Outpatient parenteral antimicrobial therapy practices among adult infectious disease physicians

Antimicrobial Stewardship Practices in Outpatient Parenteral Antimicrobial Therapy Programs in the United States

Background

Outpatient parenteral antimicrobial therapy (OPAT) regimens typically prioritize ease of antimicrobial administration, tolerability, safety, and accessibility over using the narrowest-spectrum antimicrobial. In light of this, OPAT providers often utilize different techniques to promote antimicrobial stewardship (AMS) in their OPAT programs. This study aims to characterize the AMS practices of OPAT programs across the United States that might meet The Joint Commission requirements for outpatient AMS metrics.

Methods

This is a cross-sectional electronic survey of the Vizient AMS network. A total of 95 possible questions were designed to inquire about demographics, OPAT program structure, AMS initiatives, performance metrics, and resources.

Results

Seventy-four survey responses were received, with 58 (78.4%) of the respondents indicating their institution offered OPAT services. Respondents reported having at least 1 AMS protocol and tracking at least 1 metric in 91% and 74% of OPAT programs, respectively. Only 40% of programs reported billing for OPAT-related services. Approximately 45% of respondents disagreed or strongly disagreed that their OPAT program had the resources needed to care for the population it serves. Respondents identified data analytics (69%), funding for expansion of services (67%), and pharmacists (62%) as resources of greatest need for their OPAT programs.

Conclusions

This survey collectively describes the AMS practices currently employed by OPAT programs across the United States. The results provide specific examples of AMS initiatives, metrics, and resources that institutions may reference to advance the practices of their OPAT programs to meet The Joint Commission Outpatient Antimicrobial Stewardship standards.

Current practices and challenges of outpatient parenteral antimicrobial therapy: a narrative review

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.

A Qualitative Review of Patient Feedback for the OPAT (Outpatient Antimicrobial Therapy) Service in Bristol

Outpatient parenteral antimicrobial therapy (OPAT) aims to deliver intravenous antimicrobials to medically stable patients with complex infections outside of a hospital setting. There is good evidence to demonstrate the safety and efficacy of OPAT in the literature. Anecdotally, the feedback from patients has been positive, but only a few studies evaluate this topic in detail. The aim of this qualitative study was to examine patients' experiences with and feedback on the OPAT service in Bristol, United Kingdom, which was established in 2021. A total of 92 patient feedback surveys were reviewed retrospectively, and thematic analysis was undertaken. Feedback from OPAT patients in our centre was overwhelmingly positive. The key themes identified were benefits to the patients, their friends, and family, and positive feedback about OPAT staff. The mean overall satisfaction score for OPAT was 9.6 out of 10. Areas to improve included communication between the OPAT and parent teams, improving OPAT capacity, and expansion of the service.

Barriers and facilitators for the implementation and expansion of outpatient parenteral antimicrobial therapy: a systematic review

Outpatient parenteral antimicrobial therapy (OPAT) has been expanding in recent years and serves as a viable solution in reducing the shortage of hospital beds. However, the wider implementation of OPAT faces numerous challenges. This review aimed to assess implementation barriers and facilitators of OPAT services. Studies describing barriers and facilitators of the OPAT service were retrieved from PubMed, Scopus, MEDLINE, EMBASE, CINAHL, Cochrane Library, Web of Science Proceedings, International Pharmaceutical Abstracts and PsycINFO. All types of study designs published in the English language were included. Studies that did not mention any barrier or facilitator, did not differentiate OPAT and inpatient, focused on specific antimicrobials or diseases, and made no distinction between parenteral and other treatments were excluded. Qualitative analysis was performed using the 'best-fit' framework approach and the Consolidated Framework for Implementation Research (CFIR). The review was PROSPERO registered (CRD42023441083). A total of 8761 studies were screened for eligibility and 147 studies were included. Problems in patient selection, lack of awareness, poor communication and co-ordination, lack of support, lack of structured service and inappropriate prescriptions were identified. OPAT provides safe, effective and efficient treatment while maintaining patients' privacy and comfort, resulting in less daily life disruption, and reducing the risk of infection. Satisfaction and preference for OPAT were very high. Initiatives in strengthening OPAT such as antimicrobial stewardship and telemedicine are beneficial. Challenges to and facilitators of OPAT were identified among patients, health professionals, OPAT service providers and healthcare administrators. Understanding them is crucial to designing targeted initiatives for successful OPAT service implementation.

Bridging the gap: opportunities for transitions of care pharmacist review of outpatient parenteral antimicrobial therapy prescriptions prior to hospital discharge

Purpose

Pharmacist-led initiatives providing optimization of medications during transitions of care (TOC) have shown to have a positive impact on prescribing practices and patient outcomes. This study aims to evaluate the role and impact of TOC pharmacist review of outpatient parenteral antimicrobial therapy (OPAT) prescriptions prior to hospital discharge.

Methods

In a retrospective chart review, patients with OPAT prescriptions between November 1, 2022 and January 31, 2023 were evaluated using prescription-specific and intervention-specific data points. Prescription-specific data points included intravenous antimicrobials prescribed, indication, prescribing team, and time from OPAT prescription to TOC pharmacist review. Intervention-specific data points included antimicrobial optimization (dose/frequency, duration, and other), prescription clarification, and laboratory monitoring.

Results

Of the 137 OPAT prescriptions evaluated, 67 required intervention by TOC pharmacists (48.9%). The General Infectious Disease Consult team placed 71.5% of OPAT prescriptions and required interventions less frequently (42.9%) compared to the other teams. Antimicrobial optimization interventions accounted for 54.2% of interventions, which were primarily related to medication dose and frequency.

Conclusion

The TOC pharmacists can play a key role in the evaluation of OPAT prescriptions at hospital discharge. This intervention demonstrated how TOC pharmacists can effectively collaborate with the OPAT team, which builds on prior evidence of the role and value of pharmacists in the transitional care setting.

Choosing patients over placebos: oral transitional therapy vs. IV-only therapy for bacteraemia and infective endocarditis

BACKGROUND

The belief that antibiotics must be administered intravenously (IV) to treat bacteraemia and endocarditis has its origins 70 years ago and has engrained itself in the psyche of the medical community and the public at large. This has led to hesitancy in adopting evidence-based strategies utilizing oral transitional therapy for the treatment of these infections. We aim to reframe the narrative around this debate, focusing on patient safety over vestigial psychology.

OBJECTIVES

This narrative review summarizes the current state of the literature regarding the use of oral transitional therapy for the treatment of bacteraemia and infective endocarditis, focusing on studies comparing it to the traditional, IV-only approach.

SOURCES

Relevant studies and abstracts from PubMed reviewed in April 2023.

