Outpatient parenteral antibiotic therapy in Singapore

Outpatient parenteral antimicrobial therapy (OPAT) across the world: a comparative analysis-what lessons can we learn?

This paper presents a comparative analysis of Outpatient Parenteral Antimicrobial Therapy (OPAT) structures and delivery options across different countries. OPAT, a cost-effective alternative to inpatient care for patients requiring IV antimicrobial therapy, has demonstrated multiple benefits such as patient satisfaction, economic cost savings, and reduced hospital-acquired infections. Despite these advantages, there is considerable international variation in OPAT use and implementation. By examining the OPAT structures of multiple countries, we aim to identify areas of variation and explore opportunities for expansion and improvement of OPAT services.

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 Practice in United Kingdom: A Single-center Experience

OBJECTIVES

This study sought to analyze the outpatient parenteral antimicrobial therapy (OPAT) services provided by a tertiary hospital, in terms of types and duration of antimicrobials administered, and assess whether these services were in line with current good practice recommendations.

METHODS

The electronic healthcare records of all stable patients with infectious diseases, aged ≥ 18 years, who received OPAT services between January 2019 and March 2021, were analyzed. For statistical analysis, the patients were divided into younger (< 65 years) and older (≥ 65 years) adults and the difference between them, in terms of healthcare resources utilization, was assessed.

RESULTS

Over 27 months, 199 patients received OPAT services, resulting in saving of 7514 bed-days. Bone and joint infections (38.7%) were the predominant diagnoses. The median actual OPAT duration was significantly greater than the planned duration for the total study population, younger adults, and older adults (p < 0.050). Of 28 (14.1%) patients with adverse events, 25 were related to antimicrobials while the remaining three were associated with catheters. There were no significant differences between younger and older adults in the characteristics evaluated, except for the higher incidence of Staphylococcus aureus (p < 0.001) and Escherichia coli, Staphylococcal spp., Streptococcal spp., and Pseudomonas spp. (p =0.003) infection in older adults.

CONCLUSIONS

The actual median duration of OPAT therapy was significantly longer than planned, with suboptimal adherence to the principles of antimicrobial stewardship. OPAT has been shown to be safe for both younger and older adults.

Validation of Vancomycin Dosing Guidance During Transition of Care

Vancomycin is an antibiotic commonly used to treat serious gram-positive infections. Patients requiring prolonged therapy in Singapore routinely receive intermittent vancomycin infusion in the hospital and are switched to continuous infusion for outpatient parenteral antibiotic therapy. During this transition of care, there may be a risk of not achieving therapeutic targets. We evaluated the performance of a model-based dosing algorithm in achieving a therapeutic target within 7 days of care transition. A published population pharmacokinetic model was used as the foundation to guide vancomycin dosing when discharging inpatients on intermittent infusion to outpatient care on continuous infusion. Selected demographic variables (age, weight, and creatinine clearance) were used to devise initial dosing. Patients with guided dosing were compared with historic controls (dosing by clinicians alone). The primary outcome of the study was to achieve vancomycin steady-state concentration of 20-25 mg/L. Compared with historic controls, the proportion of patients attaining a therapeutic target by day 7 was significantly improved (6 of 19 [31.6%] vs 12 of 17 [70.6%], P = .04). Our model-based approach could guide customized dosing to facilitate switching patients from intermittent to continuous infusion during transition of care. Further validation in a larger patient cohort is warranted.

Stability of antimicrobial agents in an elastomeric infusion pump used for outpatient parenteral antimicrobial therapy

OBJECTIVES

The long-term stability of antimicrobials dissolved in infusion solution is necessary to establish and spread the outpatient parenteral antimicrobial therapy (OPAT). In this study, we evaluated the stability of antimicrobial agents dissolved in infusion solutions.

METHODS

The antimicrobial agents were dissolved in infusion solutions and kept at 25 °C and 31.1 °C for 24 h or 4 °C for 10 days in a polypropylene tube or an elastomeric infusion pump. The stability was measured by high-performance liquid chromatography.

