A single centre experience of prosthetic joint infection outcomes with outpatient parenteral antimicrobial therapy

Objectives

Prosthetic joint infection (PJI) is a serious complication following arthroplasties. This study assessed the clinical outcomes, readmission rates and financial impact of PJIs treated with outpatient parenteral antimicrobial therapy (OPAT).

Methods

The study used prospectively collected data from the OPAT patient database at a tertiary care Irish hospital for PJI cases managed between 2015 and 2020. Data was analyzed using IBM-SPSS.

Results

Forty-one patients with PJIs were managed via OPAT over five years, with median age of 71.6 years. Median duration of OPAT was 32 days. Hospital readmission occurred in 34% of cases. Reasons for readmission included progression of infection in 64.3%, unplanned reoperation in 21.4% and planned admission for joint revision in 14.3%. Type 2 Diabetes Mellitus (T2DM) was found to have a statistically significant association with unplanned readmission (OR 8.5, CI 95% 1.1-67.6; p < 0.01). OPAT saved a mean of 27.49 hospital-bed days per patient. 1,127 bed days were saved in total, estimating a total savings of 963,585 euros and median savings of 26,505 euros.

Conclusions

The readmission rate observed was comparable to international data. Most readmissions were related to primary infections rather than due to OPAT-specific complications. Our main findings were that patients with PJIs can be safely managed via OPAT, and the finding of association between T2DM and increased risk of readmission.

Opportunities, associations, and impact of early intravenous to oral antimicrobial switch for hospitalized patients in Ethiopia

Objective:

Short intravenous antimicrobial therapy for 2–3 days followed by its per oral comparable antimicrobial course is a crucial part of the antimicrobial stewardship program. However, nothing is known about this practice in Ethiopian hospitals. Therefore, this study assessed the proportion, associations, and outcomes of early intravenous to per oral antimicrobial switch for patients who were admitted to the three wards of Ambo University Referral Hospital.

Method:

A hospital-based prospective cohort pilot study was conducted. During the 3-month period, 117 patients met initial inclusion criteria and were followed until Day 3 of intravenous antimicrobial. Of these, 92 (78.6%) subsequently met criteria for early intravenous to per oral switch and are the cohort investigated in this study. Written informed consent was sought from participants and/or parents or guardian for ages 15–17 years. Logistic regression models and independent t-tests were done with a significance of p ⩽ 0.05.

Results:

Out of 92 study participants, early intravenous to per oral antimicrobial switch was done only for 36 (39.1%). The only independent predictors for lack of early intravenous to per oral antimicrobials switch were poly-pharmacy (adjusted odds ratio = 3.4 at 95% confidence interval, 1.036–11.16; p = 0.044). There was a significant difference in terms of mean length of hospital stay (8.80 ± 3.57 versus 3.17 ± 0.74; p < 0.0001), in-hospital complication rate (95% versus 5%; p < 0.0001), and the mean cost of healthcare in Ethiopian Birrs (652.29 ± 403.29 versus 126.67 ± 29.47; p < 0.0001) between the comparator/early intravenous to per oral not switched and early switched group, respectively.

Conclusion:

The proportion of early intravenous to per oral antimicrobial switch was unsatisfactory. There was a significant difference between the intervention and comparator groups in terms of length of hospital stay, in-hospital complications, and extra cost. Therefore, implementation of interventions that improve the practice of early intravenous to per oral switch is needed urgently.

Safety and Clinical Outcomes of Hospital in the Home

OBJECTIVES

The aim of the study was to evaluate clinical outcomes and adverse events (AEs) experienced by patients treated within the Hospital in the Home (HITH) service of a major metropolitan hospital in South Australia.

METHODS

A retrospective case note audit of 100 HITH episodes among adults who received continuous intravenous antimicrobial therapy via an elastomeric or electronic infusion device was undertaken. Age- and sex-adjusted binomial logistic regression analyses were undertaken to identify factors associated with major and minor AEs.

