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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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Mohammed SA, Roberts JA, Cotta MO, Rogers B, Pollard J, Assefa GM, Erku D, Sime FB. Safety and efficacy of outpatient parenteral antimicrobial therapy: A systematic review and meta-analysis of randomized clinical trials. Int J Antimicrob Agents 2024; 64:107263. [PMID: 38960209 DOI: 10.1016/j.ijantimicag.2024.107263] [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: 04/16/2024] [Revised: 06/05/2024] [Accepted: 06/25/2024] [Indexed: 07/05/2024]
Abstract
BACKGROUND Outpatient parenteral antimicrobial therapy (OPAT) offers an alternative to inpatient (hospital bed-based) treatment of infections that require intravenous administration of antimicrobials. This meta-analysis aimed to summarise the evidence available from randomised controlled trials (RCTs) regarding the efficacy and safety of OPAT compared to inpatient parenteral antimicrobial therapy. METHODS We searched the Cochrane Library, MEDLINE, Embase, PubMed, and Web of Sciences databases for RCTs comparing outpatient versus inpatient parenteral antimicrobial therapy. We included studies without restrictions on language or publication year. Eligibility was reviewed independently by two assessors, and data extraction was cross validated. We evaluated bias risk via the Cochrane tool and determined the evidence certainty using GRADE. Meta-analysis was conducted using a random effects model. The protocol of this review was registered on PROSPERO (CRD42023460389). RESULT Thirteen RCTs, involving 1,310 participants were included. We found no difference in mortality (Risk Ratio [RR] 0.54, 95% Confidence Interval [CI] 0.23 to 1.26; P = 0.93), treatment failure (RR 1.0, CI 0.59 to 1.72; P = 0.99), adverse reaction related to antimicrobials (RR 0.89, CI 0.69 to 1.15; P = 0.38), and administration device (RR 0.58, CI 0.17 to 1.98; P = 0.87) between outpatient and inpatient parenteral antimicrobial therapy. The overall body of evidence had a low level of certainty. CONCLUSION Existing evidence suggests OPAT is a safe and effective alternative to inpatient treatment. Further RCTs are warranted for a thorough comparison of inpatient and outpatient parenteral antimicrobial therapy with a high level of certainty.
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Affiliation(s)
- Solomon Ahmed Mohammed
- UQ Centre for Clinical Research, The University of Queensland, Queensland, Australia; Department of Pharmacy, Wollo University, Dessie, Ethiopia
| | - Jason A Roberts
- UQ Centre for Clinical Research, The University of Queensland, Queensland, Australia; Department of Pharmacy and Intensive Care Medicine, Royal Brisbane and Women's Hospital, Queensland, Australia; Herston Infectious Disease Institute (HeIDI), Metro North Health, Queensland, Australia; Division of Anaesthesiology Critical Care Emerging and Pain Medicine, Nimes University Hospital, University of Montpellier, Nimes, France
| | - Menino Osbert Cotta
- UQ Centre for Clinical Research, The University of Queensland, Queensland, Australia; Herston Infectious Disease Institute (HeIDI), Metro North Health, Queensland, Australia
| | - Benjamin Rogers
- Centre for Inflammatory Disease, Monash University, Melbourne, Australia
| | - James Pollard
- Cabrini @ Home, Cabrini Health, Melbourne, Australia
| | - Getnet Mengistu Assefa
- UQ Centre for Clinical Research, The University of Queensland, Queensland, Australia; Department of Pharmacy, Wollo University, Dessie, Ethiopia
| | - Daniel Erku
- Centre for Applied Health Economics, Griffith University, Queensland, Australia
| | - Fekade B Sime
- UQ Centre for Clinical Research, The University of Queensland, Queensland, Australia.
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Reidy P, Breslin T, Muldoon E. Outpatient parenteral antimicrobial therapy (OPAT) across the world: a comparative analysis-what lessons can we learn? JAC Antimicrob Resist 2024; 6:dlae111. [PMID: 39035018 PMCID: PMC11258576 DOI: 10.1093/jacamr/dlae111] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/23/2024] Open
Abstract
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.
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Affiliation(s)
- Paul Reidy
- Department of Infectious Diseases, Mater Misericordiae University Hospital, Dublin, Ireland
- School of Medicine, Trinity College Dublin, Dublin, Ireland
| | - Tara Breslin
- School of Medicine, Trinity College Dublin, Dublin, Ireland
| | - Eavan Muldoon
- Department of Infectious Diseases, Mater Misericordiae University Hospital, Dublin, Ireland
- School of Medicine, University College Dublin, Dublin, Ireland
- National OPAT Programme, Health Services Executive, Dublin, Ireland
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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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Mohammed SA, Cotta MO, Assefa GM, Erku D, Sime F. Barriers and facilitators for the implementation and expansion of outpatient parenteral antimicrobial therapy: a systematic review. J Hosp Infect 2024; 147:1-16. [PMID: 38423135 DOI: 10.1016/j.jhin.2024.02.006] [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: 12/01/2023] [Revised: 02/05/2024] [Accepted: 02/09/2024] [Indexed: 03/02/2024]
Abstract
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.
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Affiliation(s)
- S A Mohammed
- UQ Centre for Clinical Research, The University of Queensland, Brisbane, Australia; Department of Pharmacy, Wollo University, Dessie, Ethiopia
| | - M O Cotta
- UQ Centre for Clinical Research, The University of Queensland, Brisbane, Australia; Herston Infectious Diseases Institute, Metro North Health, Brisbane, Australia
| | - G M Assefa
- UQ Centre for Clinical Research, The University of Queensland, Brisbane, Australia; Department of Pharmacy, Wollo University, Dessie, Ethiopia
| | - D Erku
- Centre for Applied Health Economics, Griffith University, Nathan, Australia
| | - F Sime
- UQ Centre for Clinical Research, The University of Queensland, Brisbane, Australia.
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Fernandez-Sanchez J, Rodgers R, Maknojia AA, Shaikh N, Yan H, Mejia ME, Hendricks H, Jenq RR, Reddy P, Banerjee R, Schraw JM, Baldridge MT, King KY. Antibiotic-associated neutropenia is marked by depletion of intestinal Lachnospiraceae in pediatric patients. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2024:2024.04.25.24306386. [PMID: 38712139 PMCID: PMC11071563 DOI: 10.1101/2024.04.25.24306386] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/08/2024]
Abstract
Hematologic side effects are associated with prolonged antibiotic exposure in up to 34% of patients. Neutropenia, reported in 10-15% of patients, increases the risk of sepsis and death. Murine studies have established a link between the intestinal microbiota and normal hematopoiesis. We sought to identify predisposing factors, presence of microbiota-derived metabolites, and changes in intestinal microbiota composition in otherwise healthy pediatric patients who developed neutropenia after prolonged courses of antibiotics. In this multi-center study, patients with infections requiring anticipated antibiotic treatment of two or more weeks were enrolled. Stool samples were obtained at the start and completion of antibiotics and at the time of neutropenia. We identified 10 patients who developed neutropenia on antibiotics and 29 controls matched for age, sex, race, and ethnicity. Clinical data demonstrated no association between neutropenia and type of infection or type of antibiotic used; however intensive care unit admission and length of therapy were associated with neutropenia. Reduced intestinal microbiome richness and decreased abundance of Lachnospiraceae family members correlated with neutropenia. Untargeted stool metabolomic profiling revealed several metabolites that were depleted exclusively in patients with neutropenia, including members of the urea cycle pathway, pyrimidine metabolism and fatty acid metabolism that are known to be produced by Lachnospiraceae . Our study confirms a relationship between intestinal microbiota disruption and abnormal hematopoiesis and identifies taxa and metabolites likely to contribute to microbiota-sustained hematopoiesis. As the microbiome is a key determinant of stem cell transplant and immunotherapy outcomes, these findings are likely to be of broad significance. Key Points Neutropenia occurred in 17% of patients receiving prolonged antibiotic therapy.We found no association between neutropenia and type of infection or class of antibiotic used. Development of neutropenia after prolonged antibiotic treatment was associated with decreased prevalence of Lachnospiraceae and Lachnospiraceae metabolites such as citrulline.
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Kaul CM, Haller M, Yang J, Solomon S, Khan MR, Pitts RA, Phillips MS. Factors associated with loss to follow-up in outpatient parenteral antimicrobial therapy: A retrospective cohort study. Infect Control Hosp Epidemiol 2024; 45:387-389. [PMID: 37782035 PMCID: PMC10933499 DOI: 10.1017/ice.2023.216] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2023] [Revised: 08/10/2023] [Accepted: 08/21/2023] [Indexed: 10/03/2023]
Abstract
We assessed factors associated with increased risk to loss of follow-up with infectious diseases staff in OPAT patients. Discharge to subacute healthcare facilities is strongly associated with loss to follow-up. We did not identify sociodemographic disparities. Poor communication between OPAT providers and subacute healthcare facilities remains a serious issue.
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Affiliation(s)
- Christina M. Kaul
- Division of Infectious Diseases, NYU Grossman School of Medicine, New York, New York
- Department of Population Health, NYU Grossman School of Medicine, New York, New York
| | | | - Jenny Yang
- Department of Medicine, NYU Grossman School of Medicine, New York, New York
| | - Sadie Solomon
- Department of Hospital Epidemiology, NYU Langone Health, New York, New York
| | - Maria R. Khan
- Department of Population Health, NYU Grossman School of Medicine, New York, New York
| | - Robert A. Pitts
- Division of Infectious Diseases, NYU Grossman School of Medicine, New York, New York
| | - Michael S. Phillips
- Division of Infectious Diseases, NYU Grossman School of Medicine, New York, New York
- Department of Hospital Epidemiology, NYU Langone Health, New York, New York
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Sime FB, Wallis S, Jamieson C, Hills T, Gilchrist M, Santillo M, Seaton RA, Drummond F, Roberts J. Evaluation of the stability of aciclovir in elastomeric infusion devices used for outpatient parenteral antimicrobial therapy. Eur J Hosp Pharm 2024:ejhpharm-2023-003784. [PMID: 38071555 DOI: 10.1136/ejhpharm-2023-003784] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Accepted: 11/07/2023] [Indexed: 02/08/2024] Open
Abstract
OBJECTIVES To investigate the stability of aciclovir solutions in elastomeric devices used for outpatient parenteral antimicrobial therapy (OPAT). METHODS Triplicates of two elastomeric devices, Accufuser and Easypump II, were filled with a solution of 200 mg, 2400 mg, and 4500 mg aciclovir in 240 mL 0.9% w/v saline. Devices were stored at room temperature for 14 days, followed by 24 hours storage at 32°C. Assessment using a stability indicating assay, pH and subvisible particle analysis was undertaken at 11 time points throughout the study. RESULTS Aciclovir solution at 200 mg and 2400 mg in 240 mL was stable for 14 days at room temperature (<20°C) and 24 hours of 32°C 'in-use' temperature exposure, remaining above the 95% limit for NHS stability protocols. The high dose was also stable for 14 days at room temperature, but when stored at 32°C there was precipitation of aciclovir within 4 hours in both devices. The precipitate was confirmed as aciclovir and precipitation was not a sign of chemical degradation. CONCLUSIONS Aciclovir concentrations above 2400 mg/240 mL are liable to precipitation and cannot be recommended for OPAT services because of heightened risks of nephrotoxicity. Aciclovir solution can be given as a continuous 24-hour infusion for OPAT services at a concentration range of 200-2400 mg in 240 mL in Accufuser and Easypump II elastomeric devices following 14 days storage at room temperature, protected from light.
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Affiliation(s)
- Fekade Bruck Sime
- University of Queensland Centre for Clinical Research, Brisbane, Queensland, Australia
| | - Steven Wallis
- University of Queensland Centre for Clinical Research, Brisbane, Queensland, Australia
| | | | - Tim Hills
- Pharmacy Department, Nottingham University Hospitals, Nottingham, UK
| | - Mark Gilchrist
- Department of Pharmacy/Infection, Imperial College Healthcare NHS Trust, London, UK
| | - Mark Santillo
- University Hospitals Plymouth NHS Trust, Plymouth, UK
- University Hospitals Bristol and Weston NHS Trust, Bristol, UK
| | - R Andrew Seaton
- Department of Infectious Diseases, Queen Elizabeth University Hospital, Glasgow, UK
| | | | - Jason Roberts
- University of Queensland Centre for Clinical Research, Brisbane, Queensland, 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, Queensland, Australia
- Division of Anaesthesiology Critical Care Emergency and Pain Medicine, Nîmes University Hospital, University of Montpellier, Nîmes, France
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9
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Missiaen L, Vogelaers D, De Roo PJ, Van Hoecke F, Vanmierlo B, Ravelingien T, Langbeen J. Retrospective evaluation of an intervention bundle on OPAT implementation in a large non-university hospital. Acta Clin Belg 2024; 79:19-25. [PMID: 37927057 DOI: 10.1080/17843286.2023.2278237] [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: 08/04/2023] [Accepted: 10/29/2023] [Indexed: 11/07/2023]
Abstract
OBJECTIVES Optimization of outpatient parenteral antimicrobial therapy (OPAT) requires interdisciplinarity and an operational algorithm. This report retrospectively assesses the impact of a multimodal quality-enhancement intervention bundle on the implementation rate, efficacy, and safety of a home OPAT program in a Belgian large community-based hospital. METHODS OPAT recipients between 1 March 2019 and 30 June 2022 were included. The OPAT trajectories were divided into pre-intervention (from 1 March 2019 to 31 October 2020) and post-intervention (from 1 November 2020 to 30 June 2022) groups. The quality-enhancement intervention bundle consisted of the involvement of an infectious disease specialist, revision and implementation of a state-of-the-art prosthetic joint infection diagnosis and treatment protocol, weekly multidisciplinary discussion of all prosthetic joint infections, revision of the OPAT algorithm, and the introduction of teicoplanin as an OPAT-convenient antimicrobial. RESULTS Eighty-five patients were included in a total of 96 OPAT trajectories (n = 33 pre-intervention; n = 63 post-intervention). After the intervention, the number of OPAT trajectories nearly doubled. The number of patients with a recurrent infection within 6 months after OPAT completion decreased 15%. The overall 6-month mortality and readmission rates during OPAT treatment decreased 8% and 10%, respectively. Mortality during OPAT treatment did not change. These differences between pre- and post-intervention did not achieve statistical significance, despite the higher risk for complications in the post-intervention group because of increased infection complexity and required treatment duration. CONCLUSION Within a Belgian, single, large community-based hospital, a multimodal intervention bundle resulted in increases in OPAT implementation, infection complexity, and required treatment durations without statistically significant differences in outcomes.
