Contribution of infectious disease consultation toward the care of inpatients being considered for community-based parenteral anti-infective therapy

Barriers and facilitators for the implementation and expansion of outpatient parenteral antimicrobial therapy: a systematic review

Outpatient parenteral antimicrobial therapy (OPAT) has been expanding in recent years and serves as a viable solution in reducing the shortage of hospital beds. However, the wider implementation of OPAT faces numerous challenges. This review aimed to assess implementation barriers and facilitators of OPAT services. Studies describing barriers and facilitators of the OPAT service were retrieved from PubMed, Scopus, MEDLINE, EMBASE, CINAHL, Cochrane Library, Web of Science Proceedings, International Pharmaceutical Abstracts and PsycINFO. All types of study designs published in the English language were included. Studies that did not mention any barrier or facilitator, did not differentiate OPAT and inpatient, focused on specific antimicrobials or diseases, and made no distinction between parenteral and other treatments were excluded. Qualitative analysis was performed using the 'best-fit' framework approach and the Consolidated Framework for Implementation Research (CFIR). The review was PROSPERO registered (CRD42023441083). A total of 8761 studies were screened for eligibility and 147 studies were included. Problems in patient selection, lack of awareness, poor communication and co-ordination, lack of support, lack of structured service and inappropriate prescriptions were identified. OPAT provides safe, effective and efficient treatment while maintaining patients' privacy and comfort, resulting in less daily life disruption, and reducing the risk of infection. Satisfaction and preference for OPAT were very high. Initiatives in strengthening OPAT such as antimicrobial stewardship and telemedicine are beneficial. Challenges to and facilitators of OPAT were identified among patients, health professionals, OPAT service providers and healthcare administrators. Understanding them is crucial to designing targeted initiatives for successful OPAT service implementation.

Outpatient Parenteral Antimicrobial Therapy in a Safety Net Hospital: Opportunities for Improvement

Background

Outpatient parenteral antimicrobial therapy (OPAT) is a safe and cost-effective transitional care approach administered via different delivery models. No standards exist for appropriate OPAT program staffing. We examined outcomes of patients receiving OPAT via different care models to identify strategies to improve safety while reducing health care overuse.

Methods

Retrospective demographic, clinical, and outcome data of patients discharged with OPAT were reviewed in 2 periods (April-June 2021 and January-March 2022; ie, when staffing changed) and stratified by care model: self-administered OPAT, health care OPAT, and skilled nursing facility OPAT.

Results

Of 342 patients, 186 (54%) received OPAT in 2021 and 156 (46%) in 2022. Hospital length of stay rose from 12.4 days to 14.3 in 2022. In a Cox proportional hazards regression model, visits to the emergency department (ED) within 30 days of OPAT initiation (hazard ratio, 1.76; 95% CI, 1.13-2.73; P = .01) and readmissions (hazard ratio, 2.34; 95% CI, 1.22-4.49; P = .01) increased in 2022 vs 2021, corresponding to decreases in OPAT team staffing. Higher readmissions in the 2022 cohort were for reasons unrelated to OPAT (P = .01) while readmissions related to OPAT did not increase (P = .08).

Conclusions

In a well-established OPAT program, greater health care utilization-length of stay, ED visits, and readmissions-were seen during periods of higher staff turnover and attrition. Rather than blunt metrics such as ED visits and readmissions, which are influenced by multiple factors besides OPAT, our findings suggest the need to develop OPAT-specific outcome measures as a quality assessment tool and to establish optimal OPAT program staffing ratios.

Improving antimicrobial treatment in terms of antimicrobial stewardship and health costs by an OPAT service

PURPOSE

Outpatient parenteral antimicrobial therapy (OPAT) is a standard for antimicrobial therapy internationally. With this prospective cohort study, we aimed to assess the impact of an OPAT service as part of antimicrobial stewardship (AMS) and evaluate the safety and efficiency of the program while illuminating the financial benefit for the hospital.

METHODS

Socio-demographic data, treatment regimen and outcomes were prospectively recorded for all patients assigned to the program of the OPAT unit of the University Hospital of Zurich between November 2018 and September 2022.

