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Mohammed SA, Cotta MO, Assefa GM, Erku D, Sime F. Barriers and facilitators for the implementation and expansion of outpatient parenteral antimicrobial therapy: a systematic review. J Hosp Infect 2024; 147:1-16. [PMID: 38423135 DOI: 10.1016/j.jhin.2024.02.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2023] [Revised: 02/05/2024] [Accepted: 02/09/2024] [Indexed: 03/02/2024]
Abstract
Outpatient parenteral antimicrobial therapy (OPAT) has been expanding in recent years and serves as a viable solution in reducing the shortage of hospital beds. However, the wider implementation of OPAT faces numerous challenges. This review aimed to assess implementation barriers and facilitators of OPAT services. Studies describing barriers and facilitators of the OPAT service were retrieved from PubMed, Scopus, MEDLINE, EMBASE, CINAHL, Cochrane Library, Web of Science Proceedings, International Pharmaceutical Abstracts and PsycINFO. All types of study designs published in the English language were included. Studies that did not mention any barrier or facilitator, did not differentiate OPAT and inpatient, focused on specific antimicrobials or diseases, and made no distinction between parenteral and other treatments were excluded. Qualitative analysis was performed using the 'best-fit' framework approach and the Consolidated Framework for Implementation Research (CFIR). The review was PROSPERO registered (CRD42023441083). A total of 8761 studies were screened for eligibility and 147 studies were included. Problems in patient selection, lack of awareness, poor communication and co-ordination, lack of support, lack of structured service and inappropriate prescriptions were identified. OPAT provides safe, effective and efficient treatment while maintaining patients' privacy and comfort, resulting in less daily life disruption, and reducing the risk of infection. Satisfaction and preference for OPAT were very high. Initiatives in strengthening OPAT such as antimicrobial stewardship and telemedicine are beneficial. Challenges to and facilitators of OPAT were identified among patients, health professionals, OPAT service providers and healthcare administrators. Understanding them is crucial to designing targeted initiatives for successful OPAT service implementation.
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Affiliation(s)
- S A Mohammed
- UQ Centre for Clinical Research, The University of Queensland, Brisbane, Australia; Department of Pharmacy, Wollo University, Dessie, Ethiopia
| | - M O Cotta
- UQ Centre for Clinical Research, The University of Queensland, Brisbane, Australia; Herston Infectious Diseases Institute, Metro North Health, Brisbane, Australia
| | - G M Assefa
- UQ Centre for Clinical Research, The University of Queensland, Brisbane, Australia; Department of Pharmacy, Wollo University, Dessie, Ethiopia
| | - D Erku
- Centre for Applied Health Economics, Griffith University, Nathan, Australia
| | - F Sime
- UQ Centre for Clinical Research, The University of Queensland, Brisbane, Australia.
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Brand H, Fryer M, Mehdi AM, Melon A, Morcombe B, Choong K, Subedi S. Home nursing and self-administered outpatient parenteral antimicrobial treatment: a comparison of demographics and outcomes from a large regional hospital in Queensland, Australia. Intern Med J 2024. [PMID: 38591847 DOI: 10.1111/imj.16394] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2023] [Accepted: 03/15/2024] [Indexed: 04/10/2024]
Abstract
BACKGROUND Outpatient parenteral antimicrobial treatment (OPAT) is a safe and effective therapy used in several settings across Australia. As OPAT services expand their inclusion criteria to include complex patient populations, there is an increased need for selecting appropriate patients to receive either healthcare-administered OPAT (H-OPAT) or self-administered OPAT (S-OPAT). AIMS To describe patient demographics, diagnosis, microbiology and outcomes of patients treated by H-OPAT and S-OPAT within the Sunshine Coast Hospital and Health Service, Australia. METHODS Data on demographics, diagnoses, treatment and outcomes on all patients treated by H-OPAT and S-OPAT from March 2017 to December 2019 were collected retrospectively. RESULTS One hundred and sixty-five patients (62.26%) were enrolled in H-OPAT and 100 patients (37.74%) in S-OPAT. S-OPAT patients were significantly younger. H-OPAT patients were more comorbid. Bone and joint infections were the most treated infections and were more likely to be treated by S-OPAT. There was no difference in treatment duration, cure and complication rates between S-OPAT and H-OPAT. Longer duration of therapy was associated with more complications. Treatment failure was associated with infections due to multiple organisms, number of comorbidities and treatment of surgical site, skin and soft tissue infections. CONCLUSIONS There were significant differences in demographics between H-OPAT and S-OPAT without any difference in outcomes. Overall failure and complication rates were low. Higher rates of treatment failure were predicted by the diagnosis, number of comorbidities and number of organisms treated.
