Successful outpatient parenteral antibiotic therapy delivery via telemedicine

Safety and efficacy of outpatient parenteral antimicrobial therapy: A systematic review and meta-analysis of randomized clinical trials

BACKGROUND

Outpatient parenteral antimicrobial therapy (OPAT) offers an alternative to inpatient (hospital bed-based) treatment of infections that require intravenous administration of antimicrobials. This meta-analysis aimed to summarise the evidence available from randomised controlled trials (RCTs) regarding the efficacy and safety of OPAT compared to inpatient parenteral antimicrobial therapy.

METHODS

We searched the Cochrane Library, MEDLINE, Embase, PubMed, and Web of Sciences databases for RCTs comparing outpatient versus inpatient parenteral antimicrobial therapy. We included studies without restrictions on language or publication year. Eligibility was reviewed independently by two assessors, and data extraction was cross validated. We evaluated bias risk via the Cochrane tool and determined the evidence certainty using GRADE. Meta-analysis was conducted using a random effects model. The protocol of this review was registered on PROSPERO (CRD42023460389).

RESULT

Thirteen RCTs, involving 1,310 participants were included. We found no difference in mortality (Risk Ratio [RR] 0.54, 95% Confidence Interval [CI] 0.23 to 1.26; P = 0.93), treatment failure (RR 1.0, CI 0.59 to 1.72; P = 0.99), adverse reaction related to antimicrobials (RR 0.89, CI 0.69 to 1.15; P = 0.38), and administration device (RR 0.58, CI 0.17 to 1.98; P = 0.87) between outpatient and inpatient parenteral antimicrobial therapy. The overall body of evidence had a low level of certainty.

CONCLUSION

Existing evidence suggests OPAT is a safe and effective alternative to inpatient treatment. Further RCTs are warranted for a thorough comparison of inpatient and outpatient parenteral antimicrobial therapy with a high level of certainty.

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.

Nutrition and Intestinal Rehabilitation of Children With Short Bowel Syndrome: A Position Paper of the ESPGHAN Committee on Nutrition. Part 2: Long-Term Follow-Up on Home Parenteral Nutrition

Short bowel syndrome (SBS) is the leading cause of intestinal failure (IF) in children. The preferred treatment for IF is parenteral nutrition which may be required until adulthood. The aim of this position paper is to review the available evidence on managing SBS and to provide practical guidance to clinicians dealing with this condition. All members of the Nutrition Committee of the European Society for Paediatric Gastroenterology Hepatology and Nutrition (ESPGHAN) contributed to this position paper. Some renowned experts in the field joined the team to guide with their expertise. A systematic literature search was performed from 2005 to May 2021 using PubMed, MEDLINE, and Cochrane Database of Systematic Reviews. In the absence of evidence, recommendations reflect the expert opinion of the authors. Literature on SBS mainly consists of retrospective single-center experience, thus most of the current papers and recommendations are based on expert opinion. All recommendations were voted on by the expert panel and reached >90% agreement. This second part of the position paper is dedicated to the long-term management of children with SBS-IF. The paper mainly focuses on how to achieve intestinal rehabilitation, treatment of complications, and on possible surgical and medical management to increase intestinal absorption.

Improving Antimicrobial Use to Protect the Environment: What Is the Role of Infection Specialists?

Anthropogenic environmental changes are causing severe damage to the natural and social systems on which human health depends. The environmental impacts of the manufacture, use, and disposal of antimicrobials cannot be underestimated. This article explores the meaning of environmental sustainability and four sustainability principles (prevention, patient engagement, lean service delivery, and low carbon alternatives) that infection specialists can apply to support environmental sustainability in health systems. To prevent inappropriate use of antimicrobials and consequent antimicrobial resistance (AMR) requires international, national, and local surveillance plans and action supporting antimicrobial stewardship (AMS). Engaging patients in addressing environmental sustainability, for example through public awareness campaigns about the appropriate disposal of unused and expired antimicrobials, could drive environmentally sustainable changes. Streamlining service delivery may include using innovative methods such as C-reactive protein (CRP), procalcitonin (PCT), or genotype-guided point of care testing (POCT) to reduce unnecessary antimicrobial prescribing and risk of adverse effects. Infection specialists can assess and advise on lower carbon alternatives such as choosing oral (PO) over intravenous (IV) antimicrobials where clinically appropriate. By applying sustainability principles, infection specialists can promote the effective use of healthcare resources, improve care quality, protect the environment, and prevent harm to current and future generations.