RESULTS

In total, we recorded 303 OPAT assignments of which 260 resulted in effective OPAT episodes. The 260 OPAT episodes were further optimized toward the choice of antimicrobial agent (n = 18) and length of therapy (n = 6). Moreover, OPAT resulted in alteration of patient assessment and care led by AMS strategies in 247 of 260 episodes (95%). While the bed days saved per year increased consistently with time, a total of 3934 in-hospital treatment days were saved amounting to a cost saving of 9,835,000 CHF over 47 months. Adverse events were recorded in 46 cases whilst only two of these have been the reason for readmission during OPAT treatment. Clinical cure was noted in 77% (199/260) and was negatively associated with Charlson Comorbidity Index (CCI; OR per 1 unit higher 0.85 (95% CI 0.78-0.93)).

CONCLUSION

This study demonstrates the impact of an OPAT service in the framework of AMS as well as its benefits for the hospital whilst preserving safety and efficacy for the patient's parenteral antimicrobial treatment.

A Needs Assessment for Infectious Diseases Consultation in Community Hospitals

INTRODUCTION

Infectious diseases (ID) consultations have been demonstrated to improve patient outcomes in the treatment of severe infections. However, ID consultation is often unavailable to patients that live in rural communities. Little is known regarding the treatment of infections in rural hospitals with no coverage from an ID specialist. We characterized the outcomes of patients cared for in hospitals without coverage from an ID physician.

METHODS

Patients aged 18 years or older admitted to eight community hospitals without access to ID consultation during a 6.5-month period were assessed. All patients had received at least three days of continuous antimicrobial therapy. The primary outcome was the need for transfer to a tertiary facility for ID services. The secondary outcome was the characterization of antimicrobials received. Antimicrobial courses were evaluated independently by two board-certified ID physicians.

RESULTS

3706 encounters were evaluated. Transfers for ID consultation occurred in 0.01% of patients. The ID physician would have made modifications in 68.5% of patients. Areas for improvement included treatment of chronic obstructive pulmonary disease exacerbations, broad-spectrum treatment of skin and soft tissue infection, long courses of azithromycin, and management of Staphylococcus aureus bacteremia, including choice and length of therapy, as well as obtaining echocardiography. Patients evaluated received 22,807 days of antimicrobial therapy.

CONCLUSIONS

Patients hospitalized in community hospitals are rarely transferred for ID consultation. Our work demonstrates a need for ID consultation in community hospitals, identifying opportunities to enhance patient care by modifying antimicrobial regimens to improve antimicrobial stewardship and avoid inappropriate antimicrobials. Efforts to expand the ID workforce to include coverage at rural hospitals will likely improve antibiotic utilization.

Recent innovations and new applications of outpatient parenteral antimicrobial therapy

INTRODUCTION

Outpatient parenteral antimicrobial therapy (OPAT) is safe and effective for selected patients managed within an organized clinical service. Service configurations however are evolving, patient populations are changing and new evidence is emerging which challenges traditional OPAT practice.

AREAS COVERED

This review will discuss evolving OPAT service delivery from the traditional model of infusion center toward nonspecialist, community and remotely delivered OPAT and the challenges this represents. We consider new patient populations including those with incurable infection or infections at the end of life and difficult to reach populations including people who inject drugs. The evidence base that underpins the multi-disciplinary approach to OPAT delivery will be examined and particularly the role of the antimicrobial pharmacist and specialist nurse. Evidence for new treatment options which challenge established OPAT practice including complex oral antibiotic regimens, long acting parenteral agents and drug stability in continuous infusion antibiotics will be considered. Finally we emphasize the central importance of antimicrobial stewardship and good clinical governance which should underpin OPAT practice.

EXPERT OPINION

Changing patient populations, service structures and team roles coupled with a growing infection management evidence base means that OPAT services and practice must evolve. Challenging traditional practice is essential to ensure best patient outcomes and cost-efficiency.

Measuring antimicrobial prescribing quality in outpatient parenteral antimicrobial therapy (OPAT) services: development and evaluation of a dedicated national antimicrobial prescribing survey

Background

Antimicrobial stewardship programmes are important in driving safety and quality of antimicrobial prescribing. The National Antimicrobial Prescribing Survey (NAPS) is a point-prevalence audit of inpatient antimicrobial prescribing in Australian hospitals.

Objectives

To design and adapt the NAPS tool for use in the outpatient parenteral antimicrobial therapy (OPAT) and hospital-in-the-home (HITH) setting.

Methods

An inter-disciplinary working group with expertise in OPAT and HITH services was established to adapt the NAPS template for use in the OPAT setting—called HITH-NAPS. This was initially trialled in 5 HITH services, subsequently adapted following participant feedback, then offered nationally to 50 services in 2017.