RESULTS AND CONCLUSION

The residual ratio of cefazolin (CEZ), cefmetazole (CMZ), piperacillin (PIPC), and tazobactam (TAZ) at 31.1 °C for 24 h was as follows: 95.7 ± 3.0%, 94.8 ± 0.9%, 102.6 ± 1.8%, and 103.9 ± 3.6% in saline, respectively; 94.7 ± 3.0%, 94.3 ± 1.5%, 106.1 ± 3.0%, and 107.3 ± 2.4% in 5% dextrose solution, respectively. The residual ratio of these antimicrobials at 4 °C for 10 days was maintained above 90% in both saline and 5% dextrose solution. The residual ratio of all the above antimicrobials in an elastomeric infusion pump at 31.1 °C for 24 h was equivalent to that in the polypropylene tube. On the other hand, doripenem and meropenem were not stable in any infusion solution at 31.1 °C. CEZ, CMZ, and PIPC/TAZ dissolved in saline or 5% dextrose solution can be used in OPAT with continuous infusion pumps.

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.

Health-related quality of life and its association with outcomes of outpatient parenteral antibiotic therapy

While health-related quality of life (HRQoL) is an important component of patient-centred care, few studies have looked at the association between HRQoL and outcomes while on OPAT. From 2014 to 2017, we conducted a prospective cohort study of all patients referred to Singapore General Hospital's (SGH) OPAT service. At baseline, we collected sociodemographic, clinical, and treatment-related factors for OPAT recipients. We also measured baseline HRQoL using the EuroQoL EQ5D-3 L. We evaluated the association between HRQoL and the following outcomes: complications experienced while on OPAT, early termination requiring readmission during planned course of OPAT, all-cause readmission 30 days after completion of OPAT, and return to work while on OPAT. We used chi-squared test for univariate analysis and cox regression for multivariate analysis. From 2014 to 2017, 1213 patients received OPAT at our centre. Of those, 13.2% (160/1213) developed complications. About 10% (132/1213) of patients were readmitted while on OPAT and OPAT was terminated early. Amongst patients who completed OPAT (N = 1081), about 3.6% (39/1081) were readmitted within 30 days after OPAT completion. About half (50.8%, 278/547) returned to work while on OPAT. On multivariate analysis, patients with perfect health-related quality of life (HRQoL) (adjusted relative risk, aRR = 0.62, 95%CI = 0.45-0.85) were less likely to experience complications, had lower risk of OPAT termination (aRR = 0.57, 95%0.38-0.86), and were more likely to return to work while on OPAT (aRR = 1.94, 95%CI = 1.30-2.89). HRQoL at baseline was significantly associated with lower risk of complications and early OPAT termination, as well as greater likelihood of return to work while on OPAT.

Sociodemographic and clinical factors associated with acceptance of outpatient parenteral antibiotic therapy in a Singapore tertiary hospital from 2014 to 2017

Outpatient parenteral antibiotic therapy (OPAT) can facilitate early discharge; however, not all offered OPAT can accept. We assessed factors associated with acceptance of OPAT in a large Asian tertiary hospital cohort. From 2014 to 2017, we reviewed all referrals to Singapore General Hospital's (SGH) Outpatient Parenteral Antibiotic Therapy (OPAT) service. We compared differences in sociodemographic and clinical factors between patients who opted for OPAT and those who declined, using chi-square test for univariate analysis and logistic regression for multivariate analysis. From 2014 to 2017, a total of 1406 OPAT referrals were made. Of these, 95.9% (1349/1406) were deemed suitable for OPAT. Amongst those suitable, 90.0% (1213/1349) accepted OPAT treatment. On multivariate analysis, being independently ambulant (aOR = 3.46, 95%CI = 2.21-5.37) was independently associated with higher odds of acceptance for OPAT; whereas, patients with peripheral vascular disease had lower odds of accepting OPAT (aOR = 0.32, 95%CI = 0.16-0.62). Lower socioeconomic status (SES) was closely associated with rejection of OPAT, with markers of both individual-level SES (subsidized ward class) and area-level SES (staying in a public rental flat) being independently associated with lower odds of OPAT preference. Distance and travel time were not associated with OPAT acceptance. The top reasons for rejecting OPAT were lack of caregiver (n = 35), mobility issues (n = 24), financial issues (n = 24), and difficulty caring for the line (n = 21). Comorbidities, mobility, and financial issues are important factors to consider when determining suitability for OPAT. More can be done to improve accessibility of OPAT amongst lower-income patients and those staying in lower-SES areas.