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Affiliation(s)
| | - Dirk Vogelaers
- General Internal Medicine and Infectious Diseases, AZ Delta, Roeselare, Belgium
- Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium
| | | | | | | | | | - Jodie Langbeen
- General Internal Medicine and Infectious Diseases, AZ Delta, Roeselare, Belgium
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Hamad Y, Nickel KB, Olsen MA, George IA. Outcomes of Ceftriaxone Compared With Cefazolin or Nafcillin/Oxacillin for Outpatient Therapy for Methicillin-Sensitive Staphylococcus aureus Bloodstream Infections: Results From a Large United States Claims Database. Open Forum Infect Dis 2024; 11:ofad662. [PMID: 38352150 PMCID: PMC10863560 DOI: 10.1093/ofid/ofad662] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2023] [Accepted: 12/22/2023] [Indexed: 02/16/2024] Open
Abstract
Background Ceftriaxone is a convenient option for methicillin-sensitive Staphylococcus aureus (MSSA) outpatient parenteral antimicrobial therapy (OPAT), but population-based studies for its effectiveness are lacking. Methods In this retrospective cohort, a large insurance claims database was queried from 2010 to 2018 for adults with MSSA bloodstream infection (BSI). Patients discharged on OPAT on cefazolin or oxacillin/nafcillin were compared with ceftriaxone with respect to 90-day hospital readmission with the same infection category and 90-day all-cause readmission using logistic regression models. Results Of 1895 patients with MSSA BSI, 1435 (75.7%) patients received cefazolin, oxacillin, or nafcillin and 460 (24.3%) ceftriaxone. Readmission due to the same infection category occurred in 366 (19.3%), and all-cause readmission occurred in 535 (28.3%) within 90 days. Risk factors significantly associated with readmission with the same infection category were the oldest sampled age group (61-64 years: adjusted odds ratio [aOR], 1.47 [95% confidence interval {CI}, 1.01-2.14]), intensive care unit stay during index admission (aOR, 2.33 [95% CI, 1.81-3.01]), prosthetic joint infection (aOR, 1.96 [95% CI, 1.18-2.23]), central line-associated BSI (aOR, 1.72 [95% CI, 1.33-2.94]), and endocarditis (aOR, 1.63 [95% CI, 1.18-2.23]). Ceftriaxone was not associated with increased risk of readmission with the same infection category (aOR, 0.89 [95% CI, .67-1.18]), or 90-day all-cause readmission (aOR, 0.86 [95% CI, .66-1.10]) when compared with oxacillin/nafcillin/cefazolin. Conclusions In this cohort of MSSA BSI patients discharged on OPAT, there were no differences in outcomes of readmission with the same infection and 90-day all-cause readmission in patients treated with ceftriaxone compared to oxacillin/nafcillin or cefazolin. Patients with complicated BSIs such as endocarditis and epidural abscess were more likely to be prescribed cefazolin or oxacillin/nafcillin.
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Affiliation(s)
- Yasir Hamad
- Critical Care Medicine Department, National Institutes of Health, Bethesda, Maryland, USA
| | - Katelin B Nickel
- Division of Infectious Diseases, Department of Medicine, Washington University School of Medicine in St Louis, St Louis, Missouri, USA
| | - Margaret A Olsen
- Division of Infectious Diseases, Department of Medicine, Washington University School of Medicine in St Louis, St Louis, Missouri, USA
- Division of Public Health Sciences, Department of Surgery, Washington University School of Medicine in St Louis, St Louis, Missouri, USA
| | - Ige A George
- Division of Infectious Diseases, Department of Medicine, Washington University School of Medicine in St Louis, St Louis, Missouri, USA
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Bowhay TR, Tsang T, Wei JCZ, Edwik W, Fridman A, Hubber J, Jo JY, Mckay N, O'Brien C, Osmond-Wallam J, Smythe J, Crump JA, Arnold B. Oral antimicrobial therapy for cellulitis versus outpatient parenteral antimicrobial therapy: a single-centre audit of cellulitis outcomes. Intern Med J 2024; 54:320-327. [PMID: 37461382 DOI: 10.1111/imj.16173] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2022] [Accepted: 06/05/2023] [Indexed: 02/15/2024]
Abstract
BACKGROUND Cellulitis is a common acute skin and soft tissue infection that causes substantial morbidity and healthcare costs. AIMS To audit the impact on cellulitis management, regimen tolerability and outcomes of switching from outpatient parenteral antimicrobial therapy (OPAT) using intravenous (i.v.) cefazolin once daily plus probenecid to oral beta-lactam therapy (OBLT) using oral flucloxacillin plus probenecid. METHODS We undertook a retrospective audit on cellulitis management, regimen tolerability and outcomes at the Dunedin Public Hospital Emergency Department (ED) before and after a change of the local outpatient cellulitis treatment pathway from OPAT using i.v. cefazolin once daily plus probenecid to OBLT using oral flucloxacillin plus probenecid. RESULTS OPAT was used in 97/123 (78.9%) patients with cellulitis before compared to 1/70 (1.4%) after the pathway change (odds ratio (OR), 0.04, P < 0.01). OBLT was used in 26/123 (21.1%) patients with cellulitis before and 69/70 (98.6%) after (OR, 218.8, P < 0.01). Antimicrobial change due to intolerance occurred in 4/123 (3.2%) patients with cellulitis before and 4/70 (5.7%) after (OR, 1.8, P, not significant (NS)) the pathway change. Inpatient admission within 28 days occurred in 15/123 (12.2%) cellulitis patients before and 9/70 (12.9%) after (OR, 1.1, P, NS) the pathway change. CONCLUSIONS Implementation of a change in outpatient cellulitis treatment pathway resulted in a significant change in prescribing practice. Our findings suggest that OBLT was both tolerable and had similar outcomes to OPAT.
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Affiliation(s)
- Thomas R Bowhay
- Dunedin Public Hospital, Te Whatu Ora (Health New Zealand) Southern, Dunedin, New Zealand
- Centre for International Health, University of Otago, Dunedin, New Zealand
| | - Tiffany Tsang
- Dunedin School of Medicine, University of Otago, Dunedin, New Zealand
| | - Jeremy C Z Wei
- Dunedin School of Medicine, University of Otago, Dunedin, New Zealand
| | - Wafa Edwik
- Dunedin School of Medicine, University of Otago, Dunedin, New Zealand
| | - Avi Fridman
- Dunedin School of Medicine, University of Otago, Dunedin, New Zealand
| | - Julia Hubber
- Dunedin School of Medicine, University of Otago, Dunedin, New Zealand
| | - Jae Y Jo
- Dunedin School of Medicine, University of Otago, Dunedin, New Zealand
| | - Nicole Mckay
- Dunedin School of Medicine, University of Otago, Dunedin, New Zealand
| | - Catherine O'Brien
- Dunedin School of Medicine, University of Otago, Dunedin, New Zealand
| | - Joe Osmond-Wallam
- Dunedin School of Medicine, University of Otago, Dunedin, New Zealand
| | - James Smythe
- Dunedin School of Medicine, University of Otago, Dunedin, New Zealand
| | - John A Crump
- Centre for International Health, University of Otago, Dunedin, New Zealand
| | - Brendan Arnold
- Dunedin Public Hospital, Te Whatu Ora (Health New Zealand) Southern, Dunedin, New Zealand
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12
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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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Staples JA, Ho M, Ferris D, Liu G, Brubacher JR, Khan M, Daly-Grafstein D, Tran KC, Sutherland JM. Physician Financial Incentives for Use of Outpatient Intravenous Antimicrobial Therapy: An Interrupted Time Series Analysis. Clin Infect Dis 2023; 76:2098-2105. [PMID: 36795054 DOI: 10.1093/cid/ciad082] [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: 11/23/2022] [Revised: 01/15/2023] [Accepted: 02/09/2023] [Indexed: 02/17/2023] Open
Abstract
BACKGROUND In 2011, policymakers in British Columbia introduced a fee-for-service payment to incentivize infectious diseases physicians to supervise outpatient parenteral antimicrobial therapy (OPAT). Whether this policy increased use of OPAT remains uncertain. METHODS We conducted a retrospective cohort study using population-based administrative data over a 14-year period (2004-2018). We focused on infections that required intravenous antimicrobials for ≥10 days (eg, osteomyelitis, joint infection, endocarditis) and used the monthly proportion of index hospitalizations with a length of stay shorter than the guideline-recommended "usual duration of intravenous antimicrobials" (LOS < UDIVA) as a surrogate for population-level OPAT use. We used interrupted time series analysis to determine whether policy introduction increased the proportion of hospitalizations with LOS < UDIVA. RESULTS We identified 18 513 eligible hospitalizations. In the pre-policy period, 82.3% of hospitalizations exhibited LOS < UDIVA. Introduction of the incentive was not associated with a change in the proportion of hospitalizations with LOS < UDIVA, suggesting that the policy intervention did not increase OPAT use (step change, -0.06%; 95% confidence interval [CI], -2.69% to 2.58%; P = .97 and slope change, -0.001% per month; 95% CI, -.056% to .055%; P = .98). CONCLUSIONS The introduction of a financial incentive for physicians did not appear to increase OPAT use. Policymakers should consider modifying the incentive design or addressing organizational barriers to expanded OPAT use.
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Affiliation(s)
- John A Staples
- Department of Medicine, University of British Columbia, Vancouver, Canada
- Centre for Clinical Epidemiology & Evaluation, Vancouver, Canada
| | - Meghan Ho
- Department of Medicine, University of British Columbia, Vancouver, Canada
| | - Dwight Ferris
- Department of Medicine, University of British Columbia, Vancouver, Canada
| | - Guiping Liu
- Center for Health Services and Policy Research, School of Population and Public Health, University of British Columbia, Vancouver, Canada
| | - Jeffrey R Brubacher
- Department of Emergency Medicine, University of British Columbia, Vancouver, Canada
| | - Mayesha Khan
- Department of Medicine, University of British Columbia, Vancouver, Canada
| | - Daniel Daly-Grafstein
- Department of Medicine, University of British Columbia, Vancouver, Canada
- Department of Statistics, University of British Columbia, Vancouver, Canada
| | - Karen C Tran
- Department of Medicine, University of British Columbia, Vancouver, Canada
- Centre for Health Evaluation & Outcome Sciences, Vancouver, Canada
| | - Jason M Sutherland
- Center for Health Services and Policy Research, School of Population and Public Health, University of British Columbia, Vancouver, Canada
- Centre for Health Evaluation & Outcome Sciences, Vancouver, Canada
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Kutubi A, O'Brien L, Murphy B, Fitzpatrick P, Hurson C, Rajendran D, Feeney E, Mallon P, Waqas S. A single centre experience of prosthetic joint infection outcomes with outpatient parenteral antimicrobial therapy. Heliyon 2023; 9:e15212. [PMID: 37113779 PMCID: PMC10126847 DOI: 10.1016/j.heliyon.2023.e15212] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2022] [Revised: 03/26/2023] [Accepted: 03/29/2023] [Indexed: 04/29/2023] Open
Abstract
Objectives Prosthetic joint infection (PJI) is a serious complication following arthroplasties. This study assessed the clinical outcomes, readmission rates and financial impact of PJIs treated with outpatient parenteral antimicrobial therapy (OPAT). Methods The study used prospectively collected data from the OPAT patient database at a tertiary care Irish hospital for PJI cases managed between 2015 and 2020. Data was analyzed using IBM-SPSS. Results Forty-one patients with PJIs were managed via OPAT over five years, with median age of 71.6 years. Median duration of OPAT was 32 days. Hospital readmission occurred in 34% of cases. Reasons for readmission included progression of infection in 64.3%, unplanned reoperation in 21.4% and planned admission for joint revision in 14.3%. Type 2 Diabetes Mellitus (T2DM) was found to have a statistically significant association with unplanned readmission (OR 8.5, CI 95% 1.1-67.6; p < 0.01). OPAT saved a mean of 27.49 hospital-bed days per patient. 1,127 bed days were saved in total, estimating a total savings of 963,585 euros and median savings of 26,505 euros. Conclusions The readmission rate observed was comparable to international data. Most readmissions were related to primary infections rather than due to OPAT-specific complications. Our main findings were that patients with PJIs can be safely managed via OPAT, and the finding of association between T2DM and increased risk of readmission.
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Affiliation(s)
| | - Luke O'Brien
- St. Vincent's University Hospital, Elm Park, Dublin 4, Ireland
| | - Ben Murphy
- St. Vincent's University Hospital, Elm Park, Dublin 4, Ireland
| | - Patricia Fitzpatrick
- St. Vincent's University Hospital, Elm Park, Dublin 4, Ireland
- University College Dublin, Belfield, Dublin 4, Ireland
| | - Conor Hurson
- St. Vincent's University Hospital, Elm Park, Dublin 4, Ireland
| | - Deepa Rajendran
- St. Vincent's University Hospital, Elm Park, Dublin 4, Ireland
| | - Eoin Feeney
- St. Vincent's University Hospital, Elm Park, Dublin 4, Ireland
- University College Dublin, Belfield, Dublin 4, Ireland
| | - Patrick Mallon
- St. Vincent's University Hospital, Elm Park, Dublin 4, Ireland
- University College Dublin, Belfield, Dublin 4, Ireland
| | - Sarmad Waqas
- St. Vincent's University Hospital, Elm Park, Dublin 4, Ireland
- University College Dublin, Belfield, Dublin 4, Ireland
- Tallaght University Hospital, Dublin 24, Ireland
- Trinity College Dublin, Dublin 2, Ireland
- Corresponding author.
