Adverse Drug Reactions in the Home Care Patient
November 15, 1997
Adverse Drug Reactions in the Home Care Patient
ABSTRACT & COMMENTARY
Synopsis: The rate of adverse drug reactions to nafcillin and oxacillin were higher than those observed with other antibiotics.
Source: Dahlgren AF. Adverse drug reactions in home care patients receiving nafcillin or oxacillin. Am J Health-Syst Pharm 1997;54:1176-1179.
An independent, freestanding, home infusion pharmacy performed a retrospective analysis of adverse drug reactions (ADRs) to a variety of antibiotic agents. The study reviewed a five-year period between 1990 and 1994. Out of 2488 courses reviewed, there was an average incidence of ADRs of 10.9%. (The ADR occurrence rate was determined by taking the number of ADRs, dividing by the courses of antibiotic therapy, and multiplying by 100.) Of particular interest was that nafcillin and oxacillin exhibited an extremely high ADR rate of 31.4%. Of the 99 patients that received either nafcillin or oxacillin, 24 had ADRs (for a total of 33 ADRs in 105 courses of therapy). The most common ADRs seen with nafcillin and oxacillin were rash, phlebitis, fever, neutropenia, and itching, in descending order of occurrence. By comparison, the ADR occurrence rates for other antibiotics were 13.3% for vancomycin, 11.4% for aminoglycosides, 7.0% for cephalosporins, and 4.1% for penicillins other than nafcillin and oxacillin. Dahlgren concluded that home care patients receiving nafcillin or oxacillin had a disproportionately high risk for ADRs, and that other antibiotics should be considered in home care.
COMMENT BY THOMAS SCHLEIS, MS, RPh
Allergic reactions to penicillins were stated to occur in 0.7-10% of the patients.1 If one looked at only the allergic reactions to nafcillin and oxacillin in this study, the ADR rate would still be 18.1%. Even if the only preventable ADR, that of phlebitis, were prevented with the use of peripherally inserted central catheters (PICCs) or central lines, it would only reduce the overall incidence of ADRs to 25.7%. It is also important to note that Dahlgren stated that the occurrence of these ADRs did not seem to differ substantially by method of delivery or by diluent used.
Table
OPIVITA Study 1997
Percent of ADRs
Resulting in Change
Antibiotic # ADRs/# Courses of Medication
Ceftriaxone 8/257 3% Oxacillin/Nafcilli3/26 12% Vancomyci11/134 8%
The Outpatient Intravenous Infusion Therapy Association (OPIVITA) conducted a multi-center study looking at ADRs that resulted in a change in medication.2 The results of some of the commonly used antibiotics are shown in the table. Since OPIVITA only looked at ADRs that resulted in a change in medication, the data from the AJHP article can be filtered for comparison. In the AJHP article, 54.2% of the patients that had an ADR to nafcillin or oxacillin were changed to another antibiotic agent. This would reduce their ADR rate to approximately 15%, which is similar to the 12% reported by the OPIVITA organization. Again, this is still a higher rate of adverse reactions than seen with other antibiotics.
It may not be immediately obvious that some medications have a higher incidence of ADRs than others. That is where the collection of ADR and outcomes data are especially helpful in determining potential problems and in establishing antibiotic use guidelines. Alternative antibiotics that could be used for treatment of infections caused by susceptible strains of S. aureus include cefazolin and ceftriaxone. These antibiotics had ADR occurrence rates of 5.2% and 6.7%, respectively, and in many cases produced similar outcomes to that of oxacillin and nafcillin. Hopefully, continued work in this area will assist us in optimizing antibiotic therapy.
References
1. Olin BR, ed. Drug Facts and Comparisons. (Loose-leaf edition.) St. Louis: Facts and Comparisions; 1997.
2. Kunkel ML, Tice AD, and the OPIVITA study group. Serious adverse events in outpatient parenteral antibiotic therapy: A prospective multicenter study. Presentation (#132) at IDSA Conference, San Francisco, 1997.
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