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Wolie ZT, Roberts JA, Gilchrist M, McCarthy K, Sime FB. Current practices and challenges of outpatient parenteral antimicrobial therapy: a narrative review. J Antimicrob Chemother 2024; 79:2083-2102. [PMID: 38842523 PMCID: PMC11368434 DOI: 10.1093/jac/dkae177] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2024] Open
Abstract
Extended hospitalization for infection management increases inpatient care costs and the risk of healthcare-associated adverse events, including infections. The growing global demand for healthcare, the diminishing availability of hospital beds and an increasing patient preference for care within their own home have been the primary drivers of the expansion of hospital-in-the-home programmes. Such programmes include the use of IV antimicrobials in outpatient settings, known as outpatient parenteral antimicrobial therapy (OPAT). However, OPAT practices vary globally. This review article aims to describe the current OPAT practices and challenges worldwide. OPAT practice begins with patient evaluation and selection using eligibility criteria, which requires collaboration between the interdisciplinary OPAT team, patients and caregivers. Depending on care requirements, eligible patients may be enrolled to various models of care, receiving medication by healthcare professionals at outpatient infusion centres, hospital clinics, home visits or through self-administration. OPAT can be used for the management of many infections where an effective oral treatment option is lacking. Various classes of parenteral antimicrobials, including β-lactams, aminoglycosides, glycopeptides, fluoroquinolones and antifungals such as echinocandins, are used globally in OPAT practice. Despite its benefits, OPAT has numerous challenges, including complications from medication administration devices, antimicrobial side effects, monitoring requirements, antimicrobial instability, patient non-adherence, patient OPAT rejection, and challenges related to OPAT team structure and administration, all of which impact its outcome. A negative outcome could include unplanned hospital readmission. Future research should focus on mitigating these challenges to enable optimization of the OPAT service and thereby maximize the documented benefits for the healthcare system, patients and healthcare providers.
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Affiliation(s)
- Zenaw T Wolie
- UQ Centre for Clinical Research, Faculty of Medicine, University of Queensland, Brisbane, QLD 4029, Australia
| | - Jason A Roberts
- UQ Centre for Clinical Research, Faculty of Medicine, University of Queensland, Brisbane, QLD 4029, Australia
- Herston Infectious Diseases Institute (HeIDI), Metro North Health, Brisbane, Queensland, Australia
- Departments of Pharmacy and Intensive Care Medicine, Royal Brisbane and Women’s Hospital, Brisbane, QLD 4029, Australia
- Division of Anaesthesiology Critical Care Emergency and Pain Medicine, Nîmes University Hospital, University of Montpellier, 30029 Nîmes, France
| | - Mark Gilchrist
- Department of Pharmacy/Infection, Imperial College Healthcare NHS Trust, London, UK
- Department of Infectious Diseases, Imperial College, London, UK
| | - Kate McCarthy
- Royal Brisbane Clinical School, Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia
- Department of Infectious Diseases, Royal Brisbane and Women’s Hospital, Brisbane, Queensland, Australia
| | - Fekade B Sime
- UQ Centre for Clinical Research, Faculty of Medicine, University of Queensland, Brisbane, QLD 4029, Australia
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Brand H, Fryer M, Mehdi AM, Melon A, Morcombe B, Choong K, Subedi S. Home nursing and self-administered outpatient parenteral antimicrobial treatment: a comparison of demographics and outcomes from a large regional hospital in Queensland, Australia. Intern Med J 2024; 54:1351-1359. [PMID: 38591847 DOI: 10.1111/imj.16394] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2023] [Accepted: 03/15/2024] [Indexed: 04/10/2024]
Abstract
BACKGROUND Outpatient parenteral antimicrobial treatment (OPAT) is a safe and effective therapy used in several settings across Australia. As OPAT services expand their inclusion criteria to include complex patient populations, there is an increased need for selecting appropriate patients to receive either healthcare-administered OPAT (H-OPAT) or self-administered OPAT (S-OPAT). AIMS To describe patient demographics, diagnosis, microbiology and outcomes of patients treated by H-OPAT and S-OPAT within the Sunshine Coast Hospital and Health Service, Australia. METHODS Data on demographics, diagnoses, treatment and outcomes on all patients treated by H-OPAT and S-OPAT from March 2017 to December 2019 were collected retrospectively. RESULTS One hundred and sixty-five patients (62.26%) were enrolled in H-OPAT and 100 patients (37.74%) in S-OPAT. S-OPAT patients were significantly younger. H-OPAT patients were more comorbid. Bone and joint infections were the most treated infections and were more likely to be treated by S-OPAT. There was no difference in treatment duration, cure and complication rates between S-OPAT and H-OPAT. Longer duration of therapy was associated with more complications. Treatment failure was associated with infections due to multiple organisms, number of comorbidities and treatment of surgical site, skin and soft tissue infections. CONCLUSIONS There were significant differences in demographics between H-OPAT and S-OPAT without any difference in outcomes. Overall failure and complication rates were low. Higher rates of treatment failure were predicted by the diagnosis, number of comorbidities and number of organisms treated.
