A prospective cohort study of the use of domiciliary intravenous antibiotics in bronchiectasis

Outpatient parenteral antibiotic therapy (OPAT) for the management of bronchiectasis

Background

Patients with bronchiectasis often require hospitalisation for the administration of intravenous antibiotics for the management of acute exacerbations. Increasingly, Outpatient Parenteral Antibiotic Therapy (OPAT) services have become available as a potential alternative for domiciliary management.

Aims

This study assessed outcomes in both cystic fibrosis (CF) and non-CF bronchiectasis patients who received OPAT for the management of an acute exacerbation of bronchiectasis.

Methods

A retrospective study of consecutive subjects was done in both CF and non-CF groups in a large metropolitan Health Service in Australia from 2016 to 2022.

Results

There were 51 episodes of care in the non-CF group (22 subjects) and 73 episodes in the CF group (13 subjects). The non-CF group were nearly all treated with once daily domiciliary intravenous (IV) ceftriaxone (49/51 episodes) for a duration of 9.1 ± 3.0 days (mean and standard deviation (SD)) via a peripherally inserted venous canula (84% of episodes). In contrast, the CF group generally received dual IV antibiotics (64% of episodes), with an average duration of 16.8 ± 6.3 days via central venous access (100%). In the non-CF group, the admission rate to hospital after 1 month was 9.6% and in the CF group was 0%. At 3 and 6 months the readmission rate for the non-CF group was 15.7% and 19.6% and CF group was 21.9% and 31.5%. There was a low rate of complications for the OPAT admissions (2% for the non-CF group and 7% for CF group).

Conclusions

OPAT is a viable alternative for the management of bronchiectasis exacerbations.

Outpatient Versus Inpatient Intravenous Antimicrobial Therapy: A Population-Based Observational Cohort Study of Adverse Events and Costs

BACKGROUND

Bacterial infections such as osteomyelitis and endocarditis routinely require several weeks of treatment with intravenous (IV) antimicrobials. Outpatient parenteral antimicrobial therapy (OPAT) programs allow patients to receive IV antimicrobials in an outpatient clinic or at home. The outcomes and costs of such treatments remain uncertain.

METHODS

We conducted a retrospective observational cohort study over a 5-year study interval (1 June 2012 to 31 March 2018) using population-based linked administrative data from British Columbia, Canada. Patients receiving OPAT following a hospitalization for bacterial infection were matched based on infection type and implied duration of IV antimicrobials to patients receiving inpatient parenteral antimicrobial therapy (IPAT). Cumulative adverse events and direct healthcare costs were estimated over a 90-day outcome interval.

RESULTS

In a matched cohort of 1842 patients, adverse events occurred in 35.6% of OPAT patients and 39.0% of IPAT patients (adjusted odds ratio, 1.04 [95% confidence interval {CI}, .83-1.30; P = .61). Relative to IPAT patients, OPAT patients were significantly more likely to experience hospital readmission (30.5% vs 23.0%) but significantly less likely to experience Clostridioides difficile diarrhea (1.2% vs 3.1%) or death (2.0% vs 8.8%). Estimated mean direct healthcare costs were $30 166 for OPAT patients and $50 038 for IPAT patients (cost ratio, 0.60; average cost savings with OPAT, $17 579 [95% CI, $14 131-$21 027]; P < .001).

CONCLUSIONS

Outpatient IV antimicrobial therapy is associated with a similar overall prevalence of adverse events and with substantial cost savings relative to patients remaining in hospital to complete IV antimicrobials. These findings should inform efforts to expand OPAT use.

Staphylococcus aureus in Non-Cystic Fibrosis Bronchiectasis: Prevalence and Genomic Basis of High Inoculum Beta-Lactam Resistance