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15
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Identifying and addressing social determinants of health in pediatric outpatient parenteral antimicrobial therapy. Infect Control Hosp Epidemiol 2023; 44:850-852. [PMID: 36891954 DOI: 10.1017/ice.2023.36] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/10/2023]
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16
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A Multidisciplinary Approach to Outpatient Parenteral Antimicrobial Therapy Care. INFECTIOUS DISEASES IN CLINICAL PRACTICE 2023. [DOI: 10.1097/ipc.0000000000001254] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/06/2023]
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17
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Agnihotri G, Gross AE, Seok M, Yen CY, Khan F, Ebbitt LM, Gay C, Bleasdale SC, Sikka MK, Trotter AB. Decreased hospital readmissions after programmatic strengthening of an outpatient parenteral antimicrobial therapy (OPAT) program. ANTIMICROBIAL STEWARDSHIP & HEALTHCARE EPIDEMIOLOGY : ASHE 2023; 3:e33. [PMID: 36865701 PMCID: PMC9972539 DOI: 10.1017/ash.2022.330] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 08/03/2022] [Revised: 10/14/2022] [Accepted: 10/17/2022] [Indexed: 06/18/2023]
Abstract
OBJECTIVE To determine whether a structured OPAT program supervised by an infectious disease physician and led by an OPAT nurse decreased hospital readmission rates and OPAT-related complications and whether it affected clinical cure. We also evaluated predictors of readmission while receiving OPAT. PATIENTS A convenience sample of 428 patients admitted to a tertiary-care hospital in Chicago, Illinois, with infections requiring intravenous antibiotic therapy after hospital discharge. METHODS In this retrospective, quasi-experimental study, we compared patients discharged on intravenous antimicrobials from an OPAT program before and after implementation of a structured ID physician and nurse-led OPAT program. The preintervention group consisted of patients discharged on OPAT managed by individual physicians without central program oversight or nurse care coordination. All-cause and OPAT-related readmissions were compared using the χ2 test. Factors associated with readmission for OPAT-related problems at a significance level of P < .10 in univariate analysis were eligible for testing in a forward, stepwise, multinomial, logistic regression to identify independent predictors of readmission. RESULTS In total, 428 patients were included in the study. Unplanned OPAT-related hospital readmissions decreased significantly after implementation of the structured OPAT program (17.8% vs 7%; P = .003). OPAT-related readmission reasons included infection recurrence or progression (53%), adverse drug reaction (26%), or line-associated issues (21%). Independent predictors of hospital readmission due to OPAT-related events included vancomycin administration and longer length of outpatient therapy. Clinical cure increased from 69.8% before the intervention to 94.9% after the intervention (P < .001). CONCLUSION A structured ID physician and nurse-led OPAT program was associated with a decrease in OPAT-related readmissions and improved clinical cure.
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Affiliation(s)
- Gaurav Agnihotri
- College of Medicine, University of Illinois at Chicago, Chicago, Illinois
| | - Alan E. Gross
- Department of Pharmacy Practice, College of Pharmacy, University of Illinois at Chicago, Chicago, Illinois
| | - Minji Seok
- College of Medicine, University of Illinois at Chicago, Chicago, Illinois
| | - Cheng Yu Yen
- Department of Pharmacy Practice, College of Pharmacy, University of Illinois at Chicago, Chicago, Illinois
| | - Farah Khan
- Department of Pharmacy Practice, College of Pharmacy, University of Illinois at Chicago, Chicago, Illinois
| | - Laura M. Ebbitt
- College of Pharmacy, University of Kentucky, Lexington, Kentucky
| | - Cassandra Gay
- Division of Infectious Disease, Department of Medicine, College of Medicine, University of Illinois at Chicago, Chicago, Illinois
| | - Susan C. Bleasdale
- Division of Infectious Disease, Department of Medicine, College of Medicine, University of Illinois at Chicago, Chicago, Illinois
| | - Monica K. Sikka
- Division of Infectious Disease, Department of Medicine, Oregon Health & Science University, Portland, Oregon
| | - Andrew B. Trotter
- Division of Infectious Disease, Department of Medicine, College of Medicine, University of Illinois at Chicago, Chicago, Illinois
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18
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Rajaratnam D, Rajaratnam R. Outpatient Parenteral Antimicrobial Therapy for Infective Endocarditis-Model of Care. Antibiotics (Basel) 2023; 12:antibiotics12020355. [PMID: 36830266 PMCID: PMC9952299 DOI: 10.3390/antibiotics12020355] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2022] [Revised: 02/01/2023] [Accepted: 02/06/2023] [Indexed: 02/11/2023] Open
Abstract
Infective endocarditis (IE) is a serious infectious disease with significant mortality and morbidity placing a burden on healthcare systems. Outpatient antimicrobial therapy in selected patients has been shown to be safe and beneficial to both patients and the healthcare system. In this article, we review the literature on the model of care for outpatient parenteral antimicrobial therapy in infective endocarditis and propose that systems of care be developed based on local resources and all patients admitted with infective endocarditis be screened appropriately for outpatient antimicrobial therapy.
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Affiliation(s)
| | - Rohan Rajaratnam
- Liverpool Hospital, Sydney, NSW 2170, Australia
- School of Medicine, Western Sydney University, Campbelltown Campus, Sydney, NSW 2560, Australia
- School of Medicine, Southwest Clinical School, The University of New South Wales, Sydney, NSW 2170, Australia
- Correspondence:
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19
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Nodoushani AY, Wang Y, Datar Y, Mohnot J, Karlson KJ, Edwards NM, Yin K, Dobrilovic N. Association of Intravenous Drug Use and Length of Stay Following Infective Endocarditis. J Surg Res 2023; 282:239-245. [PMID: 36332302 DOI: 10.1016/j.jss.2022.10.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2022] [Revised: 09/13/2022] [Accepted: 10/07/2022] [Indexed: 11/23/2022]
Abstract
INTRODUCTION Intravenous drug use (IVDU) and associated infective endocarditis (IE) has been on the rise in the US since the beginning of the opioid epidemic. IVDU-IE has high morbidity and mortality, and treatment can be lengthy. We aim to quantify the association between IVDU and length of stay (LOS) in IE patients. METHODS The National Inpatient Sample database was used to identify IE patients, which was then stratified into IVDU-IE and non-IVDU-IE groups. Weighted values of hospitalizations were used to generate national estimates. Multivariable linear and logistic regression analyses were applied to estimate the effects of IVDU on LOS. RESULTS We identified 1,114,257 adult IE patients, among which 123,409 (11.1%) were IVDU-IE. Compared to non-IVDU-IE patients, IVDU-IE patients were younger, had fewer comorbidities, and had an overall longer LOS (median [interquartile range]: 10 [5-20] versus 7 [4-13] d, P < 0.001), with a greater percentage of patients with a LOS longer than 30 d (13.7% versus 5.7%, P < 0.001). After adjusting for multiple demographic and clinical factors, IVDU was independently associated with a 1.25-d increase in LOS (beta-coefficient = 1.25, 95% confidence interval [CI]: 0.95-1.54, P < 0.001) and 35% higher odds of being hospitalized for more than 30 d (odds ratio = 1.35, 95% CI: 1.27-1.44, P < 0.001). CONCLUSIONS Among IE patients, being IVDU has associated with a longer LOS and a higher risk of prolonged hospital stay. Steps toward the prevention of IE in the IVDU population should be taken to avoid an undue burden on the healthcare system.
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Affiliation(s)
- Ariana Y Nodoushani
- Division of Cardiothoracic Surgery, Boston Medical Center, Boston University School of Medicine, Boston, Massachusetts
| | - Yunda Wang
- Division of Cardiothoracic Surgery, Boston Medical Center, Boston University School of Medicine, Boston, Massachusetts
| | - Yesh Datar
- Division of Cardiothoracic Surgery, Boston Medical Center, Boston University School of Medicine, Boston, Massachusetts
| | - Joy Mohnot
- Division of Cardiothoracic Surgery, Boston Medical Center, Boston University School of Medicine, Boston, Massachusetts
| | - Karl J Karlson
- Division of Cardiothoracic Surgery, Boston Medical Center, Boston University School of Medicine, Boston, Massachusetts
| | - Niloo M Edwards
- Division of Cardiothoracic Surgery, Boston Medical Center, Boston University School of Medicine, Boston, Massachusetts
| | - Kanhua Yin
- Department of Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Nikola Dobrilovic
- Division of Cardiac Surgery, NorthShore University HealthSystem, Chicago, Illinois.
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Johnson TM, Whitman Webster LC, Mehta M, Johnson JE, Cortés-Penfield N, Rivera CG. Pushing the agenda for intravenous push administration in outpatient parenteral antimicrobial therapy. Ther Adv Infect Dis 2023; 10:20499361231193920. [PMID: 37600976 PMCID: PMC10434178 DOI: 10.1177/20499361231193920] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Accepted: 07/25/2023] [Indexed: 08/22/2023] Open
Abstract
Intravenous push (IVP) antimicrobial administration refers to rapid bolus infusion of medication. This drug delivery method offers improved patient convenience, superior patient and nursing satisfaction, and cost savings when used in outpatient parenteral antimicrobial therapy (OPAT). Antimicrobial agents must demonstrate optimal physiochemical and pharmacologic characteristics, as well as sufficient syringe stability, to be administered in this manner. Additionally, impacts on medication tolerability, patient safety, and effectiveness must be considered. This narrative review summarizes the available data and practical implications of IVP administration of antimicrobials in the OPAT setting.
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Affiliation(s)
- Tanner M. Johnson
- Department of Pharmacy, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA
| | | | - Meera Mehta
- West Virginia University Hospitals, Morgantown, WV, USA
| | - Jessica E. Johnson
- Department of Medicine, Section of Infectious Diseases, West Virginia University, Morgantown, WV, USA
| | | | - Christina G. Rivera
- Department of Pharmacy, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA
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21
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Bradley AC, Wingler MJB, Artman KL, Ward LM, Lucar J. An evaluation of risk factors for readmission in patients receiving outpatient parenteral antimicrobial therapy. Ther Adv Infect Dis 2023; 10:20499361231195966. [PMID: 37667754 PMCID: PMC10475225 DOI: 10.1177/20499361231195966] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2023] [Accepted: 08/02/2023] [Indexed: 09/06/2023] Open
Abstract
Background Outpatient parenteral antimicrobial therapy (OPAT), when required, is beneficial to patients and healthcare systems by reducing hospital length-of-stay, providing cost savings, and improving patient satisfaction. Objectives The purpose of this study is to determine readmission rates and associated risk factors in patients receiving OPAT at home. Methods This retrospective study included hospitalized patients 15 years and older who were discharged on intravenous antimicrobial therapy via OPAT at home between January 2018 and December 2019. Patients receiving antimicrobials at a skilled nursing facility, long-term acute care, or dialysis center, and those who began OPAT at home directly from the outpatient setting were excluded. The primary outcome of this study was all-cause 30-day readmission rate. Secondary outcomes included 90-day readmission rate, rates of complications related to OPAT, emergency department visits during OPAT, and predictors of all-cause 30-day readmission through a logistic regression analysis. Results Two hundred individual patients were included in the analysis; 60% were male and the mean age was 49 years. The most common indications for OPAT at home were bone and joint infection (52%) and bacteremia (26%). Forty patients (20%) experienced an unplanned, all-cause 30-day readmission, with a total of 48 readmission events. Of the 40 patients who were readmitted within 30 days, 20 (50%) were due to non-OPAT related reasons. Sixty patients (30%) experienced an OPAT-related complication, and chronic kidney disease was found to be an independent predictor of readmission (OR: 2.8, 95% CI: 1.0-7.6). Conclusions Patients receiving OPAT at home are at increased risk for early hospital readmission, but it is often due to reasons not associated with OPAT. Patients with chronic kidney disease beginning OPAT at home should be closely monitored after discharge.
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Affiliation(s)
- Abby C. Bradley
- Department of Pharmacy, University of Mississippi Medical Center, Jackson, MS, USA
- Department of Pharmacy, Ascension St. Vincent’s East, Birmingham, AL, USA
| | - Mary Joyce B. Wingler
- Department of Antimicrobial Stewardship, University of Mississippi Medical Center, 2500 N State Street, Jackson, MS 39216-4505, USA
| | - Katherine L. Artman
- Department of Pharmacy, University of Mississippi Medical Center, Jackson, MS, USA
| | - Lori M. Ward
- Department of Population Health Science, University of Mississippi Medical Center, Jackson, MS, USA
| | - Jose Lucar
- Division of Infectious Diseases, Department of Medicine, University of Mississippi Medical Center, Jackson, MS, USA
- Division of Infectious Diseases, Department of Medicine, The George Washington University, Washington, DC, USA
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22
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Billmeyer KN, Ross JK, Hirsch EB, Evans MD, Kline SE, Galdys AL. Predictors of adverse safety events and unscheduled care among an outpatient parenteral antimicrobial therapy (OPAT) patient cohort. Ther Adv Infect Dis 2023; 10:20499361231179668. [PMID: 37332294 PMCID: PMC10272639 DOI: 10.1177/20499361231179668] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Accepted: 05/16/2023] [Indexed: 06/20/2023] Open
Abstract
Background Select circumstances require outpatient parenteral antimicrobial therapy (OPAT). The potency of OPAT agents presents an increased risk of adverse events and unscheduled medical care. We analyzed these outcomes among OPAT recipients as part of the implementation of a collaborative OPAT program. Methods Adult patients discharged home from an academic hospital with OPAT between January 2019 and June 2021 were included in this retrospective cohort; participants discharged between June 2020 and June 2021 were part of the collaborative OPAT program. Patients with cystic fibrosis were excluded. Data on patient characteristics and outcomes were collected from electronic medical records by two reviewers. Multivariable analysis was conducted to identify predictors of vascular access device (VAD) complications, adverse drug events (ADEs), and OPAT-related emergency department (ED) visits and rehospitalizations. Results Among 265 patients included in the cohort, 57 (21.5%) patients experienced a VAD complication; obesity [odds ratio (OR): 3.32; 95% confidence interval (CI): 1.38-8.73; p = 0.01) and multi-drug therapy (OR: 2.56; 95% CI: 1.21-5.39; p = 0.01) were associated with an increased odds of VAD complication. Eighty-two (30.9%) participants experienced an ADE; 30 (11.3%) experienced a severe/serious ADE. Lipo/glycopeptide receipt, (OR: 5.28; 95% CI: 1.89-15.43; p < 0.01) and Black/African American race (OR: 4.85; 95% (CI): 1.56-15.45; p < 0.01) were associated with an increased odds of severe/serious ADE. Inclusion in the OPAT collaborative was associated with a decreased odds of severe/serious ADE (OR: 0.26; 95% CI: 0.08-0.77; p = 0.01). Fifty-eight (21.9%) patients experienced an OPAT-related ED visit and 53 (20.0%) experienced an OPAT-related rehospitalization. VAD complication (OR: 2.37; 95% (CI): 1.15-4.86, p = 0.02) and ADEs (OR: 2.19; CI: 1.13-4.22; p = 0.02) were associated with OPAT-related ED visits. ADE was associated with 90-day OPAT-related rehospitalization (OR: 3.21; (CI): 1.59-6.58; p < 0.01). Conclusion Adverse safety events and OPAT-related unscheduled care occurred often in our cohort. A structured OPAT program that includes ID pharmacist antibiotic reconciliation may reduce rates of ADEs.