CONTENT

Treating bacteraemia with oral transitional therapy has been studied in 9 randomized controlled trials (RCTs), totalling 625 patients, as well as numerous large, retrospective cohorts, including 3 published in the last 5 years alone, totalling 4763 patients. We identified 3 large, retrospective cohort studies; one quasi-experimental, pre-post study, and 3 RCTs of patients with endocarditis, totalling 748 patients in the retrospective cohorts and 815 patients in prospective, controlled studies. In all these studies, no worse outcomes were observed in the oral transitional therapy arm as compared with IV-only therapy. The main difference has consistently been longer durations of inpatient hospitalization and increased risk of catheter-related adverse events like venous thrombosis and line-associated blood stream infections in the IV-only groups.

IMPLICATIONS

There are ample data showing that choosing oral therapy reduces hospital stay and has fewer adverse events for patients than IV-only therapy, all with similar or better outcomes. In selected patients, choosing IV-only therapy may serve more as an anxiolytic "placebo" for the patient and provider rather than a necessity for treating the actual infection.

Physician Financial Incentives for Use of Outpatient Intravenous Antimicrobial Therapy: An Interrupted Time Series Analysis

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.

From sea to shining IV: the current state of OPAT in the United States

First described in the United States, outpatient parenteral antibiotic therapy (OPAT) has become an indispensable part of treating serious infections. The proportion of infectious disease (ID) physicians utilizing a formal OPAT program has increased in recent years, but remains a minority. In addition, many ID physicians have indicated that OPAT programs have inadequate financial and administrative support. Given the medical complexity of patients receiving OPAT, as well as the challenges of communicating with OPAT providers across health care facilities and systems, OPAT programs ideally should involve a multidisciplinary team. The majority of patients in the United States receive OPAT either at home with assistance from home infusion companies and visiting nurses or at a skilled nursing facility (SNF), though the latter has been associated with lower rates of patient satisfaction. Current and future opportunities and challenges for OPAT programs include providing OPAT services for people who inject drugs (PWID) and incorporating the increasing use of oral antibiotics for infections historically treated with parenteral therapy. In this review, we will discuss the current practice patterns and patient experiences with OPAT in the United States, as well as identify future challenges and opportunities for OPAT programs.

Best practices, implementation and challenges of outpatient parenteral antimicrobial therapy: results of a worldwide survey among healthcare providers

Background

Outpatient Parenteral Antimicrobial Therapy (OPAT) is considered a patient-friendly and cost-effective practice. Patients in the OPAT service can be at risk for developing adverse events. Due to extensive variations in practice, guidelines have been developed to minimize the risks.

Objectives

In this first worldwide survey on OPAT, we explored the current OPAT services around the world, adherence to recommendations and identified best practices and challenges from different perspectives.

Methods

An e-survey was conducted and consisted of questions about demographics, characteristics of the OPAT service, role of pharmacy, future developments, and respondents' views on improvements as well as best practices.

Results

A total of 126 responses from 28 countries were included. Seventy-eight percent (78%) of the respondents stated that their facility provides antimicrobial therapy in the outpatient setting, whereas 22% did not. Forty-two percent (42%) of the hospitals with OPAT services had a specialized OPAT service, while 14% lacked specialized services and 22% had a partially specialized team in place. In facilities with a specialized OPAT service, the number of mandatory infectious disease (ID) consultations before discharge and clinical monitoring by an ID specialist or OPAT team member, the frequency of monitoring, and the availability of an OPAT registry were higher. A multidisciplinary team's presence was commonly noted as best practices. On the other hand, respondents experienced difficulties with reimbursement and lack of standardization in the screening, follow-up and monitoring of patients.

Conclusion

This survey provides a better understanding of the implementation and practices of OPAT services globally and describes best practices and the challenges from different professionals.

Prevalence and risk factors associated with readmission with acute kidney injury in patients receiving vancomycin outpatient parenteral antimicrobial therapy

INTRODUCTION

Vancomycin is commonly used during outpatient parenteral antimicrobial therapy (OPAT). Therapeutic drug monitoring (TDM) of vancomycin is recommended to ensure effective and safe therapy, as use has been associated with acute kidney injury (AKI).

METHODS

The MarketScan® Commercial Database was queried from 2010 to 2016 to identify patients aged 18-64 years discharged from an inpatient hospitalization on vancomycin OPAT. The primary endpoint was hospital readmission with AKI within 6 weeks of index hospital discharge. TDM was defined as at least one vancomycin level obtained during outpatient therapy. Bivariate analysis was used to examine associations with outcomes; significant factors were incorporated into a multivariable logistic regression model.

RESULTS

A total of 14,196 patients were included in the study; median age was 54 years and 53.8% were male. Readmission with AKI occurred in 385 (2.7%) and was independently associated with chronic kidney disease (aOR 2.63 [95%CI 1.96-3.52]), congestive heart failure (1.81 [1.34-2.44]), chronic liver disease (1.74 [1.17-2.59]), hypertension (1.73 [1.39-2.17]), septicemia (1.61 [1.30-2.00]), and concomitant OPAT with IV penicillins (1.73 [1.21-2.49]) while skin and soft tissue infection (0.67 [0.54-0.83]) and surgical site infection (0.74 [0.59-0.93]) were associated with lower risk of readmission with AKI. TDM was not associated with lower risk of readmission with AKI.

CONCLUSION

Chronic kidney disease, congestive heart failure, hypertension, chronic liver disease, septicemia, and concomitant OPAT with IV penicillins were significantly associated with higher risk of readmission with AKI during vancomycin OPAT.

Current Practices and Opportunities for Outpatient Parenteral Antimicrobial Therapy in Hospitals: A National Cross-Sectional Survey

This nationwide study assessed how outpatient parenteral antimicrobial therapy (OPAT) is organised by Dutch acute care hospitals, the barriers experienced, and how an OPAT program affects the way hospitals organised OPAT care. We systematically developed and administered a survey to all 71 Dutch acute care hospitals between November 2021 and February 2022. Analyses were primarily descriptive and included a comparison between hospitals with and without an OPAT program. Sixty of the 71 hospitals (84.5%) responded. Fifty-five (91.7%) performed OPAT, with a median number of 20.8 (interquartile range [IQR] 10.3-29.7) patients per 100 hospital beds per year. Of these 55 hospitals, 31 (56.4%) had selection criteria for OPAT and 34 (61.8%) had a protocol for laboratory follow-up. Sixteen hospitals (29.1%) offered self-administered OPAT (S-OPAT), with a median percentage of 5.0% of patients (IQR: 2.3%-10.0%) actually performing self-administration. Twenty-five hospitals (45.5%) had an OPAT-related outcome registration. The presence of an OPAT program (22 hospitals, 40.0%) was significantly associated with aspects of well-organised OPAT care. The most commonly experienced barriers to OPAT implementation were a lack of financial, administrative, and IT support and insufficient time of healthcare staff. Concluding, hospital-initiated OPAT is widely available in the Netherlands, but various aspects of well-organised OPAT care can be improved. Implementation of a team-based OPAT program can contribute to such improvements. The observed variation provides leads for further scientific research, guidelines, and practical implementation programs.

