Outpatient and home parenteral antibiotic therapy (OHPAT) in the UK: a consensus statement by a working party

Abstract

Dr Chris Conlon, Consultant Physician in Infectious Diseases, Nuffield Department of Medicine, John Radcliffe Hospital, Headley Way, Oxford OX3 9DU Dr Dilip Nathwani, Consultant Physician in Infectious Diseases, King's Cross Hospital (Dundee Teaching Hospitals NHS Trust), Clepington Road, Dundee DD3 8EA Mr Peter Bower, Managing Consultant, Health Management Consultancy, Quayside, Ouseburn Building, Albion Row, East Quayside, Newcastle upon Tyne, NE6 1LL Ms Janet Finucane, Chief Officer, Manchester Community Health Council, Lancaster Buildings, 77 Deansgate, Manchester M3 2BW Ms Janice Gabriel, Oncology Nurse Specialist/Manager, Portsmouth Oncology Centre, Saint Mary's Hospital, Milton Road, Portsmouth PO3 6AD Mr Philip Hewitson, Management Consultant, Greystones, Husthwaite, York YO6 3SX Dr Andrew Lowes, Public Health Laboratory Service, Level B, South Block, Southampton General Hospital, Tremona Road, Southampton SO16 6YD Mr Steve Fuller, Clinical Effectiveness Pharmacist, Pharmacy Directorate, North Tyneside Health Care NHS Trust, North Shields, Tyne and Wear NE29 8NH Ms Jill Kayley, Community Specialist Nurse HIV and IV Therapy, Oxfordshire Community Health NHS Trust, East Oxford Health Centre, Manzil Way, Cowley Road, Oxford OX4 1XD Mr Archie McEwen, Contract Manager, Scottish Healthcare Supplies, Scottish Health Service Common Services Agency, South Trinity Road, Edinburgh EH5 3SH Dr Stephen Newell, General Practitioner, 3 Wayside Close, Romford, Essex RM1 4ES Mr Mark Pilling, Prescribing Advisor, Kirkby GP Multifund, Kirkby Health Suite, Civic Centre Buildings, Cherryfield Drive, Kirkby, Liverpool L32 8UR Dr Bill Smith, Medical Legal Advisor, Medical Protection Society, Granary Wharf House, Leeds LS11 5PY Technology, procedures, devices and drugs account for 50–75% of the increase in healthcare costs. The UK National Health Service (NHS) executive is keen to promote the provision of high-technology care at home as part of its commitment to providing high-quality care in the community. The provision of parenteral antimicrobial therapy in the community lends itself to this philosophy. Despite this, and though outpatient and home parenteral antibiotic therapy (OHPAT) is an accepted ‘standard of care’ for managing many infections in North America, Europe has been slow to respond to this innovation in healthcare delivery. At present, a few enthusiasts are responding to this challenge but most infections requiring parenteral therapy are treated in the inpatient hospital setting. Currently, OHPAT in the UK has low government priority and existing activity is poorly coordinated and under-resourced. However, emergency medical admissions have risen by 50% since 1984 and now account for almost half of all NHS admissions. This in turn has necessitated an emergency cash boost for the NHS, and led to calls for approaches that reduce delays in discharging patients and lessen the need for people to be admitted to hospital in the first place. These aims are ably met by OHPAT strategies. This consensus statement aims to advise those healthcare workers and managers on how best to develop, fund, implement and evaluate a new or existing OHPAT program. Recent developments in clinical technology and expertise, coupled with consumerist pressures for individual, high-quality health care and diminishing healthcare budgets [1Blatchford O Capewell S Emergency medical admissions: taking stock and planning for winter.Br Med J. 1997; 315: 1322-1323Crossref PubMed Google Scholar,2Department of Health. £300 million cash boost for NHS. Press release 97/274. London, 14 October 1997.Google Scholar], have combined to make the delivery of outpatient and home parenteral antibiotic therapy (OHPAT) an attractive possibility for improving patient care. Delivered by healthcare personnel, carers or patients themselves, in the domestic setting or in the hospital as outpatients, these therapies now provide a distinct option for patients and their physicians. Whatever the initial attraction in terms of heightening patient independence, the practical implementation of OHPAT requires careful consideration of a number of clinical and organizational issues. These issues were explored in workshops in London on 25 March and 3 September 1997. The members of the workshops included key experts involved or interested in OHPAT, comprising a broad multidisciplinary group of primary care physicians, microbiologists, hospital physicians with an interest in infection, primary care and hospital nurses, pharmacists, health service strategists, health service managers, patient representatives and medico-legal experts. Guidelines already existed, from Canada [3Canadian Home IV Guidelines. Canadian Advisory Committee on Home IV Antibiotic Therapy. Highlights of a Consensus Conference. 