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Affiliation(s)
- Holly Brand
- Griffith University School of Medicine, Gold Coast, Queensland, Australia
| | - Michael Fryer
- Sunshine Coast University Hospital, Sunshine Coast, Queensland, Australia
| | - Ahmed M Mehdi
- QCIF Bioinformatics, Queensland Cyber Infrastructure Foundation Ltd, Brisbane, Queensland, Australia
| | - Alex Melon
- Sunshine Coast University Hospital, Sunshine Coast, Queensland, Australia
| | - Bridie Morcombe
- Sunshine Coast University Hospital, Sunshine Coast, Queensland, Australia
| | - Keat Choong
- Infectious Diseases Department, Sunshine Coast University Hospital, Sunshine Coast, Queensland, Australia
- Infection Research Network, Sunshine Coast Hospital and Health Service, Sunshine Coast, Queensland, Australia
| | - Shradha Subedi
- Infectious Diseases Department, Sunshine Coast University Hospital, Sunshine Coast, Queensland, Australia
- Infection Research Network, Sunshine Coast Hospital and Health Service, Sunshine Coast, Queensland, Australia
- Microbiology, Pathology Queensland, Sunshine Coast University Hospital, Sunshine Coast, Queensland, Australia
- School of Medicine, University of Queensland, Brisbane, Queensland, Australia
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3
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Fläring U, Lundevall H, Norberg Å, Andersson A. The success rate and complications of midline catheters in pediatric outpatient parenteral antibiotic therapy (OPAT). Eur J Pediatr 2024; 183:1703-1709. [PMID: 38227054 PMCID: PMC11001649 DOI: 10.1007/s00431-024-05432-7] [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: 11/02/2023] [Revised: 01/09/2024] [Accepted: 01/10/2024] [Indexed: 01/17/2024]
Abstract
The use of outpatient parenteral antimicrobial therapy (OPAT) for children has several advantages, including reduced length of hospital stay and costs. A reliable vascular access is key to delivering safe and effective pediatric OPAT. In recent years, midline catheters (MC) have been increasingly used for short-term intravenous antibiotic therapy in children. However, there are no studies investigating the use of MCs in the OPAT setting. The main aim of this paper was to evaluate the success and complications of using MCs for pediatric OPAT. This was a retrospective cohort study from a tertiary academic pediatric hospital. All MCs inserted at the hospital and used for OPAT were eligible for study inclusion. The primary objective was to describe the percentage of patients able to complete OPAT without the need for additional venous access. Forty-one MCs were included in the study. Patient mean (SD) age was 5.9 (4.9) years. In 31 cases (76%, 95% CI 62-86%), the iv therapy could be successfully completed using only the MC. Imbalances between the groups suggested unfavorable outcome for saphenous vein catheters as well as for shorter and smaller-sized catheters. Fourteen patients (34%) were subjected to a MC-related complication. Pain on injection in the MC was the most frequent complication (n = 10, 24%). Conclusion: Midline catheters could be an alternative to central venous access for pediatric OPAT. Avoiding saphenous vein insertion and using longer and larger-sized catheters could increase MC success rate. No severe MC-related complication was found. Further randomized studies comparing different catheter types are needed. What is Known: • For selected patients, pediatric outpatient parenteral antimicrobial therapy (OPAT) is safe and provides health-economic, psychosocial, and medical advantages compared to in-hospital care. • A reliable venous access is one of the key factors to the success of OPAT, but this can be a challenge in children. What is New: • Using midline catheters, 76% of patients could complete their intended iv therapy without the need for additional venous access. Avoiding saphenous vein insertion and using longer and larger-sized catheters could increase the success rate. • Thirty-four percent of catheters were subject to some kind of complication, the most common being pain on injection in the catheter.
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Affiliation(s)
- Urban Fläring
- Department of Pediatric Perioperative Medicine and Intensive Care, Astrid Lindgren Children's Hospital, Karolinska University Hospital, Stockholm, Sweden
- Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden
| | - Henrik Lundevall
- Department of Pediatric Perioperative Medicine and Intensive Care, Astrid Lindgren Children's Hospital, Karolinska University Hospital, Stockholm, Sweden
- Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden
| | - Åke Norberg
- Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
| | - Andreas Andersson
- Department of Pediatric Perioperative Medicine and Intensive Care, Astrid Lindgren Children's Hospital, Karolinska University Hospital, Stockholm, Sweden.
- Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden.
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Canterino J, Malinis M, Liu J, Kashyap N, Brandt C, Justice A. Creation and Validation of an Automated Registry for Outpatient Parenteral Antibiotics. Open Forum Infect Dis 2024; 11:ofae004. [PMID: 38412514 PMCID: PMC10866572 DOI: 10.1093/ofid/ofae004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2023] [Accepted: 01/08/2024] [Indexed: 02/29/2024] Open
Abstract
Existing outpatient parenteral antibiotic therapy (OPAT) registries are resource intensive, and OPAT programs struggle to produce objective data to show the value of their work. We describe the building and validation of an automated OPAT registry within our electronic medical record and provide objective data on the value of the program. Variables and outcomes include age, sex, race, ethnicity, primary insurance payor, antibiotic names, infection syndromes treated, discharge disposition, 30-day all-cause readmission and death rates, complications, and an estimate of the hospital days saved. Records for 146 OPAT episodes were reviewed manually to validate the registry. Data were displayed in a dashboard within the electronic medical record. Over the 4-year time frame, our registry collected 3956 unique patients who completed 4710 episodes (approximately 1200 episodes per year). A total of 400 complications during OPAT were identified. All variables had an accuracy of >90% on validation. The OPAT program resulted in a reduction in hospital length of stay by 88 820 days, or roughly 22 000 days per year. We intend our registry to serve as a blueprint for similar OPAT programs with limited administrative resources. Wider application of our system would allow for easier aggregation and comparisons of OPAT practice and address the lack interinstitutional standardization of OPAT data and outcomes.
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Affiliation(s)
| | - Maricar Malinis
- Yale University School of Medicine, New Haven, Connecticut, USA
| | - Jing Liu
- Yale–New Haven Health, New Haven, Connecticut, USA
| | - Nitu Kashyap
- Yale University School of Medicine, New Haven, Connecticut, USA
- Yale–New Haven Health, New Haven, Connecticut, USA
| | - Cynthia Brandt
- Veterans Affairs Heathcare System, West Haven CT; Yale University School of Medicine, New Haven, Connecticut, USA
| | - Amy Justice
- Veterans Affairs Heathcare System, West Haven CT; Yale University School of Medicine, New Haven, Connecticut, USA
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Sunagawa SW, Arduser S, Miller MM, Lyden E, LeMaster M, Cortes-Penfield N, Hankins RJ, Bergman SJ, Alexander BT. Serious Adverse Events and Laboratory Monitoring Regimens for Outpatient Parenteral Antimicrobial Therapy With Cefazolin and Ceftriaxone. Open Forum Infect Dis 2023; 10:ofad606. [PMID: 38111751 PMCID: PMC10727193 DOI: 10.1093/ofid/ofad606] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2023] [Accepted: 11/29/2023] [Indexed: 12/20/2023] Open
Abstract
The optimal laboratory monitoring frequency for outpatient parenteral antimicrobial therapy-related adverse events (OPAT-AEs) during cefazolin and ceftriaxone therapy is not well defined. We identified 2.7 OPAT-AEs per 1000 sets of weekly laboratory tests in this population, suggesting that less intensive laboratory monitoring may be safe and reasonable.