Retrospective Cohort Study of the 12-Month Epidemiology, Treatment Patterns, Outcomes, and Healthcare Costs Among Adult Patients with Complicated Urinary Tract Infections

Background

Limited data are available in the United States on the 12-month epidemiology, outpatient (OP) antibiotic treatment patterns, outcomes, and costs associated with complicated urinary tract infections (cUTIs) in adult patients.

Methods

A retrospective observational cohort study of adult patients with incident cUTIs in IBM MarketScan Databases between 2017 and 2019 was performed. Patients were categorized as OP or inpatient (IP) based on initial setting of care for index cUTI and were stratified by age (<65 years vs ≥65 years). OP antibiotic treatment patterns, outcomes, and costs associated with cUTIs among adult patients over a 12-month follow-up period were examined.

Results

During the study period, 95 322 patients met inclusion criteria. Most patients were OPs (84%) and age <65 years (87%). Treatment failure (receipt of new unique OP antibiotic or cUTI-related ED visit/IP admission) occurred in 23% and 34% of OPs aged <65 years and ≥65 years, respectively. Treatment failure was observed in >38% of IPs, irrespective of age. Across both cohorts and age strata, >78% received ≥2 unique OP antibiotics, >34% received ≥4 unique OP antibiotics, >16% received repeat OP antibiotics, and >33% received ≥1 intravenous (IV) OP antibiotics. The mean 12-month cUTI-related total health care costs were $4697 for OPs age <65 years, $8924 for OPs age >65 years, $15 401 for IPs age <65 years, and $17 431 for IPs age ≥65 years.

Conclusions

These findings highlight the substantial 12-month health care burden associated with cUTIs and underscore the need for new outpatient treatment approaches that reduce the persistent or recurrent nature of many cUTIs.

The 30-Day Economic Burden of Newly Diagnosed Complicated Urinary Tract Infections in Medicare Fee-for-Service Patients Who Resided in the Community

Introduction: Scant data are available on the 30-day financial burden associated with incident complicated urinary tract infections (cUTIs) in a cohort of predominately elderly patients. This study sought to examine total and cUTI-related 30-day Medicare spending (MS), a proxy for healthcare costs, among Medicare fee-for-service (FFS) beneficiaries who resided in the community with newly diagnosed cUTIs. Methods: A retrospective multicenter cohort study of adult beneficiaries in the Medicare FFS database with a cUTI between 2017 and 2018 was performed. Patients were included if they were enrolled in Medicare FFS and Medicare Part D from 2016 to 2019, had a cUTI first diagnosis in 2017–2018, no evidence of any UTI diagnoses in 2016, and residence in the community between 2016 and 2018. Results: During the study period, 723,324 cases occurred in Medicare beneficiaries who met the study criteria. Overall and cUTI-related 30-day MS were $7.6 and $4.5 billion, respectively. The average overall and cUTI-related 30-day MS per beneficiary were $10,527 and $6181, respectively. The major driver of cUTI-related 30-day MS was acute care hospitalizations ($3.2 billion) and the average overall and cUTI-related 30-day MS per hospitalizations were $16,431 and $15,438, respectively. Conclusion: Overall 30-day MS for Medicare FSS patients who resided in the community with incident cUTIs was substantial, with cUTI-related MS accounting for 59%. As the major driver of cUTI-related 30-day MS was acute care hospitalizations, healthcare systems should develop well-defined criteria for hospital admissions that aim to avert hospitalizations in clinically stable patients and expedite the transition of patients to the outpatient setting to complete their care.

Survey of pharmacists on their roles and perceptions of outpatient parenteral antimicrobial therapy in the United States

OBJECTIVES

To define outpatient parenteral antimicrobial therapy (OPAT) clinical pharmacy practice across the United States, specifically pharmacist functions, design of pharmacist involvement, and to compare pharmacist training of those who practice in OPAT to infectious diseases pharmacists who do not.

METHODS

A survey of a possible 32 questions was emailed to the American College of Clinical Pharmacists (ACCP) Infectious Diseases Practice and Research Network (PRN) e-mail list. Results were focused on US-based respondents.

PARTICIPANTS

In total, 87 pharmacists responded; 27 of these pharmacists (31%) practiced in OPAT.

RESULTS

Training background did not differ between groups. Programs with an OPAT pharmacist were more likely to have a formal OPAT team compared to those without an OPAT pharmacist (P < .001). OPAT pharmacists were early in their careers with 66.7% practicing <5 years in OPAT. Most OPAT pharmacists (66.7%) practiced at an academic medical center with a median full-time equivalent (FTE) of 0.6. Moreover, 63% utilized a collaborative practice agreement and 81.5% shared job functions with other pharmacist roles, most commonly antimicrobial stewardship. Few OPAT programs involved a dispensing component (28%). The median daily census was 43 patients followed by an OPAT pharmacist. Pharmacists performed a variety of tasks in OPAT.

CONCLUSION

Pharmacist nondispensing involvement in OPAT is an emerging trend in the United States with wide variability in program structure and pharmacist tasks. A ratio of 1 OPAT pharmacist for every 45-70 OPAT patients is proposed to facilitate expansion of pharmacist clinical practice in OPAT.

The Impact of a Standardized Discharge Process on 30-Day Readmissions for Patients on Outpatient Parenteral Antibiotic Treatment

Introduction: Outpatient parenteral antibiotic treatment (OPAT) is associated with shorter length of hospital stay and reduced cost. Yet, patients discharged home on OPAT are at risk of hospital readmissions due to adverse events and complications. Although the impact of a multidisciplinary approach to readmission has been assessed by previous studies, addition of an innovative technology has not been evaluated for OPAT. This study examines the impact of a multidisciplinary approach including automated voice calls on 30-day readmissions of OPAT patients. Methods: A post-discharge transitional care process (PDTCP) targeting OPAT patients was implemented in fall 2016. This process included an automated telephone patient engagement service and coordination among pharmacy, nursing, medicine, and social work personnel. The patients on OPAT received automated telephone calls at 2, 9, 16, 28, and 40 days post-discharge to ensure medication availability and adherence and to circumvent issues that would otherwise result in an emergency room visit or readmission to the hospital. Results: A total 429 voice calls were made to 148 patients from November 8, 2016 to February 28, 2019. Overall, 61% (n = 90/148) of the patients were successfully reached by the automated voice system. The patients who were reached by the automated voice system were less likely to be readmitted than those not reached (18.9% vs 41.4%; relative risk (RR) 0.46, 95% CI 0.27-0.77, P = .003). Conclusion: Our study demonstrated that a multidisciplinary approach involving the use of automated telephone calls was associated with decreased hospital readmissions.