RESULTS

Of the 100 patients included, 71 were male and the mean (SD) patient age was 62.8 (17.19) years. Elastomeric infusion devices were used for 98 patients. The mean (SD) HITH treatment duration was 20.1 (11.9) days. Overall, 130 AEs were documented for 72 patients (72%), of whom 12 patients experienced a major AE and 68 patients experienced a minor AE. There were 45 occasions among 23 patients where an infusion administered through an elastomeric device did not run to completion. Fifteen patients were readmitted to hospital. Minor AEs were more likely among people with more vascular line days (adjusted odds ratio [aOR] = 1.05; 95% confidence interval (CI) = 1.01-1.10 per day increase) and females (aOR = 4.43; 95% CI = 1.14-17.17). An increased number of vascular line days was associated with an increased likelihood of an incomplete infusion (aOR = 1.05; 95% CI = 1.01-1.09). Hospital readmission was more likely with increasing age (aOR = 1.06; 95% CI = 1.01-1.11 per year increase).

CONCLUSIONS

Adverse events need to be monitored carefully when HITH treatment is provided for extended periods.

Evaluation of a thrice weekly administration of teicoplanin in the outpatient setting: a retrospective observational multicentre study

Introduction

The glycopeptide teicoplanin is commonly utilized to facilitate outpatient parenteral antimicrobial therapy (OPAT). Licensed for once daily maintenance dosing, teicoplanin’s long half-life allows for less frequent dosing (e.g. thrice weekly) following successful loading. This service evaluation reviews the safety and effectiveness of a novel thrice weekly teicoplanin dosing regimen.

Methods

A retrospective, observational study was conducted at Chelsea and Westminster Hospital (March 2018 to July 2020), evaluating trough serum teicoplanin concentrations for patients receiving >5 days of teicoplanin in the OPAT setting. Teicoplanin dosing and administration (once daily versus thrice weekly), clinical outcomes and therapeutic levels were analysed for all patients. The project was registered with clinical governance locally.

Results

A total of 82 patients treated with teicoplanin in the OPAT service were included; 53/82 receiving thrice weekly and 29/82 receiving once daily dosing. Mean teicoplanin trough levels were similar in both groups (26.2 mg/L and 25.8 mg/L in once daily and thrice weekly groups, P = 0.8895). High clinical success rates were recorded in both groups (25/29 [86.2%] versus 50/53 [94.3%]). No correlation with clinical outcomes and initial teicoplanin serum levels was identified. Normal renal function (>90 mL/min) was associated with lower teicoplanin serum concentrations (mean [±SD] 21.4 mg/L [±10.1] versus 29.7 mg/L [±14], P = 0.0178) in the thrice weekly dosed group but not with the once daily dosed group (mean [±SD] 28.2 mg/L [±9.4] versus 23.7 mg/L [±9.9], P = 0.2201).

Conclusions

This study supports thrice weekly teicoplanin as a convenient and effective OPAT for administration in the OPAT setting. Therapeutic drug monitoring is advised to adjust for intra-patient variability.

Outpatient Antimicrobial Therapy for Infective Endocarditis is Safe

Infective endocarditis (IE) is common and is associated with significant mortality, morbidity and health care burden. Outpatient antimicrobial therapy in carefully selected patients, supported by a multidisciplinary team is safe and beneficial for both the patient and the health care system. In this article, we review current literature of outpatient antimicrobial therapy in infective endocarditis and propose that most patients with IE should be considered and appropriate pathways developed to facilitate this.

Infectious Diseases Society of America Position Statement on Telehealth and Telemedicine as Applied to the Practice of Infectious Diseases

Over the last 2 decades, telemedicine has effectively demonstrated its ability to increase access to care. This access has the ability to deliver quality clinical care and offer potential savings to the healthcare system. With increasing frequency, physicians, clinics, and medical centers are harnessing modern telecommunications technologies to manage a multitude of acute and chronic conditions, as well as incorporating telehealth into teaching and research. The technologies spanning telehealth, telemedicine, and mobile health (mHealth) are rapidly evolving, and the Infectious Diseases Society of America (IDSA) has prepared this updated position statement to educate its membership on the use of telemedicine and telehealth technologies. IDSA supports the appropriate and evidence-based use of telehealth technologies to provide up-to-date, timely, cost-effective subspecialty care to resource-limited populations.