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Affiliation(s)
- Shawnalyn W Sunagawa
- Department of Pharmaceutical and Nutrition Care, Nebraska Medicine, Omaha, Nebraska, USA
- College of Pharmacy, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Sarah Arduser
- Department of Pharmaceutical and Nutrition Care, Nebraska Medicine, Omaha, Nebraska, USA
- College of Pharmacy, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Molly M Miller
- Department of Pharmaceutical and Nutrition Care, Nebraska Medicine, Omaha, Nebraska, USA
| | - Elizabeth Lyden
- College of Public Health, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Melissa LeMaster
- Department of Pharmaceutical and Nutrition Care, Nebraska Medicine, Omaha, Nebraska, USA
| | | | - Richard J Hankins
- Divison of Infectious Diseases, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Scott J Bergman
- Department of Pharmaceutical and Nutrition Care, Nebraska Medicine, Omaha, Nebraska, USA
- College of Pharmacy, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Bryan T Alexander
- Department of Pharmaceutical and Nutrition Care, Nebraska Medicine, Omaha, Nebraska, USA
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Stubbs RD, Shorten RJ, Benedetto V, Muir A. Does comorbidity index predict OPAT readmission? JAC Antimicrob Resist 2023; 5:dlad125. [PMID: 38021037 PMCID: PMC10667028 DOI: 10.1093/jacamr/dlad125] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Accepted: 11/06/2023] [Indexed: 12/01/2023] Open
Abstract
Objectives To determine if the Charlson comorbidity index (CCI) is an accurate predictor of unplanned readmissions for patients using outpatient parenteral antimicrobial therapy (OPAT) services. Methods Retrospective analysis of patients >16 years of age who had received OPAT at Lancashire Teaching Hospitals between 2019 and 2021. The number of unplanned hospitalizations was measured and categorized as OPAT related or non-OPAT related. The CCI for each patient group was calculated using an online tool, and logistic regression was used to assess the association between risk factors and risk of being readmitted. Results The cohort consisted of 741 patients. Unplanned readmission was seen in 112 patients (15.1%). The mean CCI score for patients with OPAT-related readmissions was 4.22, 0.92 higher than the mean for patients who were not readmitted (3.30). The mean CCI score for patients with non-OPAT-related readmissions was higher still at 4.89. The logistic regression showed that increased CCI, age, male gender and home location compared with clinic were associated with increased odds of readmission, although these effects did not meet statistical significance. Conclusions These results suggest that a higher CCI score is associated with a non-statistically significant increased risk of unplanned hospitalization. We concluded that the CCI may therefore be used in future decision-making regarding the acceptance of patients to OPAT and requires further investigation.
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Affiliation(s)
- Ryan D Stubbs
- Faculty of Biology, Medicine and Health, University of Manchester, Oxford Road, Manchester M13 9PL, UK
| | - Robert J Shorten
- Department of Microbiology, Lancashire Teaching Hospitals NHS Foundation Trust, Sharoe Green Lane, Preston PR2 9HT, UK
| | - Valerio Benedetto
- Applied Health Research hub, University of Central Lancashire, Victoria Street, Preston PR1 2HE, UK
| | - Alison Muir
- Department of Microbiology, Lancashire Teaching Hospitals NHS Foundation Trust, Sharoe Green Lane, Preston PR2 9HT, UK
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Gallagher CK, Cummins H, Benefield RJ, Certain LK. Switching from intravenous vancomycin to oral antibiotics reduces adverse events in a retrospective cohort of outpatients with orthopedic infections. Pharmacotherapy 2023; 43:1277-1285. [PMID: 37681344 DOI: 10.1002/phar.2872] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2023] [Revised: 08/16/2023] [Accepted: 09/01/2023] [Indexed: 09/09/2023]
Abstract
INTRODUCTION Vancomycin is frequently used for prolonged courses in treating osteoarticular infections despite a high rate of adverse drug events (ADE). The objective of this study was to evaluate the safety and effectiveness of transitioning to oral therapy compared to continuing parenteral vancomycin in patients with orthopedic infections. METHODS We conducted a single-center, retrospective cohort study of patients with orthopedic infections discharged on parenteral vancomycin with a planned duration of at least 4 weeks. We compared rates of ADE while on vancomycin to rates of ADE after switching to an oral regimen. As a secondary analysis, we compared unplanned hospital readmission within 60 days and treatment failure at 1 year between patients who were transitioned to oral antibiotics within 4 weeks of vancomycin initiation and those that were not. RESULTS Two hundred twenty-eight patients met the inclusion criteria. Vancomycin was associated with significantly greater toxicity compared to oral regimens. Fifty-one patients had an adverse event while on vancomycin (5.87 ADE per 1000 patient-days) while 9 patients had an adverse event on oral therapy (1.49 ADE per 1000 patient-days) (Rate difference 4.39 per 1000 patient days, 95% CI: 2.52 to 6.26 events per 1000 patient-days). In proportional hazards analysis, transition to an oral antibiotic regimen was independently associated with a lower rate of ADE (aHR 0.12, 95% CI: 0.02-0.86). Forty-one patients (18%) were transitioned to oral therapy within 4 weeks; these patients did not have an increased rate of unplanned readmission (12.2% vs 17.1%) or treatment failure (17.1% vs 21.9%). CONCLUSIONS Patients transitioned to oral therapy within 4 weeks of discharge had significantly fewer adverse events and similar incidences of 1-year treatment failure compared to patients maintained on parenteral vancomycin. Substituting oral antibiotics for parenteral vancomycin is a potential strategy to minimize vancomycin toxicity during the treatment of orthopedic infections.
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Affiliation(s)
- Chanah K Gallagher
- Department of Pharmacy, University of Utah Health, Salt Lake City, Utah, USA
| | - Heather Cummins
- University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Russell J Benefield
- Department of Pharmacy, University of Utah Health, Salt Lake City, Utah, USA
- Department of Pharmacotherapy, University of Utah College of Pharmacy, Salt Lake City, Utah, USA
| | - Laura K Certain
- Division of Infectious Diseases, University of Utah Health, Salt Lake City, Utah, USA
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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.