Risk Factors Associated With Nephrotoxicity During Outpatient Intravenous Vancomycin Administration

Background: Many studies have described an association between intravenous vancomycin and nephrotoxicity; however, the majority have evaluated incidence and risk factors among hospitalized patients. Outpatient administration of intravenous antibiotics is a growing practice and presents its own set of unique challenges. Objective: The aim of this study was to identify risk factors for vancomycin-associated nephrotoxicity in the outpatient setting. Methods: A case-control study of patients who received intravenous vancomycin through an Outpatient Parenteral Antimicrobial Therapy (OPAT) program was conducted. Patients were identified who developed an acute kidney injury (AKI) during treatment. The primary outcome was the incidence of AKI during treatment. Results: A total of 37 out of 130 patients (28.5%) met the criteria for AKI. AKI was more likely to occur in patients with a longer duration of therapy, higher maximum trough concentration, co-administration of a fluoroquinolone or metronidazole, and those who received another potentially nephrotoxic medication. Co-administration of a fluoroquinolone (OR = 5.96, P = 0.009, [CI: 1.59, 24.38]), any nephrotoxic medication (OR = 11.17, P < 0.001, [CI 3.14, 51.23]), and a higher maximum vancomycin trough (OR = 1.29, P < 0.001, [CI 1.17, 1.44]) were all indicative of a higher odds of an AKI. Conclusion: In this cohort, vancomycin-associated nephrotoxicity was common during outpatient intravenous antibiotic therapy. Co-administration of a fluoroquinolone, any nephrotoxic medication, and a higher maximum vancomycin trough were associated with AKI development. Further study is needed to determine how this impacts long-term clinical outcomes and what measures can be taken to reduce nephrotoxicity risk.

Experience with Liposomal Amphotericin B in Outpatient Parenteral Antimicrobial Therapy

Outpatient parenteral antimicrobial therapy (OPAT) is a safe, effective, and convenient treatment strategy for patients receiving intravenous antimicrobials in the outpatient setting; however, data are limited describing the use and safety of liposomal amphotericin B (L-AMB). Records of patients receiving L-AMB OPAT between 1/1/2015 and 7/31/2018 were retrospectively reviewed. The primary objective was to describe the OPAT patient population discharged on L-AMB and evaluate factors associated with readmission and adverse events (AEs). Analysis was performed to evaluate for predictors of worse outcomes. Forty-two patients (67% male, median age 50 years) were identified, most of whom were treated for histoplasmosis. The most common doses of L-AMB were 3 mg/kg (n = 16, 38%) or 5 mg/kg (n = 14, 33%) based on actual body weight. Twenty-six (62%) patients completed their anticipated course of L-AMB. Twenty-two (52%) patients were readmitted within 30 days of discharge; median time to readmission was 11 days (interquartile range [IQR] 5 to 18). While hypokalemia and acute kidney injury (AKI) were common, occurring in 26 (62%) and 20 (48%) patients, respectively, only 5 (12%) were readmitted to the hospital due to L-AMB-associated AEs. Ninety percent of patients achieved at least partial renal recovery within 30 days after L-AMB discontinuation. Factors significantly associated with AKI include higher L-AMB dose, lower serum potassium levels after therapy initiation, and receipt of potassium supplementation at discharge. L-AMB is associated with significant AEs; however, these results suggest that treatment is feasible in the outpatient setting with close monitoring, as the majority of AEs were managed effectively in an outpatient without long-term sequelae.

Evaluating the safety and effectiveness of a nurse-led outpatient virtual IV vancomycin monitoring clinic: a retrospective cohort study

Background

Outpatient parenteral antimicrobial therapy (OPAT) with vancomycin is a common treatment modality for certain Gram-positive infections. Data regarding the safety of various models of delivery are limited.

Objectives

To review outcomes of a nurse-led OPAT vancomycin monitoring service.

Methods

This was a retrospective cohort study of consecutive patients referred to a nurse-led OPAT vancomycin clinic from December 2015 to March 2018. Patients were administered IV vancomycin in the home with active laboratory monitoring of vancomycin trough levels, renal function and complete blood count using an integrated electronic database linked with community laboratories (virtual vancomycin clinic, VVC). Monitoring was coordinated by nurses with physician approval of recommended dosing changes. Data were extracted from the electronic medical record. Demographics; clinical indication; microbial aetiology; culture source; antimicrobial regimen(s); serum creatinine and vancomycin trough values; initiation, discharge and completion dates; hospitalizations; adverse events; and outcomes were all evaluated.

Results

Two hundred and seventy-five patients underwent a total of 301 courses of OPAT with vancomycin; 285 courses were completed. The rate of treatment discontinuation due to adverse effects was 33/301 (11.0%), with 15/33 (45.5%) being due to renal adverse effects (15/301 [5.0%] of episodes). Two of 15 (18.2%) patients developed stage 2 acute kidney injury (AKI), and no patients had stage 3 AKI or required haemodialysis. Nine of 301 (3.0%) required readmission for treatment failure. Nursing costs associated with monitoring were $63.93 CAD/patient ($48.43 USD).

Conclusions

A nurse-led VVC was a safe, effective and inexpensive modality for administering outpatient vancomycin.

Risk Factors for Adverse Events in Children Receiving Outpatient Parenteral Antibiotic Therapy

BACKGROUND

Outpatient parenteral antibiotic therapy (OPAT) can decrease length of hospital stay but is associated with adverse events (AEs). The purpose of this study was to quantify and identify risk factors for OPAT-associated AEs in children.

METHODS

Retrospective single-center study of children ≤21 years old discharged on OPAT from January 2016 to April 2019 with infectious diseases follow-up. Demographic and clinical factors and medication and central venous catheter (CVC)-associated AEs were assessed through chart review. Univariable and multivariable analyses were performed.