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Affiliation(s)
| | - Jennifer K. Ross
- M Health Fairview University of Minnesota Medical Center, Minneapolis, MN, USA
| | | | - Michael D. Evans
- Clinical and Translational Science Institute, University of Minnesota, Minneapolis, MN, USA
| | - Susan E. Kline
- M Health Fairview University of Minnesota Medical Center, Minneapolis, MN, USA
- University of Minnesota Medical School, Minneapolis, MN, USA
| | - Alison L. Galdys
- Division of Infectious Diseases and International Medicine, Department of Medicine, Medical School, University of Minnesota, 420 Delaware Street SE, Mayo Mail Code 250, Minneapolis, MN 55455, USA
- M Health Fairview University of Minnesota Medical Center, Minneapolis, MN, USA
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Scholten N, Leisse C, Brandes V, Oberröhrmann C, Ihle P, Peter S, Hagemeier A, Hellmich M, Lindemann CH, Samel C, Pfaff H, Lehmann C. Outpatient parenteral antimicrobial therapy in Germany: a prospective cohort study protocol. BMJ Open 2022; 12:e061417. [PMID: 36375971 PMCID: PMC9664305 DOI: 10.1136/bmjopen-2022-061417] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
INTRODUCTION Outpatient parenteral antimicrobial therapy (OPAT) means intravenous administration of antibiotics outside the hospital. The antibiotics are administered at the patient's home. The advantages are the shortening of the inpatient stay, which means that patients can remain in their familiar environment, the reduction of nosocomial infections as well as the reduction of hospital and therapy costs. Nevertheless, OPAT is rarely performed in Germany, despite its international application. Therefore, systematic data on OPAT are not available in Germany. The project objective is to investigate the medical care using OPAT under medical, epidemiological and economic aspects within the framework of the Cologne Network of Infectious Diseases. METHODS AND ANALYSIS Observational study with mixed-methods approach, qualitative analysis to identify physician-side factors to assess the attitude of general practitioners in Cologne with regard to possible implementation barriers of an OPAT. Longitudinal analysis of an OPAT patient cohort with respect to clinical and patient-relevant outcomes using descriptive and conclusive statistics. ETHICS AND DISSEMINATION The study has been approved by the Institutional Review Board of the University of Cologne, Germany (19-1284-1). Written informed consent was obtained from all participants. The results will be submitted for publication in a peer-reviewed journal and presented at one or more scientific conferences. TRIAL REGISTRATION NUMBER NCT04002453.
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Affiliation(s)
- Nadine Scholten
- University of Cologne, Faculty of Human Sciences & Faculty of Medicine and University Hospital Cologne, Institute of Medical Sociology, Health Services Research, and Rehabilitation Science, Cologne, Germany
| | - Charlotte Leisse
- Department I of Internal Medicine, Medical Faculty and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Vanessa Brandes
- Department I of Internal Medicine, Medical Faculty and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Charlotte Oberröhrmann
- University of Cologne, Faculty of Human Sciences & Faculty of Medicine and University Hospital Cologne, Institute of Medical Sociology, Health Services Research, and Rehabilitation Science, Cologne, Germany
| | - Peter Ihle
- PMV research group at the Department of Psychiatry and Psychotherapy for Children and Young Adults, Faculty of Medicine and University Hospital Cologne, Cologne, Germany
| | - Sophie Peter
- University of Cologne, Faculty of Human Sciences & Faculty of Medicine and University Hospital Cologne, Institute of Medical Sociology, Health Services Research, and Rehabilitation Science, Cologne, Germany
| | - Anna Hagemeier
- Institute of Medical Statistics and Computational Biology (IMSB), Medical Faculty, University of Cologne, Cologne, Germany
| | - Martin Hellmich
- Institute of Medical Statistics and Computational Biology (IMSB), Medical Faculty, University of Cologne, Cologne, Germany
| | - Christoph H Lindemann
- Department II of Internal Medicine and Center for Molecular Medicine Cologne, University of Cologne, Faculty of Medicine and University Hospital Cologne, Cologne, Germany
| | - Christina Samel
- Institute of Medical Statistics and Computational Biology (IMSB), Medical Faculty, University of Cologne, Cologne, Germany
| | - Holger Pfaff
- University of Cologne, Faculty of Human Sciences & Faculty of Medicine and University Hospital Cologne, Institute of Medical Sociology, Health Services Research, and Rehabilitation Science, Cologne, Germany
| | - Clara Lehmann
- Department I of Internal Medicine, Medical Faculty and University Hospital Cologne, University of Cologne, Cologne, Germany
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24
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Zinzi D, Vlachaki I, Falla E, Mantopoulos T, Nathwani D. Cost-minimisation analysis of oritavancin for the treatment of acute bacterial skin and skin structure infections from a United Kingdom perspective. THE EUROPEAN JOURNAL OF HEALTH ECONOMICS : HEPAC : HEALTH ECONOMICS IN PREVENTION AND CARE 2022; 23:1371-1381. [PMID: 35113269 PMCID: PMC9550763 DOI: 10.1007/s10198-022-01432-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 03/05/2021] [Accepted: 01/11/2022] [Indexed: 06/14/2023]
Abstract
BACKGROUND Early discharge (ED) from hospital and outpatient parenteral antibiotic therapy (OPAT) are effective approaches for the management of a range of infections, including acute bacterial skin and skin structure infections (ABSSSI). Strategies that facilitate ED, thereby reducing complications such as healthcare-acquired infection whilst enhancing patient quality of life, are being increasingly adopted in line with good antimicrobial stewardship practice. This study presents a cost-minimisation analysis for the use of oritavancin at ED versus relevant comparators from a National Health Service (NHS) and personal and social services United Kingdom perspective. METHODS A cost-minimisation model considering adult patients with ABSSSI with suspected or confirmed methicillin-resistant Staphylococcus aureus (MRSA) infection, was developed based on publicly available NHS costs, practice guidelines for ABSSSI and clinical expert's opinion. Cost of treatment and treatment days were compared for oritavancin at ED to dalbavancin, teicoplanin, daptomycin and linezolid. RESULTS Following the empiric use of either flucloxacillin or vancomycin in the inpatient setting, oritavancin was compared to OPAT with dalbavancin, teicoplanin and daptomycin, and oral linezolid from day 4 of treatment. Oritavancin at ED reduced treatment duration by 0.8 days and led to cost savings of £281 in comparison to dalbavancin. In comparison to teicoplanin, daptomycin and linezolid, oritavancin reduced treatment duration by 5 days, with marginally higher costs (£446, £137, and £1,434, respectively). CONCLUSION Oritavancin, used to support ED, is associated with lower costs compared with dalbavancin and reduced treatment duration relative to all comparators. Its use would support an ED approach in MRSA ABSSSI management.
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Affiliation(s)
| | | | - Edel Falla
- EMEA Real World Methods and Evidence Generation, IQVIA Ltd, London, UK
| | - Theo Mantopoulos
- EMEA Real World Methods and Evidence Generation, IQVIA Ltd, Athens, Greece.
| | - Dilip Nathwani
- Medical School, University of Dundee, Dundee, DD19SY, UK
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25
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Moore N, Kohut M, Stoddard H, Burris D, Chessa F, Sikka MK, Solomon D, Kershaw CM, Eaton E, Hutchinson R, Fairfield KM, Stopka TJ, Friedmann P, Thakarar K. Health care professional perspectives on discharging hospitalized patients with injection drug use-associated infections. Ther Adv Infect Dis 2022; 9:20499361221126868. [PMID: 36225855 PMCID: PMC9549088 DOI: 10.1177/20499361221126868] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2022] [Accepted: 08/30/2022] [Indexed: 11/07/2022] Open
Abstract
Background: Patients with injection drug use (IDU)-associated infections traditionally
experience prolonged hospitalizations, which often result in negative
experiences and bad outcomes. Harm reduction approaches that value patient
autonomy and shared decision-making regarding outpatient treatment options
may improve outcomes. We sought to identify health care professionals (HCPs)
perspectives on the barriers to offering four different options to
hospitalized people who use drugs (PWUD): long-term hospitalization, oral
antibiotics, long-acting antibiotics at an infusion center, and outpatient
parenteral antibiotics. Methods: We recruited HCPs (n = 19) from a single tertiary care
center in Portland, Maine. We interviewed HCPs involved with discharge
decision-making and other HCPs involved in the specialized care of PWUD.
Semi-structured interviews elicited lead HCP values, preferences, and
concerns about presenting outpatient antimicrobial treatment options to
PWUD, while support HCPs provided contextual information. We used the
iterative categorization approach to code and thematically analyze
transcripts. Results: HCPs were willing to present outpatient treatment options for patients with
IDU-associated infections, yet several factors contributed to reluctance.
First, insufficient resources, such as transportation, may make these
options impractical. However, HCPs may be unaware of existing community
resources or viable treatment options. They also may believe the hospital
protects patients, and that discharging patients into the community exposes
them to structural harms. Some HCPs are concerned that patients with
substance use disorder will not make ‘good’ decisions regarding outpatient
antimicrobial options. Finally, there is uncertainty about how
responsibility for offering outpatient treatment is shared across changing
care teams. Conclusion: HCPs perceive many barriers to offering outpatient care for people with
IDU-associated infections, but with appropriate interventions to address
their concerns, may be open to considering more options. This study provides
important insights and contextual information that can help inform specific
harm reduction interventions aimed at improving care of people with
IDU-associated infections.
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Affiliation(s)
- Nichole Moore
- Tufts University School of Medicine, Boston,
MA, USA
| | - Michael Kohut
- Center for Interdisciplinary Population and
Health Research, MaineHealth Institute for Research, Portland, ME, USA
| | - Henry Stoddard
- Center for Interdisciplinary Population and
Health Research, MaineHealth Institute for Research, Portland, ME, USA
| | - Debra Burris
- Center for Interdisciplinary Population and
Health Research, MaineHealth Institute for Research, Portland, ME, USA
| | - Frank Chessa
- Tufts University School of Medicine, Boston,
MA, USA
| | - Monica K. Sikka
- Division of Infectious Diseases, Department of
Medicine, Oregon Health & Science University, Portland, OR, USA
| | - Daniel Solomon
- Division of Infectious Disease, Brigham and
Women’s Hospital, Boston, MA, USA
| | - Colleen M. Kershaw
- Section of Infectious Disease and International
Health, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA,Geisel School of Medicine at Dartmouth,
Hanover, NH, USA
| | - Ellen Eaton
- Division of Infectious Disease, The University
of Alabama at Birmingham, Birmingham, AL, USA
| | - Rebecca Hutchinson
- Tufts University School of Medicine, Boston,
MA, USA,Center for Interdisciplinary Population and
Health Research, MaineHealth Institute for Research, Portland, ME, USA,Maine Medical Center, Portland, ME, USA
| | - Kathleen M. Fairfield
- Tufts University School of Medicine, Boston,
MA, USA,Center for Interdisciplinary Population and
Health Research, MaineHealth Institute for Research, Portland, ME, USA,Maine Medical Center, Portland, ME, USA
| | - Thomas J. Stopka
- Department of Public Health & Community
Medicine, Tufts University School of Medicine, Boston, MA, USA
| | - Peter Friedmann
- Office of Research, UMass Chan Medical
School-Baystate, Springfield, MA, USA,Frank Chessa is also affiliated to MaineHealth
Institute for Research, Portland, ME, USA; Maine Medical Center, Portland,
ME, USA
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26
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Baddour LM, Weimer MB, Wurcel AG, McElhinney DB, Marks LR, Fanucchi LC, Esquer Garrigos Z, Pettersson GB, DeSimone DC. Management of Infective Endocarditis in People Who Inject Drugs: A Scientific Statement From the American Heart Association. Circulation 2022; 146:e187-e201. [PMID: 36043414 DOI: 10.1161/cir.0000000000001090] [Citation(s) in RCA: 41] [Impact Index Per Article: 20.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
BACKGROUND The American Heart Association has sponsored both guidelines and scientific statements that address the diagnosis, management, and prevention of infective endocarditis. As a result of the unprecedented and increasing incidence of infective endocarditis cases among people who inject drugs, the American Heart Association sponsored this original scientific statement. It provides a more in-depth focus on the management of infective endocarditis among this unique population than what has been provided in prior American Heart Association infective endocarditis-related documents. METHODS A writing group was named and consisted of recognized experts in the fields of infectious diseases, cardiology, addiction medicine, and cardiovascular surgery in October 2021. A literature search was conducted in Embase on November 19, 2021, and multiple terms were used, with 1345 English-language articles identified after removal of duplicates. CONCLUSIONS Management of infective endocarditis in people who inject drugs is complex and requires a unique approach in all aspects of care. Clinicians must appreciate that it requires involvement of a variety of specialists and that consultation by addiction-trained clinicians is as important as that of more traditional members of the endocarditis team to improve infective endocarditis outcomes. Preventive measures are critical in people who inject drugs and are cured of an initial bout of infective endocarditis because they remain at extremely high risk for subsequent bouts of infective endocarditis, regardless of whether injection drug use is continued.
