1
|
Anderson S, Sanders JM, Cutrell JB, Tessier J, Johns M, Hennessy SA, Golnabi EY. Early Oral Step-Down Versus Continued Intravenous Antibiotic Treatment of Complicated Intra-Abdominal Infection. Surg Infect (Larchmt) 2024. [PMID: 39324191 DOI: 10.1089/sur.2024.076] [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: 09/27/2024] Open
Abstract
Background: Complicated intra-abdominal infections (cIAIs) require a combined tactic, of source control and antimicrobial therapy. This study aimed to evaluate the safety and efficacy of oral step-down antimicrobial therapy in cIAIs after initial intravenous (IV) antimicrobial therapy. Methods: This retrospective cohort study included hospitalized adult patients diagnosed with a cIAI who received more than seven days of IV therapy from March 2017 to October 2021. Exclusion criteria included primary/peritoneal dialysis-related peritonitis, necrotizing pancreatitis, fistulizing inflammatory bowel disease, or upper gastrointestinal tract infection. Patients were assigned into two groups: IV-only or oral step-down therapy. The primary outcome was infection recurrence, defined as re-initiation of antimicrobial agents after a treatment-free period of more than or equal to three days. Secondary outcomes included treatment escalation, repeat source control procedure, treatment-related complications, and all-cause mortality. Results: The cohort consisted of 248 patients (199 IV-only and 49 oral step-down). Patients receiving IV-only therapy had a shorter median antimicrobial duration than the oral step-down group (13 vs. 23 d; p <0.0001). Infection recurrence occurred in 26 (13.1%) and 6 (12.2%) patients in the IV-only and oral step-down groups, respectively (p = 0.88). Treatment escalation, repeat source control, and 28-day mortality were similar between groups. Oral step-down therapy resulted in more adverse drug events (10.2% vs. 3.0%; p = 0.04). Discussion: Transition to oral step-down after initial IV therapy had a similar rate of infection recurrence as IV-only therapy but was associated with a longer duration of antimicrobial therapy and an increased rate of adverse drug reactions. Larger randomized non-inferiority studies are needed to confirm this approach.
Collapse
Affiliation(s)
- Stephanie Anderson
- Department of Pharmacy, The University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - James M Sanders
- Department of Pharmacy, The University of Texas Southwestern Medical Center, Dallas, Texas, USA
- Division of Infectious Diseases and Geographic Medicine, Department of Internal Medicine, The University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - James B Cutrell
- Division of Infectious Diseases and Geographic Medicine, Department of Internal Medicine, The University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Jeffrey Tessier
- Division of Infectious Diseases and Geographic Medicine, Department of Internal Medicine, The University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Meagan Johns
- Department of Pharmacy, The University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Sara A Hennessy
- Department of Surgery, The University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Esther Y Golnabi
- Department of Pharmacy, The University of Texas Southwestern Medical Center, Dallas, Texas, USA
| |
Collapse
|
2
|
Hakkarainen T, Lahelma M, Rahkonen T, Lehtinen V, Shepelev J, Gram T, Heikkila E. Cost comparison analysis of continuous versus intermittent antimicrobial therapy infusions in inpatient and outpatient care: real-world data from Finland. BMJ Open 2024; 14:e085242. [PMID: 39317496 PMCID: PMC11423756 DOI: 10.1136/bmjopen-2024-085242] [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] [Received: 02/09/2024] [Accepted: 08/28/2024] [Indexed: 09/26/2024] Open
Abstract
