Parenteral therapy in the outpatient or home setting: evidence, evaluation and future prospects

Providing community intravenous therapy during the COVID-19 pandemic

Community intravenous therapy is well-established in most regions of the UK. Although there are national good practice recommendations detailing the service provision of outpatient parenteral antibiotic therapy (OPAT), examples of extended service delivery of other therapies are limited. This article describes the development of a community IV therapy service through integration with acute and primary care teams. IV therapies delivered in addition to antimicrobials safely outside of the hospital setting are also discussed with scope for future areas of development explored. The benefits of care closer to home for patients during the global COVID-19 pandemic are examined, as well as the potential for widening the whole gamut of practice for already established NHS community services through the development of integrated working in a local care organisation.

Assisting women to make informed choices about screening for Group B Streptococcus in pregnancy: a critical review of the evidence

The approach to the prevention of early onset GBS disease in the newborn varies considerably from country to country. The Centre for Disease Control in the United States advocates universal culture based screening with the administration of intra-partum antibiotics, usually benzylpenicillin or ampicillin, to women who are colonised with GBS. National groups in the UK and New Zealand advocate a risk-based approach where intra-partum antibiotics are given to women with identified risk factors. The Canadian Taskforce on preventive health care has identified a third approach; where intra-partum antibiotics are given to women with a positive GBS culture and an identified risk factor. There are no national guidelines or consensus in Australia. The aim of this paper is to explore the evidence for screening and intrapartum prophylaxis for GBS. The three main methods of detection and management of GBS in pregnancy are described and the implications for women and midwifery practice are addressed. It is hoped that this discussion will provide women, midwives and other clinicians with a summary of the evidence, risks and benefits to enable informed decision making.

Impact of a Multidisciplinary Team Review of Potential Outpatient Parenteral Antimicrobial Therapy Prior to Discharge from an Academic Medical Center

Background::

Outpatient parenteral antimicrobial therapy (OPAT) is frequently prescribed at hospital discharge, often without infectious diseases (ID) clinician oversight. We developed a multidisciplinary team, including an ID pharmacist, to review OPAT care plans at hospital discharge to improve safety, clinical efficacy, practicality, and appropriateness of the proposed antimicrobial regimen.

Objective:

To evaluate the impact of the OPAT team on regimen safety, efficacy, and complexity; calculate the economic benefits of the service by avoiding hospital discharge delay, central venous catheter placement, or need for OPAT; and evaluate the discharge environment among OPAT referrals.

Methods:

In an observational design, we analyzed the impact of an OPAT team from July 2009 through June 2010 at a large academic tertiary care hospital. All patients with plans for continued parenteral therapy after discharge referred to the OPAT team were included in the analysis. Patients were excluded if OPAT was cancelled prior to processing of the referral.

Results:

During the 1-year study period. 569 of 644 consecutive referrals to the OPAT team met inclusion criteria, resulting in 494 OPAT courses. Interventions by an ID pharmacist were made for safety (56%), regimen complexity (41%), and efficacy (29%). Lack of formal ID physician consultation resulted in more interventions for safety (64% vs 48%, p < 0.001) and efficacy (36% vs 21%, p < 0.001). Discharge delays were avoided for 35 referrals, resulting in 228 hospital days avoided and approximately $366,000 in hospital bed cost savings. Use of OPAT was avoided in 75 referrals (13.2%), preventing central venous catheter placement in 48 patients (8.4%), resulting in an additional $58,080 in cost savings.

Conclusions:

The OPAT team optimized safety, efficacy, and convenience of OPAT while providing substantial cost savings. Further studies are needed to confirm the program's cost-effectiveness.

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.

Comparison of the pharmacokinetics, safety and tolerability of daptomycin in healthy adult volunteers following intravenous administration by 30 min infusion or 2 min injection

OBJECTIVES

Two randomized Phase I studies in separate populations of healthy adult volunteers investigated the pharmacokinetics, safety and tolerability of daptomycin (Cubicin; Novartis Pharma AG, Basel, Switzerland) administered as a 2 min intravenous (iv) injection, relative to the currently licensed 30 min iv infusion.

METHODS

Study 1 was an open-label, single-dose, two-period, crossover study in which each subject received 6 mg/kg daptomycin administered as a 30 min iv infusion (n = 15) and as a 2 min iv injection (n = 16). In Study 2, a single-blind, multiple-dose, parallel-group study, subjects received a once-daily 2 min iv injection of 6 mg/kg daptomycin (n = 12), 4 mg/kg daptomycin (n = 8) or placebo (n = 4) for 7 days. Single-dose pharmacokinetics were assessed at various timepoints up to 36 and 24 h post-dose in Study 1 and Study 2, respectively, and multiple-dose pharmacokinetics were assessed in Study 2 at day 7 for 48 h post-dose.

RESULTS

In Study 1, pharmacokinetic comparability between the two administration regimens was demonstrated by meeting the bioequivalence criteria for the exposure parameters, AUC(0-t), AUC(0-infinity) and C(max). In Study 2, time-invariant pharmacokinetic properties as well as dose-proportional pharmacokinetics were demonstrated for the daptomycin 2 min iv injection regimen. In both studies, daptomycin was well tolerated and the majority of treatment-emergent adverse events were of mild intensity and considered to be unrelated to daptomycin.

CONCLUSIONS

The similar pharmacokinetic and safety profiles of the two administration regimens suggest that the 2 min iv injection may be a convenient treatment option for both patients and healthcare professionals.

Providing outpatient antibiotic therapy for cellulitis in primary care

Outpatient parenteral antimicrobial therapy (OPAT) is becoming more widespread. OPAT therapy can be used to treat certain patients who have cellulitis. The decision as to which patients to treat at home must be based on local PCT guidelines--not all patients are suitable for OPAT. OPAT improves patient quality of life by delivering care in the patient's home. This is highly skilled work and the community nurse must have appropriate training and support in order to gain the skills required.