Rationale The pathobiology of Staphylococcus aureus in non-cystic fibrosis bronchiectasis (nCFB) is poorly defined. When present at high density or "inoculum", some methicillin-sensitive S. aureus (MSSA) can inefficiently degrade anti-Staphylococcal beta-lactam antibiotics via BlaZ penicillinases (termed, the inoculum effect). Given the high burden of organisms in bronchiectatic airways, this is particularly relevant. Objectives Drawing from a prospectively-collected biobank, we sought to understand the prevalence, natural history, potential for transmission, and antibiotic resistance profiles amongst nCFB-derived MSSA isolates. Methods All individuals attending a regional consultancy nCFB clinic with sputum collected between 1981-2017 were considered, and those with ≥1 S. aureus-positive culture comprised the cohort. Each individual's most recent biobank isolate was subjected to whole genome sequencing (including the blaZ gene), antibacterial susceptibility testing, and comparative beta-lactam testing at standard (5 x 105CFU/mL) and high (5 x 107CFU/mL) inoculum to assess for the inoculum, and pronounced inoculum effect (IE and pIE, respectively). Results Seventy-four of 209 (35.4%) individuals had ≥1 sputum sample(s) with S. aureus (68 MSSA, 6 MRSA). Those with S. aureus infection were more likely to be female. Amongst 60/74 MSSA isolates subjected to WGS, no evidence of transmission was identified, although specific MLST types were prevalent including ST-1, ST-15, ST-30, and ST-45. Antibiotic resistance was uncommon except for macrolides (~20%). Amongst the 60 MSSA, prevalence of IE and pIE, respectively, were observed to be drug specific; meropenem (0%, 0%), cefepime (3%, 5%), ceftazidime (8%, 0%), cloxacillin (12%, 0%), cefazolin (23%, 0%) and piperacillin-tazobactam (37%, 17%). The cefazolin IE associated with blaZ type A (p<0.01) and ST-30 (p<0.01), whereas the piperacillin-tazobactam IE associated with type C blaZ (p<0.001) and ST-15 (p<0.05). Conclusions S. aureus infection was common, although no evidence of transmission was apparent in our nCFB cohort. While routine susceptibility testing did not identify significant resistance, inoculum-related resistance was found to be relevant for commonly used nCFB antibiotics including cefazolin and piperacillin-tazobactam. Given previous associations between IEs and negative patient outcomes, further work is warranted to understand how this phenotype impacts nCFB disease progression.

Bronchiectasis: moving from an orphan disease to an unpleasant socioeconomic burden

Bronchiectasis has received increasing attention in recent years. At the same time, studies have shown a high incidence of this disease, especially in older populations, associated with high health-related costs and economic burden. https://bit.ly/2WPfVZ7.

Feasibility of shortening intravenous antibiotic therapy based on bacterial load- a proof of concept randomised controlled trial

INTRODUCTION

There is lack of evidence to guide duration of intravenous antibiotics for bronchiectasis exacerbations.

AIMS

To assess whether it is feasible based on bacterial load to shorten intravenous antibiotics during exacerbations and whether 14 days treatment is superior.

METHOD

We recruited participants requiring intravenous antibiotics for exacerbations. Participants were randomised into two groups to receive antibiotics for 14 days or bacterial load guided group(BLGG). Bacterial load was checked on day 0/7/10/14/21. If bacterial load was <10⁶ cfu·mL^-1 on day7 or 10 in BLGG, antibiotics were stopped the following day.

RESULTS

47 received 14 days antibiotics and 43 were in BLGG. 88% of participants in the BLGG were able to stop antibiotics by day8 and potentially 81% could have stopped antibiotics at day8 in the 14 day arm. There was a non-significant trend for increased clinical improvement by day21 with 14 days compared to BLGG. However, overall group data showed the median (interquartile range) time to next exacerbation was 27.5(12.5-60) days in the group receiving antibiotics for 14 days and 60(18-110) days in the in BLGG; p=0.0034. In Cox proportional hazard model, 14 days was more likely to experience exacerbations (Hazard Ratio(95% CI)1.80 (1.16-2.80), p=0.009 compared to BLGG and those with mild bronchiectasis less likely to experience exacerbations than patients with more severe bronchiectasis (HR 0.359 (0.13-0.99), p=0.048).

CONCLUSION

Bacterial load guided therapy is feasible in most exacerbations requiring intravenous antibiotics. There was a non-significant trend for increased clinical improvement by day21 with 14 day antibiotics compared with BLGG but paradoxically there was a prolonged time to next exacerbation in BLGG.

Update on pharmacotherapy for adult bronchiectasis

Bronchiectasis refers to abnormal dilatation of the bronchi, which leads to the failure of mucus clearance and increased risk of infection. Pharmacotherapy for stable bronchiectasis includes oral or inhaled mucoactive agents, anti-inflammatory therapy, inhaled bronchodilators, long-term antibiotics, and long-term macrolide treatment. Among them, mucoactive agents are the most common adjunctive agents to airway clearance techniques. When patients with impaired lung function suffer from dyspnea, inhaled bronchodilators may be prescribed to relieve the symptom. Long-term macrolide treatment has been proven to prevent exacerbation in patients with frequent bronchiectasis exacerbation. If exacerbation occurs despite the above mentioned treatments, one or two weeks of antibiotics should be prescribed to cover respiratory bacteria that include <i>Pseudomonas aeruginosa</i>. Because evidence supporting the use of pharmacotherapy for bronchiectasis is weak, further research is warranted.