OBJECTIVE This study compared the costs and nursing time associated with the delivery of continuous infusion of antibiotics via elastomeric infusion pumps (EIP) versus conventional intermittent infusion (CII) across different care pathways. DESIGN Retrospective real-world data informed a cost comparison analysis that compared costs and nursing hours between infusion of antibiotics via EIP versus CII across eight care pathways in inpatient or outpatient care during infection episodes. Real-world data were obtained from patients treated within a year with parenteral antimicrobial therapy in Päijät-Häme Region, Finland. SETTING Inpatient care with hospital admission and outpatient care at hospital at home in Päijät-Häme Region in Finland. PARTICIPANTS 3778 patients with a total of 4214 infection episodes treated with intravenous antimicrobial therapy. INTERVENTIONS Eight treatment strategies with various combinations of EIP and CII administered in inpatient or outpatient care. PRIMARY AND SECONDARY OUTCOME MEASURES Direct costs and nursing time. RESULTS Skin and soft tissue infections accounted for the highest number of episodes treated with EIP overall (30.8%; 74 out of 240 episodes) and in outpatient care specifically (53.3%; 128 out of 240 episodes). Compared with inpatient care costs with CII (€4590 per episode), treating skin and soft tissue infections in outpatient care with EIP or CII incurred only 24% (€1104) and 35% (€1620) of the costs, respectively. Across all treatment strategies and infections studied, the use of EIP consistently required less nursing time. The highest nursing time in the outpatient care was observed in sepsis episodes treated with CII (37 hours with CII vs 7 hours with EIP per episode). CONCLUSION Delivery of antimicrobial therapy using continuous infusions with EIP instead of CII can significantly decrease the nursing time and cost in both inpatient and outpatient care. For skin and soft tissue infections and sepsis, the utilisation of EIP is a cost-saving option in outpatient care compared with the use of CII.
Collapse
Affiliation(s)
- Tuukka Hakkarainen
- Nordic Healthcare Group, Helsinki, Finland
- University of Eastern Finland, Kuopio, Finland
| | | | - Terhi Rahkonen
- Department of Emergency Care of Lahti Central Hospital, Lahti, Finland
| | - Ville Lehtinen
- Department of Internal Medicine of Lahti Central Hospital, Lahti, Finland
| | - Julian Shepelev
- Health Economics and Outcomes Research, Baxter Healthcare SA, Opfikon, Switzerland
| | - Trine Gram
- Health Economics and Outcomes Research, Baxter Healthcare SA, Opfikon, Switzerland
| | | |
Collapse
|
3
|
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.
Collapse
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
| |
Collapse
|
4
|
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.
Collapse
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
| |
Collapse
|
5
|
Gehlen L, Lehmann C. [Outpatient parenteral anti-infective therapy (OPAT)]. INNERE MEDIZIN (HEIDELBERG, GERMANY) 2024; 65:566-575. [PMID: 38743073 DOI: 10.1007/s00108-024-01707-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 04/03/2024] [Indexed: 05/16/2024]
Abstract
Outpatient parenteral anti-infective therapy (OPAT) involves the administration of intravenous anti-infectives outside a hospital setting. This shortens the inpatient stay and leads to a reduction in treatment costs, fewer instances of nosocomial infections and enhanced quality of life for the patient.
Collapse
Affiliation(s)
- Liseth Gehlen
- Klinische Infektiologie, Klinik I für Innere Medizin, Universitätsklinikum Köln, Köln, Deutschland.
| | - Clara Lehmann
- Klinische Infektiologie, Klinik I für Innere Medizin, Universitätsklinikum Köln, Köln, Deutschland
- Deutsches Zentrum für Infektionsforschung Köln-Bonn, Standort Köln, Köln, Deutschland
| |
Collapse
|
6
|
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.
Collapse
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.