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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
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Durojaiye OC, Cole J, Kritsotakis EI. Risk of venous thromboembolism in outpatient parenteral antimicrobial therapy (OPAT): A systematic review and meta-analysis. Int J Antimicrob Agents 2023; 62:106911. [PMID: 37422098 DOI: 10.1016/j.ijantimicag.2023.106911] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Accepted: 06/30/2023] [Indexed: 07/10/2023]
Abstract
The risk of venous thromboembolism (VTE) in outpatient parenteral antimicrobial therapy (OPAT) is not fully understood and the optimal strategy for thromboprophylaxis remains unclear. This systematic review investigated the incidence of VTE in OPAT settings (PROSPERO CRD42022381523). MEDLINE, CINAHL, Emcare, Embase, Cochrane Library and grey literature were searched from earliest records to 18 January 2023. Primary studies reporting non-catheter-related VTE or catheter-related thromboembolism (CRT) events in adults who received parenteral antibiotics in home or outpatient settings were eligible. In total, 43 studies involving 23 432 patient episodes were reviewed, of which 4 studies reported non-catheter-related VTE and 39 included CRT. Based on generalised linear mixed-effects models, pooled risk estimates of non-catheter-related VTE and CRT were 0.2% [95% confidence interval (CI) 0.0-0.7%] and 1.1% [95% CI 0.8-1.5%; prediction interval (PI) 0.2-5.4%]. Heterogeneity was largely attributed to risk of bias by meta-regression (R2 = 21%). Excluding high-risk-of-bias studies, CRT risk was 0.8% (95% CI 0.5-1.2%; PI 0.1-4.5%). From 25 studies, the pooled CRT rate per 1000 catheter-days was 0.37 (95% CI 0.25-0.55; PI 0.08-1.64). These findings do not support universal thromboprophylaxis or routine use of an inpatient VTE risk assessment model in the OPAT setting. However, a high index of suspicion should be maintained, especially for patients with known risk factors for VTE. An optimised protocol of OPAT-specific VTE risk assessment should be sought.
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Affiliation(s)
- Oyewole Christopher Durojaiye
- Department of Infection and Tropical Medicine, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield S10 2JF, UK; Department of Microbiology, University Hospitals of Derby and Burton NHS Foundation Trust, Derby, DE22 3NE, UK.
| | - Joby Cole
- Department of Infection and Tropical Medicine, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield S10 2JF, UK; Department of Infection, Immunity & Cardiovascular Disease, University of Sheffield, Sheffield, S10 2RX, UK
| | - Evangelos I Kritsotakis
- Laboratory of Biostatistics, School of Medicine, University of Crete, Heraklion, 71003, Greece; School of Health and Related Research, Faculty of Medicine, Dentistry and Health, University of Sheffield, Sheffield, S1 4DA, UK
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Sendi P, Lora-Tamayo J, Cortes-Penfield NW, Uçkay I. Early switch from intravenous to oral antibiotic treatment in bone and joint infections. Clin Microbiol Infect 2023; 29:1133-1138. [PMID: 37182643 DOI: 10.1016/j.cmi.2023.05.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2023] [Revised: 04/25/2023] [Accepted: 05/06/2023] [Indexed: 05/16/2023]
Abstract
OBJECTIVES The timing of the switch from intravenous (i.v.) to oral antibiotic therapy for orthopaedic bone and joint infections (BJIs) is debated. In this narrative article, we discuss the evidence for and against an early switch in BJIs. DATA SOURCES We performed a PubMed and internet search investigating the association between the duration of i.v. treatment for BJI and remission of infection among adult orthopaedic patients. CONTENT Among eight randomized controlled trials and multiple retrospective studies, we failed to find any minimal duration of postsurgical i.v. therapy associated with clinical outcomes. We did not find scientific data to support the prolonged use of i.v. therapy or to inform a minimal duration of i.v. THERAPY Growing evidence supports the safety of an early switch to oral medications once the patient is clinically stable. IMPLICATIONS After surgery for BJI, a switch to oral antibiotics within a few days is reasonable in most cases. We recommend making the decision on the time point based on clinical criteria and in an interdisciplinary team at the bedside.
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Affiliation(s)
- Parham Sendi
- Institute for Infectious Diseases, University of Bern, Bern, Switzerland.
| | - Jaime Lora-Tamayo
- Department of Internal Medicine, Hospital Universitario 12 de Octubre, Instituto de Investigación Biomédica 'i+12' Hospital 12 de Octubre, Madrid, Spain; CIBER Enfermedades Infecciosas, Instituto de Salud Carlos III, Madrid, Spain
| | | | - Ilker Uçkay
- Infectiology, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
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Oliver NT, Skalweit MJ. Outpatient Parenteral Antibiotic Therapy in Older Adults. Infect Dis Clin North Am 2023; 37:123-137. [PMID: 36805009 DOI: 10.1016/j.idc.2022.09.002] [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: 02/17/2023]
Abstract
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.
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Affiliation(s)
- Nora T Oliver
- Section of Infectious Diseases, Atlanta VA Medical Center, 1670 Clairmont Road, RIM 111, Decatur, GA 30033, USA.
| | - Marion J Skalweit
- Department of Medicine and Biochemistry, Case Western Reserve University School of Medicine, 11100 Euclid Avenue, Cleveland OH 44106, USA
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Agnihotri G, Gross AE, Seok M, Yen CY, Khan F, Ebbitt LM, Gay C, Bleasdale SC, Sikka MK, Trotter AB. Decreased hospital readmissions after programmatic strengthening of an outpatient parenteral antimicrobial therapy (OPAT) program. ANTIMICROBIAL STEWARDSHIP & HEALTHCARE EPIDEMIOLOGY : ASHE 2023; 3:e33. [PMID: 36865701 PMCID: PMC9972539 DOI: 10.1017/ash.2022.330] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 08/03/2022] [Revised: 10/14/2022] [Accepted: 10/17/2022] [Indexed: 06/18/2023]
Abstract
OBJECTIVE To determine whether a structured OPAT program supervised by an infectious disease physician and led by an OPAT nurse decreased hospital readmission rates and OPAT-related complications and whether it affected clinical cure. We also evaluated predictors of readmission while receiving OPAT. PATIENTS A convenience sample of 428 patients admitted to a tertiary-care hospital in Chicago, Illinois, with infections requiring intravenous antibiotic therapy after hospital discharge. METHODS In this retrospective, quasi-experimental study, we compared patients discharged on intravenous antimicrobials from an OPAT program before and after implementation of a structured ID physician and nurse-led OPAT program. The preintervention group consisted of patients discharged on OPAT managed by individual physicians without central program oversight or nurse care coordination. All-cause and OPAT-related readmissions were compared using the χ2 test. Factors associated with readmission for OPAT-related problems at a significance level of P < .10 in univariate analysis were eligible for testing in a forward, stepwise, multinomial, logistic regression to identify independent predictors of readmission. RESULTS In total, 428 patients were included in the study. Unplanned OPAT-related hospital readmissions decreased significantly after implementation of the structured OPAT program (17.8% vs 7%; P = .003). OPAT-related readmission reasons included infection recurrence or progression (53%), adverse drug reaction (26%), or line-associated issues (21%). Independent predictors of hospital readmission due to OPAT-related events included vancomycin administration and longer length of outpatient therapy. Clinical cure increased from 69.8% before the intervention to 94.9% after the intervention (P < .001). CONCLUSION A structured ID physician and nurse-led OPAT program was associated with a decrease in OPAT-related readmissions and improved clinical cure.