RESULTS

Among 181 OPAT courses, an AE occurred in 70 (39%). Medication AEs occurred in 30 of 181 courses (16.6%). Children residing in an urban area had a 4.5 times higher risk of having a medication-related AE compared with those in a rural area (odds ratio: 4.51; 95% confidence interval: 1.60-12.77; P = .005). CVC AEs occurred in 47 of 181 courses (26%). Every additional day of OPAT increased the odds of having a CVC-related AE by 4% (odds ratio: 1.04; 95% confidence interval: 1.01-1.07; P = .003). Twenty (11.1%) courses resulted in readmission to the hospital because of an AE.

CONCLUSIONS

In this cohort, 39% of children experienced an OPAT-associated AE, and CVC AEs were more common than medication AEs. Longer duration of intravenous therapy and urban residence were independently associated with OPAT-associated AEs, highlighting the importance of converting to oral antibiotic therapy as soon as feasible to reduce OPAT-associated AEs.

Recent innovations and new applications of outpatient parenteral antimicrobial therapy

INTRODUCTION

Outpatient parenteral antimicrobial therapy (OPAT) is safe and effective for selected patients managed within an organized clinical service. Service configurations however are evolving, patient populations are changing and new evidence is emerging which challenges traditional OPAT practice.

AREAS COVERED

This review will discuss evolving OPAT service delivery from the traditional model of infusion center toward nonspecialist, community and remotely delivered OPAT and the challenges this represents. We consider new patient populations including those with incurable infection or infections at the end of life and difficult to reach populations including people who inject drugs. The evidence base that underpins the multi-disciplinary approach to OPAT delivery will be examined and particularly the role of the antimicrobial pharmacist and specialist nurse. Evidence for new treatment options which challenge established OPAT practice including complex oral antibiotic regimens, long acting parenteral agents and drug stability in continuous infusion antibiotics will be considered. Finally we emphasize the central importance of antimicrobial stewardship and good clinical governance which should underpin OPAT practice.

EXPERT OPINION

Changing patient populations, service structures and team roles coupled with a growing infection management evidence base means that OPAT services and practice must evolve. Challenging traditional practice is essential to ensure best patient outcomes and cost-efficiency.

Human Factors approaches to evaluating outpatient parenteral antimicrobial therapy services: A systematic review

BACKGROUND

The expansion in terms of available treatment options and models of care has led to a growing global momentum for outpatient antimicrobial therapy (OPAT) services. A systematic review was undertaken to explore Human Factors aspects relating to OPAT service delivery and to evaluate whether OPAT is amenable to description using the Systems Engineering Initiative for Patient Safety (SEIPS 2.0) model.

METHOD

Following a preliminary search, a search string was applied to four databases, including Medline, Cumulative Index of Nursing and Allied Health Literature, International Pharmaceutical Abstracts and PsychINFO. Inclusion criteria ensured only articles published after the year 2000 and written in English were accepted. The methodological quality of studies was assessed by three reviewers. Narrative synthesis was performed to uncover the key interactions between work system entities which underpin OPAT processes and outcomes as described using the SEIPS 2.0 model.

RESULTS

A total of twenty-seven studies were deemed eligible for the final review. Of these, most described sample populations representative of the population under study, while duration of the studies varied from a few months to years. Some studies evaluated a single model of care whilst others evaluated all three currently available models. The breadth and scope of the studies included enabled extraction of rich Human Factors data describing barriers and enablers to service provision.

CONCLUSION

OPAT is a service which offers significant benefits to both patients and care providers. These benefits include patient satisfaction and wellbeing, as well as financial performance. OPAT is a complex sociotechnical system, and a systems approach may offer the opportunity to enhance system design, maximising system performance. This review demonstrates that the service can be better understood using the SEIPS 2.0 model to identify key work system interactions that support performance.

2018 Infectious Diseases Society of America Clinical Practice Guideline for the Management of Outpatient Parenteral Antimicrobial Therapy

A panel of experts was convened by the Infectious Diseases Society of America (IDSA) to update the 2004 clinical practice guideline on outpatient parenteral antimicrobial therapy (OPAT) [1]. This guideline is intended to provide insight for healthcare professionals who prescribe and oversee the provision of OPAT. It considers various patient features, infusion catheter issues, monitoring questions, and antimicrobial stewardship concerns. It does not offer recommendations on the treatment of specific infections. The reader is referred to disease- or organism-specific guidelines for such support.

Rates of and Risk Factors for Adverse Drug Events in Outpatient Parenteral Antimicrobial Therapy

Background

To better monitor patients on outpatient parenteral antimicrobial therapy (OPAT), we need an improved understanding of risk factors for and timing of OPAT-associated adverse drug events (ADEs).

Methods

We analyzed a prospective cohort of patients on OPAT discharged from 2 academic medical centers. Patients underwent chart abstraction and a telephone survey. Multivariable analyses estimated adjusted incident rate ratios (aIRR) between clinical and demographic risk factors and clinician-determined clinically significant ADEs. Descriptive data were used to present patient-reported ADEs.

Results

Of 339 patients enrolled in the study, 18.0% experienced an ADE (N = 65), of which 49 were significant (14.5%, 2.24/1000 home-OPAT days). Patients with longer courses of therapy had lower rates of ADEs compared with patients treated for 0-13 days (14-27 days: aIRR, 0.44; 95% confidence interval [CI], 0.20-0.99; at least 28 days: aIRR, 0.11; 95% CI, 0.056-0.21). Risk factors for ADEs included female gender and receipt of daptomycin or vancomycin, while treatment for uncomplicated bacteremia and empiric treatment were associated with lower rates of ADEs.

Conclusions

OPAT-related ADEs were common and often occurred within 2 weeks of hospital discharge. Patients on OPAT should be monitored more closely for ADEs, including clinical assessment and laboratory monitoring, especially within the first weeks after hospital discharge and particularly among women and patients who receive vancomycin.

Updated good practice recommendations for outpatient parenteral antimicrobial therapy (OPAT) in adults and children in the UK

UK good practice recommendations for outpatient parenteral antimicrobial therapy (OPAT) were published in 2012 and 2015 for adult and paediatric patients, respectively. Here we update the initial good practice recommendations in a combined document based on a further review of the OPAT literature and an extensive consultation process. As with the previous good practice recommendations, these updated recommendations are intended to provide pragmatic guidance for new and established OPAT services across a range of settings and to act as a set of quality indicators for service evaluation and quality improvement.

Perspectives of United States-based Infectious Diseases Physicians on Outpatient Parenteral Antimicrobial Therapy Practice

BACKGROUND

While outpatient parenteral antimicrobial therapy (OPAT) is generally considered safe, patients are at risk for complications and thus require close monitoring. The purpose of this study is to determine how OPAT programs are structured and how United States-based infectious diseases (ID) physicians perceive barriers to safe OPAT care.