Daptomycin to bone and joint infections and prosthesis joint infections: a systematic review

Backgroud

Daptomycin has been used in bone and joint infections (BJI) and prosthesis joint infections (PJI) considering spectrum of activity and biofilm penetration. However, the current experience is based on case reports, case series, cohorts, and international surveys. The aim of this systematic review was to evaluate studies about daptomycin treatment efficacy in BJI/PJI compared to other antibiotic regimens.

Methods

PubMed, LILACS, Scielo and Web of Science databases were searched for articles about daptomycin and treatment of BJI and PJI from inception to March 2018. Inclusion criteria were any published researches that included patients with BJI treated with daptomycin. Diagnosis of BJI was based on clinical, laboratory and radiological findings according to IDSA guidelines.

Results

From 5107 articles, 12 articles were included. Only three studies described the outcomes of patients with BJI treated with daptomycin with comparator regimen (vancomycin, teicoplanin and oxacillin). Studies presented large heterogeneity regarding device related infections, surgical procedures, and daptomycin regimens (varied from 4 mg/kg to 10 mg/kg). A total of 299 patients have been included in all studies (184 infections associated with orthopedic disposal and 115 osteomyelitis/septic arthritis). Two hundred and thirty-three patients were treated with daptomycin. The clinical cure rates on device related and non-device related infections (i.e. osteomyelitis) were 70% and 78%, respectively. Compared to all regimens evaluated, daptomycin group outcomes were non-inferior.

Conclusion

Although a randomized clinical trial is needed, this systematic review tends to support daptomycin usage for bone and joint infections.

Safety and effectiveness of 'hospital in the home' and 'outpatient parenteral antimicrobial therapy' in different age groups: A systematic review of observational studies

OBJECTIVE

The aim of this study was .to systematically review the published literature of observational studies evaluating the safety and effectiveness of hospital in the home (HITH) and outpatient parenteral antimicrobial therapy (OPAT) in the general population, older people and children.

STUDY DESIGN

The review included retrospective studies and prospective studies performed on HITH and OPAT within different age groups. Only the studies that analysed the safety and effectiveness of HITH and OPAT were included for review.

DATA SOURCES

A literature search of electronic databases CINAHL, Web of Science, PubMed and SCOPUS from 1997 to 2016 was performed.

DATA SYNTHESIS

Forty-four studies met the inclusion criteria. Five studies were undertaken on HITH within the general population, 26 studies were undertaken on OPAT within the general population, 8 studies were on HITH and OPAT for older people and 5 studies were on OPAT with children. More than 88% of the studies reported a cure or treatment success rate of greater than 80%. Adverse events with drugs ranged from 0% to 30.2%; adverse events with vascular access devices ranged from 0% to 29%; readmission rate varied from 1% to 26%; mortality varied from 0% to 27.5%.

CONCLUSIONS

This review quantifies the rates of success and harm in real world practice, and demonstrates that while most patients experience treatment success, adverse events may be high in some groups. However, the methodologies used to measure these parameters were inconsistent and some demographic groups had only a small number of studies.

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 qualitative study of patients' feedback about Outpatient Parenteral Antimicrobial Therapy (OPAT) services in Northern England: implications for service improvement

OBJECTIVE

Outpatient parenteral antimicrobial therapy (OPAT) provides opportunities for improved cost savings, but in the UK, implementation is patchy and a variety of service models are in use. The slow uptake in the UK and Europe is due to a number of clinical, financial and logistical issues, including concern about patient safety. The measurement of patient experience data is commonly used to inform commissioning decisions, but these focus on functional aspects of services and fail to examine the relational aspects of care. This qualitative study examines patients' experiences of OPAT.

DESIGN

In-depth, semistructured interviews.

SETTING

Purposive sample of OPAT patients recruited from four acute National Health Service (NHS) Trusts in Northern England. These NHS Trusts between them represented both well-established and recently set-up services running nurse at home, hospital outpatient and/or self-administration models.