Results

There were 1154 prescriptions for 715 patients audited via the HITH-NAPS. The most common antimicrobials prescribed were cefazolin (22%), flucloxacillin (12%), piperacillin/tazobactam (10%) and ceftriaxone (10%). The most common infections treated were cellulitis (30%) and respiratory tract infections (14%). Eighty-seven percent of prescriptions were assessed as appropriate, 11% inappropriate and 2% not assessable. Prolonged durations of antimicrobials and unnecessarily broad-spectrum antibiotics were used in 9% of prescriptions.

Conclusions

The HITH-NAPS pilot project revealed that auditing of this type is feasible in HITH. It showed that antibiotic use in these HITH services was generally appropriate, but there are some areas for improvement. A national OPAT/HITH-NAPS can facilitate benchmarking between services, identify potentially inappropriate prescribing and help guide quality improvement.

Review of the first comprehensive outpatient parenteral antimicrobial therapy program in a tertiary care hospital in Japan

OBJECTIVES

The infectious diseases team at Kameda Medical Center, Japan, implemented a new outpatient parenteral antimicrobial therapy (OPAT) program in July 2012 and expanded the program with the support of home care services. This study reviews the OPAT program after 5.5 years of operation.

METHODS

We prospectively collected data about the age, sex, diagnoses, causative organisms, types of OPAT, modes of administration, selected antibiotics, treatment durations, bed days saved, outcomes, readmissions, and estimated cost reductions of all patients who were treated in the OPAT program from July 2012 to December 2017.

RESULTS

Of the 66 patients treated under the OPAT program, 45 (68.2%) were treated using clinic OPAT, and 21 (31.8%) were treated using homecare OPAT. The most commonly targeted organism was methicillin-susceptible Staphylococcus aureus. Continuous infusion with elastomeric pumps was employed in 55 patients (83.3%). Cefazolin was the most frequently used antibiotic (39.4%), followed by penicillin G (24.2%). The median OPAT duration was 13 days (range, 3-51), and the total bed days saved was 923. The estimated medical cost reduction was approximately 87,000 US dollars.

CONCLUSIONS

Our experience shows that OPAT is a safe and feasible practice not only for efficient bed utilization and medical cost savings but also for better antimicrobial stewardship.

2018 Infectious Diseases Society of America Clinical Practice Guideline for the Management of Outpatient Parenteral Antimicrobial Therapy

A panel of experts was convened by the Infectious Diseases Society of America (IDSA) to update the 2004 clinical practice guideline on outpatient parenteral antimicrobial therapy (OPAT) [1]. This guideline is intended to provide insight for healthcare professionals who prescribe and oversee the provision of OPAT. It considers various patient features, infusion catheter issues, monitoring questions, and antimicrobial stewardship concerns. It does not offer recommendations on the treatment of specific infections. The reader is referred to disease- or organism-specific guidelines for such support.

Inappropriateness of Intravenous Antibiotic Prescriptions at Hospital Discharge at a Tertiary Care hospital in Thailand

Background

Intravenous antibiotics, either as outpatient parenteral antimicrobial therapy (OPAT) or transition of care to community-based management, is a common practice in tertiary care hospitals to minimize hospital stays. However, infectious disease consultation was not mandated for those prescriptions. Therefore, we conducted this study to evaluate the appropriateness of intravenous antibiotic prescriptions at hospital discharge.

Methods

This retrospective cross-sectional study was conducted among patients receiving care at the internal medicine units of the Maharaj Nakorn Chiang Mai Hospital from November 1, 2015, to April 30, 2016. Intravenous antibiotics at hospital discharge were reviewed by an infectious diseases (ID) specialist.

Results

One hundred and twenty-nine prescriptions for 117 patients were reviewed. The most common diagnoses requiring intravenous antibiotics at hospital discharge were upper urinary tract infection (34.2%) and hepatobiliary tract infections (15.4%). The most common intravenous antibiotic was ceftriaxone (36.4%), followed by ertapenem (20.1%). Overall, the inappropriateness of prescriptions was 85.3%. The most common reason for inappropriateness was a failure to switch to oral antibiotics (52.7%), followed by incorrect duration (16.3%).

Conclusion

Antimicrobial stewardship should be considered for intravenous antibiotics at hospital discharge to reduce the inappropriateness of those prescriptions.