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Affiliation(s)
- Gaurav Agnihotri
- College of Medicine, University of Illinois at Chicago, Chicago, Illinois
| | - Alan E. Gross
- Department of Pharmacy Practice, College of Pharmacy, University of Illinois at Chicago, Chicago, Illinois
| | - Minji Seok
- College of Medicine, University of Illinois at Chicago, Chicago, Illinois
| | - Cheng Yu Yen
- Department of Pharmacy Practice, College of Pharmacy, University of Illinois at Chicago, Chicago, Illinois
| | - Farah Khan
- Department of Pharmacy Practice, College of Pharmacy, University of Illinois at Chicago, Chicago, Illinois
| | - Laura M. Ebbitt
- College of Pharmacy, University of Kentucky, Lexington, Kentucky
| | - Cassandra Gay
- Division of Infectious Disease, Department of Medicine, College of Medicine, University of Illinois at Chicago, Chicago, Illinois
| | - Susan C. Bleasdale
- Division of Infectious Disease, Department of Medicine, College of Medicine, University of Illinois at Chicago, Chicago, Illinois
| | - Monica K. Sikka
- Division of Infectious Disease, Department of Medicine, Oregon Health & Science University, Portland, Oregon
| | - Andrew B. Trotter
- Division of Infectious Disease, Department of Medicine, College of Medicine, University of Illinois at Chicago, Chicago, Illinois
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13
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Brenneman E, Funaro J, Dicks K, Yarrington M, Lee HJ, Erkanli A, Hung F, Drew R. Utility of a risk assessment model in predicting 30 day unplanned hospital readmission in adult patients receiving outpatient parenteral antimicrobial therapy. JAC Antimicrob Resist 2023; 5:dlad019. [PMID: 36824226 PMCID: PMC9942543 DOI: 10.1093/jacamr/dlad019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2022] [Accepted: 02/01/2023] [Indexed: 02/23/2023] Open
Abstract
Objectives Outpatient parenteral antimicrobial therapy (OPAT) is associated with high hospital readmission rates. A 30 day unplanned readmission risk prediction model for OPAT patients has been developed in the UK. Given significant differences in patient mix and methods of OPAT delivery, we explored the model for its utility in Duke University Health System (DUHS) patients receiving OPAT. Methods We analysed OPAT episodes of adult patients from two hospitals between 1 July 2019 and 1 February 2020. The discriminative ability of the model to predict 30 day unplanned all-cause and OPAT-related admission was examined. An updated model was created by logistic regression with the UK risk factors and additional risk factors, OPAT delivery in a skilled nursing facility, vancomycin use and IV drug abuse. Results Compared with patients of the UK cohort, our study patients were of higher acuity, treated for more invasive infections, and received OPAT through different modes. The 30 day unplanned readmission rate in our cohort was 20% (94/470), with 59.5% (56/94) of those being OPAT-related. The original model was unable to discriminate for all-cause readmission with a C-statistic of 0.52 (95% CI 0.46-0.59) and for OPAT-related readmission with a C-statistic of 0.55 (95% CI 0.47-0.64). The updated model with additional risk factors did not have improved performance, with a C-statistic of 0.55 (95% CI 0.49-0.62). Conclusions The UK 30 day unplanned hospital readmission model performed poorly in predicting readmission for the OPAT population at a US academic medical centre.
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Affiliation(s)
| | - Jason Funaro
- Department of Pharmacy, Duke University Hospital, 2301 Erwin Road Durham, Durham, NC, USA
| | - Kristen Dicks
- Division of Infectious Diseases, Duke University School of Medicine, Durham, NC, USA
| | - Michael Yarrington
- Division of Infectious Diseases, Duke University School of Medicine, Durham, NC, USA
| | - Hui-Jie Lee
- Biostatistics & Bioinformatics, Duke University School of Medicine, Durham, NC, USA
| | - Alaattin Erkanli
- Biostatistics & Bioinformatics, Duke University School of Medicine, Durham, NC, USA
| | - Frances Hung
- Biostatistics & Bioinformatics, Duke University School of Medicine, Durham, NC, USA
| | - Richard Drew
- Division of Infectious Diseases, Duke University School of Medicine, Durham, NC, USA,Campbell University College of Pharmacy & Health Sciences, Buies Creek, NC, USA
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14
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TP L, Manjelievskaia J, EH M, Rodriguez M. Retrospective Cohort Study of the 12-Month Epidemiology, Treatment Patterns, Outcomes, and Healthcare Costs Among Adult Patients with Complicated Urinary Tract Infections. Open Forum Infect Dis 2022; 9:ofac307. [PMID: 35891695 PMCID: PMC9308450 DOI: 10.1093/ofid/ofac307] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2022] [Accepted: 06/17/2022] [Indexed: 11/12/2022] Open
Abstract
Background Limited data are available in the United States on the 12-month epidemiology, outpatient (OP) antibiotic treatment patterns, outcomes, and costs associated with complicated urinary tract infections (cUTIs) in adult patients. Methods A retrospective observational cohort study of adult patients with incident cUTIs in IBM MarketScan Databases between 2017 and 2019 was performed. Patients were categorized as OP or inpatient (IP) based on initial setting of care for index cUTI and were stratified by age (<65 years vs ≥65 years). OP antibiotic treatment patterns, outcomes, and costs associated with cUTIs among adult patients over a 12-month follow-up period were examined. Results During the study period, 95 322 patients met inclusion criteria. Most patients were OPs (84%) and age <65 years (87%). Treatment failure (receipt of new unique OP antibiotic or cUTI-related ED visit/IP admission) occurred in 23% and 34% of OPs aged <65 years and ≥65 years, respectively. Treatment failure was observed in >38% of IPs, irrespective of age. Across both cohorts and age strata, >78% received ≥2 unique OP antibiotics, >34% received ≥4 unique OP antibiotics, >16% received repeat OP antibiotics, and >33% received ≥1 intravenous (IV) OP antibiotics. The mean 12-month cUTI-related total health care costs were $4697 for OPs age <65 years, $8924 for OPs age >65 years, $15 401 for IPs age <65 years, and $17 431 for IPs age ≥65 years. Conclusions These findings highlight the substantial 12-month health care burden associated with cUTIs and underscore the need for new outpatient treatment approaches that reduce the persistent or recurrent nature of many cUTIs.