Is out-patient based treatment of bronchiectasis exacerbations in children comparable to inpatient based treatment?

BACKGROUND AND OBJECTIVE

Children with bronchiectasis have recurrent exacerbations and may require hospitalization. "Hospital in the home (HITH)" is used as an alternative to hospitalization for children with cystic fibrosis (CF) but to date, there is no published data on children without CF. We describe our experience of HITH (intravenous [IV] antibiotics and at least once-daily physiotherapy-treated airway clearance therapy) in a cohort of children with bronchiectasis, comparing outcomes between hospital and HITH-based pathways.

METHODS

Medical records were retrospectively reviewed in children with bronchiectasis who were hospitalized in our center from July 2016 to July 2018. We compared treatment duration, symptom resolution, adverse events, oral antibiotic prescription on discharge and "time-to-next hospitalization" between children managed with the two treatment pathways.

RESULTS

Exacerbations in 63 children (median age = 6 years [range: 1-17]; females = 33, indigenous = 8) with bronchiectasis treated with IV antibiotic therapy were analyzed (HITH n = 45, 71.5%). Duration of treatment and symptom resolution was similar between groups (hospital: median = 14 days [interquartile range {IQR}: 14-14] and 12/18 [66.6%], respectively vs HITH: 14 [14-15.5] and 31/45 [69%]; P = .53 and .85, respectively). There was no significant difference in adverse events (16.6% vs 9%), prescription of oral antibiotics on discharge (44% vs 24%), or "time-to-next hospitalization" (median 42 [IQR: 24-100] vs 67 [IQR: 32-95] weeks) between hospital and HITH groups, respectively.

CONCLUSIONS

In children with bronchiectasis treated for a severe exacerbation, receiving treatment in the home setting with HITH does not compromise short-term clinical outcomes compared to hospital only treatment. Prospective studies are required to provide more robust evidence in this under-researched area.

Outpatient Parenteral Antimicrobial Treatment for Non-Cystic Fibrosis Bronchiectasis Exacerbations: A Prospective Multicentre Observational Cohort Study

BACKGROUND

The recently published guidelines of the Spanish Society of Pulmonology and Thoracic Surgery encourage physicians to use outpatient antimicrobial therapy to treat exacerbations in patients with non-cystic fibrosis bronchiectasis (NCFB). The published literature on this topic, however, is scarce.

METHODS

We report a prospective observational cohort study of patients with NCFB who received treatment at home for at least one exacerbation episode between September 2012 and September 2017 as part of an outpatient parenteral antimicrobial therapy (OPAT) program. Patients were included in the analysis if they fulfilled all of the following criteria: established diagnosis of bronchiectasis according to current guidelines criteria, clinical exacerbation, requiring intravenous antibiotics because of failure to respond to oral antibiotics, or isolation of a microorganism resistant to oral options.

OBJECTIVES

To evaluate the effectiveness and safety of the treatment of patients with NCFB exacerbations in an OPAT program under "real-world" conditions.

RESULTS

Sixty-seven patients were treated in the OPAT program due to bacterial exacerbations of NCFB. Forty-five (67.2%) patients were admitted to hospital for a median of 7 days before starting OPAT. Sixty-three (94%) patients achieved resolution of the exacerbation at the end of therapy. Four patients needed hospital readmission, and one died. The OPAT program saved 11,586 days of hospital admission, equivalent to EUR 7,866,904.

CONCLUSIONS

OPAT appears to be a safe, effective, and efficient strategy for treating patients with exacerbations of NCFB.