METHODS

We queried members of the Emerging Infections Network (EIN) between November and December 2018 about practice patterns and barriers to providing OPAT.

RESULTS

672 members of the EIN (50%) responded to the survey. Seventy-five percent of respondents were actively involved in OPAT, although only 37% of respondents reported ID consultation was mandatory for OPAT. The most common location for OPAT care was at home with home-health support, followed by post-acute-care facilities. Outpatient and inpatient ID physicians were identified as being responsible for monitoring laboratory results (73% and 54% of respondents, respectively), but only 36% had a formal OPAT program. The majority of respondents reported a lack of support in data analysis (80%), information technology (66%), financial assistance (65%), and administrative assistance (60%). Perceived amount of support did not differ significantly across employment models. Inability to access laboratory results in a timely manner, lack of leadership awareness of OPAT value, and failure to communicate with other providers administering OPAT were reported as the most challenging aspects of OPAT care.

CONCLUSION

ID providers are highly involved in OPAT, but only a third of respondents have a dedicated OPAT program. Lack of financial and institutional support are perceived as significant barriers to providing safe OPAT care.

Outpatient ertapenem therapy in an ESBL-high-prevalence area: an efficacy, safety, and cost study

Introduction

Outpatient parenteral antimicrobial therapy is a safe, effective, and convenient way of administering antimicrobials for a wide variety of infections. So far there are no reports on the efficacy of outpatient antimicrobial therapy in Mexico. Our objective was to determine the outcomes, safety, and cost of outpatient ertapenem therapy (OET) in our hospital.

Patients and methods

A case series of 99 patients that received intravenous OET was conducted. The primary outcomes were clinical cure, relapse, and recurrence of infection.

Results

Of the 99 patients who received OET the most common diagnosis was urinary tract infection in 56%. Extended-spectrum-β-lactamase-producing Enterobacteriaceae caused 67% of infections in our population. Ninety-seven percent of the patients were cured at the completion of OET. One patient presented relapse 12 days after the end of OET; two patients presented recurrence, one with skin and soft tissue infection and one with pyelonephritis at days 35 and 34, respectively, after the end of OET. Three patients were readmitted after OET, one with an episode of phlebitis, one with recurrence, and one with relapse. A case of non-Clostridium difficile-associated diarrhea was observed. The intravascular line complications observed during OET were phlebitis in two patients.

Conclusion

In our hospital, the OET was found to be effective, safe, and cost-saving when compared to inpatient care.

Outpatient parenteral antimicrobial therapy and antibiotic stewardship: opponents or teammates?

PURPOSE

This narrative review aims to describe barriers of outpatient parenteral antimicrobial therapy at home (OPAT), potentially compromising general standards of antibiotic stewardship (ABS) and facilitators of OPAT for ABS.

METHODS

After a literature review, five authors determined the barriers and facilitators to discuss in this review.

RESULTS

Sixty-six publications were included in the narrative review and seven barriers and five facilitators are discussed in this article. The impracticability of multiple daily dosing during OPAT, the impact of real-life temperature variations, deviations of the infusion rates of elastomeric devices, access to prolonged intravenous antibiotic therapy, not administering loading doses before the initiation of extended or continuous infusions and the transmural nature of care associated with OPAT, can lead to deviations of recommended treatment regimens and sub-optimal clinical and laboratory follow-up, with a risk of inferior clinical outcomes, adverse events, drug-resistance and higher costs. On the other hand, OPAT provides access to treatments with intravenous antibiotics and simultaneously avoids prolonged hospitalization.

CONCLUSION

Implementing ABS guidelines in OPAT programs, e.g., by using a multidisciplinary team approach and facility-specific protocols for OPAT with patient selection criteria and instructions for selection, storage, preparation and administration of antibiotics, can improve appropriate antibiotic use. Additionally, further research should examine the effectiveness of these interventions on outcomes of OPAT.

Outpatient Parenteral Therapy for Complicated Staphylococcus aureus Infections: A Snapshot of Processes and Outcomes in the Real World

Background

In the United States, patients discharged on outpatient parenteral antimicrobial therapy (OPAT) are often treated by home health companies (HHCs) or skilled nursing facilities (SNFs). Little is known about differences in processes and outcomes between these sites of care.

Methods

We performed a retrospective study of 107 patients with complicated Staphylococcus aureus infections discharged on OPAT from 2 academic medical centers. Clinical characteristics, site of posthospital care, process measures (lab test monitoring, clinic follow-up), adverse events (adverse drug events, Clostridium difficile infection, line events), and clinical outcomes at 90 days (cure, relapse, hospital readmission) were collected. Comparisons between HHCs and SNFs were conducted.

Results

Overall, 33% of patients experienced an adverse event during OPAT, and 64% were readmitted at 90 days. Labs were received for 44% of patients in SNFs and 56% of patients in HHCs. At 90 days after discharge, a higher proportion of patients discharged to an SNF were lost to follow-up (17% vs 3%; P = .03) and had line-related adverse events (18% vs 2%; P < .01). Patients discharged to both sites of care experienced similar clinical outcomes, with favorable outcomes occurring in 61% of SNF patients and 70% of HHC patients at 90 days. There were no differences in rates of relapse, readmission, or mortality.

Conclusions

Patients discharged to SNFs may be at higher risk for line events than patients discharged to HHCs. Efforts should be made to strengthen basic OPAT processes, such as lab monitoring and clinic follow-up, at both sites of care.

Risk factors for readmission in patients discharged with outpatient parenteral antimicrobial therapy: a retrospective cohort study

Background

Outpatient parenteral antimicrobial therapy (OPAT) is a practical and effective way of delivering antimicrobial therapy, but may be associated with significant risk for hospital readmission. This study aimed to elucidate risk factors related to 30-day readmissions in patients who were discharged with OPAT at Mount Sinai Beth Israel (MSBI).

Methods

This IRB approved retrospective cohort study included patients who were at least 18 years or older, admitted to MSBI from August 2015 to March 2016, and discharged to receive OPAT. Patients with intravenous antibiotics prescribed for chronic suppression or planned readmission within 30 days were excluded. The main outcome was readmission to the hospital within 30 days from previous hospital discharge. Univariate and logistic regression analyses were performed to determine predictors of 30-day readmission.

Results

There were a total of 200 patients included in the analysis; the median age was 60 years, 65.5% were male, and the median Charlson score was 2. A total of 155 (78%) patients received a peripherally inserted central catheter (PICC); the remainder was discharged with a midline. The most common medications prescribed for OPAT included cephalosporins (41%), vancomycin (31%), carbapenems (23%), and penicillins (16%). A total of 42 patients (21%) were readmitted within 30 days after previous discharge. Discharge to a skilled nursing facility or subacute rehabilitation center was found to be an independent predictor of readmission on logistic regression analyses (p <  0.05).