| |
Collapse
|
7
|
Peter S, Oberröhrmann C, Pfaff H, Lehmann C, Schmidt-Hellerau K, Brandes V, Leisse C, Lindemann CH, Ihle P, Küpper-Nybelen J, Hagemeier A, Scholten N. Exploring patients' perspectives: a mixed methods study on Outpatient Parenteral Antimicrobial Therapy (OPAT) experiences. BMC Health Serv Res 2024; 24:544. [PMID: 38685017 PMCID: PMC11057129 DOI: 10.1186/s12913-024-11017-9] [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: 02/20/2024] [Accepted: 04/19/2024] [Indexed: 05/02/2024] Open
Abstract
BACKGROUND Outpatient Parenteral Antimicrobial Therapy (OPAT), an alternative to inpatient intravenous antibiotic therapy, has shown benefits in international studies such as increased patient satisfaction. Because OPAT has been used only sporadically in Germany so far, no structured results on patients' experiences and concerns regarding OPAT have yet been available. This study therefore aims to explore the experiences of OPAT patients in a pilot region in Germany. METHODS This is an observational study in a German pilot region, including a survey of 58 patients on their experiences with OPAT, and in-depth interviews with 12 patients (explanatory-sequential mixed-methods design). RESULTS Patients reported that they were satisfied with OPAT. That a hospital discharge was possible and anti-infective therapy could be continued in the home environment was rated as being particularly positive. In the beginning, many patients in the interviews were unsure about being able to administer the antibiotic therapy at home on their own. However, healthcare providers (doctors and pharmacy service provider staff) were able to allay these concerns. Patients appreciated regular contact with care providers. There were suggestions for improvement, particularly concerning the organization of the weekly check-up appointments and the provision of information about OPAT. CONCLUSIONS Patients were generally satisfied with OPAT. However, the treatment structures in Germany still need to be expanded to ensure comprehensive and high-quality OPAT care. TRIAL REGISTRATION NCT04002453, https://www. CLINICALTRIALS gov/ , (registration date: 2019-06-21).
Collapse
Affiliation(s)
- Sophie Peter
- Chair of General Practice II and Patient-Centredness in Primary Care, Institute of General Practice and Primary Care, Faculty of Health, Witten/Herdecke University, Witten, Germany.
- University of Cologne, Faculty of Medicine and University Hospital Cologne, Institute of Medical Sociology, Health Services Research and Rehabilitation Science, Chair of Health Services Research, Cologne, Germany.
| | - Charlotte Oberröhrmann
- University of Cologne, Faculty of Medicine and University Hospital Cologne, Institute of Medical Sociology, Health Services Research and Rehabilitation Science, Chair of Health Services Research, Cologne, Germany
| | - Holger Pfaff
- University of Cologne, Faculty of Human Sciences and Faculty of Medicine and University Hospital Cologne, Institute of Medical Sociology, Health Services Research and Rehabilitation Science Cologne, Cologne, Germany
- Center for Health Services Research Cologne, Cologne, Germany
| | - Clara Lehmann
- Department I of Internal Medicine, Medical Faculty, University Hospital Cologne, University of Cologne, Cologne, Germany
- Center for Molecular Medicine Cologne (CMMC), University of Cologne, Cologne, Germany
- German Center for Infection Research (DZIF), Bonn-Cologne, Germany
| | - Kirsten Schmidt-Hellerau
- Department I of Internal Medicine, Medical Faculty, University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Vanessa Brandes
- Department I of Internal Medicine, Medical Faculty, University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Charlotte Leisse
- Department I of Internal Medicine, Medical Faculty, University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Christoph Heinrich Lindemann
- Department II of Internal Medicine and Center for Molecular Medicine Cologne (CMMC),, University of Cologne, Faculty of Medicine and University Hospital Cologne, Cologne, Germany
| | - Peter Ihle
- PMV forschungsgruppe, Faculty of Medicine and University Hospital Cologne, Cologne, Germany
| | - Jutta Küpper-Nybelen
- PMV forschungsgruppe, Faculty of Medicine and University Hospital Cologne, Cologne, Germany
| | - Anna Hagemeier
- Institute of Medical Statistics and Computational Biology (IMSB), Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Nadine Scholten
- University of Cologne, Faculty of Medicine and University Hospital Cologne, Institute of Medical Sociology, Health Services Research and Rehabilitation Science, Chair of Health Services Research, Cologne, Germany
| |
Collapse
|
8
|
Deng H, Gross AE, Trotter AB, Touchette DR. Cost evaluation of a nurse coordinated outpatient parenteral antimicrobial therapy (OPAT) program. ANTIMICROBIAL STEWARDSHIP & HEALTHCARE EPIDEMIOLOGY : ASHE 2024; 3:e252. [PMID: 38178876 PMCID: PMC10762635 DOI: 10.1017/ash.2023.526] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 09/16/2023] [Revised: 11/27/2023] [Accepted: 11/28/2023] [Indexed: 01/06/2024]
Abstract
A structured, nurse-driven outpatient parenteral antimicrobial therapy (OPAT) program within an academic healthcare system was associated with reduced odds of 60-day unplanned OPAT readmissions and costs after hospital discharge. These findings may facilitate justifying additional resources for OPAT programs to improve care while decreasing costs.