Safety and effectiveness of 'hospital in the home' and 'outpatient parenteral antimicrobial therapy' in different age groups: A systematic review of observational studies

OBJECTIVE

The aim of this study was .to systematically review the published literature of observational studies evaluating the safety and effectiveness of hospital in the home (HITH) and outpatient parenteral antimicrobial therapy (OPAT) in the general population, older people and children.

STUDY DESIGN

The review included retrospective studies and prospective studies performed on HITH and OPAT within different age groups. Only the studies that analysed the safety and effectiveness of HITH and OPAT were included for review.

DATA SOURCES

A literature search of electronic databases CINAHL, Web of Science, PubMed and SCOPUS from 1997 to 2016 was performed.

DATA SYNTHESIS

Forty-four studies met the inclusion criteria. Five studies were undertaken on HITH within the general population, 26 studies were undertaken on OPAT within the general population, 8 studies were on HITH and OPAT for older people and 5 studies were on OPAT with children. More than 88% of the studies reported a cure or treatment success rate of greater than 80%. Adverse events with drugs ranged from 0% to 30.2%; adverse events with vascular access devices ranged from 0% to 29%; readmission rate varied from 1% to 26%; mortality varied from 0% to 27.5%.

CONCLUSIONS

This review quantifies the rates of success and harm in real world practice, and demonstrates that while most patients experience treatment success, adverse events may be high in some groups. However, the methodologies used to measure these parameters were inconsistent and some demographic groups had only a small number of studies.

Stability of benzylpenicillin potassium and ampicillin in an elastomeric infusion pump

Some infectious diseases, such as infective endocarditis, osteomyelitis, and abscesses, require treatment with long-term intravenous antimicrobial treatment. Therefore, the patient is required to stay in the hospital to receive therapy, which lowers their quality of life. Establishing an outpatient parenteral antimicrobial therapy (OPAT) by continuous infusion pump is desired in Japan to overcome these issues. However, the 24-h stability of antimicrobial agents dissolved in infusion solutions is unclear. Thus, we investigated the stability of antimicrobial agents in five different infusion solutions in a clinical setting. Benzylpenicillin potassium (PCG) and ampicillin (ABPC) were dissolved separately in five different infusion solutions and kept at 25 or 31.1 °C for 24 h. The residual ratios were determined by high-performance liquid chromatography (HPLC). Dissolved PCG in acetate ringer solution remained stable for 24 h at temperatures of 25 and 31.1 °C (101.7 ± 1.4% and 92.9 ± 1.3%, respectively). In addition, the PCG solution did not adsorb onto the elastomeric infusion pump after 24 h at 31.1 °C. PCG dissolved in acetate ringer solution was also stable for 10 days after being kept in an elastomeric infusion pump at 4 °C (99.7 ± 0.5%). ABPC was unstable in all of the tested infusion solutions and temperatures. Based on our results, PCG in acetate ringer solution can be used in OPAT with continuous infusion pumps.

Outpatient parenteral antibiotic therapy (OPAT) in Asia: missing an opportunity

Objectives

Healthcare facilities internationally have grown outpatient parenteral antibiotic administration services for the last few decades. The literature contains publications from dozens of countries describing systematized processes with specialist oversight and their levels of service provision and outcomes. Such descriptions are absent in the majority of Asian countries. We sought to elucidate the extent and nature of outpatient parenteral antibiotic therapy (OPAT) in Asia and to consider the ramifications and opportunities for improvement.

Methods

Utilizing colleagues and their personal networks, we surveyed healthcare facilities across 17 countries in Asia to ascertain the current means (if any) of providing OPAT. In that survey we also sought to explore the capacity and interest of these facilities in developing systematized OPAT services.

Results

Responses were received from 171 different healthcare facilities from 17 countries. Most (97/171, 57%) stated that they administer outpatient parenteral antibiotics, but only 5 of 162 facilities (3%) outside of Singapore described comprehensive services with specialist oversight.

Conclusions

There is very likely a large unrecognized problem of unchecked outpatient parenteral antibiotic administration in Asia. Developing comprehensive and systematized OPAT in Asia is needed as a priority in an environment in which the infectious diseases community is demanding broad stewardship approaches. There are nonetheless challenges in establishing and sustaining OPAT programmes. Local champions and leverage off identified local incentives and needs are key to regional advancement.