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27
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Bouji N, Wen S, Dietz M. Intravenous antibiotic duration in the treatment of prosthetic joint infection: systematic review and meta-analysis. J Bone Jt Infect 2022; 7:191-202. [PMID: 36267262 PMCID: PMC9562697 DOI: 10.5194/jbji-7-191-2022] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2022] [Accepted: 08/20/2022] [Indexed: 08/22/2023] Open
Abstract
Introduction: Long antibiotic courses, including intravenous (IV) and oral administrations, are utilized in prosthetic joint infection (PJI) treatment. This meta-analysis examines the non-inferiority of short courses ( < 4 weeks) of IV antibiotics compared to long courses in treating PJI. Critical review of IV treatment is necessary due to the clinical, physical, and financial burden associated with it and its continued prolonged use in the US without much evidence to support the practice. Methods: Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA), databases were searched using predefined medical subject headings (MeSH). Results: The nine included studies reported 521 total hip arthroplasties (THAs) and 530 total knee arthroplasties (TKAs). There was no significant difference in the overall success rate in short- vs. long-duration IV antibiotics for PJI treatment: odds ratio (OR) of 1.65, 95 % confidence interval (CI) of 0.78-3.46, and p = 0 .18. However, due to the moderate to high heterogeneity (I 2 = 68 %, p < 0.01) amongst studies, an adjusted success rate was calculated after the exclusion of two studies. This showed a statistically significant difference between both groups (OR of 2.45, 95 % CI of 1.21-4.96, p < 0.001) favoring a short course of antibiotics and reflecting a more homogenous population (I 2 = 51 %, p = 0 .06). Conclusion: This study highlights the limited data available for evaluating IV antibiotic duration in the setting of PJI. We found that a shorter duration of IV antibiotics was non-inferior to a longer duration, with an improved OR of 2.45 for treatment success, likely shortening inpatient stay as well as lessening side effects and antimicrobial resistance with a lower cost to patients and overall healthcare.
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Affiliation(s)
- Nour Bouji
- Department of Orthopaedics, School of
Medicine, West Virginia University, Morgantown, WV 26506, USA
| | - Sijin Wen
- Department of Epidemiology and BioStatistics, School of Public Health, West Virginia University, Morgantown, WV 26506, USA
| | - Matthew J. Dietz
- Department of Orthopaedics, School of
Medicine, West Virginia University, Morgantown, WV 26506, USA
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Ortonobes S, Mujal-Martínez A, de Castro Julve M, González-Sánchez A, Jiménez-Pérez R, Hernández-Ávila M, De Alfonso N, Maye-Pérez I, Valle-Delmás T, Rodríguez-Sánchez A, Pino-García J, Gómez-Valent M. Successful Integration of Clinical Pharmacists in an OPAT Program: A Real-Life Multidisciplinary Circuit. Antibiotics (Basel) 2022; 11:1124. [PMID: 36009993 PMCID: PMC9404975 DOI: 10.3390/antibiotics11081124] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2022] [Revised: 08/08/2022] [Accepted: 08/16/2022] [Indexed: 11/16/2022] Open
Abstract
Outpatient parenteral antimicrobial therapy (OPAT) programs encompass a range of healthcare processes aiming to treat infections at home, with the preferential use of the intravenous route. Although several barriers arise during the implementation of OPAT circuits, recent cumulative data have supported the effectiveness of these programs, demonstrating their application in a safe and cost-effective manner. Given that OPAT is evolving towards treating patients with higher complexity, a multidisciplinary team including physicians, pharmacists, and nursing staff should lead the program. The professionals involved require previous experience in infectious diseases treatment as well as in outpatient healthcare and self-administration. As we describe here, clinical pharmacists exert a key role in OPAT multidisciplinary teams. Their intervention is essential to optimize antimicrobial prescriptions through their participation in stewardship programs as well as to closely follow patients from a pharmacotherapeutic perspective. Moreover, pharmacists provide specialized counseling on antimicrobial treatment technical compounding. In fact, OPAT elaboration in sterile environments and pharmacy department clean rooms increases OPAT stability and safety, enhancing the quality of the program. In summary, building multidisciplinary teams with the involvement of clinical pharmacists improves the management of home-treated infections, promoting a safe self-administration and increasing OPAT patients' quality of life.
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Affiliation(s)
- Sara Ortonobes
- Pharmacy Department, Consorci Corporació Sanitària Parc Taulí, Universitat Autònoma de Barcelona, 08208 Sabadell, Barcelona, Spain
- Parc Taulí Research and Innovation Institute Foundation (I3PT), 08028 Sabadell, Barcelona, Spain
| | - Abel Mujal-Martínez
- Parc Taulí Research and Innovation Institute Foundation (I3PT), 08028 Sabadell, Barcelona, Spain
- Hospital at Home Unit, Consorci Corporació Sanitària Parc Taulí, Universitat Autònoma de Barcelona, 08208 Sabadell, Barcelona, Spain
| | - María de Castro Julve
- Pharmacy Department, Consorci Corporació Sanitària Parc Taulí, Universitat Autònoma de Barcelona, 08208 Sabadell, Barcelona, Spain
- Parc Taulí Research and Innovation Institute Foundation (I3PT), 08028 Sabadell, Barcelona, Spain
| | - Alba González-Sánchez
- Hospital at Home Unit, Consorci Corporació Sanitària Parc Taulí, Universitat Autònoma de Barcelona, 08208 Sabadell, Barcelona, Spain
| | - Rafael Jiménez-Pérez
- Hospital at Home Unit, Consorci Corporació Sanitària Parc Taulí, Universitat Autònoma de Barcelona, 08208 Sabadell, Barcelona, Spain
| | - Manuel Hernández-Ávila
- Hospital at Home Unit, Consorci Corporació Sanitària Parc Taulí, Universitat Autònoma de Barcelona, 08208 Sabadell, Barcelona, Spain
| | - Natalia De Alfonso
- Hospital at Home Unit, Consorci Corporació Sanitària Parc Taulí, Universitat Autònoma de Barcelona, 08208 Sabadell, Barcelona, Spain
| | - Ingrid Maye-Pérez
- Hospital at Home Unit, Consorci Corporació Sanitària Parc Taulí, Universitat Autònoma de Barcelona, 08208 Sabadell, Barcelona, Spain
| | - Teresa Valle-Delmás
- Hospital at Home Unit, Consorci Corporació Sanitària Parc Taulí, Universitat Autònoma de Barcelona, 08208 Sabadell, Barcelona, Spain
| | - Alba Rodríguez-Sánchez
- Hospital at Home Unit, Consorci Corporació Sanitària Parc Taulí, Universitat Autònoma de Barcelona, 08208 Sabadell, Barcelona, Spain
| | - Jessica Pino-García
- Pharmacy Department, Consorci Corporació Sanitària Parc Taulí, Universitat Autònoma de Barcelona, 08208 Sabadell, Barcelona, Spain
| | - Mònica Gómez-Valent
- Pharmacy Department, Consorci Corporació Sanitària Parc Taulí, Universitat Autònoma de Barcelona, 08208 Sabadell, Barcelona, Spain
- Parc Taulí Research and Innovation Institute Foundation (I3PT), 08028 Sabadell, Barcelona, Spain
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29
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Chew SM, Heath CH, Petursson C, Boan PA, Robinson JO, Italiano CM, Dyer JR, Manning L, Ingram PR. Antifungal use via outpatient parenteral antimicrobial therapy. Mycoses 2022; 65:946-952. [PMID: 35923125 DOI: 10.1111/myc.13513] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Revised: 07/27/2022] [Accepted: 08/01/2022] [Indexed: 11/27/2022]
Abstract
BACKGROUND Antifungal administration via outpatient parenteral antimicrobial therapy (OPAT) is infrequent. As patients with invasive fungal infections (IFIs) receiving OPAT are at high risk of readmissions, careful, risk based patient selection and monitoring is important. OBJECTIVES To describe our experience managing IFIs via OPAT, including assessment of risk factors associated with unplanned readmissions. PATIENTS AND METHODS A retrospective cohort study of outpatients from two tertiary hospitals in Western Australia managed with parenteral antifungals for the treatment of IFIs from 2012 to 2020. Outcomes assessed were unplanned OPAT-related readmissions, adverse events and achievement of treatment aims at the completion of OPAT. RESULTS Forty six patients were included, encompassing 696 OPAT days. Twenty three (50%) patients received intravenous (IV) liposomal amphotericin B (L-AmB), 23 (50%) received IV echinocandins and one (2%) patient received IV fluconazole. One patient received both IV L-AmB and an echinocandin. Unplanned OPAT-related readmissions occurred in 13 (28%) patients and any adverse event occurred in 19 (41%), most commonly nephrotoxicity amongst patients receiving L-AmB. On univariate analysis, unplanned OPAT-related readmissions were more common in Mucorales infection, L-AmB doses of ≥5mg/kg and otorhinolaryngologic (ENT) infections. At the completion of OPAT, attainment of treatment aims occurred in 28 (61%) patients. CONCLUSIONS Patients receiving parenteral antifungals via OPAT experience high rates of unplanned readmissions and adverse events. Risk factor identification may facilitate optimal patient selection and establishment of treatment aims.
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Affiliation(s)
- Su M Chew
- Department of Infectious Diseases, Fiona Stanley Hospital, 11 Robin Warren Drive, Murdoch, Western Australia
| | - Christopher H Heath
- Department of Infectious Diseases, Fiona Stanley Hospital, 11 Robin Warren Drive, Murdoch, Western Australia.,Department of Microbiology and Infectious Diseases, Royal Perth Hospital, Victoria Square, Perth, Western Australia.,PathWest Laboratory Medicine WA, Fiona Stanley Hospital, 11 Robin Warren Drive, Murdoch, Western Australia.,School of Pathology and Laboratory Medicine, University of Western Australia, 35 Stirling Hwy, Crawley, Western Australia, Australia
| | - Cecilia Petursson
- Department of Microbiology and Infectious Diseases, Royal Perth Hospital, Victoria Square, Perth, Western Australia
| | - Peter A Boan
- Department of Infectious Diseases, Fiona Stanley Hospital, 11 Robin Warren Drive, Murdoch, Western Australia.,Department of Microbiology and Infectious Diseases, Royal Perth Hospital, Victoria Square, Perth, Western Australia.,PathWest Laboratory Medicine WA, Fiona Stanley Hospital, 11 Robin Warren Drive, Murdoch, Western Australia
| | - James Owen Robinson
- Department of Infectious Diseases, Fiona Stanley Hospital, 11 Robin Warren Drive, Murdoch, Western Australia.,Department of Microbiology and Infectious Diseases, Royal Perth Hospital, Victoria Square, Perth, Western Australia.,PathWest Laboratory Medicine WA, Fiona Stanley Hospital, 11 Robin Warren Drive, Murdoch, Western Australia.,Antimicrobial Resistance and Infectious Diseases Research Laboratory, School of Veterinary and Life Sciences, Murdoch University, Murdoch, Western Australia
| | - Claire M Italiano
- Department of Microbiology and Infectious Diseases, Royal Perth Hospital, Victoria Square, Perth, Western Australia
| | - John R Dyer
- Department of Infectious Diseases, Fiona Stanley Hospital, 11 Robin Warren Drive, Murdoch, Western Australia
| | - Laurens Manning
- Department of Infectious Diseases, Fiona Stanley Hospital, 11 Robin Warren Drive, Murdoch, Western Australia.,Medical School, University of Western Australia, 35 Stirling Hwy, Crawley, Western Australia, Australia
| | - Paul R Ingram
- Department of Infectious Diseases, Fiona Stanley Hospital, 11 Robin Warren Drive, Murdoch, Western Australia.,Department of Microbiology and Infectious Diseases, Royal Perth Hospital, Victoria Square, Perth, Western Australia.,PathWest Laboratory Medicine WA, Fiona Stanley Hospital, 11 Robin Warren Drive, Murdoch, Western Australia.,School of Pathology and Laboratory Medicine, University of Western Australia, 35 Stirling Hwy, Crawley, Western Australia, Australia
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30
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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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31
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Ashraf B, Hoff E, Brown LS, Smartt J, Mathew S, Bird C, Collins R, Johnson D, Marambage K, Bhavan K. Health Care Utilization Patterns for Patients With a History of Substance Use Requiring OPAT. Open Forum Infect Dis 2022; 8:ofab540. [PMID: 35559131 PMCID: PMC9088504 DOI: 10.1093/ofid/ofab540] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2021] [Accepted: 11/01/2021] [Indexed: 11/12/2022] Open
Abstract
Background Uninsured people who use drugs (PWUD) require extended parenteral antibiotic therapy when diagnosed with complex infections such as osteomyelitis. They are ineligible to enroll in our self-administered outpatient antimicrobial therapy (S-OPAT) program and instead sent to a skilled nursing facility (SNF). We aim to retrospectively assess clinical outcomes of PWUD discharged from our safety net hospital to complete OPAT in an SNF. Methods Using our hospital electronic medical record, PWUD discharged to an SNF for extended antibiotic therapy were identified for the study period, 1/1/17–4/30/18. Demographics, drug use, discharge diagnosis, antibiotic therapy, discharge disposition from SNF (AMA, early non-AMA, completed), 30-day emergency department (ED) utilization, and 30-day readmission were collected for the study cohort. ED utilization and 30-day readmission rates were analyzed by disposition group. Results While the majority of patients completed treatment (83), a sizeable number left AMA (26) or early non-AMA (20). Patients who left early, AMA or non-AMA, had increased rates of 30-day readmission or ED utilization (P=.01) and increased rates of 30-day readmission alone (P=.01), but not ED utilization alone (P=.43), compared with patients who completed treatment. Conclusions In our cohort, many PWUD discharged to an SNF to receive parenteral antibiotics did not complete treatment. These patients were observed to have increased health care utilization compared with patients completing therapy.