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.

Perspectives of United States-based Infectious Diseases Physicians on Outpatient Parenteral Antimicrobial Therapy Practice

BACKGROUND

While outpatient parenteral antimicrobial therapy (OPAT) is generally considered safe, patients are at risk for complications and thus require close monitoring. The purpose of this study is to determine how OPAT programs are structured and how United States-based infectious diseases (ID) physicians perceive barriers to safe OPAT care.

METHODS

We queried members of the Emerging Infections Network (EIN) between November and December 2018 about practice patterns and barriers to providing OPAT.

RESULTS

672 members of the EIN (50%) responded to the survey. Seventy-five percent of respondents were actively involved in OPAT, although only 37% of respondents reported ID consultation was mandatory for OPAT. The most common location for OPAT care was at home with home-health support, followed by post-acute-care facilities. Outpatient and inpatient ID physicians were identified as being responsible for monitoring laboratory results (73% and 54% of respondents, respectively), but only 36% had a formal OPAT program. The majority of respondents reported a lack of support in data analysis (80%), information technology (66%), financial assistance (65%), and administrative assistance (60%). Perceived amount of support did not differ significantly across employment models. Inability to access laboratory results in a timely manner, lack of leadership awareness of OPAT value, and failure to communicate with other providers administering OPAT were reported as the most challenging aspects of OPAT care.

CONCLUSION

ID providers are highly involved in OPAT, but only a third of respondents have a dedicated OPAT program. Lack of financial and institutional support are perceived as significant barriers to providing safe OPAT care.

Outpatient parenteral antimicrobial therapy and antibiotic stewardship: opponents or teammates?

PURPOSE

This narrative review aims to describe barriers of outpatient parenteral antimicrobial therapy at home (OPAT), potentially compromising general standards of antibiotic stewardship (ABS) and facilitators of OPAT for ABS.

METHODS

After a literature review, five authors determined the barriers and facilitators to discuss in this review.

RESULTS

Sixty-six publications were included in the narrative review and seven barriers and five facilitators are discussed in this article. The impracticability of multiple daily dosing during OPAT, the impact of real-life temperature variations, deviations of the infusion rates of elastomeric devices, access to prolonged intravenous antibiotic therapy, not administering loading doses before the initiation of extended or continuous infusions and the transmural nature of care associated with OPAT, can lead to deviations of recommended treatment regimens and sub-optimal clinical and laboratory follow-up, with a risk of inferior clinical outcomes, adverse events, drug-resistance and higher costs. On the other hand, OPAT provides access to treatments with intravenous antibiotics and simultaneously avoids prolonged hospitalization.

CONCLUSION

Implementing ABS guidelines in OPAT programs, e.g., by using a multidisciplinary team approach and facility-specific protocols for OPAT with patient selection criteria and instructions for selection, storage, preparation and administration of antibiotics, can improve appropriate antibiotic use. Additionally, further research should examine the effectiveness of these interventions on outcomes of OPAT.

Outpatient parenteral antimicrobial therapy (OPAT) in the UK: a cross-sectional survey of acute hospital trusts and health boards

This study reviews the current OPAT service provision in the UK and evaluates concordance with the national OPAT practice guidelines (standards of care). We conducted a survey of acute hospital trusts and health boards in the UK regarding OPAT practices between June and September 2017. 165 (93%) of the 178 acute hospital trusts/health boards that were contacted responded to the survey. 100 (61%) indicated they had an OPAT service. Ten (10%) OPAT services did not involve an infection specialist. Bone and joint infections, and skin and soft-tissue infections were the most common conditions treated. Most OPAT services (74%) hold weekly multidisciplinary meetings/virtual ward rounds to review patient's progress. 73% had a dedicated OPAT database. We identified variations in practice and concordance with the national OPAT good practice guidelines. In an era of increasing demand for home-based care, further studies are required to identify the optimal configuration of OPAT services with regards to quality and patient safety.

The Value That Infectious Diseases Physicians Bring to the Healthcare System

While a career in infectious diseases (ID) has always been challenging and exciting, recognition of the value that ID physicians provide to the healthcare system as a whole, over and above the value they provide to individual patients, has been poor in this system. In response to this disparity, the Infectious Diseases Society of America Clinical Affairs Committee has long endeavored to quantify the value of ID physicians to the system, which is challenging in part because of the many avenues through which they influence healthcare. We discuss data showing that ID physicians improve clinical outcomes, positively impact transitions of care, and direct system-level improvements through infection prevention and antimicrobial stewardship. We identify areas where value-based care provides additional future opportunities for ID physicians. A Clinical Affairs Committee–sponsored study of ID physicians’ positive impact on patient outcomes shows that few medical specialties are better positioned to positively impact the Triple Aim approach—better health, better care, and lower per capita cost—that is the principle tenet of healthcare system reform.