Outpatient Parenteral Antibiotic Therapy in Older Adults

Outpatient parenteral antimicrobial therapy (OPAT) for older adults is a complex process that involves multiple stakeholders and care coordination, but it is a useful and patient-centered tool with opportunities for the treatment of complicated infections, improved patient satisfaction, and reduced health-care costs. Older age should not be an exclusion for OPAT but rather prompt the OPAT provider to thoroughly evaluate candidacy and safety. Amid the on-going COVID-19 pandemic, innovations in OPAT are needed to shepherd OPAT care into a more patient-centered, thoughtful practice, whereas minimizing harm to older patients from unnecessary health-care exposure and thus health-care associated infections.

Community antibiotic management of skin infections in the Torres Strait

BACKGROUND

There is a high burden of skin and soft tissue infections (SSTI) - including cellulitis - among Aboriginal and Torres Strait Islander peoples living in remote communities. In tropical environments, such as the Torres Strait, cellulitis accounts for 37% of potentially preventable hospitalisations. This study aimed to evaluate the safety, effectiveness and community acceptance of outpatient antibiotic treatment for the management of skin infections in the Torres Strait.

CONCLUSIONS

Outpatient management of skin infection in the Torres Strait is effective, safe and appreciated by patients.

METHODS

This was a 12-month prospective, observational study commencing in January 2019 involving 295 adults with a skin infection across the Torres Strait.

RESULTS

Most (276/295 (94%)) participants were treated successfully in the community. Of 295 enrolled patients, 151 of 295 (51%) had cellulitis, 59 of 295 (20%) had a skin abscess and 85 of 295 (28%) had a wound infection. Of the 77 of 278 (27%) infections accompanied by systemic features, 63 of 77 (82%) were managed in the community. Staphylococcus aureus was the most frequent isolate, at 165 of 261 (63%); 56 of 165 (33%) were methicillin resistant. In the 276 community-managed cases, oral trimethoprim/sulfamethoxazole was initially used in 159 (57%), oral flucloxacillin in 75 (27%) and intravenous cefazolin plus oral probenecid in 32 (13%). The clinical course was complicated in eight of 232 (3%) patients who had complete follow-up data: seven patients required hospitalisation after initial treatment in the communityand one had an antibiotic side-effect. All 232 patients with complete follow-up data were content with the care they received.

Facilitating OPAT in rural areas

A sizable portion of the United States' population lives in a rural setting. Coupled with a limited number of infectious diseases providers, this has created a need for innovative practice models to deliver outpatient antimicrobial therapy and clinical monitoring in rural settings. This article reviews existing literature regarding outpatient parenteral antimicrobial therapy in rural settings and explores existing barriers and potential solutions that may be of assistance to providers looking to provide these services.

Outpatient Versus Inpatient Intravenous Antimicrobial Therapy: A Population-Based Observational Cohort Study of Adverse Events and Costs

BACKGROUND

Bacterial infections such as osteomyelitis and endocarditis routinely require several weeks of treatment with intravenous (IV) antimicrobials. Outpatient parenteral antimicrobial therapy (OPAT) programs allow patients to receive IV antimicrobials in an outpatient clinic or at home. The outcomes and costs of such treatments remain uncertain.

METHODS

We conducted a retrospective observational cohort study over a 5-year study interval (1 June 2012 to 31 March 2018) using population-based linked administrative data from British Columbia, Canada. Patients receiving OPAT following a hospitalization for bacterial infection were matched based on infection type and implied duration of IV antimicrobials to patients receiving inpatient parenteral antimicrobial therapy (IPAT). Cumulative adverse events and direct healthcare costs were estimated over a 90-day outcome interval.

RESULTS

In a matched cohort of 1842 patients, adverse events occurred in 35.6% of OPAT patients and 39.0% of IPAT patients (adjusted odds ratio, 1.04 [95% confidence interval {CI}, .83-1.30; P = .61). Relative to IPAT patients, OPAT patients were significantly more likely to experience hospital readmission (30.5% vs 23.0%) but significantly less likely to experience Clostridioides difficile diarrhea (1.2% vs 3.1%) or death (2.0% vs 8.8%). Estimated mean direct healthcare costs were $30 166 for OPAT patients and $50 038 for IPAT patients (cost ratio, 0.60; average cost savings with OPAT, $17 579 [95% CI, $14 131-$21 027]; P < .001).

CONCLUSIONS

Outpatient IV antimicrobial therapy is associated with a similar overall prevalence of adverse events and with substantial cost savings relative to patients remaining in hospital to complete IV antimicrobials. These findings should inform efforts to expand OPAT use.

Effectiveness of telemedicine in outpatient parenteral antimicrobial therapy (Tele-OPAT): A systematic review

INTRODUCTION

Telemedicine is increasingly used to deliver healthcare in many clinical specialities. However, the adoption of telemedicine in the delivery of outpatient parenteral antimicrobial therapy (OPAT) has been relatively slow and limited. This study aims to collate current evidence for telemedicine in OPAT regarding clinical efficacy, safety, acceptability and cost-effectiveness.