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Affiliation(s)
- Holly Brand
- Griffith University School of Medicine, Gold Coast, Queensland, Australia
| | - Michael Fryer
- Sunshine Coast University Hospital, Sunshine Coast, Queensland, Australia
| | - Ahmed M Mehdi
- QCIF Bioinformatics, Queensland Cyber Infrastructure Foundation Ltd, Brisbane, Queensland, Australia
| | - Alex Melon
- Sunshine Coast University Hospital, Sunshine Coast, Queensland, Australia
| | - Bridie Morcombe
- Sunshine Coast University Hospital, Sunshine Coast, Queensland, Australia
| | - Keat Choong
- Infectious Diseases Department, Sunshine Coast University Hospital, Sunshine Coast, Queensland, Australia
- Infection Research Network, Sunshine Coast Hospital and Health Service, Sunshine Coast, Queensland, Australia
| | - Shradha Subedi
- Infectious Diseases Department, Sunshine Coast University Hospital, Sunshine Coast, Queensland, Australia
- Infection Research Network, Sunshine Coast Hospital and Health Service, Sunshine Coast, Queensland, Australia
- Microbiology, Pathology Queensland, Sunshine Coast University Hospital, Sunshine Coast, Queensland, Australia
- School of Medicine, University of Queensland, Brisbane, Queensland, Australia
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Campbell PO, Gallagher K, Dalton SC, Metcalf SCL, Douglas NM, Chambers ST. Safety and clinical outcomes of outpatient parenteral antibiotic therapy for infective endocarditis in Christchurch, New Zealand: A retrospective cohort study. Int J Infect Dis 2023; 134:172-176. [PMID: 37331565 DOI: 10.1016/j.ijid.2023.06.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2023] [Revised: 06/06/2023] [Accepted: 06/09/2023] [Indexed: 06/20/2023] Open
Abstract
OBJECTIVES We examined the safety and clinical outcomes of outpatient parenteral antibiotic therapy (OPAT) for patients with infective endocarditis (IE) in Christchurch, New Zealand. METHODS Demographic and clinical data were collected from all adult patients treated for IE over 5 years. Outcomes were stratified by receipt of at least partial OPAT vs entirely hospital-based parenteral therapy. RESULTS There were 172 episodes of IE between 2014 and 2018. OPAT was administered in 115 cases (67%) for a median of 27 days after a median of 12 days of inpatient treatment. In the OPAT cohort, viridans group streptococci were the commonest causative pathogens (35%) followed by Staphylococcus aureus (25%) and Enterococcus faecalis (11%). There were six (5%) antibiotic-related adverse events and 26 (23%) readmissions in the OPAT treatment group. Mortality in OPAT patients was 6% (7/115) at 6 months and 10% (11/114) at 1 year and for patients receiving wholly inpatient parenteral therapy was 56% (31/56) and 58% (33/56), respectively. Three patients (3%) in the OPAT group had a relapse of IE during the 1-year follow-up period. CONCLUSION OPAT can be used safely in patients with IE, even in selected cases with complicated or difficult-to-treat infections.
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Affiliation(s)
- Patrick O Campbell
- Department of Infectious Diseases, Christchurch Hospital, Te Whatu Ora Waitaha Canterbury, New Zealand.
| | - Kate Gallagher
- Department of Infectious Diseases, Christchurch Hospital, Te Whatu Ora Waitaha Canterbury, New Zealand
| | - Simon C Dalton
- Department of Infectious Diseases, Christchurch Hospital, Te Whatu Ora Waitaha Canterbury, New Zealand
| | - Sarah C L Metcalf
- Department of Infectious Diseases, Christchurch Hospital, Te Whatu Ora Waitaha Canterbury, New Zealand
| | - Nicholas M Douglas
- Department of Infectious Diseases, Christchurch Hospital, Te Whatu Ora Waitaha Canterbury, New Zealand; Division of Medicine, University of Otago, Christchurch, New Zealand; Division of Global and Tropical Health, Menzies School of Health Research, Charles Darwin University, Darwin, Australia
| | - Stephen T Chambers
- Department of Infectious Diseases, Christchurch Hospital, Te Whatu Ora Waitaha Canterbury, New Zealand; Department of Pathology and Biomedical Science, University of Otago, Christchurch, New Zealand
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Wen W, Li H, Wang C, Chen C, Tang J, Zhou M, Hong X, Cheng Y, Wu Q, Zhang X, Feng Z, Wang M. Efficacy and safety of outpatient parenteral antibiotic therapy in patients with infective endocarditis: a meta-analysis. REVISTA ESPANOLA DE QUIMIOTERAPIA : PUBLICACION OFICIAL DE LA SOCIEDAD ESPANOLA DE QUIMIOTERAPIA 2022; 35:370-377. [PMID: 35652306 PMCID: PMC9333124 DOI: 10.37201/req/011.2022] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVE To investigate the clinical outcome of patients with infective endocarditis (IE) during and after outpatient parenteral antimicrobial treatment (OPAT), and to further clarify the safety and efficacy of OPAT for IE patients. METHODS Through December 20, 2021, a total of 331 articles were preliminarily searched in Pubmed, Web