acute kidney injury (AKI) and other adverse drug events in outpatient parenteral antimicrobial therapy patients receiving vancomycin or daptomycin at home after hospital discharge. Among 191 patients included, AKI was the most common adverse drug event. Early antibiotic discontinuation and AKI were more frequent in the vancomycin group. Vancomycin use (odds ratio [OR], 4.57; 95% confidence interval [CI], 1.02-20.51); p = 0.04], female sex (OR, 3.28; 95%CI, 1.41-7.67; P < .01), and longer hospitalization (OR, 1.06; 95%CI, 1.01-1.11; P = .02] independently predicted moderate-to-severe AKI. In the vancomycin group, trough concentrations increased after discharge, and were higher in female compared to male patients, and in those who developed moderate-to-severe AKI compared to those who did not. Female sex (OR, 8.37; 95%CI, 2.35-29.82; P < .01) and higher concentrations (OR, 1.12; 95%CI, 1.05-1.19; P < .01) predicted moderate-to-severe AKI in patients receiving vancomycin. In conclusion, premature antibiotic discontinuations and nephrotoxicity are more frequent in patients treated at home with vancomycin compared to daptomycin. Among patients receiving vancomycin, plasma concentrations increased after hospital discharge and predicted moderate-to-severe AKI. Women had higher vancomycin concentrations and higher risk for AKI.

Updated good practice recommendations for outpatient parenteral antimicrobial therapy (OPAT) in adults and children in the UK

UK good practice recommendations for outpatient parenteral antimicrobial therapy (OPAT) were published in 2012 and 2015 for adult and paediatric patients, respectively. Here we update the initial good practice recommendations in a combined document based on a further review of the OPAT literature and an extensive consultation process. As with the previous good practice recommendations, these updated recommendations are intended to provide pragmatic guidance for new and established OPAT services across a range of settings and to act as a set of quality indicators for service evaluation and quality improvement.

A Clinical Review of Diabetic Foot Infections

"Diabetic foot infections (DFIs) are a common cause of morbidity and mortality. This article summarizes current knowledge regarding DFI epidemiology, disease pathogenesis, and the impact of antimicrobial resistance among DFI. An evidence-based approach to clinical assessment, diagnosing osteomyelitis, as well as medical and surgical treatment is discussed, including a review of empiric and directed antibiotic treatment recommendations. The current state and needs of the clinical literature are identified throughout, with a discussion of the supporting role of infectious diseases specialists as well as future directions of the field."