PARTICIPANTS

We undertook 28 semistructured interviews and one focus group (n=4).

RESULTS

Despite good patient outcomes, experiences were coloured by patients' personal situation and material circumstances. Many found looking after themselves at home more difficult than they expected, while others continued to work despite their infection. Expensive car parking, late running services and the inconvenience of waiting in for the nurse to arrive frustrated patients, while efficient services, staffed by nurses with the specialist skills needed to manage intravenous treatment had the opposite effect. Many patients felt a local, general practitioner or community health centre based service would resolve many of the practical difficulties that made OPAT inconvenient. Patients could find OPAT anxiety provoking but this could be ameliorated by staff taking the time to reassure patients and provide tailored information.

CONCLUSION

Services configurations must accommodate the diversity of the local population. Poor communication can leave patients lacking the confidence needed to be a competent collaborator in their own care and affect their perceptions of the service.

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.

Daptomycin: an evidence-based review of its role in the treatment of Gram-positive infections

Infections caused by Gram-positive pathogens remain a major public health burden and are associated with high morbidity and mortality. Increasing rates of infection with Gram-positive bacteria and the emergence of resistance to commonly used antibiotics have led to the need for novel antibiotics. Daptomycin, a cyclic lipopeptide with rapid bactericidal activity against a wide range of Gram-positive bacteria including methicillin-resistant Staphylococcus aureus, has been shown to be effective and has a good safety profile for the approved indications of complicated skin and soft tissue infections (4 mg/kg/day), right-sided infective endocarditis caused by S. aureus, and bacteremia associated with complicated skin and soft tissue infections or right-sided infective endocarditis (6 mg/kg/day). Based on its pharmacokinetic profile and concentration-dependent bactericidal activity, high-dose (>6 mg/kg/day) daptomycin is considered an important treatment option in the management of various difficult-to-treat Gram-positive infections. Although daptomycin resistance has been documented, it remains uncommon despite the increasing use of daptomycin. To enhance activity and to minimize resistance, daptomycin in combination with other antibiotics has also been explored and found to be beneficial in certain severe infections. The availability of daptomycin via a 2-minute intravenous bolus facilitates its outpatient administration, providing an opportunity to reduce risk of health care-associated infections, improve patient satisfaction, and minimize health care costs. Daptomycin, not currently approved for use in the pediatric population, has been shown to be widely used for treating Gram-positive infections in children.

Implementing criteria-based early switch/early discharge programmes: a European perspective

Early switch (ES) from intravenous (IV) to oral antibiotic therapy programmes is increasingly included as a component of hospital antimicrobial stewardship initiatives that aim to optimize antimicrobial therapy while limiting toxicity and resistance. In terms of prioritizing the most cost-effective stewardship interventions, ES has been seen as a 'low-hanging fruit', which refers to selecting the most obtainable targets rather than confronting more complicated issues. Administration of highly bioavailable oral antibiotics should be considered for nearly all non-critically ill patients and has been recommended as an effective and safe strategy for over two decades. However, to accrue the most benefit from ES, it should be combined with an early discharge (ED) plan, protocol, or care pathway. Benefits of this combined approach include improved patient comfort and mobility, reduced incidence of IV-line-related adverse effects, reduced IV antimicrobial preparation time, decreased hospital stays, reduced antimicrobial purchasing and administration costs, decreased patient deconditioning, and shortened recovery times. Results from published studies document decreases in healthcare resource use and costs following implementation of ES programmes, which in most studies facilitate the opportunity for ED and ED programmes. Barriers to the implementation of these programmes include clinician misconceptions, practical considerations, organizational factors, and a striking lack of awareness of IV to oral switch guidance. These and other barriers will need to be addressed to maximize the effectiveness of ES and ED programmes. As national antimicrobial stewardship programmes dictate the inclusion of ES and ED programmes within healthcare facilities, programmes must be developed and success must be documented.