of Science, Cochrane Library and Embase, and 9 articles were eventually included in this study. RESULTS A total of 9 articles comprising 1,116 patients were included in this study. The overall mortality rate of patients treated with OPAT was 0.04 (95% CI, 0.02-0.07), that means 4 deaths per 100 patients treated with OPAT. Separately, mortality was low during the follow-up period after OPAT treatment, with an effect size (ES) of 0.03 (95%CI, 0.02-0.07) and the mortality of patients during OPAT treatment was 0.04 (95% CI, 0.01-0.12). In addition, the readmission rate was found to be 0.14 (95% CI, 0.09-0.22) during the follow-up and 0.18 (95% CI, 0.08-0.39) during treatment, and 0.16 (95% CI, 0.10-0.24) for patients treated with OPAT in general. Regarding the relapse of IE in patients, our results showed a low overall relapse rate, with an ES of 0.03 (95% CI, 0.01-0.05). In addition, we found that the incidence of adverse events was low, with an ES of 0.26 (95% CI, 0.19-0.33). CONCLUSIONS In general, the incidence of adverse events and mortality, readmission, and relapse rates in IE patients treated with OPAT are low both during treatment and follow-up period after discharge, indicating that OPAT is safe and effective for IE patients. However, our study did not compare routine hospitalization as a control group, so conclusions should be drawn with caution. In order to obtain more scientific and rigorous conclusions and reduce clinical risks, it is still necessary to conduct more research in this field and improve the patient selection criteria for OPAT treatment, especially for IE patients. Finally, clinical monitoring and follow-up of OPAT-treated patients should be strengthened.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | - M Wang
- Mingwei Wang, MD, PhD, Hangzhou Institute of Cardiovascular Diseases, Affiliated Hospital of Hangzhou Normal University, Hangzhou Normal University, Hangzhou, 310015, China.
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Durojaiye OC, Slucka A, Kritsotakis EI. Retrospective analysis of outcomes of outpatient parenteral antimicrobial therapy (OPAT) for necrotising otitis externa. Eur J Clin Microbiol Infect Dis 2022; 41:941-949. [PMID: 35556187 DOI: 10.1007/s10096-022-04455-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Accepted: 05/05/2022] [Indexed: 11/03/2022]
Abstract
Necrotising otitis externa (NOE) is an uncommon but life-threatening infection that requires prolonged systemic antimicrobial therapy. This study aims to identify factors associated with treatment response and outcome in patients with NOE treated through outpatient parenteral antimicrobial therapy (OPAT). We performed a retrospective analysis of patients with NOE treated over a 4-year period (January 2018-January 2022) at a tertiary referral hospital in Derbyshire, UK. We defined OPAT failure as unplanned readmission within 30 days of discontinuation of OPAT. Prolonged duration of therapy was defined as length of parenteral antimicrobial treatment of more than 8 weeks. A total of 46 cases of NOE were reviewed. OPAT failure and prolonged therapy were recorded in 9 (19.6%) and 23 (50.0%) episodes respectively. Facial nerve involvement (odds ratio [OR], 14.54; 95% confidence interval [CI], 2.76-76.60; p = 0.002), dementia (OR, 7.65; 95% CI, 1.23-47.46; p = 0.029), Charlson comorbidity score (OR, 1.41 per unit increase; 95% CI, 1.00-2.00; p = 0.049) and peak CRP level (OR, 1.03 per unit increase; 95% CI, 1.00-1.06; p = 0.027) were associated with increased risk of treatment failure. Facial nerve involvement (OR, 16.30; 95% CI, 2.60-102.31; p = 0.003) and peak CRP level (OR, 1.04; 95% CI, 1.01-1.07; p = 0.016) were also associated with an increased need for prolonged antimicrobial therapy. In addition, extent of disease (based on imaging findings) was linked to prolonged therapy (OR, 22.89; 95% CI, 3.62-144.76; p = 0.001). NOE could be effectively managed as outpatient via OPAT. However, vigorous antimicrobial treatment and close monitoring of patients with pre-existing comorbidities, facial nerve paralysis, extensive disease and markedly elevated inflammatory markers are essential to optimise clinical outcomes.
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Affiliation(s)
- Oyewole Chris Durojaiye
- Department of Infection and Tropical Medicine, Royal Hallamshire Hospital, Sheffield, S10 2JF, UK. .,Department of Microbiology, Royal Derby Hospital, Derby, DE22 3NE, UK.
| | - Augustinas Slucka
- Department of Pharmacist, Royal Derby Hospital, Derby, DE22 3NE, UK.,Present Address: NHS Sheffield Clinical Commissioning Group, Sheffield, S9 4EU, UK
| | - Evangelos I Kritsotakis
- Laboratory of Biostatistics, School of Medicine, University of Crete, 71003, Heraklion, Greece.,School of Health and Related Research, Faculty of Medicine, Dentistry and Health, University of Sheffield, S1 4DA, Sheffield, UK
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