Spanish Guidelines on Treatment of Bronchiectasis in Adults

In 2008, the Spanish Society of Pulmonology (SEPAR) published the first guidelines in the world on the diagnosis and treatment of bronchiectasis. Almost 10 years later, considerable scientific advances have been made in both the treatment and the evaluation and diagnosis of this disease, and the original guidelines have been updated to include the latest therapies available for bronchiectasis. These new recommendations have been drafted following a strict methodological process designed to ensure quality of content, and are linked to a large amount of online information that includes a wealth of references. The guidelines are focused on the treatment of bronchiectasis from both a multidisciplinary perspective, including specialty areas and the different healthcare levels involved, and a multidimensional perspective, including a comprehensive overview of the specific aspects of the disease. A series of recommendations have been drawn up, based on an in-depth review of the evidence for treatment of the underlying etiology, the bronchial infection in its different forms of presentation using existing therapies, bronchial inflammation, and airflow obstruction. Nutritional aspects, management of secretions, muscle training, management of complications and comorbidities, infection prophylaxis, patient education, home care, surgery, exacerbations, and patient follow-up are addressed.

Clinical and cost-effectiveness, safety and acceptability of community intravenous antibiotic service models: CIVAS systematic review

OBJECTIVE

Evaluate evidence of the efficacy, safety, acceptability and cost-effectiveness of outpatient parenteral antimicrobial therapy (OPAT) models.

DESIGN

A systematic review.

DATA SOURCES

MEDLINE, EMBASE, CINAHL, Cochrane Library, National Health Service (NHS) Economic Evaluation Database (EED), Research Papers in Economics (RePEc), Tufts Cost-Effectiveness Analysis (CEA) Registry, Health Business Elite, Health Information Management Consortium (HMIC), Web of Science Proceedings, International Pharmaceutical Abstracts, British Society for Antimicrobial Chemotherapy website. Searches were undertaken from 1993 to 2015.

STUDY SELECTION

All studies, except case reports, considering adult patients or practitioners involved in the delivery of OPAT were included. Studies combining outcomes for adults and children or non-intravenous (IV) and IV antibiotic groups were excluded, as were those focused on process of delivery or clinical effectiveness of 1 antibiotic over another. Titles/abstracts were screened by 1 reviewer (20% verified). 2 authors independently screened studies for inclusion.

RESULTS

128 studies involving >60 000 OPAT episodes were included. 22 studies (17%) did not indicate the OPAT model used; only 29 involved a comparator (23%). There was little difference in duration of OPAT treatment compared with inpatient therapy, and overall OPAT appeared to produce superior cure/improvement rates. However, when models were considered individually, outpatient delivery appeared to be less effective, and self-administration and specialist nurse delivery more effective. Drug side effects, deaths and hospital readmissions were similar to those for inpatient treatment, but there were more line-related complications. Patient satisfaction was high, with advantages seen in being able to resume daily activities and having greater freedom and control. However, most professionals perceived challenges in providing OPAT.

CONCLUSIONS

There were no systematic differences related to the impact of OPAT on treatment duration or adverse events. However, evidence of its clinical benefit compared with traditional inpatient treatment is lacking, primarily due to the dearth of good quality comparative studies. There was high patient satisfaction with OPAT use but the few studies considering practitioner acceptability highlighted organisational and logistic barriers to its delivery.

Raising awareness of bronchiectasis in primary care: overview of diagnosis and management strategies in adults

Bronchiectasis is a chronic lung disease characterised by recurrent infection, inflammation, persistent cough and sputum production. The disease is increasing in prevalence, requiring a greater awareness of the disease across primary and secondary care. Mild and moderate cases of bronchiectasis in adults can often be managed by primary care clinicians. Initial assessments and long-term treatment plans that include both pharmacological and non-pharmacological treatments, however, should be undertaken in collaboration with a secondary care team that includes physiotherapists and specialists in respiratory medicine. Bronchiectasis is often identified in patients with other lung diseases, such as chronic obstructive pulmonary disease, asthma, and in a lesser but not insignificant number of patients with other inflammatory diseases, such as rheumatoid arthritis and inflammatory bowel disease. Overall goals of therapy are to prevent exacerbations, improve symptoms, improve quality of life and preserve lung function. Prompt treatment of exacerbations with antibiotic therapy is important to limit the impact of exacerbations on quality of life and lung function decline. Patient education and cooperation with health-care providers to implement treatment plans are key to successful disease management. It is important for the primary care provider to work with secondary care providers to develop an individualised treatment plan to optimise care with the goal to delay disease progression. Here, we review the diagnosis and treatment of bronchiectasis with a focus on practical considerations that will be useful to primary care.

The Community IntraVenous Antibiotic Study (CIVAS): a mixed-methods evaluation of patient preferences for and cost-effectiveness of different service models for delivering outpatient parenteral antimicrobial therapy

Background

Outpatient parenteral antimicrobial therapy (OPAT) is widely used in most developed countries, providing considerable opportunities for improved cost savings. However, it is implemented only partially in the UK, using a variety of service models.