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Affiliation(s)
- Lodise TP
- Albany College of Pharmacy and Health Sciences , Albany, NY , USA
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15
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Keller SC, Salinas A, Gurses AP, Levering M, Hohl D, Hirsch D, Grimes M, Ziemba K, Cosgrove SE. Implementing a Toolkit to Improve the Education of Patients on Home-based Outpatient Parenteral Antimicrobial Therapy (OPAT). Jt Comm J Qual Patient Saf 2022; 48:468-474. [PMID: 35850954 PMCID: PMC10184031 DOI: 10.1016/j.jcjq.2022.05.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2021] [Revised: 05/25/2022] [Accepted: 05/26/2022] [Indexed: 11/26/2022]
Abstract
BACKGROUND Patients discharged to the home on home-based outpatient parenteral antimicrobial therapy (OPAT) perform their own infusions and catheter care; thus, they require high-quality training to improve safety and the likelihood of treatment success. This article describes the study team's experience piloting an educational toolkit for patients on home-based OPAT. METHODS An OPAT toolkit was developed to address barriers such as unclear communication channels, rushed instruction, safe bathing with an intravenous (IV) catheter, and lack of standardized instructions. The research team evaluated the toolkit through interviews with home infusion nurses implementing the intervention, surveys of 20 patients who received the intervention, and five observations of the home infusion nurses delivering the intervention to patients and caregivers. RESULTS Of surveyed patients, 90.0% were comfortable infusing medications at the time of discharge, and 80.0% with bathing with the IV catheter. While all practiced on equipment, 75.0% used the videos and the paper checklists. Almost all (95.0%) were satisfied with their training, and all were satisfied with managing their IV catheters at home. The videos were considered very helpful, particularly as reference. Overall, nurses adjusted training to patient characteristics and modified the toolkit over time. Shorter instruction forms were more helpful than longer instruction forms. CONCLUSION Developing a toolkit to improve the education of patients on home-based OPAT has the potential to improve the safety of and experience with home-based OPAT.
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16
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Lodise TP, Nowak M, Rodriguez M. The 30-Day Economic Burden of Newly Diagnosed Complicated Urinary Tract Infections in Medicare Fee-for-Service Patients Who Resided in the Community. Antibiotics (Basel) 2022; 11:antibiotics11050578. [PMID: 35625222 PMCID: PMC9137853 DOI: 10.3390/antibiotics11050578] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Revised: 04/20/2022] [Accepted: 04/20/2022] [Indexed: 02/05/2023] Open
Abstract
Introduction: Scant data are available on the 30-day financial burden associated with incident complicated urinary tract infections (cUTIs) in a cohort of predominately elderly patients. This study sought to examine total and cUTI-related 30-day Medicare spending (MS), a proxy for healthcare costs, among Medicare fee-for-service (FFS) beneficiaries who resided in the community with newly diagnosed cUTIs. Methods: A retrospective multicenter cohort study of adult beneficiaries in the Medicare FFS database with a cUTI between 2017 and 2018 was performed. Patients were included if they were enrolled in Medicare FFS and Medicare Part D from 2016 to 2019, had a cUTI first diagnosis in 2017–2018, no evidence of any UTI diagnoses in 2016, and residence in the community between 2016 and 2018. Results: During the study period, 723,324 cases occurred in Medicare beneficiaries who met the study criteria. Overall and cUTI-related 30-day MS were $7.6 and $4.5 billion, respectively. The average overall and cUTI-related 30-day MS per beneficiary were $10,527 and $6181, respectively. The major driver of cUTI-related 30-day MS was acute care hospitalizations ($3.2 billion) and the average overall and cUTI-related 30-day MS per hospitalizations were $16,431 and $15,438, respectively. Conclusion: Overall 30-day MS for Medicare FSS patients who resided in the community with incident cUTIs was substantial, with cUTI-related MS accounting for 59%. As the major driver of cUTI-related 30-day MS was acute care hospitalizations, healthcare systems should develop well-defined criteria for hospital admissions that aim to avert hospitalizations in clinically stable patients and expedite the transition of patients to the outpatient setting to complete their care.
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Affiliation(s)
- Thomas P. Lodise
- Albany College of Pharmacy and Health Sciences, Albany, NY 12208, USA
- Correspondence: ; Tel.: +1-518-694-7292
| | - Michael Nowak
- Spero Therapeutics, Inc., Cambridge, MA 02139, USA; (M.N.); (M.R.)
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17
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Certain LK, Benefield RJ, Newman M, Zhang M, Thomas FO. A Quality Initiative to Improve Post-discharge Care for Patients on Outpatient Parenteral Antimicrobial Therapy. Open Forum Infect Dis 2022; 9:ofac199. [PMID: 35794930 PMCID: PMC9251666 DOI: 10.1093/ofid/ofac199] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Accepted: 04/08/2022] [Indexed: 11/13/2022] Open
Abstract
Abstract
Background/Objective
Patients discharged from the hospital on outpatient parenteral antimicrobial therapy (OPAT) require close monitoring, including weekly blood tests and an early post-hospital follow-up visit. However, because patients often receive OPAT in a separate healthcare system from where they received inpatient care, the OPAT plan often fails, with less than 75% of OPAT patients receiving the recommended laboratory monitoring. We sought to determine if changing our inpatient OPAT documentation method would improve post-discharge care.
Methods
As a quality improvement initiative, we conducted two Plan-Do-Study-Act interventions on our OPAT documentation. Our first intervention was to create a standardized OPAT Progress Note, and our second was to turn that note into a SmartForm (Epic) with discrete fields for the key information. We examined the effects of these changes on the rate of completion of recommended lab monitoring, attendance at outpatient follow-up visits, and 30-day readmission rates.
Results
Changing our documentation to a standardized Progress Note and then to a SmartForm with discrete fields led to an increase in the proportion of patients with a serum creatinine checked within ten days of discharge (from 63% to 71% to 73%) and who attended an infectious disease clinic visit within three weeks of discharge (from 21% to 36% to 47%). However, the rate of readmissions for OPAT-related problems did not change, nor did a composite outcome of 30-day mortality/unplanned readmission.