Collapse
Affiliation(s)
- Huiwen Deng
- Department of Pharmacy Systems, Outcomes and Policy, University of Illinois Chicago College of Pharmacy, Chicago, IL, USA
| | - Alan E. Gross
- Department of Pharmacy Practice, University of Illinois Chicago College of Pharmacy, Chicago, IL, USA
| | - Andrew B. Trotter
- Division of Infectious Disease, Department of Medicine, University of Illinois Chicago College of Medicine, Chicago, IL, USA
| | - Daniel R. Touchette
- Department of Pharmacy Systems, Outcomes and Policy, University of Illinois Chicago College of Pharmacy, Chicago, IL, USA
| |
Collapse
|
9
|
Phillips MC, Wald-Dickler N, Davar K, Lee R, Baden R, Holtom P, Spellberg B. Choosing patients over placebos: oral transitional therapy vs. IV-only therapy for bacteraemia and infective endocarditis. Clin Microbiol Infect 2023; 29:1126-1132. [PMID: 37179005 DOI: 10.1016/j.cmi.2023.04.030] [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: 01/31/2023] [Revised: 04/16/2023] [Accepted: 04/30/2023] [Indexed: 05/15/2023]
Abstract
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.
Collapse
Affiliation(s)
- Matthew C Phillips
- Division of Infectious Diseases, Department of Medicine, Massachusetts General Hospital, Boston, MA, United States; Harvard Medical School, Boston, MA, United States.
| | - Noah Wald-Dickler
- Los Angeles County + University of Southern California (LAC+USC) Medical Center, Los Angeles, CA, United States
| | - Kusha Davar
- Los Angeles County + University of Southern California (LAC+USC) Medical Center, Los Angeles, CA, United States
| | - Rachael Lee
- Department of Medicine, Division of Infectious Diseases, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Rachel Baden
- Los Angeles County + University of Southern California (LAC+USC) Medical Center, Los Angeles, CA, United States
| | - Paul Holtom
- Los Angeles County + University of Southern California (LAC+USC) Medical Center, Los Angeles, CA, United States
| | - Brad Spellberg
- Los Angeles County + University of Southern California (LAC+USC) Medical Center, Los Angeles, CA, United States
| |
Collapse
|
10
|
Tiemann AR, Guastadisegni JM, Kouma MA, Kelly KC, Arasaratnam RJ, Storey DF. We'll take it from here: Veterans Affairs OPAT management of home IV therapy initiated at community hospitals. ANTIMICROBIAL STEWARDSHIP & HEALTHCARE EPIDEMIOLOGY : ASHE 2023; 3:e197. [PMID: 38028919 PMCID: PMC10654944 DOI: 10.1017/ash.2023.476] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 08/09/2023] [Revised: 09/18/2023] [Accepted: 09/23/2023] [Indexed: 12/01/2023]
Abstract
An outpatient parenteral antimicrobial therapy team from a Veterans Affairs facility managed patients discharged from their own facility and neighboring community hospitals. There were no significant differences in adverse outcomes between the groups, but a majority of regimens were modified from those initially proposed by community providers.