11–12 November 1994. Toronto, Canada.Google Scholar] and more recently from the USA [4Williams DN Rehm SJ Tice AD Bradley JS Kind AC Craig WA Practice guidelines for community-based parenteral anti-infective therapy.Clin Infect Dis. 1997; 25: 787-801Crossref PubMed Scopus (100) Google Scholar]. The deliberations of the group concentrated on sharing experience, primarily from the UK, but also adapting existing guidelines for local use. The results of the two workshops and subsequent detailed discussion between members of the group resulted in the development of an OHPAT consensus statement aimed mainly at UK practice, and are presented here for further discussion and development. OHPAT programs (referred to as community-based parenteral anti-infective therapy, CoPAT) in the USA have a well-developed infrastructure and deliver a high-quality service to a large number of patients [4Williams DN Rehm SJ Tice AD Bradley JS Kind AC Craig WA Practice guidelines for community-based parenteral anti-infective therapy.Clin Infect Dis. 1997; 25: 787-801Crossref PubMed Scopus (100) Google Scholar,5Nathwani D Seaton W Davey P Key issues in the development of a non-inpatient intravenous (NIPIV) antibiotic therapy programme—a European perspective.Rev Med Microbiol. 1997; 8: 137-147Crossref Scopus (6) Google Scholar]. A set of guidelines commissioned by the Infectious Diseases Society of America (IDSA) details current trends in CoPAT [4Williams DN Rehm SJ Tice AD Bradley JS Kind AC Craig WA Practice guidelines for community-based parenteral anti-infective therapy.Clin Infect Dis. 1997; 25: 787-801Crossref PubMed Scopus (100) Google Scholar]. These guidelines reveal that many elements of European OHPAT practices are developing along similar lines to US programs. A number of areas are covered by these and act as a useful checklist for consideration when discussing OHPAT services in Europe [4Williams DN Rehm SJ Tice AD Bradley JS Kind AC Craig WA Practice guidelines for community-based parenteral anti-infective therapy.Clin Infect Dis. 1997; 25: 787-801Crossref PubMed Scopus (100) Google Scholar]: •patient evaluation and selection criteria;•key elements for a community-based parenteral anti-infective program;•the roles and responsibilities of the multidisciplinary team members;•clinical aspects of care (including monitoring);•anti-infective selection and administration;•outcome measures;•economic considerations;•risks and benefits. While the guidelines commissioned by the IDSA [4Williams DN Rehm SJ Tice AD Bradley JS Kind AC Craig WA Practice guidelines for community-based parenteral anti-infective therapy.Clin Infect Dis. 1997; 25: 787-801Crossref PubMed Scopus (100) Google Scholar] show many similarities between US CoPAT and European OHPAT activities, the extent of European efforts is limited to a few clinical enthusiasts working without national support towards the development, implementation and funding of such programs [6Nathwani D Davey P Intravenous antimicrobial therapy in the community: underused, inadequately resourced, or irrelevant to healthcare in Britain.Br Med J. 1996; 313: 1541-1543Crossref PubMed Scopus (18) Google Scholar]. The potential benefits to be gained from OHPAT programs, and the large size of the potential patient group that could be treated using this type of therapy, suggest that we should be investing in a more organized strategy development in Europe [5Nathwani D Seaton W Davey P Key issues in the development of a non-inpatient intravenous (NIPIV) antibiotic therapy programme—a European perspective.Rev Med Microbiol. 1997; 8: 137-147Crossref Scopus (6) Google Scholar]. Barriers to effective development of OHPAT programs in Europe might include [5Nathwani D Seaton W Davey P Key issues in the development of a non-inpatient intravenous (NIPIV) antibiotic therapy programme—a European perspective.Rev Med Microbiol. 