A Model to Predict Central-Line-Associated Bloodstream Infection Among Patients With Peripherally Inserted Central Catheters: The MPC Score

BACKGROUND Peripherally inserted central catheters (PICCs) are associated with central-line-associated bloodstream infections (CLABSIs). However, no tools to predict risk of PICC-CLABSI have been developed. OBJECTIVE To operationalize or prioritize CLABSI risk factors when making decisions regarding the use of PICCs using a risk model to estimate an individual's risk of PICC-CLABSI prior to device placement. METHODS Using data from the Michigan Hospital Medicine Safety consortium, patients that experienced PICC-CLABSI between January 2013 and October 2016 were identified. A Cox proportional hazards model with robust sandwich standard error estimates was then used to identify factors associated with PICC-CLABSI. Based on regression coefficients, points were assigned to each predictor and summed for each patient to create the Michigan PICC-CLABSI (MPC) score. The predictive performance of the score was assessed using time-dependent area-under-the-curve (AUC) values. RESULTS Of 23,088 patients that received PICCs during the study period, 249 patients (1.1%) developed a CLABSI. Significant risk factors associated with PICC-CLABSI included hematological cancer (3 points), CLABSI within 3 months of PICC insertion (2 points), multilumen PICC (2 points), solid cancers with ongoing chemotherapy (2 points), receipt of total parenteral nutrition (TPN) through the PICC (1 point), and presence of another central venous catheter (CVC) at the time of PICC placement (1 point). The MPC score was significantly associated with risk of CLABSI (P<.0001). For every point increase, the hazard ratio of CLABSI increased by 1.63 (95% confidence interval, 1.56-1.71). The area under the receiver-operating-characteristics curve was 0.67 to 0.77 for PICC dwell times of 6 to 40 days, which indicates good model calibration. CONCLUSION The MPC score offers a novel way to inform decisions regarding PICC use, surveillance of high-risk cohorts, and utility of blood cultures when PICC-CLABSI is suspected. Future studies validating the score are necessary. Infect Control Hosp Epidemiol 2017;38:1155-1166.

Antibiotic prescribing at the transition from hospitalization to discharge: a target for antibiotic stewardship

Of 300 patients prescribed oral antibiotics at the time of hospital discharge, urinary tract infection, community-acquired pneumonia, and skin infections accounted for 181 of the treatment indications (60%). Half of the prescriptions were antibiotics with broad Gram-negative activity. Discharge prescriptions were inappropriate in 79 of 150 cases reviewed (53%).

Self-Administered Outpatient Antimicrobial Infusion by Uninsured Patients Discharged from a Safety-Net Hospital: A Propensity-Score-Balanced Retrospective Cohort Study

BACKGROUND

Outpatient parenteral antimicrobial therapy (OPAT) is accepted as safe and effective for medically stable patients to complete intravenous (IV) antibiotics in an outpatient setting. Since, however, uninsured patients in the United States generally cannot afford OPAT, safety-net hospitals are often burdened with long hospitalizations purely to infuse antibiotics, occupying beds that could be used for patients requiring more intensive services. OPAT is generally delivered in one of four settings: infusion centers, nursing homes, at home with skilled nursing assistance, or at home with self-administered therapy. The first three-termed healthcare-administered OPAT (H-OPAT)--are most commonly used in the United States by patients with insurance funding. The fourth--self-administered OPAT (S-OPAT)--is relatively uncommon, with the few published studies having been conducted in the United Kingdom. With multidisciplinary planning, we established an S-OPAT clinic in 2009 to shift care of selected uninsured patients safely to self-administration of their IV antibiotics at home. We undertook this study to determine whether the low-income mostly non-English-speaking patients in our S-OPAT program could administer their own IV antimicrobials at home with outcomes as good as, or better than, those receiving H-OPAT.