Outpatient parenteral antimicrobial therapy for surgery patients: A comparison with previous standard of care

BACKGROUND

Current literature reports that outpatient parenteral antimicrobial therapy (OPAT) programs improve cure rates, and reduce length of hospitalization and costs. OPAT programs are still relatively new in Canada.

OBJECTIVE

To evaluate the benefits of an OPAT program initiated at a multispecialty tertiary care facility in Toronto, Ontario, compared with the previous standard of care.

METHODS

The present retrospective observational study was conducted using data from a group of surgical patients who were treated for active infections. Between February 1, 2010 and November 30, 2010, a total of 108 surgical patients were enrolled in the OPAT program. Patients were matched 1:1 with historical controls discharged between January 1, 2001 and January 1, 2010 according to age, sex, type of surgery, infection and comorbidities (Charlson Comorbidity Index). Cure rate, 30-day rehospitalization and length of stay were evaluated as primary end points.

RESULTS

Of 108 eligible OPAT patients, 21 were matched to the control group using the prespecified criteria. For this cohort, the OPAT program was associated with improved cure rates (OPAT 61.7% versus control 57.1%; P>0.10), reduction in rehospitalization rate (14.3% versus 28.6%; P>0.10) and reduced length of stay (10.7 versus 13.9 days, P>0.10) compared with the control group.

CONCLUSIONS

For this cohort of surgery patients, the OPAT program demonstrated a trend toward improved outcomes but did not achieve statistical significance. Due to the lack of statistical power, further evaluation is required to determine the full benefit of OPAT to patients and the health care system.

Early in vitro and in vivo development of high-level daptomycin resistance is common in mitis group Streptococci after exposure to daptomycin

The development of high-level daptomycin resistance (HLDR; MIC of ≥ 256 mg/liter) after exposure to daptomycin has recently been reported in viridans group streptococcus (VGS) isolates. Our study objectives were as follows: to know whether in vitro development of HLDR after exposure to daptomycin was common among clinical isolates of VGS and Streptococcus bovis; to determine whether HLDR also developed during the administration of daptomycin to treat experimental endocarditis caused by the daptomycin-susceptible, penicillin-resistant Streptococcus mitis strain S. mitis 351; and to establish whether combination with gentamicin prevented the development of HLDR in vitro and in vivo. In vitro studies were performed with 114 VGS strains (mitis group, 92; anginosus group, 10; mutans group, 8; and salivarius group, 4) and 54 Streptococcus bovis strains isolated from 168 consecutive patients with infective endocarditis diagnosed between 1995 and 2010. HLDR was only observed after 24 h of exposure to daptomycin in 27% of the mitis group, including 27% of S. mitis isolates, 47% of S. oralis isolates, and 13% of S. sanguis isolates. In our experimental model, HLDR was detected in 7/11 (63%) and 8/12 (67%) isolates recovered from vegetations after 48 h of daptomycin administered at 6 mg/kg of body weight/24 h and 10 mg/kg/24 h, respectively. In vitro, time-kill experiments showed that daptomycin plus gentamicin was bactericidal against S. mitis 351 at tested concentrations of 0.5 and 1 times the MIC and prevented the development of HLDR. In vivo, the addition of gentamicin at 1 mg/kg/8 h to both daptomycin arms prevented HLDR in 21 out of 23 (91%) rabbits. Daptomycin plus gentamicin was at least as effective as vancomycin plus gentamicin. In conclusion, HLDR develops rapidly and frequently in vitro and in vivo among mitis group streptococci. Combining daptomycin with gentamicin enhanced its activity and prevented the development of HLDR in most cases.