1997; 8: 137-147Crossref Scopus (6) Google Scholar]: •political and cultural reluctance to consider any healthcare innovation in many European countries;•diversity of healthcare infrastructure—for example, in France and Germany healthcare is mainly hospital-led, while in the UK, The Netherlands and many parts of Scandinavia there is a strong primary care structure;•a lack of good clinical and economic data relevant to each country's healthcare system;•organizational issues, including unresolved funding issues, level of responsibility and delivery of care;•lack of the intravenous route as a ‘standard of care’ and, thereby, underestimation of the need for OHPAT;•low government and clinician priority;•lack of national guidelines. In the UK there is a long-standing tradition of high-quality community care with a sophisticated, well-established infrastructure. Hospital experts working in close association with those in primary care should ideally form the basis of future OHPAT programs. We should build on the existing experience of community intravenous therapy for chronic or recurrent infections [6Nathwani D Davey P Intravenous antimicrobial therapy in the community: underused, inadequately resourced, or irrelevant to healthcare in Britain.Br Med J. 1996; 313: 1541-1543Crossref PubMed Scopus (18) Google Scholar]. This paper is aimed at all interested parties who are either actively participating in delivering OHPAT or considering developing such programs. They aim to identify the key considerations in developing, implementing and evaluating OHPAT programs so as to provide a high-quality service that is cost-effective, safe and, above all, respected by patients and their carers. The objective of OHPAT must be to provide ‘treatment that is equivalent to inpatient therapy if not superior’. We make recommendations about which patients and which diseases are amenable to OHPAT, by whom and how the service could be delivered, and what the key organizational issues are, including funding, pharmacy and recommendations related to quality assurance and medico-legal issues. In general, OHPAT can be considered either after a period of hospital assessment and stabilization, or directly, without hospital inpatient admission. Patients with unstable ‘high-risk’ infections such as meningitis, endocarditis, severe pneumonia, severe arthritis or septicemia should usually be hospitalized initially. However, many ‘low-risk’ infections can be managed directly by OHPAT [7Sheldon P Bender M High technology in home care. An overview of intravenous therapy.Nurs Clin North Am. 1994; 29: 507-519PubMed Google Scholar]. These include: •infections in cystic fibrosis [8van Aalderen WM Mannes GP van Bommel G Voorthuis I Bosnia E Heymans HS Continuous intravenous antibiotic home treatment in 11 patients with cystic fibrosis in The Northern Netherlands.Ned Tijdschr Geneeskd. 1993; 137: 2482-2486PubMed Google Scholar, 9Ninan TK Russell G Intravenous antibiotic therapy in cystic fibrosis: in hospital or at home?.Respir Med. 1994; 88: 158-159Abstract Full Text PDF PubMed Scopus (3) Google Scholar, 10Winter RJ George RJ Deacock SJ Shee CD Geddes DM Self-administered home intravenous antibiotic therapy in bronchiectasis and adult cystic fibrosis.Lancet. 1984; 161: 1338-1339Abstract Scopus (45) Google Scholar];•chronic bone and prosthetic joint infections [11Ingram C Eron LJ Goldenberg RI et al.Antibiotic therapy of osteomyelitis in outpatients.Med Clin North Am. 1988; 72: 723-738PubMed Google Scholar, 12Couch L Cierny G Mader JT Inpatient and outpatient use of the Hickman catheter for adults with osteomyelitis.Clin Orthop. 1987; 219: 226-235PubMed Google Scholar, 13Tice AD Outpatient parenteral antibiotic therapy. Management of serious infections. Part II: Amenable infections and models for delivery. Osteomyelitis.Hosp Pract (Off Ed). 1993; 8 (suppl 2), 60–1.: 36-39Google Scholar, 14Graninger W Presterl E Weinisch C Schwameis E Breyer S Vukovich T Management of serious staphylococcal infections in the outpatient setting.Drugs. 1997; 54 (suppl 6): 21-28Crossref PubMed Scopus (36) Google Scholar];•‘low-risk’ neutropenic fevers [15Kibbler CC Prentice HG Which febrile neutropenic patients are suitable for outpatient management?.Curr Opin Infect Dis. 1997; 10: 251-254Crossref Scopus (4) Google Scholar, 16Freifeld AG Pizzo PA The outpatient management of febrile neutropenia in cancer patients.Oncology (Huntingt). 1996; 10 (611–12, 615–16.): 599-606PubMed Google Scholar, 17Rubenstein EB Rolston K Outpatient management of febrile episodes in neutropenic cancer patients.Support Care Cancer. 1994; 2: 369-373Crossref PubMed Scopus (28) Google Scholar, 18Talcott JA Whalen A Clark J Rieker PP Finberg R Home antibiotic therapy for low-risk cancer patients with fever and neutropenia: a pilot study of 30 patients based on a validated prediction rule.J Clin Oncol. 1994; 12: 107-114PubMed Google Scholar, 19Kinsey SE Experience with teicoplanin in non-inpatient therapy in children with central line infections.Eur J Haematol. 1998; 59: 11-14Crossref Scopus (8) Google Scholar, 20Ketley NJ Kelsey SM Newland AZ Teicoplanin and oral ciprofloxacin as outpatient treatment of infective episodes in patients with indwelling central venous catheters and haematological malignancy.Clin Lab Haematol. 