Conclusion

Readmissions are common in patients discharged with OPAT. Recognizing predictors of readmission may help determine strategies to optimize care.

Outpatient parenteral antimicrobial therapy (OPAT) in the UK: a cross-sectional survey of acute hospital trusts and health boards

This study reviews the current OPAT service provision in the UK and evaluates concordance with the national OPAT practice guidelines (standards of care). We conducted a survey of acute hospital trusts and health boards in the UK regarding OPAT practices between June and September 2017. 165 (93%) of the 178 acute hospital trusts/health boards that were contacted responded to the survey. 100 (61%) indicated they had an OPAT service. Ten (10%) OPAT services did not involve an infection specialist. Bone and joint infections, and skin and soft-tissue infections were the most common conditions treated. Most OPAT services (74%) hold weekly multidisciplinary meetings/virtual ward rounds to review patient's progress. 73% had a dedicated OPAT database. We identified variations in practice and concordance with the national OPAT good practice guidelines. In an era of increasing demand for home-based care, further studies are required to identify the optimal configuration of OPAT services with regards to quality and patient safety.

Successful outpatient parenteral antibiotic therapy delivery via telemedicine

Objectives

Most outpatient parenteral antimicrobial therapy (OPAT) services use a hospital-based model of care in which patients remain in proximity to large hospitals facilitating clinical review. We aimed to evaluate clinical outcomes and complication rates for patients living in geographically isolated locations managed by telemedicine-supported OPAT. Methods: This was a retrospective cohort study.

Results

Between 2011 and 2015, we delivered 88 episodes of care involving 83 adult patients resulting in 2261 days of OPAT. The median age was 56 years, 8 of 83 (10%) were indigenous Australian and the median Charlson comorbidity index score was 2 (IQR 1-4). The median distance of patients' residence from our hospital was 288 km (IQR 201-715) and the median duration on the programme was 26 days (IQR 14-34). Bone and joint infections accounted for 75% of infections treated. Favourable clinical outcomes (improvement or cure) were achieved in 87% of patients and the unplanned, OPAT-related readmission rate was 8%. Nineteen percent and 10% of patients had drug-related and line-related adverse effects, respectively.

Conclusions

Despite a complex case mix, our adverse event and readmission rates are similar to the published literature describing a non-telemedicine model to deliver OPAT. High rates of favourable clinical outcomes and likely cost benefits suggest that telemedicine-supported OPAT is an efficacious and safe substitute for inpatient care in our setting.

A retrospective analysis of adverse events among patients receiving daptomycin versus vancomycin during outpatient parenteral antimicrobial therapy

OBJECTIVE

Outpatient parenteral antimicrobial therapy (OPAT) is a safe and effective alternative to prolonged inpatient stays for patients requiring long-term intravenous antimicrobials, but antimicrobial-associated adverse events remain a significant challenge. Thus, we sought to measure the association between choice of antimicrobial agent (vancomycin vs daptomycin) and incidence of adverse drug events (ADEs).

METHODS

Patients receiving OPAT treatment with vancomycin or daptomycin for skin and soft-tissue infections, bone and joint infections, endocarditis, and bacteremia or endovascular infections during the period from July 1, 2013, through September 30, 2016, were included. Demographic and clinical data were abstracted from the medical record. Logistic regression was used to compare ADEs requiring a change in or early discontinuation of therapy, hospital readmission, and emergency room visits between groups. Time from OPAT enrollment to ADE was compared using the log-rank test.

RESULTS

In total, 417 patients were included: 312 (74·8%) received vancomycin and 105 (25·2%) received daptomycin. After adjusting for age, Charlson comorbidity index, location of OPAT treatment, receipt of combination therapy with either β-lactam or fluoroquinolone, renal function, and availability of safety labs, patients receiving vancomycin had significantly higher incidence of ADEs (adjusted odds ratio [aOR], 3·71; 95% CI, 1·64-8·40). ADEs occurred later in the treatment course for patients treated with daptomycin (P<·01). Rates of readmission and emergency room visits were similar.

CONCLUSIONS

In the OPAT setting, vancomycin use was associated with higher incidence of ADEs than daptomycin use. This finding is an important policy consideration for programs aiming to optimize outcomes and minimize cost. Careful selection of gram-positive agents for prolonged treatment is necessary to limit toxicity.

Utilizing a Modified Care Coordination Measurement Tool to Capture Value for a Pediatric Outpatient Parenteral and Prolonged Oral Antibiotic Therapy Program

BACKGROUND

Outpatient parenteral or prolonged oral antibiotic therapy (OPAT) programs reduce inpatient healthcare costs by shifting care to outpatient settings. Care coordination (CC) is a necessary component to successfully transition patients. Our objective was to assess outcomes of provider time spent on nonreimbursable CC activities in a pediatric OPAT program.

METHODS

We used a qualitative feasibility pilot design and modified the Care Coordination Measurement Tool. We captured nonreimbursable CC activity and associated outcome(s) among pediatric patients enrolled in OPAT from March 1 to April 30, 2015 (44 work days) at Doernbecher Children's Hospital. We generated summary statistics for this institutional review board-waived QI project.

RESULTS

There were 154 nonreimbursable CC encounters conducted by 2 infectious diseases (ID) providers for 29 patients, ages 17 months-15 years, with complex infections. Total estimated time spent on CC was 54 hours, equivalent to at least 6 workdays. Five patients with complex social issues used 37% of total CC time. Of 129 phone events, 38% involved direct contact with families, pharmacies (13%), primary care providers (13%), and home health nursing (11%). Care coordination prevented 10 emergency room (ER) visits and 2 readmissions. Care coordination led to 16 additional, not previously scheduled subspecialist and 13 primary care visits. The OPAT providers billed for 32 clinic visits during the study period.

CONCLUSIONS

Nonreimbursable CC work by OPAT providers prevented readmissions and ER visits and helped facilitate appropriate healthcare use. The value of pediatric OPAT involvement in patient care would have been underestimated based on reimbursable ID consultations and clinic visits alone.

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

OBJECTIVE

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

DESIGN

A systematic review.