Outpatient parenteral antibiotic therapy (OPAT) at home in Attica, Greece

Outpatient parenteral antibiotic therapy (OPAT) is considered to be a cost-effective and safe alternative treatment strategy to hospitalization. We retrospectively evaluated data regarding the demographic and treatment characteristics of patients that sought medical advice from a network of physicians performing house-call visits and who received OPAT at home during a 17-month period (May 2009 to September 2010) in Attica, Greece. A total of 91 patients (69.2 % females) received intravenous antibiotic therapy at home during the evaluated period. The mean age [± standard deviation (SD)] of the patients was 85.3 (± 9) years. The main indications were pneumonia [46 patients (50.5 %)], urinary tract infection [25 (27.5 %)], and gastrointestinal tract infection [9 (9.9 %)]. Of the patients, 76.4 % received a beta-lactam, 17.5 % a fluoroquinolone, 15.3 % an imidazole, 8.7 % an aminoglycoside, and 5.4 % a lincosamide. The cure rate was 72.5 % and mortality was 27.5 %. The mean duration (± SD) of intravenous antibiotic treatment was 4.7 (± 3.3) days. The mean cost per patient was <euro>637 and was comparable to the mean cost if the patient were to be hospitalized for the same infection. There was significant clinical effectiveness of OPAT at home in this mainly elderly population, at an acceptable cost.

Native valve endocarditis caused by coagulase negative staphylococci; an appeal to start outpatient antimicrobial therapy: an unusual case report

Coagulase negative staphylococci (CNS) were a rare cause of native valve endocarditis. However, they are emerging as an important cause of native valve endocarditis (NVE) in both community and healthcare settings. We describe a 64 yrs. old male who developed mitral valve endocarditis caused by coagulase negative staphylococci. There were no predisposing conditions or underlying cardiac disease that could have been the risk factor for the development of native valve infection. The patient had good recovery after six weeks of treatment with anti-staphylococcal antibiotics.

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

Background::

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

Objective:

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

Methods:

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

Results:

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

Conclusions:

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

Changes in the classification and management of skin and soft tissue infections

Although skin and soft tissue infections (SSTIs) are extremely common in both primary and secondary care, there is a lack of validated evidence-based schemes for the classification of clinical presentation or severity, and there are few data available on treatment outcomes. The commonly used 'Eron classification' is based on the consensus views of an expert panel, while the Clinical Resource Efficiency Support Team (CREST) 'Guidelines on the Management of Cellulitis in Adults' have not been validated in clinical trials. In the current issue of JAC, investigators at Ninewells Hospital in Dundee, Scotland, report a retrospective study of patients with SSTIs who were treated with antibiotics. The patients were stratified into four classes of clinical severity, based on the presence or absence of sepsis and co-morbidity, and their standardized early warning score. The empirical treatment received by patients in each class was compared with the recommendations of the CREST guidelines. The findings do not make comfortable reading. Overall, 43% of patients (and 65% at the mildest end of the clinical spectrum) were overtreated, while mortality (at 30 days) and inadequate antimicrobial therapy increased with severity class. Strikingly, 35 different empirical antimicrobial prescribing regimens were noted. These findings, which are likely to reflect the situation in many hospitals, show that SSTIs remain a significant cause of mortality and that empirical therapy is bordering on the haphazard, with significant under treatment of severely ill patients.

A European survey of antibiotic management of methicillin-resistant Staphylococcus aureus infection: current clinical opinion and practice

Although the epidemiology of methicillin-resistant Staphylococcus aureus (MRSA) varies across Europe, healthcare-associated MRSA infections are common in many countries. Despite several national guidelines, the approach to treatment of MRSA infections varies across the continent, and there are multiple areas of management uncertainty for which there is little clinical evidence to guide practice. A faculty, convened to explore some of these areas, devised a survey that was used to compare the perspectives of infection specialists from across Europe on the management of MRSA infections with those of the faculty specialists. The survey instrument, a web-based questionnaire, was sent to 3840 registered delegates of the 19th European Congress of Clinical Microbiology and Infectious Diseases, held in April 2009. Of the 501 (13%) respondents to the survey, 84% were infection/microbiology specialists and 80% were from Europe. This article reports the survey results from European respondents, and shows a broad range of opinion and practice on a variety of issues pertaining to the management of minor and serious MRSA infections, such as pneumonia, bacteraemia, and skin and soft tissue infections. The issues include changing epidemiology, when and when not to treat, choice of treatment, and duration and route of treatment. The survey identified areas where practice can be improved and where further research is needed, and also identified areas of pan-European consensus of opinion that could be applied to European guidelines for the management of MRSA infection.