Collapse
Affiliation(s)
| | | | - Marcus A. Kouma
- Veterans Affairs North Texas Health Care System, Dallas, TX, USA
| | - Kevin C. Kelly
- Veterans Affairs North Texas Health Care System, Dallas, TX, USA
| | - Reuben J. Arasaratnam
- Veterans Affairs North Texas Health Care System and University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Donald F. Storey
- Veterans Affairs North Texas Health Care System and University of Texas Southwestern Medical Center, Dallas, TX, USA
| |
Collapse
|
11
|
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.
Collapse
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
| |
Collapse
|
12
|
Kovacik CN, Shah MD, Thomas TA, Eby JC. First-Dose Antimicrobial Infusion Reactions in Patients Enrolled in Outpatient Parenteral Antimicrobial Therapy Services. Open Forum Infect Dis 2023; 10:ofad239. [PMID: 37305845 PMCID: PMC10249267 DOI: 10.1093/ofid/ofad239] [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: 03/01/2023] [Accepted: 04/26/2023] [Indexed: 06/13/2023] Open
Abstract
After receiving a monitored first-dose antimicrobial infusion at an infusion center, 6 of 93 (6%) patients enrolled in outpatient parenteral antimicrobial therapy services experienced an immediate reaction, none of which were consistent with immunoglobulin E-mediated reactions. These findings suggest it would be reasonable to forgo monitoring for most patients receiving first-dose intravenous antimicrobials outpatient.
Collapse
Affiliation(s)
- Carrie N Kovacik
- Correspondence: Carrie N. Kovacik, PharmD, MSHA, Department of Pharmacy, University of Virginia Health, P.O. Box 800674, Charlottesville, VA 22908 (); Joshua C. Eby, MD, Division of Infectious Diseases and International Health, University of Virginia Health, P.O. Box 800419, Charlottesville, VA 22908 ()
| | - Megan D Shah
- Department of Pharmacy, University of Virginia Health, Charlottesville, Virginia, USA
| | - Tania A Thomas
- Division of Infectious Diseases and International Health, Department of Medicine, University of Virginia Health, Charlottesville, Virginia, USA
| | - Joshua C Eby
- Correspondence: Carrie N. Kovacik, PharmD, MSHA, Department of Pharmacy, University of Virginia Health, P.O. Box 800674, Charlottesville, VA 22908 (); Joshua C. Eby, MD, Division of Infectious Diseases and International Health, University of Virginia Health, P.O. Box 800419, Charlottesville, VA 22908 ()
| |
Collapse
|
13
|
Childs-Kean LM, Beieler AM, Coroniti AM, Cortés-Penfield N, Keller SC, Mahoney MV, Rajapakse NS, Rivera CG, Yoke LH, Ryan KL. A Bundle of the Top 10 OPAT Publications in 2022. Open Forum Infect Dis 2023; 10:ofad283. [PMID: 37323428 PMCID: PMC10264063 DOI: 10.1093/ofid/ofad283] [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: 03/28/2023] [Accepted: 05/19/2023] [Indexed: 06/17/2023] Open
Abstract
Outpatient parenteral antimicrobial therapy (OPAT) has become more common in clinical settings. Correspondingly, OPAT-related publications have also increased; the objective of this article was to summarize clinically meaningful OPAT-related publications in 2022. Seventy-five articles were initially identified, with 54 being scored. The top 20 OPAT articles published in 2022 were reviewed by a group of multidisciplinary OPAT clinicians. This article provides a summary of the "top 10" OPAT publications of 2022.