Objectives

The aims of this research were to (1) establish the extent of OPAT service models in England and identify their development; (2) evaluate patients’ preferences for different OPAT service delivery models; (3) assess the cost-effectiveness of different OPAT service delivery models; and (4) convene a consensus panel to consider our evidence and make recommendations.

Methods

This mixed-methods study included seven centres providing OPAT using four main service models: (1) hospital outpatient (HO) attendance; (2) specialist nurse (SN) visiting at home; (3) general nurse (GN) visiting at home; and (4) self-administration (SA) or carer administration. Health-care providers were surveyed and interviewed to explore the implementation of OPAT services in England. OPAT patients were interviewed to determine key service attributes to develop a discrete choice experiment (DCE). This was used to perform a quantitative analysis of their preferences and attitudes. Anonymised OPAT case data were used to model cost-effectiveness with both Markov and simulation modelling methods. An expert panel reviewed the evidence and made recommendations for future service provision and further research.

Results

The systematic review revealed limited robust literature but suggested that HO is least effective and SN is most effective. Qualitative study participants felt that different models of care were suited to different types of patient and they also identified key service attributes. The DCE indicated that type of service was the most important factor, with SN being strongly preferred to HO and SA. Preferences were influenced by attitudes to health care. The results from both Markov and simulation models suggest that a SN model is the optimal service for short treatment courses (up to 7 days). Net monetary benefit (NMB) values for HO, GN and SN services were £2493, £2547 and £2655, respectively. For longer treatment, SA appears to be optimal, although SNs provide slightly higher benefits at increased cost. NMB values for HO, GN, SN and SA services were £8240, £9550, £10,388 and £10,644, respectively. The simulation model provided useful information for planning OPAT services. The expert panel requested more guidance for service providers and commissioners. Overall, they agreed that mixed service models were preferable.

Limitations

Recruitment to the qualitative study was suboptimal in the very elderly and ethnic minorities, so the preferences of patients from these groups might not be represented. The study recruited from Yorkshire, so the findings may not be applicable nationally.

Conclusions

The quantitative preference analysis and economic modelling favoured a SN model, although there are differences between sociodemographic groups. SA provides cost savings for long-term treatment but is not appropriate for all.

Future work

Further research is necessary to replicate our results in other regions and populations and to evaluate mixed service models. The simulation modelling and DCE methods used here may be applicable in other health-care settings.

Funding

The National Institute for Health Research Health Service and Delivery Research programme.

Risk factors for requiring intravenous antibiotic therapy in hospital and 30-day readmission for exacerbations of bronchiectasis

BACKGROUND

The safety and efficacy of domiciliary intravenous (IV) antibiotic therapy compared to inpatient hospital treatment for exacerbations of bronchiectasis has been established. Factors that determine the setting for IV antibiotic therapy need to be characterized further.

AIM

We aimed to identify factors at presentation that were associated with the requirement for IV antibiotic therapy delivered in hospital and 30-day readmission.

DESIGN

Retrospective cohort study of all IV antibiotic courses administered to patients with bronchiectasis by a specialist respiratory unit over a 2-year period.

METHODS

We assessed demographic data, treatment outcomes, morbidity, mortality, and 30-day readmission rates. Multiple linear regression analysis was performed to identify factors associated with inpatient IV antibiotics and 30-day readmission.

RESULTS

One hundred six patients received 243 courses of IV antibiotic therapy in 2 years. Sixty-six cases (27.2%) were managed in hospital, 28 cases (11.5%) required initial admission prior to early supported discharge to complete IV antibiotics at home and 149 cases (61.3%) received domiciliary IV antibiotics. Bronchiectasis Severity Index (P < 0.0001) and emergency presentation with an exacerbation (P < 0.0001) were independent factors associated with the requirement for inpatient IV antibiotic therapy. There were no differences between mortality (P = 0.06) and morbidity (P = 0.1) between groups. Thirty-day readmission following early supported discharge was higher compared to inpatient or domiciliary therapy (P=0.0004).

CONCLUSION

A higher Bronchiectasis Severity Index and emergency presentation with an exacerbation are independently associated with the need for IV antibiotics delivered in hospital. We could not identify any factors that predicted 30-day readmission in a multi-variable model.