DATA SOURCES

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

STUDY SELECTION

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

RESULTS

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

CONCLUSIONS

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

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

Background

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

Objectives

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

Methods

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

Results

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

Limitations

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

Conclusions

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

Future work

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

Funding

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

Single-Dose Oritavancin Compared to Standard of Care IV Antibiotics for Acute Bacterial Skin and Skin Structure Infection in the Outpatient Setting: A Retrospective Real-World Study

INTRODUCTION

Cost-containment strategies are shifting the treatment of acute bacterial skin and skin structure infections (ABSSSI) from inpatient to outpatient settings. Current standard of care (SoC) requires multiple-dose regimens, which are associated with high hospitalization rates and high costs. Oritavancin, a new single-dose antibiotic for ABSSSI, may be suitable for outpatient therapy. This analysis evaluates the effectiveness, costs, and resource utilization of oritavancin vs. SoC in a real-world, outpatient setting.

METHODS

A single-site, retrospective chart review was conducted of 118 adult patients diagnosed with ABSSSI and treated with either single-dose oritavancin or multi-dose SoC therapy between 6 August 2014 and 30 June 2015. Patients were assigned to two matched cohorts: oritavancin and SoC. Primary clinical effectiveness endpoints was the success (cured or improved) at 5-30 days after the course of antibiotic therapy has been completed. Secondary economic endpoints were total costs and healthcare resource utilization.

RESULTS

Oritavancin showed comparable clinical effectiveness vs. multi-dose SoC in the outpatient setting. A similar percentage of patients in the oritavancin (90.2%) and SoC cohorts (77.4%) achieved successful outcomes ("cure" or "improved"), with the cure rate higher for oritavancin (73.2%) vs. SoC (48.4%; P = 0.0315). Oritavancin's clinical effectiveness was consistent across patient subgroups with varying demographic, clinical, and ABSSSI characteristics. Oritavancin was consistently associated with lower costs (per-patient savings $2319) and reduced resource utilization measures, and it required just 1.0 day of therapy vs. 7.2 days for SoC.

CONCLUSION

Oritavancin is well suited for the outpatient treatment of ABSSSI. Compared with SoC, oritavancin offers comparable effectiveness, is more economical, and requires fewer healthcare resources.

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSION

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

Outcomes and Pharmacoeconomic Analysis of a Home Intravenous Antibiotic Infusion Program in Veterans

PURPOSE

The use of outpatient parenteral antibiotic therapy (OPAT) programs has become more frequent because of benefits in costs with equivalent clinical outcomes compared with inpatient care. The purpose of this study was to evaluate the outcomes of our program. A modified pharmacoeconomic analysis was performed to compare costs of our program with hospital or rehabilitation facility care.

METHODS

This was a retrospective chart review of 96 courses of OPAT between April 1, 2011, and July 31, 2013. Clinical failures were defined as readmission or death due to worsening infection or readmission secondary to adverse drug event (ADE) to antibiotic therapy. This does not include those patients readmitted for reasons not associated with OPAT therapy, including comorbidities or elective procedures. Baseline characteristics and program-specific data were analyzed. Statistically significant variables were built into a multivariate logistic regression model to determine predictors of failure. A pharmacoeconomic analysis was performed with the use of billing records.

FINDINGS

Of the total episodes evaluated, 17 (17.71%) clinically failed therapy, and 79 (82.29%) were considered a success. In the multivariate analysis, number of laboratory draws (P = 0.02) and occurrence of drug reaction were significant in the final model, P = 0.02 and P = 0.001, respectively. The presence an adverse drug reaction increases the odds of failure (OR = 10.10; 95% CI, 2.69-44.90). Compared with inpatient or rehabilitation care, the cost savings was $6,932,552.03 or $2,649,870.68, respectively.

IMPLICATIONS

In our study, patients tolerated OPAT well, with a low number of failures due to ADE. The clinical outcomes and cost savings of our program indicate that OPAT can be a viable alternative to long-term inpatient antimicrobial therapy.

Diffusion of Newer HIV Prevention Innovations: Variable Practices of Frontline Infectious Diseases Physicians

BACKGROUND

US Public Health Service guidelines recommend early initiation of antiretroviral treatment (ART) for human immunodeficiency virus infection (HIV)-infected patients and preexposure prophylaxis (PrEP) as a prevention option for persons at risk for HIV acquisition. Before issuance of these guidelines, few clinicians reported prescribing early ART or PrEP.

METHODS

The Emerging Infections Network, a national network of infectious diseases physicians in the United States and Canada, was surveyed in September 2014 to assess practices of adult HIV-care providers with early ART, PrEP, and other guideline-recommended HIV prevention methods.

RESULTS

Almost half of the 1191 active members invited (48.1%) participated; 415 (72.4%) were HIV-care providers. Most providers (86.5%) indicated that they typically recommended ART initiation at diagnosis, irrespective of CD4(+) cell count. However, for patients with a CD4(+) cell count >500/µL, clinicians would defer ART if patients did not feel ready to initiate ART (94.7%) or had uncontrolled substance abuse (66.0%). Many providers had counseled HIV-infected patients about PrEP for partners (59.0%) or offered visits for partners to discuss PrEP (40.7%), and 31.8% had prescribed PrEP. Clinicians who deferred ART were less likely to endorse and engage in aspects of PrEP provision.

CONCLUSIONS

Concordant with guidelines, most infectious diseases physicians recommend early ART, and many have experience with aspects of PrEP provision, suggesting recent evolution of clinician practices. Providers who defer ART are also cautious about PrEP. Interventions that help physicians motivate patients to initiate ART and identify missed opportunities to provide PrEP could enhance HIV prevention.

The history and evolution of outpatient parenteral antibiotic therapy (OPAT)

Outpatient parenteral antibiotic therapy (OPAT) is now a widely accepted and safe therapeutic option for carefully selected patients. Benefits include cost savings and improved patient satisfaction; risks include failure to adhere to care, unexpected changes in the underlying infection, and adverse drug and intravenous access events. We report on our 40-year experience with OPAT in a single healthcare system in the USA and highlight OPAT developments in several countries. We compared data on patients treated in our programme over two time periods: Period 1 from 1978 to 1990; and Period 2, calendar year 2014. In Period 2 paediatric patients were excluded. Between Periods 1 and 2, changes included an almost three-fold increase in the number of patients treated per year (80 vs. 229), treatment of more patients with severe orthopaedic-related infections (20% vs. 38%), a marked increase in the use of peripherally inserted central catheters to administer antibiotics (20% vs. 98%), a shorter duration of inpatient stay and a longer duration of OPAT (13 days vs. 24 days). Other changes in Period 2 included treatment of 20% of patients without antecedent hospitalisation, and use of carbapenems rather than cephalosporins as the most frequently administered agents. OPAT was safe, with rehospitalisation rates of 6% and 1% in Periods 1 and 2, respectively. We recommend increased access to structured OPAT teams and the development of standard definitions and criteria for important outcome measures (e.g. clinical 'cure' and unplanned hospital re-admissions). These steps are critical for patient safety and financial stewardship of resources.