METHODS

We systematically searched the Cochrane Library, CINAHL, EMCARE, EMBASE and MEDLINE databases through 24 July 2022, for relevant studies published in English. Research articles and conference abstracts were included if they involved any form of telephone or video consultation in delivering parenteral antibiotics in the home or outpatient setting. Study findings were synthesised into three main themes: patient outcomes and safety, patient and provider satisfaction and cost-effectiveness. The mixed methods appraisal tool was used to review the methodological quality of the studies. PROSPERO CRD42022342874.

RESULTS

The literature search yielded 311 articles, of which 12 (five full-length articles and seven conference abstracts) reporting over 1245 telemedicine interventions were reviewed. The reported outcomes were heterogeneous. Telemedicine was cost-effective and associated with high patient satisfaction and comparable complication rates compared to conventional OPAT. Considering six comparative studies, rehospitalisation risk was lower for telemedicine than conventional OPAT (risk ratio, 0.58; 95% confidence interval, 0.38-0.88; I2  =  31%).

DISCUSSION

The results of this review demonstrate that telemedicine has a role in delivering safe and cost-effective OPAT care, especially for patients residing in remote and geographically isolated locations. Nevertheless, high-quality studies and publication of existing data and experiences are needed to further validate this model of care delivery.

Recent Updates in Antimicrobial Stewardship in Outpatient Parenteral Antimicrobial Therapy

Purpose of Review

Antimicrobial stewardship within acute care is common and has been expanding to outpatient areas. Some inpatient antimicrobial stewardship tactics apply to outpatient parenteral antimicrobial therapy (OPAT) and complex outpatient antimicrobial therapy (COpAT) management, but differences do exist.

Recent Findings

OPAT/COpAT is a growing area of practice and research with its own unique considerations for antimicrobial stewardship. Potential ideas for antimicrobial stewardship in the OPAT/COpAT setting include redesigning the regimen to COpAT instead of OPAT, ensuring the use of the shortest effective duration of antimicrobial therapy; using antimicrobials dosed less frequently, such as long-acting glycopeptides; optimizing antimicrobial susceptibility testing reporting for common OPAT/COpAT drugs; and establishing routine laboratory and safety monitoring. Future consensus is needed to determine validated OPAT program metrics and outcomes.

Summary

As more focus is placed on outpatient antimicrobial stewardship, clinicians practicing in OPAT should publish more data regarding OPAT program methods and outcomes as they relate to antimicrobial stewardship. These can involve patient clinical outcomes, OPAT readmission rates, OPAT therapy completion, and central line-related complications.

Clinical benefits and costs of an outpatient parenteral antimicrobial therapy service

BACKGROUND

The enrolment of patients to an outpatient parenteral antimicrobial therapy (OPAT) service can be a means of mitigating financial burdens related to the provision of care and optimisation of hospital bed management.

OBJECTIVE

This study aimed to identify the clinical benefit of the Maltese OPAT service and to quantify the costs incurred to run it.

METHODS

The study period ran for 156 weeks during 1st October 2016 to 1st October 2019. Patient demographics, infection type, referring care team, antimicrobial agent/s used, type of vascular access device (VAD) available and service completion status (defined as provision of care without re-hospitalisation) were recorded. Time allocated for OPAT service delivery and expenses incurred were collected and an activity-based costing exercise was performed.

RESULTS

The patient population who benefited from the service was of 117, 15 of whom used the service twice, for a total of 132 episodes. Patients received 149 antimicrobial treatment courses, with ceftriaxone being the most common single agent used (n = 52, 34.9%). Teicoplanin with ertapenem was the most common regimen selected for combination therapy (n = 9, 52.9%). A total of 23 episodes (17.4%) resulted in a readmission, 6 (30%) of which were because of patient deterioration. The mean service running weekly cost was €455.47/$538.68 and a total of 3287 days of hospital stay were avoided. This effectively illustrates that the OPAT service optimised hospital bed availability without compromising care delivery.

CONCLUSION

The national OPAT service proved to be a safe and effective alternative for patient management to promote patient-centred care without hospitalisation.

Experiences in outpatient parenteral antimicrobial therapy (OPAT): Barriers and challenges from the front lines

Background:

Outpatient parenteral antimicrobial therapy (OPAT) is now the standard of care for managing patients who no longer need inpatient care but require prolonged intravenous antimicrobial therapy. OPAT increases patient satisfaction, reduces the lengths of hospital stay, lowers emergency department readmission rates, and decreases total healthcare spending.

Objective:

To investigate Virginia Commonwealth University Health System’s experience with OPAT and to highlight the obstacles patients and clinicians face when navigating and utilizing this program.