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Affiliation(s)
- Bilal Ashraf
- UT Southwestern Department of Internal Medicine and Pediatrics, Dallas, Texas, USA
| | - Emily Hoff
- UT Southwestern Department of Internal Medicine, Dallas, Texas, USA
| | | | - Jillian Smartt
- Parkland Health and Hospital System Center of Innovation and Value, Dallas, Texas, USA
| | - Sheryl Mathew
- Parkland Health and Hospital System Center of Innovation and Value, Dallas, Texas, USA
| | - Cylaina Bird
- UT Southwestern Department of Internal Medicine, Dallas, Texas, USA
| | - Ryan Collins
- Parkland Health and Hospital System, Dallas, Texas, USA
| | - David Johnson
- UT Southwestern Department of Internal Medicine, Dallas, Texas, USA
| | | | - Kavita Bhavan
- Parkland Health and Hospital System Center of Innovation and Value, Dallas, Texas, USA.,UT Southwestern Department of Internal Medicine, Division of Infectious Diseases, Dallas, Texas, USA
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32
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Sousa C, Pinto FJ. Infective Endocarditis: Still More Challenges Than Convictions. Arq Bras Cardiol 2022; 118:976-988. [PMID: 35613200 PMCID: PMC9368884 DOI: 10.36660/abc.20200798] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2020] [Revised: 02/12/2021] [Accepted: 03/24/2021] [Indexed: 11/18/2022] Open
Abstract
After fourteen decades of medical and technological evolution, infective endocarditis continues to challenge physicians in its daily diagnosis and management. Its increasing incidence, demographic shifts (affecting older patients), microbiology with higher rates of Staphylococcus infection, still frequent serious complications and substantial mortality make endocarditis a very complex disease. Despite this, innovations in the diagnosis, involving microbiology and imaging, and improvements in intensive care and cardiac surgical techniques, materials and timing can impact the prognosis of this disease. Ongoing challenges persist, including rethinking prophylaxis, improving the diagnosis criteria comprising blood culture-negative endocarditis and prosthetic valve endocarditis, timing of surgical intervention, and whether to perform surgery in the presence of ischemic stroke or in intravenous drug users. A combined strategy on infective endocarditis is crucial, involving advanced clinical decisions and protocols, a multidisciplinary approach, national healthcare organization and health policies to achieve better results for our patients.
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Affiliation(s)
- Catarina Sousa
- Centro Cardiovascular Universidade de LisboaFaculdade de MedicinaUniversidade de LisboaLisboaPortugalCentro Cardiovascular Universidade de Lisboa (CCUL), Faculdade de Medicina, Universidade de Lisboa, Lisboa – Portugal
- Serviço de CardiologiaCentro Hospitalar Barreiro MontijoBarreiroPortugalServiço de Cardiologia, Centro Hospitalar Barreiro Montijo (CHBM), Barreiro – Portugal
| | - Fausto J. Pinto
- Centro Cardiovascular Universidade de LisboaFaculdade de MedicinaUniversidade de LisboaLisboaPortugalCentro Cardiovascular Universidade de Lisboa (CCUL), Faculdade de Medicina, Universidade de Lisboa, Lisboa – Portugal
- Departamento Coração e VasosCentro Hospitalar e Universitário Lisboa NorteLisboaPortugalDepartamento Coração e Vasos, Centro Hospitalar e Universitário Lisboa Norte (CHULN), Lisboa – Portugal
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Certain LK, Benefield RJ, Newman M, Zhang M, Thomas FO. A Quality Initiative to Improve Post-discharge Care for Patients on Outpatient Parenteral Antimicrobial Therapy. Open Forum Infect Dis 2022; 9:ofac199. [PMID: 35794930 PMCID: PMC9251666 DOI: 10.1093/ofid/ofac199] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Accepted: 04/08/2022] [Indexed: 11/13/2022] Open
Abstract
Abstract
Background/Objective
Patients discharged from the hospital on outpatient parenteral antimicrobial therapy (OPAT) require close monitoring, including weekly blood tests and an early post-hospital follow-up visit. However, because patients often receive OPAT in a separate healthcare system from where they received inpatient care, the OPAT plan often fails, with less than 75% of OPAT patients receiving the recommended laboratory monitoring. We sought to determine if changing our inpatient OPAT documentation method would improve post-discharge care.
Methods
As a quality improvement initiative, we conducted two Plan-Do-Study-Act interventions on our OPAT documentation. Our first intervention was to create a standardized OPAT Progress Note, and our second was to turn that note into a SmartForm (Epic) with discrete fields for the key information. We examined the effects of these changes on the rate of completion of recommended lab monitoring, attendance at outpatient follow-up visits, and 30-day readmission rates.
Results
Changing our documentation to a standardized Progress Note and then to a SmartForm with discrete fields led to an increase in the proportion of patients with a serum creatinine checked within ten days of discharge (from 63% to 71% to 73%) and who attended an infectious disease clinic visit within three weeks of discharge (from 21% to 36% to 47%). However, the rate of readmissions for OPAT-related problems did not change, nor did a composite outcome of 30-day mortality/unplanned readmission.
Conclusions
Changes in how and where care plans are documented in the inpatient medical record can have significant effects on patient care outcomes after discharge.
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Affiliation(s)
- Laura K. Certain
- University of Utah Health, Division of Infectious Diseases, Salt Lake City, Utah, United States
| | | | - Michael Newman
- University of Utah Health, Data Science Services, Salt Lake City, Utah, United States
| | - Mingyuan Zhang
- University of Utah Health, Data Science Services, Salt Lake City, Utah, United States
| | - Frank O. Thomas
- University of Utah Health, Value Engineering (retired), Salt Lake City, Utah, United States
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Non-specific spondylodiscitis: a new perspective for surgical treatment. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2022; 31:461-472. [PMID: 35031861 DOI: 10.1007/s00586-021-07072-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/11/2021] [Revised: 10/10/2021] [Accepted: 11/24/2021] [Indexed: 10/19/2022]
Abstract
PURPOSE Pyogenic spondylodiscitis is a relatively rare spinal disease; non-specific spondylodiscitis (NSS) cases are increasing. This study aims to identify if changes of inflammatory markers under antibiotic therapy can be used to determine which NSS patients can benefit from surgical indication earlier than others. METHODS Two groups of patients with NSS were examined. Group A underwent surgery, while Group B was treated conservatively. Group B was also subdivided in patients undergoing antibiotic therapy for > 6 weeks (B1) and < 6 weeks (B2). Groups were compared for age, gender, BMI, blood levels of ESR and CRP and VAS scale. RESULTS There were no differences (P = 0.06) in reduction in ESR at 4 weeks between two main groups. A reduction in CRP, with < 2.7 mg/dl at 4 weeks, was observed in Group A (P = 0.01). Comparing Group B1 to B2, a reduction (P = 0.0001) in VAS, ESR and CRP at 4 weeks was observed in Group B2. It was possible to isolate the pathogen in 52.8% of Group B, without any differences on VAS, ESR and CRP values and on length of the antibiotic therapy. CONCLUSIONS The surgical treatment should be considered for patients who, after 4 weeks of conservative therapy, do not show a reduction in the ESR < 50 mm/h and of the CRP < 2.7 g/dl. The comparison between groups underwent surgically and those treated conservatively showed a reduction in the CRP at 4 weeks and better VAS for pain at 3 months in Group A.
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Debaenst N, Seyler L, Putman K, Van Den Borre I, Vanlauwe J. Outpatient parenteral antibiotic therapy for the treatment of prosthetic knee and hip infections in Belgium, a cost minimization analysis. Acta Clin Belg 2022; 77:10-17. [PMID: 32484406 DOI: 10.1080/17843286.2020.1772572] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
OBJECTIVES Prosthetic joint infections (PJI) are treated with prolonged periods of intravenous (IV) antibiotics combined with one or more appropriate surgical procedures. In Belgium, patients receive their IV treatments as inpatients, whereas in other parts of the world similar IV antibiotics can be given as outpatient parenteral antibiotic therapy (OPAT), without jeopardising patient outcomes. The purpose of this paper was to analyse the financial feasibility of OPAT for PJI in Belgium. METHODS Patients with PJI treated with a two-stage revision between January 2013 and June 2016 were selected for analysis of in-hospital costs. An OPAT cost simulation was made for comparable lengths of stay, for the different antimicrobial regimens used. A cost minimization analysis comparing the non-OPAT costs and the OPAT cost simulation was performed, with a sensitivity analysis accounting for cost uncertainties. RESULTS Based on the financial data of 12 two-stage revisions and 4 different antibiotic regimens, the average simulated cost difference for OPAT was €2.402 surplus for the patient, €-25.950 for health care and €-23.548 in total. CONCLUSION Projected cost savings for OPAT-treatment of PJI are substantial. However, OPAT within the current Belgian system was significantly more expensive for the patients. This can be attributed to the Belgian health insurance system; its current reimbursement regulations prevent OPAT from truly making a breakthrough in Belgium.
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Affiliation(s)
- Niels Debaenst
- Department of Orthopaedics, University Hospital Brussels, Brussels, Belgium
| | - Lucie Seyler
- Department of Infectious Diseases, University Hospital Brussels, Brussels, Belgium
| | - Koen Putman
- Department of Health Economics, Vrije Universiteit Brussels (VUB), Brussels, Belgium
| | | | - Johan Vanlauwe
- Department of Orthopaedics, University Hospital Brussels, Brussels, Belgium
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Garcia-Carretero R, Vazquez-Gomez O, Luna-Heredia E, Vargas-Rojo B, Fernandez-Cotarelo MJ, Naranjo-Mansilla G. Management of COPD in a Hospital-at-Home Setting at a Peripheral Spanish Hospital: 8-Year Experience. HOME HEALTH CARE MANAGEMENT AND PRACTICE 2022. [DOI: 10.1177/10848223211073710] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
We performed exploratory and descriptive analyses of data from our 8 years of experience in hospital-at-home (HaH) treatment to characterize the clinical profile of patients with exacerbated underlying chronic obstructive pulmonary disease (COPD). Our study had a retrospective research design, using historical electronic health records from patients admitted to the HaH setting between 2012 and 2019. We collected demographic, administrative, and clinical data from patients diagnosed with exacerbated COPD. Between 2012 and 2019, 420 patients diagnosed with acute respiratory infectious disease related to COPD were treated in our HaH setting (18% of all admissions to HaH). Most patients were referred from the Internal Medicine Department. The median length of the hospital stay was 10 days. Most patients (78.8%) presented acute exacerbation with no pneumonia. One-third of the patients required domiciliary oxygen therapy, and half required ventilatory devices for nebulized bronchodilator therapy. All patients were successfully discharged as clinically stable. Our HaH experience in managing patients with exacerbated COPD indicates a means of obtaining cost savings and increased quality of life for patients in which antibiotic and ventilatory therapy is not compromised.
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Assessment of risk factors associated with outpatient parenteral antimicrobial therapy (OPAT) complications: A retrospective cohort study. ANTIMICROBIAL STEWARDSHIP & HEALTHCARE EPIDEMIOLOGY 2022; 2:e183. [PMID: 36406163 PMCID: PMC9672913 DOI: 10.1017/ash.2022.313] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/02/2022] [Revised: 09/13/2022] [Accepted: 09/13/2022] [Indexed: 11/13/2022]
Abstract
Objective: To characterize factors associated with increased risk of outpatient parenteral antimicrobial therapy (OPAT) complication. Design: Retrospective cohort study. Setting: Four hospitals within NYU Langone Health (NYULH). Patients: All patients aged ≥18 years with OPAT episodes who were admitted to an acute-care facility at NYULH between January 1, 2017, and December 31, 2020, who had an infectious diseases consultation during admission. Results: Overall, 8.45% of OPAT patients suffered a vascular complication and 6.04% suffered an antimicrobial complication. Among these patients, 19.95% had a 30-day readmission and 3.35% had OPAT-related readmission. Also, 1.58% of patients developed a catheter-related bloodstream infection (CRBSI). After adjusting for key confounders, we found that patients discharged to a subacute rehabilitation center (SARC) were more likely to develop a CRBSI (odds ratio [OR], 4.75; P = .005) and to be readmitted for OPAT complications (OR, 2.89; P = .002). Loss to follow-up with the infectious diseases service was associated with increased risks of CRBSI (OR, 3.78; P = .007) and 30-day readmission (OR, 2.59; P < .001). Conclusions: Discharge to an SARC is strongly associated with increased risks of readmission for OPAT-related complications and CRBSI. Loss to follow-up with the infectious diseases service is strongly associated with increased risk of readmission and CRBSI. CRBSI prevention during SARC admission is a critically needed public health intervention. Further work must be done for patients undergoing OPAT to improve their follow-up retention with the infectious diseases service.
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Pineo T, Goldman JD, Swartzentruber G, Kanderi T, Qurashi H, Dimech C. An observational study on the use of long acting buprenorphine ( Sublocade) and a Tamper resistant PICC for Outpatient IV antibiotic administration in Patients with serious infections and Opioid Use Disorder; The STOP OUD project. DRUG AND ALCOHOL DEPENDENCE REPORTS 2021; 2:100020. [PMID: 36845901 PMCID: PMC9948820 DOI: 10.1016/j.dadr.2021.100020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/02/2021] [Revised: 12/13/2021] [Accepted: 12/14/2021] [Indexed: 11/25/2022]
Abstract
What is STOP OUD? The STOP OUD project is an observational study on the use of long-acting buprenorphine (Sublocade) and a Tamper resistant PICC clamp for Outpatient IV antibiotic administration in Patients with serious infections and Opioid Use Disorder (STOP OUD). Background The US opioid crisis is driving up serious infections related to intravenous drug use. These infections require prolonged courses of antibiotics, often resulting in lengthy hospital stays. Extended hospitalizations for monitored parenteral antibiotics for patients with opioid use disorder are challenging for patients, reduce bed capacity, and are associated with significant cost. This observational study reviews the administration of intravenous (IV) antibiotics in a monitored outpatient setting using long-acting injectable buprenorphine (Sublocade, Indivior Inc., North Chesterfield, VA) and a tamper resistant clamp in patients with opioid use disorder . Methods Long-acting buprenorphine and a tamper resistant clamp were used to treat patients with serious infections and opioid use disorder as outpatients. Results Hospital days avoided were 30-days per STOP OUD project participant. Eleven of thirteen STOP OUD project participants completed their antibiotic courses as prescribed, there was no evidence of peripherally inserted central catheter (PICC) tampering, and they rated their care as a mean of 4.9/5 (SD 0.4). Institutional savings per STOP OUD patient was $33,000. Outpatient infusion costs were $9,300 for a net savings of $23,700 per STOP OUD project participant. Infections resolved in all participants. Conclusions The STOP OUD project reduced hospital length of stay for patients with opioid use disorder and serious infections, and had a favorable financial impact.