Conclusions
Changes in how and where care plans are documented in the inpatient medical record can have significant effects on patient care outcomes after discharge.
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Affiliation(s)
- Laura K. Certain
- University of Utah Health, Division of Infectious Diseases, Salt Lake City, Utah, United States
| | | | - Michael Newman
- University of Utah Health, Data Science Services, Salt Lake City, Utah, United States
| | - Mingyuan Zhang
- University of Utah Health, Data Science Services, Salt Lake City, Utah, United States
| | - Frank O. Thomas
- University of Utah Health, Value Engineering (retired), Salt Lake City, Utah, United States
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18
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Implementation of a consensus protocol for antibiotic use for bone and joint infection to reduce unnecessary outpatient parenteral antimicrobial therapy: A quality improvement initiative. ANTIMICROBIAL STEWARDSHIP & HEALTHCARE EPIDEMIOLOGY 2022; 2:e6. [PMID: 36310771 PMCID: PMC9614991 DOI: 10.1017/ash.2021.250] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Revised: 11/24/2021] [Accepted: 11/29/2021] [Indexed: 01/15/2023]
Abstract
Objective: We aimed to decrease the use of outpatient parenteral antimicrobial therapy (OPAT) for patients admitted for bone and joint infections (BJIs) by applying a consensus protocol to suggest oral antibiotics for BJI. Design: A quasi-experimental before-and-after study. Setting: Inpatient setting at a single medical center. Patients: All inpatients admitted with a BJI. Methods: We developed a consensus table of oral antibiotics for BJI among infectious diseases (ID) specialists. Using the consensus table, we implemented a protocol consisting of a weekly reminder e-mail and case-based discussion with the consulting ID physician. Outcomes of patients during the implementation period (November 1, 2020, to May 31, 2021) were compared with those during the preimplementation period (January 1, 2019, to October 31, 2020). Our primary outcome was the proportion of patients treated with OPAT. Secondary outcomes included length of hospital stay (LOS) and recurrence or death within 6 months. Results: In total, 77 patients during the preimplementation period and 22 patients during the implementation period were identified to have a BJI. During the preimplementation period, 70.1% of patients received OPAT, whereas only 31.8% of patients had OPAT during the implementation period (P = .003). The median LOS after final ID recommendation was significantly shorter during the implementation period (median 3 days versus 1 day; P < .001). We detected no significant difference in the 6-month rate of recurrence (24.7% vs 31.8%; P = .46) or mortality (9.1% vs 9.1%; P = 1.00). Conclusions: More patients admitted with BJIs were treated with oral antibiotics during the implementation phase of our quality improvement initiative.
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19
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Recent Updates in Antimicrobial Stewardship in Outpatient Parenteral Antimicrobial Therapy. Curr Infect Dis Rep 2021; 23:24. [PMID: 34776793 PMCID: PMC8577634 DOI: 10.1007/s11908-021-00766-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/22/2021] [Indexed: 12/11/2022]
Abstract
Purpose of Review Antimicrobial stewardship within acute care is common and has been expanding to outpatient areas. Some inpatient antimicrobial stewardship tactics apply to outpatient parenteral antimicrobial therapy (OPAT) and complex outpatient antimicrobial therapy (COpAT) management, but differences do exist. Recent Findings OPAT/COpAT is a growing area of practice and research with its own unique considerations for antimicrobial stewardship. Potential ideas for antimicrobial stewardship in the OPAT/COpAT setting include redesigning the regimen to COpAT instead of OPAT, ensuring the use of the shortest effective duration of antimicrobial therapy; using antimicrobials dosed less frequently, such as long-acting glycopeptides; optimizing antimicrobial susceptibility testing reporting for common OPAT/COpAT drugs; and establishing routine laboratory and safety monitoring. Future consensus is needed to determine validated OPAT program metrics and outcomes. Summary As more focus is placed on outpatient antimicrobial stewardship, clinicians practicing in OPAT should publish more data regarding OPAT program methods and outcomes as they relate to antimicrobial stewardship. These can involve patient clinical outcomes, OPAT readmission rates, OPAT therapy completion, and central line-related complications.
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20
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Ingram PR, Ng J, Mathieson C, Mowlaboccus S, Coombs G, Raby E, Dyer J. A clinical and in vitro assessment of outpatient parenteral benzylpenicillin and ceftriaxone combination therapy for enterococcal endovascular infections. JAC Antimicrob Resist 2021; 3:dlab128. [PMID: 34377984 PMCID: PMC8346702 DOI: 10.1093/jacamr/dlab128] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Revised: 06/20/2021] [Accepted: 07/19/2021] [Indexed: 01/21/2023] Open
Abstract
Background Amoxicillin plus ceftriaxone combination therapy is now standard of care for enterococcal endocarditis. Due to amoxicillin instability in infusion devices, benzylpenicillin plus ceftriaxone may be substituted to facilitate outpatient parenteral antimicrobial therapy (OPAT) delivery, despite lack of guideline endorsement. Objectives To assess the clinical efficacy of benzylpenicillin plus ceftriaxone for the management of enterococcal endovascular infections, in addition to assessing this combination’s in vitro synergy. Patients and methods Retrospective cohort study assessing unplanned readmissions, relapses and mortality for 20 patients with endovascular Enterococcus faecalis infections treated with benzylpenicillin plus ceftriaxone delivered via OPAT. For a subset of isolates, synergism for both amoxicillin and benzylpenicillin in combination with ceftriaxone was calculated using a chequerboard method. Results Patients had endovascular infections of native cardiac valves (n = 11), mechanical or bioprosthetic cardiac valves (n = 7), pacemaker leads (n = 1) or left ventricular assistant devices (n = 1). The median duration of OPAT was 22 days, and the most frequent antimicrobial regimen was benzylpenicillin 14 g/day via continuous infusion and ceftriaxone 4 g once daily via short infusion. Rates of unplanned readmissions were high (30%), although rates of relapsed bacteraemia (5%) and 1 year mortality (15%) were comparable to the published literature. Benzylpenicillin less frequently displayed a synergistic interaction with ceftriaxone when compared with amoxicillin (3 versus 4 out of 6 isolates). Conclusions Lower rates of synergistic antimicrobial interaction and a significant proportion of unplanned readmissions suggest clinicians should exercise caution when treating enterococcal endovascular infection utilizing a combination of benzylpenicillin and ceftriaxone via OPAT.