Collapse
Affiliation(s)
- Lindsey M Childs-Kean
- Correspondence: Lindsey M. Childs-Kean, PharmD, MPH, University of Florida, 1225 Center Drive, Gainesville, FL 32610 ()
| | - Alison M Beieler
- Infectious Diseases Clinic, Harborview Medical Center, Seattle, Washington, USA
| | - Ann-Marie Coroniti
- Department of Pharmacy, Infectious Diseases and Immunology Center, The Miriam Hospital, Providence, Rhode Island, USA
| | - Nicolás Cortés-Penfield
- Division of Infectious Diseases, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Sara C Keller
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Monica V Mahoney
- Department of Pharmacy, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Nipunie S Rajapakse
- Division of Pediatric Infectious Diseases, Department of Pediatric and Adolescent Medicine, Mayo Clinic Children’s Center, Rochester, Minnesota, USA
| | | | - Leah H Yoke
- Vaccine and Infectious Disease Division, Fred Hutch Cancer Research Center, Allergy and Infectious Disease Division, University of Washington, Seattle, Washington, USA
| | | |
Collapse
|
14
|
Ito H. An Unsolved Problem of Adherence to Outpatient Parenteral Antimicrobial Therapy. Clin Infect Dis 2023; 76:1700. [PMID: 36633574 DOI: 10.1093/cid/ciad018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Accepted: 01/10/2023] [Indexed: 01/13/2023] Open
Affiliation(s)
- Hiroshi Ito
- Division of General Internal Medicine, Department of Internal Medicine, Tokyo Medical University Ibaraki Medical Center, Ibaraki, Japan
| |
Collapse
|
15
|
Staples JA, Ferris D, Sutherland JM. Reply to Ito. Clin Infect Dis 2023; 76:1700-1701. [PMID: 36661271 DOI: 10.1093/cid/ciad019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2023] [Accepted: 01/10/2023] [Indexed: 01/21/2023] Open
Affiliation(s)
- John A Staples
- Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
- Centre for Clinical Epidemiology & Evaluation, Vancouver, British Columbia, Canada
| | - Dwight Ferris
- Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Jason M Sutherland
- Centre for Health Evaluation & Outcome Sciences, Vancouver, British Columbia, Canada
- Centre for Health Services and Policy Research, School of Population and Public Health, University of British Columbia, Vancouver, British Columbia, Canada
| |
Collapse
|
16
|
Usefulness of Routine Laboratory Tests for Follow up of Patients Receiving Outpatient Parenteral Antimicrobial Therapy Run by Infectious Diseases Fellows. Antibiotics (Basel) 2023; 12:antibiotics12020330. [PMID: 36830241 PMCID: PMC9952172 DOI: 10.3390/antibiotics12020330] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2022] [Revised: 02/01/2023] [Accepted: 02/02/2023] [Indexed: 02/09/2023] Open
Abstract
BACKGROUND The infectious disease society of America (IDSA) recommends routine laboratory tests for all patients receiving outpatient parenteral antimicrobial therapy (OPAT) to monitor for adverse events. There are no data to support how often patients should take monitoring laboratory tests. In addition, the relevance of different laboratory tests commonly used for OPAT follow up is not clearly known. METHODS We conducted a retrospective observational cohort study over a 7-year study interval (1 January 2014 to 31 December 2021). Clinical data were obtained to identify the risk factors associated with abnormal laboratory tests and determine if abnormal laboratory tests led to antibiotic change or hospital readmission. RESULTS Two hundred and forty-six patients met the inclusion criteria for this study. In our multivariate analysis, the Charlson comorbidity index (CCI) of 0-4 (aOR 0.39, 95%Cl 0.18-0.86), the use of ceftriaxone without vancomycin (aOR 0.47, 95%Cl 0.24-0.91) and an OPAT duration of 2-4 weeks (aOR 0.47, 95%Cl 0.24-0.91) were associated with a lower risk of OPAT complications. A CCI of 5 or more (aOR 2.5, 95%Cl (1.1-5.7)) and an OPAT duration of 5 or more weeks (aOR 2.7, 95% Cl 1.3-5.6) were associated with a higher risk of OPAT complications. An abnormal complete metabolic panel or vancomycin levels, but not an abnormal complete blood count, were associated with antibiotic change or readmission. CONCLUSION Patients with fewer comorbidities, ceftriaxone and short OPAT durations are at lower risk for OPAT complications. These patients could be followed with less frequent laboratory monitoring.