Economic evaluation of outpatient parenteral antimicrobial therapy: a systematic review

INTRODUCTION

Outpatient parenteral antimicrobial therapy (OPAT) consists of providing antimicrobial therapy by parenteral infusion without hospitalization. A systematic review was performed to compare OPAT and hospitalization as health care modalities from an economic perspective. Areas covered: We identified 1455 articles using 13 electronic databases and manual searches. Two independent reviewers identified 35 studies conducted between 1978 and 2016. We observed high heterogeneity in the following: countries, infection site, OPAT strategies and outcomes analyzed. Of these, 88% had a retrospective observational design and one was a randomized trial. With respect to economic analyses, 71% of the studies considered the cost-consequences, 11% cost minimization, 6% cost-benefit, 6% cost-utility analyses and 6% cost effectiveness. Considering all 35 studies, the general OPAT cost saving was 57.19% (from -13.03% to 95.47%). Taking into consideration only high-quality studies (6 comparative studies), the cost saving declined by 16.54% (from -13.03% to 46.86%). Expert commentary: Although most studies demonstrate that OPAT is cost-effective, the magnitude of this effect is compromised by poor methodological quality and heterogeneity. Economic assessments of the issue are needed using more rigorous methodologies that include a broad range of perspectives to identify the real magnitude of economic savings in different settings and OPAT modalities.

Recommendations for outpatient parenteral antimicrobial therapy in Brazil

A panel of national experts was convened by the Brazilian Infectious Diseases Society in order to determine the recommendations for outpatient parenteral antimicrobial therapy (OPAT) in Brazil. The following aspects are covered in the document: organization of OPAT programs; patient evaluation and eligibility criteria, including clinical and sociocultural factors; diagnosis of eligibility; venous access and antimicrobial infusion devices; protocols for antimicrobial use and monitoring and cost-effectiveness.

Clinical efficacy, cost analysis and patient acceptability of outpatient parenteral antibiotic therapy (OPAT): a decade of Sheffield (UK) OPAT service

Outpatient parenteral antimicrobial therapy (OPAT) has evolved relatively slowly in the UK. This study describes the OPAT service based in a large UK teaching hospital in Sheffield, and examines the clinical efficacy, patient acceptability and costs saved over a 10-year period. Data on 3812 episodes of OPAT administered between January 2006 and January 2016 were retrieved from a prospectively maintained electronic database. This study compared the real costs of the OPAT service with estimated costs of conventional inpatient care for these patient episodes, and analysed patient feedback questionnaires that were administered randomly between January 2014 and January 2015. A wide range of infections were managed during the 10-year period. Skin and soft tissue infections accounted for 57% of OPAT episodes. The total number of bed-days saved was 49,854. A successful outcome (cure or improvement) was found in 3357 (88%) episodes. Re-admission occurred in 265 (7%) episodes. The rates of healthcare-associated infections were low: 15 intravenous-line-related infections were recorded (0.3 per 1000 OPAT patient-days). Patient acceptance and satisfaction with OPAT were high. OPAT cost 15%, 39%, 40% and 44% of inpatient costs for an infectious diseases unit, national average costs, other departments (non-infectious diseases unit), and the minimum national average costs for each diagnostic category, respectively. This study shows that OPAT is safe, clinically efficacious and acceptable for treating a wide range of infections with high levels of patient satisfaction and substantial cost savings.

Optimization of a model of out-of-hospital antibiotic therapy (OPAT) in a Belgian university hospital resulting in a proposal for national implementation

OBJECTIVES

Some infections require prolonged parenteral antimicrobial therapy, which can be continued in an outpatient setting. The Ghent University Hospital has 15 years of experience with Outpatient Parenteral Antimicrobial Therapy (OPAT) in the home setting of the patient.

METHODS

Multidisciplinary critical approach through identification of areas for improvement with the existing OPAT process within the Ghent University Hospital. Existing literature and guidelines were used as references. An improved model is proposed for implementation.