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Affiliation(s)
- Paul R Ingram
- Department Infectious Diseases, Fiona Stanley Hospital, Perth, Australia.,School of Pathology and Laboratory Medicine, University of Western Australia, Perth, Australia.,Department of Microbiology, PathWest Laboratory Medicine, Murdoch, Western Australia, Australia
| | - Jacinta Ng
- Department Infectious Diseases, Fiona Stanley Hospital, Perth, Australia
| | - Claire Mathieson
- Department of Microbiology, PathWest Laboratory Medicine, Murdoch, Western Australia, Australia
| | - Shakeel Mowlaboccus
- Department of Microbiology, PathWest Laboratory Medicine, Murdoch, Western Australia, Australia.,College of Science, Health, Engineering and Education, Murdoch University, Perth, Australia
| | - Geoffrey Coombs
- Department of Microbiology, PathWest Laboratory Medicine, Murdoch, Western Australia, Australia.,College of Science, Health, Engineering and Education, Murdoch University, Perth, Australia
| | - Edward Raby
- Department Infectious Diseases, Fiona Stanley Hospital, Perth, Australia.,Department of Microbiology, PathWest Laboratory Medicine, Murdoch, Western Australia, Australia
| | - John Dyer
- Department Infectious Diseases, Fiona Stanley Hospital, Perth, Australia
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21
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Sadler ED, Avdic E, Cosgrove SE, Hohl D, Grimes M, Swarthout M, Dzintars K, Lippincott CK, Keller SC. Failure modes and effects analysis to improve transitions of care in patients discharged on outpatient parenteral antimicrobial therapy. Am J Health Syst Pharm 2021; 78:1223-1232. [PMID: 33944904 DOI: 10.1093/ajhp/zxab165] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
PURPOSE To identify barriers to safe and effective completion of outpatient parenteral antimicrobial therapy (OPAT) in patients discharged from an academic medical center and to develop targeted solutions to potentially resolve or improve the identified barriers. SUMMARY A failure modes and effects analysis (FMEA) was conducted by a multidisciplinary OPAT task force to evaluate the processes for patients discharged on OPAT to 2 postdischarge dispositions: (1) home and (2) skilled nursing facility (SNF). The task force created 2 process maps and identified potential failure modes, or barriers, to the successful completion of each step. Thirteen and 10 barriers were identified in the home and SNF process maps, respectively. Task force members created 5 subgroups, each developing solutions for a group of related barriers. The 5 areas of focus included (1) the OPAT electronic order set, (2) critical tasks to be performed before patient discharge, (3) patient education, (4) patient follow-up and laboratory monitoring, and (5) SNF communication. Interventions involved working with information technology to update the electronic order set, bridging communication and ensuring completion of critical tasks by creating an inpatient electronic discharge checklist, developing patient education resources, planning a central OPAT outpatient database within the electronic medical record, and creating a pharmacist on-call pager for SNFs. CONCLUSION The FMEA approach was helpful in identifying perceived barriers to successful transitions of care in patients discharged on OPAT and in developing targeted interventions. Healthcare organizations may reproduce this strategy when completing quality improvement planning for this high-risk process.
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Affiliation(s)
| | - Edina Avdic
- Department of Pharmacy, Department of Antimicrobial Stewardship, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Sara E Cosgrove
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Dawn Hohl
- Transitions and Patient Experience, Johns Hopkins Home Care Group, Baltimore, MD, USA
| | - Michael Grimes
- Johns Hopkins Specialty Infusion Services, Johns Hopkins Home Care Group, Baltimore, MD, USA
| | - Meghan Swarthout
- Department of Pharmacy, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Kathryn Dzintars
- Department of Pharmacy, Department of Antimicrobial Stewardship, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Christopher K Lippincott
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Sara C Keller
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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22
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Diamantis S, Dawudi Y, Cassard B, Longuet P, Lesprit P, Gauzit R. Home intravenous antibiotherapy and the proper use of elastomeric pumps: Systematic review of the literature and proposals for improved use. Infect Dis Now 2021; 51:39-49. [PMID: 33576336 DOI: 10.1016/j.medmal.2020.10.019] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Revised: 04/28/2020] [Accepted: 10/15/2020] [Indexed: 11/30/2022]
Abstract
Over several decades, the economic situation and consideration of patient quality of life have been responsible for increased outpatient treatment. It is in this context that outpatient antimicrobial treatment (OPAT) has rapidly developed. The availability of elastomeric infusion pumps has permitted prolonged or continuous antibiotic administration by dint of a mechanical device necessitating neither gravity nor a source of electricity. In numerous situations, its utilization optimizes administration of time-dependent antibiotics while freeing the patient from the constraints associated with infusion by gravity, volumetric pump or electrical syringe pump and, more often than not, limiting the number of nurse interventions to one or two a day. That much said, the installation of these pumps, which is not systematically justified, entails markedly increased OPAT costs and is liable to expose the patient to a risk of therapeutic failure or adverse effects due to the instability of the molecules utilized in a non-controlled environment, instability that necessitates close monitoring of their use. More precisely, a prescriber must take into consideration the stability parameters of each molecule (infusion duration, concentration following dilution, nature of the diluent and pump temperature). The objective of this work is to evaluate the different means of utilization of elastomeric infusion pumps in intravenous antibiotic administration outside of hospital. Following a review of the literature, we will present a tool for optimized antibiotic prescription, in a town setting by means of an infusion device.
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Affiliation(s)
- S Diamantis
- Service des maladies infectieuses et tropicales, groupe hospitalier Sud Île-de-France, 270, boulevard Marc-Jacquet, 77000 Melun, France.
| | - Y Dawudi
- Service des maladies infectieuses et tropicales, groupe hospitalier Sud Île-de-France, 270, boulevard Marc-Jacquet, 77000 Melun, France
| | - B Cassard
- Service de pharmacie hospitalière, groupe hospitalier Sud Île-de-France, Melun, France
| | - P Longuet
- Équipe mobile d'antibiothérapie, centre hospitalier Victor-Dupouy, Argenteuil, France
| | - P Lesprit
- Unité transversale d'hygiène et d'infectiologie, service de biologie clinique, hôpital Foch, Suresnes, France
| | - R Gauzit
- Équipe mobile d'infectiologie, réanimation Ollier, hôpital Cochin AP-HP, Paris, France
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