1995; 17: 71-74Crossref PubMed Scopus (10) Google Scholar];•cytomegalovirus (CMV) infection in immunocompromised hosts [21Welch J Forsey P Graham E Home treatment of cytomegalovirus retinitis with intravenous Ganciclovir.Genitourin Med. 1990; 66: 460PubMed Google Scholar, 22Wood G Whitby M Hogan P Frazer I Foscarnet infusion at home.Lancet. 1989; i: 156Abstract Google Scholar, 23Kayley J Berendt AR Snelling MJM et al.Safe intravenous therapy at home: experience of a UK based programme.J Antimicrob Chemother. 1996; 37: 1023-1029Crossref PubMed Scopus (51) Google Scholar];•skin and soft tissue infections not amenable to oral therapy [24Lindbeck G Powers R Outpatient parenteral antibiotic therapy. Management of serious infections. Part II: Amenable infections and models for delivery. Cellulitis.Hosp Pract (Off Ed). 1993; 28 (suppl 2), 57.: 10-14PubMed Google Scholar,25Tice AD An office model of outpatient parenteral antibiotic therapy.Rev Infect Dis. 1991; 13 (suppl 2): S184-S188Crossref PubMed Scopus (47) Google Scholar]. When a decision is being made about which diseases are suitable for OHPAT, a useful distinction can be made between acute, chronic and intermittent treatment needs. Initially, the main focus for home-based antibiotic therapies is likely to be on the chronic conditions, where this form of service delivery is easier to organize and the benefits are more obvious. Although each of the disease areas offers opportunities for this type of treatment delivery, a number of contextual issues must be recognized as crucial for any decision to initiate home-based therapy: •the antimicrobial activity of prescribed drugs;•anticipated adverse effects of prescribed drugs;•the frequency of treatment required. Much of the literature on OHPAT concerns the treatment of bacterial infections, particularly those that require several weeks of therapy to ensure cure. These prolonged courses of therapy in patients who are often not acutely unwell are ideally suited to outpatient treatment. However, numerically there are more cases that require only a few days of intravenous therapy compared to those needing weeks of treatment. 1.Infective endocarditis is the paradigm for these sorts of infection [26Durack D Outpatient parenteral antibiotic therapy. Management of serious infections. Part II: Amenable infections and models for delivery. Endocarditis.Hosp Pract (Off Ed). 1993; 28 (suppl 2), 56.: 6-9PubMed Google Scholar]. Although details of treatments vary according to the infecting organisms and their sensitivities, intravenous antibiotics may be necessary for 2–6 weeks. Clinically stable patients who are not likely to require surgery can be safely treated at home. Patients need careful assessment of their cardiovascular status as well as assessment of their infection.2.Osteomyelitis and other orthopedic infections [11Ingram C Eron LJ Goldenberg RI et al.Antibiotic therapy of osteomyelitis in outpatients.Med Clin North Am. 1988; 72: 723-738PubMed Google Scholar, 12Couch L Cierny G Mader JT Inpatient and outpatient use of the Hickman catheter for adults with osteomyelitis.Clin Orthop. 1987; 219: 226-235PubMed Google Scholar, 13Tice AD Outpatient parenteral antibiotic therapy. Management of serious infections. Part II: Amenable infections and models for delivery. Osteomyelitis.Hosp Pract (Off Ed). 1993; 8 (suppl 2), 60–1.: 36-39Google Scholar, 14Graninger W Presterl E Weinisch C Schwameis E Breyer S Vukovich T Management of serious staphylococcal infections in the outpatient setting.Drugs. 1997; 54 (suppl 6): 21-28Crossref PubMed Scopus (36) Google Scholar]. Osteomyelitis is another condition that may require 4–6 weeks of intravenous therapy. Patients are usually stable but may have limited mobility or pain that precludes discharge.However, patients with osteomyelitis who are not limited in this way are ideal for outpatient or home therapy. Within this group would be included patients with prosthetic joint infections or with pathogens resistant to orally available antimicrobials (e.g. methicillin-resistant Staphylococcus aureus (MRSA), coagulase-negative staphylococci). Other orthopedic problems that may require several weeks of intravenous therapy include septic arthritis, vertebral discitis, infected metalwork in trauma cases, and infection following spinal surgery.3.Vascular graft infections constitute another group that can be dealt with partly out of hospital. These are more complicated than the orthopedic infections discussed above, as surgical debridement is not possible in the same manner. However, prolonged intravenous therapy may lead to better outcomes in vascular infections [27Gordon A Conlon C Collin J et al.An eight year experience of conservative management for aortic graft sepsis.Eur J Vascular Surg. 1994; 8: 611-616Abstract Full Text PDF PubMed Scopus (24) Google Scholar].4.Abscesses and difficult skin and soft tissue infections: a variety of abscesses in neurosurgical patients and some difficult skin and soft tissue infections [23Kayley J Berendt AR Snelling MJM et al.Safe intravenous therapy at home: experience of a UK based programme.J Antimicrob Chemother. 