Collapse
|
17
|
Castillo-Fernández N, Pérez-Crespo PMM, Salamanca-Rivera E, Herrera-Hidalgo L, de Alarcón A, Navarro-Amuedo MD, Marrodán Ciordia T, Pérez-Rodríguez MT, Sevilla-Blanco J, Jover-Saenz A, Fernández-Suárez J, Armiñanzas-Castillo C, Reguera-Iglesias JM, Natera Kindelán C, Boix-Palop L, León Jiménez E, Galán-Sánchez F, del Arco Jiménez A, Bahamonde-Carrasco A, Vinuesa García D, Smithson Amat A, Cuquet Pedragosa J, Reche Molina IM, Pérez Camacho I, Merino de Lucas E, Gutiérrez-Gutiérrez B, Rodríguez Baño J, López Cortés LE. Conventional Hospitalization versus Sequential Outpatient Parenteral Antibiotic Therapy for Staphylococcus aureus Bacteremia: Post-Hoc Analysis of a Multicenter Observational Cohort. Antibiotics (Basel) 2023; 12:antibiotics12010129. [PMID: 36671330 PMCID: PMC9854520 DOI: 10.3390/antibiotics12010129] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2022] [Revised: 01/01/2023] [Accepted: 01/06/2023] [Indexed: 01/12/2023] Open
Abstract
It is not known whether sequential outpatient parenteral antimicrobial (OPAT) is as safe and effective as conventional hospitalization in patients with S. aureus bacteremia (SAB). A post-hoc analysis of the comparative effectiveness of conventional hospitalization versus sequential OPAT was performed in two prospective Spanish cohorts of patients with S. aureus bacteremia. The PROBAC cohort is a national, multicenter, prospective observational cohort of patients diagnosed in 22 Spanish hospitals between October 2016 and March 2017. The DOMUS OPAT cohort is a prospective observational cohort including patients from two university hospitals in Seville, Spain from 2012 to 2021. Multivariate regression was performed, including a propensity score (PS) for receiving OPAT, stratified analysis according to PS quartiles, and matched pair analyses based on PS. Four hundred and thirteen patients were included in the analysis: 150 in sequential OPAT and 263 in the full hospitalization therapy group. In multivariate analysis, including PS and center effect as covariates, 60-day treatment failure was lower in the OPAT group than in the full hospitalization group (p < 0.001; OR 0.275, 95%CI 0.129−0.584). In the PS-based matched analyses, sequential treatment under OPAT was not associated with higher 60-day treatment failure (p = 0.253; adjusted OR 0.660; % CI 0.324−1.345). OPAT is a safe and effective alternative to conventional in-patient therapy for completion of treatment in well-selected patients with SAB, mainly those associated with a low-risk source and without end-stage kidney disease.
Collapse
Affiliation(s)
| | | | - Elena Salamanca-Rivera
- Unidad Clínica de Enfermedades Infecciosas y Microbiología, Hospital Universitario Virgen Macarena/Departamento de Medicina, Facultad de Medicina, Universidad de Sevilla/e Instituto de Biomedicina de Sevilla (IBiS)/CSIC, 41009 Sevilla, Spain
- Centro de Investigación en Red de Enfermedades Infecciosas (CIBERINFEC), Instituto de Salud Carlos III, 28029 Madrid, Spain
| | | | - Arístides de Alarcón
- Clinical Unit of Infectious Diseases, Microbiology and Preventive Medicine, Institute of Biomedicine of Seville (IBiS), University Hospital Virgen del Rocío/CSIC/University of Seville, 4103 Seville, Spain
| | - María Dolores Navarro-Amuedo