Design:

We conducted this descriptive study at a large, academic, tertiary-care hospital in Central Virginia.

Methods:

We performed manual reviews of electronic medical records of 602 patient, and we evaluated the records of those receiving OPAT between 2017 and 2020. Reviews included antimicrobial agents, diagnoses requiring OPAT, adverse effects related to antimicrobials, adverse effects related to peripherally inserted central catheters (PICC), readmission rate, discharge destination, and death. We evaluated our program with descriptive statistics.

Results:

Among 602 patients who received OPAT, most were diagnosed with bacteremia or musculoskeletal infections. Patients were either discharged home or to another healthcare facility, with the former comprising most of the rehospitalizations. Ertapenem and vancomycin were associated with the most adverse drug events among our cohort. Elevated transaminase levels were noted in 23% of patients. The rate of PICC-line adverse events in this study population was 0.05%.

Conclusions:

Our findings highlight the barriers and challenges that patients and providers face when receiving OPAT, and they can inform efforts to improve patient clinical outcomes.

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.

Out of Sight but Not Out of Mind: Caring for Patients Receiving OPAT During the SARS-CoV-2 Pandemic

In an effort to “flatten the curve” of SARS-CoV-2, society is urged to practice social distancing. However, the management of other disease states may require some patients to undergo outpatient parenteral antimicrobial therapy (OPAT). Practical considerations for OPAT management during an infectious pandemic are reviewed. These include shortening durations of therapy, utilizing the oral route, avoiding medications requiring therapeutic drug monitoring, selecting antimicrobials with long durations, decreasing frequency of laboratory blood draws, and performing tele-health visits.

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.

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.

Preparing the Patient for Home Parenteral Nutrition and for a Successful Course of Therapy

Preparing the patient for home parenteral nutrition (HPN) is a collaborative effort among many different clinicians. Identifying patients who will transition home with parenteral nutrition (PN) as early as possible allows for a thoughtful and safe approach. Communication regarding the HPN goals is critical to the patient's success, whether the requirement for PN is temporary or permanent. Management of these complex patients is best served by a multidisciplinary team with expertise in the area of nutrition support. Adherence to available guidelines that define best practice is imperative in all aspects of care for the patient on HPN.

The Current and Future Use of Telemedicine in Infectious Diseases Practice

PURPOSE OF REVIEW

Novel technologies, such as high-definition cameras, encryption software, electronic stethoscopes, microfluidic diagnostic systems, and widely available broadband Internet have expanded the potential for telemedicine. This narrative review presents current and future uses of telemedicine in the prevention, diagnosis, treatment, stewardship, and management of infectious disease.

RECENT FINDINGS

Beginning in the 1990s, early approaches to telemedicine in infectious disease focused largely on treatment of HIV/AIDS, hepatitis C, and tuberculosis. However, recent innovations allow for targeting of additional diseases and in increasingly remote settings. Telemedicine allows virtual visits between patients in the home and remote providers, permitting outpatient management of complex conditions, such as post-surgical site monitoring, and non-urgent infectious maladies, such as uncomplicated urinary tract infection. Remote provider education by videoconference and integrated clinical decision support tools create avenues to improve inpatient care, including antimicrobial stewardship. Technological strides from miniaturization of diagnostic tests to robotic telepresence physical exams improve access to infectious disease care in isolated and infrastructure-poor environments, from cargo ships to other resource-limited settings. Telemedicine in the field of infectious disease is rapidly expanding in clinical, technological, geographical, and human capacity. Recent innovations narrow gaps in access to care for populations traditionally underserved, stigmatized, isolated by remote geography, or lacking technological infrastructure. Current and future approaches will transform inpatient, outpatient, and remote care.

The age of paediatrics

The epidemiological transition towards non-communicable diseases is characterised by an upward shift in age of disease burden across the lifecourse. One response, within a suite of wider actions, would be to extend the upper age limit of paediatric practice to embrace adolescent health. We did an online survey to explore the upper age limit of paediatric care, obtaining responses from 1372 paediatricians in 115 countries. Marked variation in the upper age limit was apparent. Among high-income countries, a higher upper age limit was associated with greater disease burden in adolescents relative to young children (<5 years). Although paediatricians reported the mean upper age limit of paediatrics had risen over the past 20 years, the mean preferred age of 18·7 (SD 2·6) years was higher than the mean current age of 17·4 (SD 2·5) years (p<0·0001). Paediatricians reported the main reasons for the rising age over time was their greater awareness of adolescent health and leadership by professional associations. Reports of the quality of adolescent health education within national paediatric training suggest that this education is largely inadequate. A greater focus on adolescent health is required within paediatrics to ensure that the future paediatric workforce is appropriately equipped to respond to the changing disease burden across childhood and adolescence.

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.