RESULTS

Several challenges and barriers were identified, including regulatory obstacles for OPAT in Belgium, such as lack of uniformity in ambulatory reimbursement of parenteral antimicrobials. There is no financial incentive for the patient with OPAT, as costs for the patient of outpatient therapy can be higher as compared with hospitalization. Other barriers include delayed approval of the certificate for reimbursement, low availability of medicines in the community pharmacies and limited knowledge of the medical devices for administration in ambulatory setting. All critical steps in the revised OPAT program are summarized in a flowchart with a checklist for all stakeholders. Firstly, a list with specific criteria to include patients in an OPAT program is provided. Secondly, the Multidisciplinary Infection Team received a formal mandate to review all eligible OPAT patients. In order to select the most appropriate catheter, a decision tree was developed and standardized packages with medical devices were developed. Thirdly, patients receive oral and written information about the treatment with practical and financial implications. Fourthly, information is provided toward the general practitioners, community pharmacist and home care nurse.

CONCLUSION

Standardization of the OPAT program aims at improving quality and safety of intravenous antimicrobial therapy in the home setting.

Ertapenem in outpatient parenteral antimicrobial therapy for complicated urinary tract infections

BACKGROUND

Ertapenem is a broad-spectrum antibiotic that is increasingly being utilized. Its dosing convenience renders it suitable for outpatient therapy, and its pharmacokinetic characteristics favour its use against complicated urinary tract infections (cUTIs). Despite this, sufficient clinical data are lacking for its use against cUTIs in the outpatient setting. We assessed the microbiological and clinical cure rates associated with ertapenem treatment for cUTIs in two outpatient parenteral antimicrobial therapy (OPAT) departments.

METHODS

We undertook a prospective observational study of adult patients who received ertapenem for cUTIs between August 2010 and August 2014. Data on patient characteristics, clinical progress and microbiological results were collected and analysed.

RESULTS

Sixty-one patients were enrolled. The median age was 59 years (range 24, 83) and 61% were male. The most common diagnoses were pyelonephritis (39%) and prostatitis (15%). The most common causative organism was Escherichia coli (67%). Extended-spectrum β-lactamase (ESBL)-producing organisms were detected in 72% of infections. Microbiological cure was achieved in 67% overall, and was less likely in those with Klebsiella pneumoniae infection (OR = 0.21 [95%CI: 0.05 to 0.85] p = 0.029). Clinical cure was observed in 92% of patients.

CONCLUSION

In this study of treating cUTIs with ertapenem, we have demonstrated good clinical outcomes. A lower than expected microbiological cure rate was observed in those with Klebsiella pneumoniae infection.

Supervised self-administration of outpatient parenteral antibiotic therapy: a report from a large tertiary hospital in Australia

INTRODUCTION

Outpatient parenteral antibiotic therapy (OPAT) has become established as a standard of care in most Australian hospitals to treat a variety of infections. Since 1998, the Alternate Site Infusion Service (ASIS) has provided an OPAT service to five hospitals in southern Brisbane, Queensland, using predominantly a patient or carer administration model (self-administered, S-OPAT). The aim of this study was to evaluate outcomes of our S-OPAT programme.

METHODS

Consecutive patients treated by ASIS at the Princess Alexandra Hospital from January 1, 2011 to December 31, 2011 were reviewed. Data on patient demographics, diagnoses, microbiology, antimicrobial therapy, duration, outcome, and complications were sourced from a prospectively collected database and from patient medical records.

RESULTS

There were 150 episodes involving 144 patients resulting in 3520 days of OPAT; the median duration on the programme was 22 days (range 4–106 days). Patient or carer administration occurred in the majority of episodes. The most common indication by far was bone or joint infection (47% of patients), followed by infective endocarditis (9%). Staphylococcus aureus was the most frequently treated organism. The overall cure rate was 93%. On multivariate analysis, patients with two or more comorbidities had an increased risk of failure. Line-related complications occurred in 1.4/1000 catheter-days. Rash was the most common drug-related event. Despite the extensive use of broad-spectrum antibiotics there were no cases of Clostridium difficile infection during therapy and for up to 28 days post cessation of intravenous antibiotics. The cost of OPAT per patient excluding drug administration and home visits was approximately A$ 150.00/day, significantly lower than the cost of an inpatient bed, which is estimated to be A$ 500–800/day.5 CONCLUSION: OPAT using a patient or carer administration model is an effective and safe option for the management of selected patients with infection requiring intravenous antibiotics.