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Affiliation(s)
- Thomas Pineo
- Hospitalist, UPMC Central PA, Harrisburg Pennsylvania,Corresponding author.
| | - John D. Goldman
- Infectious Disease, UPMC Central PA, Harrisburg Pennsylvania
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Goebel MC, Trautner BW, Grigoryan L. The Five Ds of Outpatient Antibiotic Stewardship for Urinary Tract Infections. Clin Microbiol Rev 2021; 34:e0000320. [PMID: 34431702 PMCID: PMC8404614 DOI: 10.1128/cmr.00003-20] [Citation(s) in RCA: 40] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Urinary tract infections (UTI) are one of the most common indications for antibiotic prescriptions in the outpatient setting. Given rising rates of antibiotic resistance among uropathogens, antibiotic stewardship is critically needed to improve outpatient antibiotic use, including in outpatient clinics (primary care and specialty clinics) and emergency departments. Outpatient clinics are in general a neglected practice area in antibiotic stewardship programs, yet most antibiotic use in the United States is in the outpatient setting. This article provides a comprehensive review of antibiotic stewardship strategies for outpatient UTI in the adult population, with a focus on the "five Ds" of stewardship for UTI, including right diagnosis, right drug, right dose, right duration, and de-escalation. Stewardship interventions that have shown success for improving prescribing for outpatient UTI are discussed, including diagnostic stewardship strategies, such as reflex urine cultures, computerized decision support systems, and modified reporting of urine culture results. Among the many challenges to achieving stewardship for UTI in the outpatient setting, some of the most important are diagnostic uncertainty, increasing antibiotic resistance, limitations of guidelines, and time constraints of stewardship personnel and front-line providers. This article presents a stewardship framework, built on current evidence and expert opinion, that clinicians can use to guide their own outpatient management of UTI.
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Affiliation(s)
- Melanie C. Goebel
- Section of Infectious Diseases, Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
| | - Barbara W. Trautner
- Center for Innovations in Quality, Effectiveness, and Safety (IQuESt), Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas, USA
- Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
| | - Larissa Grigoryan
- Department of Family and Community Medicine, Baylor College of Medicine, Houston, Texas, USA
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Singhal T, Rodrigues C, Soman R, Wattal C, Swaminathan S, Nambi S, Talwar D, Singh RK, Todi S. Treatment of MRSA infections in India: Clinical insights from a Delphi analysis. Indian J Med Microbiol 2021; 40:35-45. [PMID: 34785281 DOI: 10.1016/j.ijmmb.2021.11.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Revised: 11/09/2021] [Accepted: 11/10/2021] [Indexed: 12/29/2022]
Abstract
PURPOSE International and Indian guidelines for the management of patients with methicillin-resistant Staphylococcus aureus (MRSA) infections are available, but the local guidelines are not MRSA-specific. This study aimed to provide clinical insights for the treatment of MRSA infections in India. METHODS We used a three-step modified Delphi method to obtain insights. Ten experts comprising infectious disease specialists, microbiologists, pulmonologists, and critical care experts agreed to participate in the analysis. In round 1, a total of 161 statements were circulated to the panel and the experts were asked to 'agree' or 'disagree' by responding 'yes' or 'no' to each statement and provide comments. The same process was used for 73 statements in round 2. Direct interaction with the experts was carried out in round 3 wherein 35 statements were discussed. At least 80% of the experts had to agree for a statement to reach concordance. RESULTS Eighty-eight statements in round 1, thirty-eight statements in round 2, and eight statements in round 3 reached concordance and were accepted without modification. The final document comprised 152 statements on the management of various syndromes associated with MRSA such as skin and soft tissue infections, bacteremia and endocarditis, pneumonia, bone and joint infections, and central nervous system infections. CONCLUSIONS This analysis will assist clinicians in India to choose an appropriate course of action for MRSA infections.
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Affiliation(s)
- Tanu Singhal
- Kokilaben Dhirubhai Ambani Hospital and Medical Research Institute, Mumbai, India
| | | | | | - Chand Wattal
- Clinical Microbiology & Immunology, Sir Ganga Ram Hospital, New Delhi, India
| | - Subramanian Swaminathan
- Infectious Diseases and Infection Control at Gleneagles Global Hospitals (Chennai, Bangalore, Hyderabad), India
| | | | - Deepak Talwar
- Metro Respiratory Center Pulmonology & Sleep Medicine, Metro Hospital, Noida, India
| | | | - Subhash Todi
- Critical Care Medicine, Department of Academics & Health Research, AMRI Hospitals, Kolkata, India.
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Recent Updates in Antimicrobial Stewardship in Outpatient Parenteral Antimicrobial Therapy. Curr Infect Dis Rep 2021; 23:24. [PMID: 34776793 PMCID: PMC8577634 DOI: 10.1007/s11908-021-00766-x] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/22/2021] [Indexed: 12/11/2022]
Abstract
Purpose of Review Antimicrobial stewardship within acute care is common and has been expanding to outpatient areas. Some inpatient antimicrobial stewardship tactics apply to outpatient parenteral antimicrobial therapy (OPAT) and complex outpatient antimicrobial therapy (COpAT) management, but differences do exist. Recent Findings OPAT/COpAT is a growing area of practice and research with its own unique considerations for antimicrobial stewardship. Potential ideas for antimicrobial stewardship in the OPAT/COpAT setting include redesigning the regimen to COpAT instead of OPAT, ensuring the use of the shortest effective duration of antimicrobial therapy; using antimicrobials dosed less frequently, such as long-acting glycopeptides; optimizing antimicrobial susceptibility testing reporting for common OPAT/COpAT drugs; and establishing routine laboratory and safety monitoring. Future consensus is needed to determine validated OPAT program metrics and outcomes. Summary As more focus is placed on outpatient antimicrobial stewardship, clinicians practicing in OPAT should publish more data regarding OPAT program methods and outcomes as they relate to antimicrobial stewardship. These can involve patient clinical outcomes, OPAT readmission rates, OPAT therapy completion, and central line-related complications.
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Huskey M, Lewis P, Brown SD. Stability of Ampicillin in Normal Saline Following Refrigerated Storage and 24-Hour Pump Recirculation. Hosp Pharm 2021; 56:507-512. [PMID: 34720153 DOI: 10.1177/0018578720925389] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Objective Use of ampicillin in outpatient parenteral antimicrobial therapy (OPAT) has historically been complicated by frequent dosing and limited stability. The purpose of this study was to evaluate stability of ampicillin using high-pressure liquid chromatography (HPLC) in an OPAT dosing model using continuous infusion at room temperature over 24 hours immediately following preparation compared with batches stored under refrigeration for 24 hours, 72 hours, and 7 days. Methods An HPLC method was developed and validated as stability indicating using guidance in USP general Chapter <1225>. Four ampicillin batches were prepared for each experimental condition (immediate use and refrigerated storage for 24 hours, 72 hours, and 7 days). A pump was used to recirculate the solutions through medical-grade tubing for 24 hours. Triplicate 1-mL aliquots were removed from each batch at time 0, 4, 8, 12, and 24 hours and analyzed for ampicillin concentration. Results Each batch was assayed for initial concentration (20.34-21.50 mg/mL), and percent recovery compared with that concentration thereafter. For the duration of infusion, the average recoveries were 96.4%, 95.8%, 94.6%, and 90.3% for immediate use, 24-hour storage, 72-hour storage, and 7-day storage, respectively. The recovery remained above 90% for all batches and time points, except for 7-day storage, which fell below 90% after 4 hours of circulation. Conclusion Ampicillin can be prepared and stored in a refrigerator for up to 72 hours prior to continuously infusing at room temperature over 24 hours with less than a 10% loss of potency over the dosing period. This model supports twice weekly OPAT delivery of ampicillin.
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Vancomycin Use in Children and Neonates across Three Decades: A Bibliometric Analysis of the Top-Cited Articles. Pathogens 2021; 10:pathogens10101343. [PMID: 34684291 PMCID: PMC8537673 DOI: 10.3390/pathogens10101343] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2021] [Revised: 09/17/2021] [Accepted: 09/29/2021] [Indexed: 12/13/2022] Open
Abstract
Vancomycin is frequently prescribed in pediatrics, especially in intensive care unit settings, to treat Gram-positive bacterial infections. This work aims to collect the top-cited articles of pediatric and infectious diseases areas to gather the current evidence and gaps of knowledge on the use of vancomycin in these populations. The most relevant journals reported in the "pediatrics" and "infectious diseases" categories of the 2019 edition of Journal Citation Reports were browsed. Articles with more than 30 citations and published over the last three decades were collected. A bibliometric analysis was performed and 115 articles were retrieved. They were published in 21 journals, with a median impact factor of 4.6 (IQR 2.9-5.4). Sixty-eight of them (59.1%) belonged to "infectious diseases" journals. The most relevant topic was "bloodstream/complicated/invasive infections", followed by "antibiotic resistance/MRSA treatment". As for population distribution, 27 articles were on children only and 27 on neonates, most of which were from intensive care unit (ICU) settings. The current literature mainly deals with vancomycin as a treatment for severe infections and antibiotic resistance, especially in neonatal ICU settings. Lately, attention to new dosing strategies in the neonatal and pediatric population has become a sensible topic.
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Thieme L, Briggs S, Duffy E, Makarewicz O, Pletz MW. In Vitro Synergism of Penicillin and Ceftriaxone against Enterococcus faecalis. Microorganisms 2021; 9:2150. [PMID: 34683470 PMCID: PMC8541343 DOI: 10.3390/microorganisms9102150] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2021] [Revised: 10/07/2021] [Accepted: 10/10/2021] [Indexed: 12/13/2022] Open
Abstract
Enterococcus faecalis infective endocarditis is commonly treated with intravenous ampicillin/ceftriaxone combination therapy. Ampicillin, however, is unsuitable for outpatient parenteral antibiotic therapy (OPAT) regimens due to its instability in 24 h continuous infusors, and has been successfully replaced by benzylpenicillin used together with ceftriaxone in a few small case series. Since in vitro synergy data of penicillin/ceftriaxone against E. faecalis are still lacking, checkerboard assays were performed for 28 clinical E. faecalis isolates and one laboratory standard strain. Synergistic effects (both lowest and median FICI) were observed for penicillin/ceftriaxone in 15/29 isolates, while ampicillin/ceftriaxone exhibited synergism in 22/29 isolates. For isolates with ceftriaxone MICs ≤ 256 mg/L, the addition of free ceftriaxone trough concentrations to penicillin or ampicillin resulted in comparable synergistic effects for both combinations. In contrast, for isolates with ceftriaxone MICs ≥ 512 mg/L free ceftriaxone trough concentrations were only sufficient to exhibit synergistic effects in combination with ampicillin, but not penicillin. This study suggests that benzylpenicillin/ceftriaxone would be expected to be suitable for the OPAT treatment of enterococcal endocarditis for E. faecalis isolates with ceftriaxone MICs ≤ 256 mg/L. However, combination therapy would be expected to provide no advantage over benzylpenicillin monotherapy for isolates with ceftriaxone MICs ≥ 512 mg/L. Further investigation is required to analyse the relationship between ceftriaxone susceptibility and penicillin/ceftriaxone synergy, especially for isolates with ceftriaxone MICs of 64 to 512 mg/L.
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Affiliation(s)
- Lara Thieme
- Institute for Infectious Diseases and Infection Control, Jena University Hospital, Friedrich Schiller University, 07747 Jena, Germany; (O.M.); (M.W.P.)
- Leibniz Center for Photonics in Infection Research, Jena University Hospital, Friedrich Schiller University, 07747 Jena, Germany
| | - Simon Briggs
- Infectious Disease Unit, Auckland City Hospital, Auckland 1023, New Zealand; (S.B.); (E.D.)
| | - Eamon Duffy
- Infectious Disease Unit, Auckland City Hospital, Auckland 1023, New Zealand; (S.B.); (E.D.)
| | - Oliwia Makarewicz
- Institute for Infectious Diseases and Infection Control, Jena University Hospital, Friedrich Schiller University, 07747 Jena, Germany; (O.M.); (M.W.P.)
| | - Mathias W. Pletz
- Institute for Infectious Diseases and Infection Control, Jena University Hospital, Friedrich Schiller University, 07747 Jena, Germany; (O.M.); (M.W.P.)
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Ozturk CN, Ozturk C, Sigurdson SL, Magner WJ, Sheedy B, Lohman R, Moon W. Broad-Spectrum Antibiotics for Breast Expander/Implant Infection: Treatment-Related Adverse Events and Outcomes. Ann Plast Surg 2021; 87:396-401. [PMID: 34559710 DOI: 10.1097/sap.0000000000002720] [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: 11/26/2022]
Abstract
BACKGROUND Despite best practices, infection remains the most common complication after breast reconstruction with expanders and implants, ranging from 2% to 29%. Empiric broad-spectrum antibiotics are frequently used in nonsurgical treatment of implant-associated infections in an effort to salvage the reconstruction. Pitfalls of antibiotherapy include adverse events, vascular access site complications, and drug resistance. Our goals were to describe management of implant infections with broad-spectrum antibiotics, review treatment related adverse events, and report on outcomes of therapy. PATIENTS AND METHODS A retrospective review was carried out to identify patients who were treated with intravenous (IV) antibiotics for periprosthetic infection. Patient characteristics, surgical details, and antibiotic therapy-related adverse events were collected. Eventual outcome related to expander/implant salvage was noted. RESULTS A total of 101 patients (111 treatment episodes) were identified. Mean duration of antibiotic treatment was 18 days (range, 1-40 days). The most commonly used parenteral treatment was a combination of daptomycin with piperacillin-tazobactam (65%) or an alternative agent (16%). Fifty-nine percent of treatment episodes resulted in salvage of the expander or implant. Thirty-five percent treatment episodes were associated with 1 or more adverse events: diarrhea (12.6%), rash (10%), vaginal candidiasis (3.6%), agranulocytosis/neutropenic fever (3.6%), nausea (3.6%), urinary complaint (0.9%), myositis (0.9%), headache (0.9%), vascular line occlusion (1.8%), deep vein thrombosis (1.8%), and finger numbness (0.9%). No patients developed Clostridium difficile colitis. Five episodes (4%) needed discontinuation of antibiotics because of severe adverse events. The prosthesis was explanted in 3 of the cases of discontinued treatment. CONCLUSIONS Our findings show favorable outcomes and well-tolerated adverse effects with broad-spectrum parenteral antibiotherapy for periprosthetic infection. However, every effort should be made to deescalate therapy by narrowing the spectrum or limiting the duration, to minimize adverse events and development of bacterial resistance. Treating surgeons need to carefully weigh benefits of therapy and be aware of potential complications that might necessitate discontinuation of treatment.