METHODS AND FINDINGS

Parkland Hospital is a safety-net hospital serving Dallas County, Texas. From 1 January 2009 to 14 October 2013, all uninsured patients meeting criteria were enrolled in S-OPAT, while insured patients were discharged to H-OPAT settings. The S-OPAT patients were trained through multilingual instruction to self-administer IV antimicrobials by gravity, tested for competency before discharge, and thereafter followed at designated intervals in the S-OPAT outpatient clinic for IV access care, laboratory monitoring, and physician follow-up. The primary outcome was 30-d all-cause readmission, and the secondary outcome was 1-y all-cause mortality. The study was adequately powered for readmission but not for mortality. Clinical, sociodemographic, and outcome data were collected from the Parkland Hospital electronic medical records and the US census, constituting a historical prospective cohort study. We used multivariable logistic regression to develop a propensity score predicting S-OPAT versus H-OPAT group membership from covariates. We then estimated the effect of S-OPAT versus H-OPAT on the two outcomes using multivariable proportional hazards regression, controlling for selection bias and confounding with the propensity score and covariates. Of the 1,168 patients discharged to receive OPAT, 944 (81%) were managed in the S-OPAT program and 224 (19%) by H-OPAT services. In multivariable proportional hazards regression models controlling for confounding and selection bias, the 30-d readmission rate was 47% lower in the S-OPAT group (adjusted hazard ratio [aHR], 0.53; 95% CI 0.35-0.81; p = 0.003), and the 1-y mortality rate did not differ significantly between the groups (aHR, 0.86; 95% CI 0.37-2.00; p = 0.73). The S-OPAT program shifted a median 26 d of inpatient infusion per patient to the outpatient setting, avoiding 27,666 inpatient days. The main limitation of this observational study-the potential bias from the difference in healthcare funding status of the groups-was addressed by propensity score modeling.

CONCLUSIONS

S-OPAT was associated with similar or better clinical outcomes than H-OPAT. S-OPAT may be an acceptable model of treatment for uninsured, medically stable patients to complete extended courses of IV antimicrobials at home.

The history and evolution of outpatient parenteral antibiotic therapy (OPAT)

Outpatient parenteral antibiotic therapy (OPAT) is now a widely accepted and safe therapeutic option for carefully selected patients. Benefits include cost savings and improved patient satisfaction; risks include failure to adhere to care, unexpected changes in the underlying infection, and adverse drug and intravenous access events. We report on our 40-year experience with OPAT in a single healthcare system in the USA and highlight OPAT developments in several countries. We compared data on patients treated in our programme over two time periods: Period 1 from 1978 to 1990; and Period 2, calendar year 2014. In Period 2 paediatric patients were excluded. Between Periods 1 and 2, changes included an almost three-fold increase in the number of patients treated per year (80 vs. 229), treatment of more patients with severe orthopaedic-related infections (20% vs. 38%), a marked increase in the use of peripherally inserted central catheters to administer antibiotics (20% vs. 98%), a shorter duration of inpatient stay and a longer duration of OPAT (13 days vs. 24 days). Other changes in Period 2 included treatment of 20% of patients without antecedent hospitalisation, and use of carbapenems rather than cephalosporins as the most frequently administered agents. OPAT was safe, with rehospitalisation rates of 6% and 1% in Periods 1 and 2, respectively. We recommend increased access to structured OPAT teams and the development of standard definitions and criteria for important outcome measures (e.g. clinical 'cure' and unplanned hospital re-admissions). These steps are critical for patient safety and financial stewardship of resources.

Evaluation of Outpatient Parenteral Antimicrobial Therapy at a Veterans Affairs Hospital

We reviewed outpatient parenteral antimicrobial therapy at a Veterans Affairs Medical Center to identify opportunities for antimicrobial stewardship intervention. A definite or possible modification would have been recommended in 60% of courses. Forty-one percent of outpatient parenteral antimicrobial therapy courses were potentially avoidable, including 22% involving infectious diseases consultation.

A national survey of infectious disease practitioners on their use of outpatient parenteral antimicrobial therapy (OPAT)

BACKGROUND

The use of outpatient parenteral antimicrobial therapy (OPAT) is standard medical practice; however, significant heterogeneity in practice exists. We hypothesized that formal OPAT programs are associated with increased physician participation in patient safety activities.

METHODS

United States Infectious Disease (ID) physicians were contacted and asked to participate in an electronic survey from April through June 2012. Data were analyzed using SPSS version 20.