Risk factors for nephrotoxicity in patients receiving outpatient continuous infusions of vancomycin in an Australian tertiary hospital

OBJECTIVES

To assess the risk factors for nephrotoxicity caused by vancomycin continuous infusion in a predominantly Caucasian outpatient population.

METHODS

This was a retrospective cohort study of 155 patient episodes from December 2006 to December 2011.

RESULTS

Vancomycin-associated nephrotoxicity (VN) occurred in 26 of 155 (17%) patient episodes. After adjustment for baseline renal function, maximum steady-state vancomycin concentrations ≥32 mg/L [OR 8.7 (95% CI 3.1-29.6), P < 0.001] and angiotensin receptor blockade [OR 9.78 (95% CI 3.1-39.4), P < 0.001] were independently associated with VN. The cumulative dose and duration of vancomycin therapy were not independent predictors of VN.

CONCLUSIONS

Cessation of angiotensin receptor-blocking medications in selected patient groups, enhanced monitoring and establishing target steady-state concentrations <30 mg/L to avoid excessive vancomycin exposure may reduce the risk of VN.

Outpatient parenteral antibiotic therapy: principles and practice

Outpatient parenteral antimicrobial therapy (OPAT) refers to the administration of a parenteral antimicrobial in a non inpatient or ambulatory setting with the explicit aim of facilitating admission avoidance or early discharge. Whilst OPAT has predominantly been the domain of the infection specialist, the internal medicine specialist has a key role in service development and delivery as a component of broader ambulatory care initiatives such as "hospital at home". Main drivers for OPAT are patient welfare, reduction of risk of health care associated infection and cost-effective use of hospital resources. The safe practice of OPAT is dependent on a team approach with careful patient selection and antimicrobial management with programmed and adaptable clinical monitoring and assessment of outcome. Gram-positive infections, including cellulitis, bone and joint infection, bacteraemia and endocarditis are key infections potentially amenable to OPAT whilst resistant Gram-negative infections are of increasing importance. Ceftriaxone, teicoplanin, daptomycin and ertapenem lend themselves well to OPAT due to daily (or less frequent) bolus administration, although any antimicrobial may be administered if the patient is trained to administer and/or an appropriate infusion device is employed. Clinical experience from NHS Greater Glasgow and Clyde is presented to illustrate the key principles of OPAT as practised in the UK. Increasingly complex patients with multiple medical needs, the relative scarcity of inpatient resources and the broader challenge of ambulatory care and "hospital at home" will ensure the internal medicine specialist will have a key role in the future development of OPAT.

Safe and successful treatment of intravenous drug users with a peripherally inserted central catheter in an outpatient parenteral antibiotic treatment service

BACKGROUND

The enrollment of intravenous drug users (IVDUs) into an outpatient parenteral antibiotic treatment (OPAT) service using a peripherally inserted central catheter (PICC) is controversial and often avoided. The National University Hospital in Singapore has a policy of permitting OPAT-based treatment of IVDU patients with appropriate medical indications. We report on our experiences.

METHODS

A prospective observational study was conducted on IVDU patients requiring parenteral antibiotics via an OPAT service from January 2005 to December 2009. Clinically appropriate patients were screened using pre-defined criteria and enrolled into our service, where standardized measures were enforced to prevent and detect PICC abuse and optimize treatment. Outcomes measured included mortality, completion of therapy, PICC abuse, and readmission for infective or treatment-related complications during OPAT and a 30 day follow-up period.

RESULTS

Twenty-nine IVDU patients received treatment in our OPAT service (total 675 patient-days). The median duration of therapy was 18 days (range 1-85). Infective endocarditis was the primary diagnosis in 42% of cases. Two patients (7%) had recrudescent infection after absconding during their inpatient stay. These two patients subsequently completed treatment in OPAT. There were no deaths or cases of PICC abuse. Five patients (17%) during OPAT and one patient (3%) during the 30-day follow-up period required readmission for infective or treatment-related complications.

CONCLUSIONS

Appropriately selected, counselled and monitored patients with a history of being an IVDU can be treated safely and successfully via OPAT centres. It is likely that some will respond better to treatment in an outpatient setting.