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Affiliation(s)
- Cemile Nurdan Ozturk
- From the Department of Head, Neck, Plastic and Reconstructive Surgery, Roswell Park Comprehensive Cancer Center, Buffalo, NY
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Talan DA, Mower WR, Lovecchio FA, Rothman RE, Steele MT, Keyloun K, Gillard P, Copp R, Moran GJ. Pathway with single-dose long-acting intravenous antibiotic reduces emergency department hospitalizations of patients with skin infections. Acad Emerg Med 2021; 28:1108-1117. [PMID: 33780567 PMCID: PMC8597095 DOI: 10.1111/acem.14258] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2020] [Revised: 03/12/2021] [Accepted: 03/25/2021] [Indexed: 01/26/2023]
Abstract
OBJECTIVES Emergency department (ED) patients with serious skin and soft tissue infections (SSTIs) are often hospitalized to receive intravenous (IV) antibiotics. Appropriate patients may avoid admission following a single-dose, long-acting IV antibiotic. METHODS We conducted a preintervention versus postintervention design trial at 11 U.S. EDs comparing hospitalization rates under usual care to those using a clinical pathway that included a single IV dalbavancin dose. We enrolled adults with cellulitis, abscess, or wound infection with an infected area of ≥75 cm2 without other indications for hospitalization. Clinical pathway participants discharged from the ED received a 24-hour follow-up telephone call and had a 48- to 72-hour in-person visit. We hypothesized that, compared to usual care, the clinical pathway would result in a significant reduction in the initial hospitalization rate. RESULTS Of 156 and 153 participants in usual care and clinical pathway periods, median infection areas were 255.0 (interquartile range [IQR] = 150.0 to 500.0) cm2 and 289.0 (IQR = 161.3 to 555.0) cm2 , respectively. During their initial care, 60 (38.5%) usual care participants were hospitalized and 27 (17.6%) pathway participants were hospitalized (difference = 20.8 percentage points [PP], 95% confidence interval [CI] = 10.4 to 31.2 PP). Over 44 days, 70 (44.9%) usual care and 44 (28.8%) pathway participants were hospitalized (difference = 16.1 PP, 95% CI = 4.9 to 27.4 PP). CONCLUSIONS Implementation of an ED SSTI clinical pathway for patient selection and follow-up that included use of a single-dose, long-acting IV antibiotic was associated with a significant reduction in hospitalization rate for stable patients with moderately severe infections. Registration: NCT02961764.
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Affiliation(s)
- David A. Talan
- Ronald Reagan UCLA Medical CenterDavid Geffen School of Medicine at the University of California at Los Angeles Los Angeles CA USA
| | - William R. Mower
- Ronald Reagan UCLA Medical CenterDavid Geffen School of Medicine at the University of California at Los Angeles Los Angeles CA USA
| | - Frank A. Lovecchio
- Valleywise HealthASUUniversity of Arizona and Creighton College of Medicine Phoenix Arizona USA
| | - Richard E. Rothman
- Johns Hopkins Medical CenterJohns Hopkins School of Medicine Baltimore Maryland USA
| | - Mark T. Steele
- Truman Medical Center University of Missouri–Kansas City School of Medicine Kansas City Missouri USA
| | | | | | | | - Gregory J. Moran
- Olive ViewUCLA Medical CenterDavid Geffen School of Medicine at the University of California at Los Angeles Los Angeles California USA
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Improving the safety of outpatient parenteral antimicrobial therapy for patients with solid tumors. Support Care Cancer 2021; 30:1643-1654. [PMID: 34550460 PMCID: PMC8727411 DOI: 10.1007/s00520-021-06549-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2021] [Accepted: 09/07/2021] [Indexed: 11/30/2022]
Abstract
Background and objectives Outpatient parenteral antimicrobial therapy (OPAT) for infections has been in use for nearly 40 years, and although it has been found safe and efficacious, its use has been studied primarily among otherwise healthy patients. We aimed to develop and evaluate an OPAT program for patients with cancer, particularly solid tumors. Methods We implemented multiple quality improvement interventions between June 2018 and January 2020. We retrospectively and prospectively collected data on demographics, the completeness of infectious diseases (ID) physician consultation notes, rates of laboratory test result monitoring, ID clinic follow-up, and 30-day outcomes, including unplanned OPAT-related readmissions, OPAT-related emergency center visits, and deaths. Results Completeness of ID provider notes improved from a baseline of 77 to 100% (p < .0001) for antimicrobial recommendations, 75 to 97% (p < .0001) for follow-up recommendations, and 19 to 98% (p < .0001) for laboratory test result monitoring recommendations. Completion of laboratory tests increased from a baseline rate of 24 to 56% (p = .027). Thirty-day unplanned OPAT-related readmission, ID clinic follow-up, 30-day emergency center visit, and death rates improved without reaching statistical significance. Conclusions Sustained efforts, multiple interventions, and multidisciplinary engagement can improve laboratory test result monitoring among solid tumor patients discharged with OPAT. Although demonstrating a decrease in unplanned readmissions through institution of a formal OPAT program among patients with solid malignancies may be more difficult compared with the general population, the program may still result in improved safety.
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March-López P, Freixa IA, Gil MM, Espinoza GA, Polonio LO, Paredes EC, Sanchez MC, Sangrador C, Pardo J, Nicolás J, Calbo E. Applicability of Quality Indicators for Appropriate Antibiotic use in Outpatient Parenteral Antimicrobial Therapy (OPAT): A Point Prevalence Survey. Front Pharmacol 2021; 12:713882. [PMID: 34512344 PMCID: PMC8425449 DOI: 10.3389/fphar.2021.713882] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Accepted: 07/28/2021] [Indexed: 11/13/2022] Open
Abstract
The ability to measure the quality of antibiotic prescription is a critical element in any antimicrobial stewardship programme. The aim of this study was to evaluate the clinimetric properties of 33 quality indicators (QIs) developed to assess Outpatient Parenteral Antimicrobial Therapy (OPAT) and to identify potential room for improvement in a hospital-at-home (HaH) unit. Study performed in a healthcare district in Barcelona, Spain with 260,657 inhabitants, nine primary healthcare centres, a 400-bed acute care teaching hospital, and an HaH unit. We studied 33 QIs on appropriate antibiotic use and classified them as qualitative or quantitative. Quantitative QIs were further categorized as measurable or non-measurable depending on the availability of data in the patients’ medical records. Data from 202 OPAT episodes in 192 patients were assessed. Adherence was found for 22 of the 24 qualitative QIs analyzed; the other two showed room for improvement. Four of the nine quantitative indicators were non-measurable. High adherence rates were achieved for QI-17 “The OPAT plan should be documented” (84.65%), QI-26 “The OPAT treatment plan should include choice, dose, frequency, duration and follow-up plan” (79.70%), and QI-33 “The team should document clinical response” (94.55%). Adverse events were documented in just 1.98% of cases (QI-32) and 92.57% patients were classified as alive on discharge (QI-24). The QIs evaluated were applicable to clinical practice and proved useful for identifying areas with room for improvement in our setting and for guiding the design of future interventions with specific objectives.
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Affiliation(s)
- Pablo March-López
- Hospital Pharmacy, Pharmacy Department, Hospital Universitari Mútua Terrassa, Barcelona, Spain.,School of Medicine, Universitat Internacional de Catalunya, Barcelona, Spain
| | | | | | | | - Lidia Ortega Polonio
- Hospital at Home Unit Nurse, Hospital Universitari Mútua Terrassa, Barcelona, Spain
| | | | | | - Cristina Sangrador
- Hospital Pharmacy, Pharmacy Department, Hospital Universitari Mútua Terrassa, Barcelona, Spain
| | - Júlia Pardo
- Hospital Pharmacy, Pharmacy Department, Hospital Universitari Mútua Terrassa, Barcelona, Spain
| | - Jordi Nicolás
- Hospital Pharmacy, Pharmacy Department, Hospital Universitari Mútua Terrassa, Barcelona, Spain.,Pharmacy Department, Universitat de Barcelona, Barcelona, Spain
| | - Esther Calbo
- School of Medicine, Universitat Internacional de Catalunya, Barcelona, Spain.,Infectious Diseases Unit, Hospital Universitari Mútua Terrassa, Barcelona, Spain
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Wu KH, Sakoulas G, Geriak M. Vancomycin or Daptomycin for Outpatient Parenteral Antibiotic Therapy: Does It Make a Difference in Patient Satisfaction? Open Forum Infect Dis 2021; 8:ofab418. [PMID: 34476284 PMCID: PMC8404740 DOI: 10.1093/ofid/ofab418] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2021] [Accepted: 08/16/2021] [Indexed: 11/13/2022] Open
Abstract
A 5-question telephone survey was administered to compare satisfaction between patients receiving vancomycin vs daptomycin outpatient parenteral antimicrobial therapy (OPAT). Twenty-seven patients completed the survey (40%). Vancomycin had higher daily interference score than daptomycin (P = .03). All patients receiving daptomycin reported a satisfaction score ≥8/10, as compared to 67% of patients who received vancomycin (P < .03). OPAT antibiotics with less cumbersome administration regimens may translate into higher patient satisfaction and quicker return to life normalcy.
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Affiliation(s)
- Katherine H Wu
- Skaggs School of Pharmacy, University of California, San Diego, La Jolla, California, USA
| | - George Sakoulas
- Division of Host-Microbe Systems and Therapeutics, Department of Pediatrics, University of California, San Diego School of Medicine, La Jolla, California, USA.,Sharp Memorial Hospital, San Diego, California, USA
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Gramlich Y, Steinkohl D, Kremer M, Kemmerer M, Hoffmann R, Klug A. Modular knee arthrodesis secures limb, mobility, improves quality of life, and leads to high infection control in periprosthetic knee infection, when revision knee arthroplasty is not an option. Arch Orthop Trauma Surg 2021; 141:1349-1360. [PMID: 33893531 DOI: 10.1007/s00402-021-03907-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2020] [Accepted: 04/12/2021] [Indexed: 10/21/2022]
Abstract
INTRODUCTION This study compared the outcome of knee arthrodesis versus hinged total knee arthroplasty (TKA) in patients suffering from periprosthetic joint infection (PJI). METHODS 104 patients with PJI were treated using a two-stage exchange of failed TKA. In case of non reconstructable bone loss or loss of extension mechanism, a modular intramedullary arthrodesis nail was used for reimplantation [Knee Arthrodesis Module (KAM); n = 52]. The control group was retrospectively matched treated using a hinged revision TKA [Rotating Hinge Knee (RHK); n = 52]. PJI remission rates, functional outcome (WOMAC; KSS) and quality of life (SF-12), as well as comorbidities and pain were evaluated. RESULTS Mean age was 72.5 years. Charlson Comorbidity Index was higher in the KAM group (3.3 vs. 2.8). PJI remission rate was 89.4% (88.5% vs. 90.4%, respectively). In case of reinfection, implant retention was mostly possible in the RHK group (7.7%), whereas amputations were mostly performed in the KAM group (9.6%). Significant pain reduction (VAS 7.9-2.8) was achieved in both groups. Walking distance was significantly reduced in the KAM groups versus the RHK group (504 vs. 1064 m). WOMAC and KSS function scores were significantly reduced in the KAM group (25 vs. 40 and 35 vs. 64). Only moderate reduction in quality of life in the KAM group was observed (SF-12 physical: 34 vs. 40; SF-12 mental: 51 vs. 56) respectively. CONCLUSIONS Arthrodesis using a modular intramedullary nail is an alternative for limb salvage, pain reduction, and preservation of quality of life and everyday mobility, when revision TKA is not an option. This study presents the largest number of case, comparing the outcome after performing an arthrodesis versus hinged TKA after septic failed TKA.
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Affiliation(s)
- Y Gramlich
- Department of Trauma and Orthopedic Surgery, Berufsgenossenschaftliche Unfallklinik Frankfurt Am Main, Friedberger Landstr. 430, 60389, Frankfurt am Main, Germany.
| | - D Steinkohl
- Department of Trauma and Orthopedic Surgery, Berufsgenossenschaftliche Unfallklinik Frankfurt Am Main, Friedberger Landstr. 430, 60389, Frankfurt am Main, Germany
| | - M Kremer
- Department of Trauma and Orthopedic Surgery, Berufsgenossenschaftliche Unfallklinik Frankfurt Am Main, Friedberger Landstr. 430, 60389, Frankfurt am Main, Germany
| | - M Kemmerer
- Department of Trauma and Orthopedic Surgery, Berufsgenossenschaftliche Unfallklinik Frankfurt Am Main, Friedberger Landstr. 430, 60389, Frankfurt am Main, Germany
| | - R Hoffmann
- Department of Trauma and Orthopedic Surgery, Berufsgenossenschaftliche Unfallklinik Frankfurt Am Main, Friedberger Landstr. 430, 60389, Frankfurt am Main, Germany
| | - A Klug
- Department of Trauma and Orthopedic Surgery, Berufsgenossenschaftliche Unfallklinik Frankfurt Am Main, Friedberger Landstr. 430, 60389, Frankfurt am Main, Germany
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