RESULTS

In all, 3718 physicians were contacted and 316 (8.5%) responded. Respondents practice in 47 states; the majority (79%) practice adult ID, 11% pediatric ID, 10% a combination of the two. Sixty percent reported that ID consultation was not mandatory before OPAT, and 75% of these respondents thought it should be compulsory. The most common indications were osteomyelitis, prosthetic joint infections, and endocarditis, and the most common antibiotics were vancomycin, ceftriaxone, and ertapenem. Most respondents (59%) discharge patients with OPAT weekly, and have a median number of 11 OPAT patients (95% confidence interval (CI) 8.5-13.4). Half of respondents have a formal OPAT program. Fifty-two percent report no systematic method of communication between inpatient and outpatient physicians when patients are discharged with OPAT, 49% have no systematic method of lab tracking, and 34% have no method of ensuring patient adherence to clinic visits. All of these patient safety measures were more likely to be present in practice sites with formal OPAT programs (p < 0.001).

CONCLUSIONS

Opportunities exist for improving OPAT monitoring and patient safety. Formal OPAT programs provide the framework for safe and effective care and are to be encouraged.

Managing an outpatient parenteral antibiotic therapy team: challenges and solutions

Outpatient parenteral antimicrobial therapy (OPAT) programs should strive to deliver safe, cost effective, and high quality care. One of the keys to developing and sustaining a high quality OPAT program is to understand the common challenges or barriers to OPAT delivery. We review the most common challenges to starting and managing an OPAT program and give practical advice on addressing these issues.

Outpatient parenteral antimicrobial therapy practices among adult infectious disease physicians

OBJECTIVE

To identify current outpatient parenteral antibiotic therapy practice patterns and complications.

METHODS

We administered an 11-question survey to adult infectious disease physicians participating in the Emerging Infections Network (EIN), a Centers for Disease Control and Prevention-sponsored sentinel event surveillance network in North America. The survey was distributed electronically or via facsimile in November and December 2012. Respondent demographic characteristics were obtained from EIN enrollment data.

RESULTS

Overall, 555 (44.6%) of EIN members responded to the survey, with 450 (81%) indicating that they treated 1 or more patients with outpatient parenteral antimicrobial therapy (OPAT) during an average month. Infectious diseases consultation was reported to be required for a patient to be discharged with OPAT by 99 respondents (22%). Inpatient (282 [63%] of 449) and outpatient (232 [52%] of 449) infectious diseases physicians were frequently identified as being responsible for monitoring laboratory results. Only 26% (118 of 448) had dedicated OPAT teams at their clinical site. Few infectious diseases physicians have systems to track errors, adverse events, or "near misses" associated with OPAT (97 [22%] of 449). OPAT-associated complications were perceived to be rare. Among respondents, 80% reported line occlusion or clotting as the most common complication (occurring in 6% of patients or more), followed by nephrotoxicity and rash (each reported by 61%). Weekly laboratory monitoring of patients who received vancomycin was reported by 77% of respondents (343 of 445), whereas 19% of respondents (84 of 445) reported twice weekly laboratory monitoring for these patients.

CONCLUSIONS

Although use of OPAT is common, there is significant variation in practice patterns. More uniform OPAT practices may enhance patient safety.

The impact of infectious diseases consultation on oncology practice

PURPOSE OF REVIEW

Traditional utilization of infectious diseases consultants by oncologists ranges from inpatient management of a variety of acute infectious syndromes to management of ambulatory patients with acute or chronic infections; however, there is a paucity of data to evaluate in which circumstances the impact of infectious diseases input may be most valuable.

RECENT FINDINGS

Data derived from the general population of patients emphasize the value of infectious diseases consultation in specific infections, such as Staphylococcus aureus bacteremia, candidemia, and hepatitis C virus infection. In addition, infectious diseases involvement has been associated with greater adherence to guidelines (up to 34% increase), more appropriate antibiotic utilization (up to 52% increase in appropriate duration), decreased cost and complications of care, and lower mortality (up to 17% decrease). Recent studies suggest that bedside, formal infectious diseases consultation is more optimal than informal interactions (e.g., e-mail, telephone, other). Furthermore, infectious diseases consultants play central roles in antibiotic stewardship, infection control, and quality improvement, particularly in oncology centers.

SUMMARY

Infectious diseases consultants contribute value in various inpatient and outpatient infections, decreasing mortality, cost, and complications.