Self-administered outpatient parenteral antimicrobial therapy: a report of three years experience in the Irish healthcare setting

Outpatient parenteral antibiotic therapy (OPAT) was first reported in 1972. OPAT programmes are not well established in Ireland, with no reported outcomes in the literature. An OPAT programme was established at St. James Hospital in 2006. Demographics, diagnoses and outcomes of the first 60 courses are reported. A retrospective analysis of prospectively recorded data was performed on patients treated from March 2006 to February 2009. The data was analysed using SPSS v.17. Sixty OPAT courses were administered to 56 patients, 57 percent of which were male. The median age was 50 years, the median inpatient stay was 19 days, the median duration of OPAT was 16 days and 1,289 inpatient bed days were saved. The additional cost per day of OPAT was 167.60 euros. Vancomycin was the most prescribed antimicrobial, administered to 35%. Musculoskeletal infection was the indication for treatment in 50%. Confirmatory microbiological diagnosis was identified in 72%, most frequently due to Staphylococcus aureus (68%). Only minor adverse events were recorded. Clinical cure was achieved in 92.8%. A patient satisfaction survey showed high satisfaction. OPAT is a safe and effective way of providing parenteral antibiotic therapy in the Irish healthcare system. Better integration of funding and the appointment of Infectious Diseases specialists will facilitate its expansion.

Community-based outpatient parenteral antimicrobial therapy (CoPAT) for Staphylococcus aureus bacteraemia with or without infective endocarditis: analysis of the randomized trial comparing daptomycin with standard therapy

Objectives

Administering outpatient parenteral antimicrobial therapy in the community setting (CoPAT) is becoming more common with the increasing emphasis on controlling costs. However, few controlled trials have evaluated this treatment modality.

Methods

Using data from a recent randomized trial comparing daptomycin with standard therapy (semi-synthetic penicillin or vancomycin, each with initial low-dose gentamicin) for Staphylococcus aureus bacteraemia and infective endocarditis (SAB/IE), patient characteristics and outcomes were evaluated. Patients receiving their full course of therapy in the hospital setting were compared with those who received some portion outside of the hospital (CoPAT).

Results

Among the 200 patients, 51.5% received CoPAT. These patients were generally younger (median age 50 versus 54 years, P = 0.028). In the CoPAT group, there tended to be fewer patients with endocardial involvement (8.7% versus 18.6%, P = 0.061) and pre-existing valvular heart disease (7.8% versus 15.5%, P = 0.120). CoPAT patients received longer therapy courses (mean 25.4 versus 13.5 days, P < 0.001) and had higher rates of therapy completion (90.3% versus 45.4%, P < 0.001) and clinical success (86.4% versus 55.7%, P < 0.001). Persisting or relapsing S. aureus was less frequent in the CoPAT group (3.9% versus 15.5%, P = 0.007) and there were fewer deaths (3.9% versus 18.6%, P = 0.001) 6 weeks after the end of therapy. Hospital readmission occurred for 18 of the 103 (17.5%) CoPAT patients. Clinical success rates were similar for CoPAT patients receiving daptomycin (90.0%) or standard therapy (83.0%).

Conclusions

With proper monitoring, stable patients can complete treatment for SAB/IE as outpatients in the community setting. Daptomycin is an appropriate option for this setting.

A cost analysis of Outpatient Parenteral Antibiotic Therapy (OPAT): an Asian perspective

The concept of Outpatient Parenteral Antibiotic Therapy (OPAT) is relatively new in Asia. This study compared the actual costs and outcomes of care involving OPAT with conventional inpatient-only care at a university hospital in Singapore. Actual costs were obtained for selected patients enrolled in OPAT after 1 January 2005 and these costs were directly compared with those of age-, gender- and diagnosis-matched patients managed as inpatients only prior to the availability of OPAT in the preceding 12 months. Outcomes of patients were also considered. The OPAT and inpatient-only groups comprised 72 and 93 enrollments, respectively. Mean treatment duration for OPAT patients was 42.5 days versus 19 days for those receiving inpatient-only care (P < 0.001). The mean total treatment cost for OPAT and inpatient-only care was US$12 736 and $12 403, respectively (P = 0.706). Mean cost per day for care including an OPAT episode was US$278 versus $457 per day for inpatient-only care (P < 0.001). There was no difference in outcomes between the two groups. OPAT is a viable alternative to inpatient care as it is safe, effective and results in lower daily costs. The trend to longer treatment courses is worthy of further review.