- Clinical Unit of Infectious Diseases, Microbiology and Preventive Medicine, Institute of Biomedicine of Seville (IBiS), University Hospital Virgen del Rocío/CSIC/University of Seville, 4103 Seville, Spain
| | - Teresa Marrodán Ciordia
- Departamento de Microbiología Clínica, Complejo Asistencial Universitario de León (CAULE), 24071 León, Spain
| | | | - Juan Sevilla-Blanco
- Unidad de Gestión Clínica de Enfermedades Infecciosas y Microbiología, Hospital Universitario Jerez de la Frontera, 11407 Cádiz, Spain
| | - Alfredo Jover-Saenz
- Unidad Funcional de Infecciones Nosocomiales, Hospital Arnau de Vilanova, 25198 Lérida, Spain
| | - Jonathan Fernández-Suárez
- Unidad de Microbiología, Instituto de Investigación Sanitaria del Principado de Asturias (ISPA), Hospital Universitario Central de Asturias, 33011 Oviedo, Spain
| | - Carlos Armiñanzas-Castillo
- Unidad de Enfermedades Infecciosas, Hospital Universitario Marqués de Valdecilla, Universidad de Cantabria, IDIVAL, 39008 Santander, Spain
| | | | - Clara Natera Kindelán
- Unidad Clínica de Enfermedades Infecciosas, Hospital Universitario Reina Sofía, 14004 Córdoba, Spain
| | - Lucía Boix-Palop
- Unidad de Enfermedades Infecciosas, Hospital Universitari Mútua de Terrassa, 08221 Barcelona, Spain
| | - Eva León Jiménez
- Unidad de Enfermedades Infecciosas y Microbiología, Hospital Universitario Nuestra Señora de Valme, 41014 Sevilla, Spain
| | - Fátima Galán-Sánchez
- Unidad de Gestión Clínica de Microbiología, Hospital Universitario Puerta del Mar, 11009 Cádiz, Spain
| | - Alfonso del Arco Jiménez
- Grupo Enfermedades Infecciosas, Servicio de Medicina Interna, Hospital Costa del Sol, 29603 Marbella, Spain
| | | | - David Vinuesa García
- Unidad Gestión Clínica Enfermedades Infecciosas, Hospital Universitario Clínico San Cecilio, 18016 Granada, Spain
| | - Alejandro Smithson Amat
- Unidad de Medicina Interna, Fundació Hospital de l’Esperit Sant, 08923 Santa Coloma de Gramenet, Spain
| | - Jordi Cuquet Pedragosa
- Departamento de Medicina Interna, Hospital Universitario de Granollers, 08402 Granollers, Spain
| | | | | | - Esperanza Merino de Lucas
- Unidad de Enfermedades Infecciosas, Hospital Universitario General de Alicante, 03010 Alicante, Spain
| | - Belén Gutiérrez-Gutiérrez
- Unidad Clínica de Enfermedades Infecciosas y Microbiología, Hospital Universitario Virgen Macarena/Departamento de Medicina, Facultad de Medicina, Universidad de Sevilla/e Instituto de Biomedicina de Sevilla (IBiS)/CSIC, 41009 Sevilla, Spain
- Centro de Investigación en Red de Enfermedades Infecciosas (CIBERINFEC), Instituto de Salud Carlos III, 28029 Madrid, Spain
| | - Jesús Rodríguez Baño
- Unidad Clínica de Enfermedades Infecciosas y Microbiología, Hospital Universitario Virgen Macarena/Departamento de Medicina, Facultad de Medicina, Universidad de Sevilla/e Instituto de Biomedicina de Sevilla (IBiS)/CSIC, 41009 Sevilla, Spain
- Centro de Investigación en Red de Enfermedades Infecciosas (CIBERINFEC), Instituto de Salud Carlos III, 28029 Madrid, Spain
| | - Luis Eduardo López Cortés
- Unidad Clínica de Enfermedades Infecciosas y Microbiología, Hospital Universitario Virgen Macarena/Departamento de Medicina, Facultad de Medicina, Universidad de Sevilla/e Instituto de Biomedicina de Sevilla (IBiS)/CSIC, 41009 Sevilla, Spain
- Centro de Investigación en Red de Enfermedades Infecciosas (CIBERINFEC), Instituto de Salud Carlos III, 28029 Madrid, Spain
- Correspondence:
| |
Collapse
|