Prevalence and predictors of compliance with discontinuation of airborne isolation in patients with suspected pulmonary tuberculosis

OBJECTIVE

Examine the use of airborne isolation by identifying reasons for nontimely discontinuation and predictors of compliance with Centers for Disease Control and Prevention (CDC) guidelines. Compliance with guidelines should result in timely (within 48 hours) discontinuation of isolation in patients without infectious pulmonary tuberculosis (TB).

DESIGN

Retrospective, observational study.

SETTING

A private, university-affiliated, tertiary-care medical center.

PATIENTS

All patients in airborne isolation for suspected pulmonary TB from June through December 2011.

METHOD

Chart reviews were performed to identify airborne isolation practices and delayed (greater than 48 hours) or very delayed (greater than 72 hours) discontinuation. We used descriptive statistics and logistic regression to determine independent predictors of nontimely discontinuation of isolation.

RESULTS

We identified 113 patients (mean age ± standard deviation, [Formula: see text] years; male sex, 75.2%; white race, 15.9%; mean collection interval ± standard deviation, [Formula: see text] hours). Delayed and very delayed isolation discontinuation was noted in 81% and 49% of patients, respectively. No significant differences in demographic characteristics and clinical characteristics were identified between groups. Predictors of timely (within 48 hours) airborne isolation discontinuation included use of alternate diagnosis for discontinuation of isolation ([Formula: see text]), early infectious diseases (ID) consultation ([Formula: see text]), pulmonary consultation ([Formula: see text]), average sputum collection interval less than 24 hours ([Formula: see text]), and need for more than 1 induced sputum specimen ([Formula: see text]). Adjusting for potential confounders, pulmonary consultation (odds ratio [OR] [95% confidence interval (CI)], 0.14 [0.03-0.58]), alternate diagnosis for discontinuation of isolation (OR [95% CI], 4.5 [1.3-15.8]), and early ID consultation (OR [95% CI], 4.0 [1.1-14.8]) were independently associated with timely discontinuation.

CONCLUSIONS

Timely airborne isolation discontinuation occurs in only 18.6% of cases and is an opportunity for cost savings, improved efficiency, and potentially patient safety and satisfaction.

Are we ready for an outpatient parenteral antimicrobial therapy bundle? A critical appraisal of the evidence

Healthcare "bundles" have been developed to help providers improve the reliability and delivery of essential healthcare processes. Bundles have been shown to be effective in reducing healthcare-associated infection rates and are increasingly used to ensure the quality of patient care. Outpatient parenteral antimicrobial therapy (OPAT) is now standard medical practice in the treatment of a wide variety of infections. We review 6 components that we believe comprise an OPAT bundle and the evidence supporting each: patient selection, infectious disease consultation, patient/caregiver education, discharge planning, outpatient monitoring/tracking, and OPAT program review. To ensure that patients are receiving optimal care, further program development and outcomes research should target these bundle components to bring the evidence base up to date with current medical practices.

Characteristics and outcomes of outpatient parenteral antimicrobial therapy at an academic children's hospital

BACKGROUND

Use of outpatient parenteral antimicrobial therapy (OPAT) in pediatrics is widespread and may be increasing. Recent data quantifying use and characteristics of pediatric OPAT are lacking.

METHODS

To evaluate the number of children receiving OPAT each year and their associated characteristics and outcomes, we conducted a retrospective review of all patients discharged with OPAT from the Mayo Clinic Children's Hospital between August 1, 2010 and December 31, 2011.

RESULTS

During the study period, there were 126 pediatric hospital discharges with OPAT (2.5% of all discharges). OPAT was used most commonly to treat bone and joint (21%), bloodstream (15%), intra-abdominal (13%) and soft tissue (9%) infections. A positive culture or serology result was found in 86 (68%) OPAT courses. The most frequently used antibiotics were ceftriaxone (17%), cefazolin (16%) and cefepime (13%). The median duration of OPAT was 12 days. Thirty-six courses (29%) resulted in catheter- or antibiotic-associated complications. Weekly laboratory monitoring was more common when OPAT was managed by the infectious disease service (88%) versus other services (20%). Among 123 courses with follow-up, 109 (89%) resulted in cure, and 13 (11%) were treatment failures.

CONCLUSION

At our children's hospital, 2.5% of hospitalized patients were discharged with OPAT. In one-third of OPAT courses children developed catheter- or antibiotic-associated complications. Opportunities to increase the role of pediatric infectious disease in OPAT initiation and management should be explored.