1996; 37: 1023-1029Crossref PubMed Scopus (51) Google Scholar]. These will include some cases of highly resistant microbes and/or multiple antibiotic allergies. Some patients may be mobile and clinically stable after a week or so, but still require a further 2–3 weeks of intravenous therapy; these cases include liver abscesses, psoas abscesses and brain abscesses.5.Patients with cystic fibrosis and bronchiectasis [8van Aalderen WM Mannes GP van Bommel G Voorthuis I Bosnia E Heymans HS Continuous intravenous antibiotic home treatment in 11 patients with cystic fibrosis in The Northern Netherlands.Ned Tijdschr Geneeskd. 1993; 137: 2482-2486PubMed Google Scholar, 9Ninan TK Russell G Intravenous antibiotic therapy in cystic fibrosis: in hospital or at home?.Respir Med. 1994; 88: 158-159Abstract Full Text PDF PubMed Scopus (3) Google Scholar, 10Winter RJ George RJ Deacock SJ Shee CD Geddes DM Self-administered home intravenous antibiotic therapy in bronchiectasis and adult cystic fibrosis.Lancet. 1984; 161: 1338-1339Abstract Scopus (45) Google Scholar] constitute a special group. They often require 10–14 days of parenteral antipseudomonal treatment on a recurrent basis. Once venous access is assured, many of these patients may be treated at home when chest infections occur. The majority of patients in most hospitals require only short courses of intravenous antibiotics to achieve a cure. Some of these may require hospitalization for reasons other than infection but some may remain in hospital purely to complete their intravenous therapy. 1.Soft tissue infections, complicated urinary tract infections, pneumonia, meningitis and bacteremia [28Trowbridge JF Outpatient parenteral antibiotic therapy. Management of serious infections. Part II: Amenable infections and models for delivery. Pneumonia and chronic lung disease.Hosp Pract (Off Ed). 1993; 28 (suppl 2), 58.: 20-24PubMed Google Scholar]. Soft tissue infections, such as cellulitis, probably account for the largest number of patients who remain in hospital purely to complete their intravenous therapy but could be treated at home [29Bradley JS Outpatient parenteral antibiotic therapy. Management of serious infections. Part II: Amenable infections and models for delivery. Meningitis.Hosp Pract (Off Ed). 1993; 28 (suppl 2), 57–8.: 15-19PubMed Google Scholar]. Other conditions include complicated urinary tract infections, pneumococcal pneumonia with bacteremia, meningitis (after initial response) and S. aureus bacteremia.2.Neutropenia and fever following cancer chemotherapy [15Kibbler CC Prentice HG Which febrile neutropenic patients are suitable for outpatient management?.Curr Opin Infect Dis. 1997; 10: 251-254Crossref Scopus (4) Google Scholar, 16Freifeld AG Pizzo PA The outpatient management of febrile neutropenia in cancer patients.Oncology (Huntingt). 1996; 10 (611–12, 615–16.): 599-606PubMed Google Scholar, 17Rubenstein EB Rolston K Outpatient management of febrile episodes in neutropenic cancer patients.Support Care Cancer. 1994; 2: 369-373Crossref PubMed Scopus (28) Google Scholar, 18Talcott JA Whalen A Clark J Rieker PP Finberg R Home antibiotic therapy for low-risk cancer patients with fever and neutropenia: a pilot study of 30 patients based on a validated prediction rule.J Clin Oncol. 1994; 12: 107-114PubMed Google Scholar, 19Kinsey SE Experience with teicoplanin in non-inpatient therapy in children with central line infections.Eur J Haematol. 1998; 59: 11-14Crossref Scopus (8) Google Scholar, 20Ketley NJ Kelsey SM Newland AZ Teicoplanin and oral ciprofloxacin as outpatient treatment of infective episodes in patients with indwelling central venous catheters and haematological malignancy.Clin Lab Haematol. 1995; 17: 71-74Crossref PubMed Scopus (10) Google Scholar]: some patients are at low risk of complications but require therapy until the fever subsides or the neutrophil count recovers. It is possible to treat these cases as outpatients, though careful clinical appraisal and follow-up is required. 1.CMV retinitis, which mainly occurs in patients with AIDS, initially required induction and then lifelong maintenance therapy with intravenous ganciclovir or foscarnet [21Welch J Forsey P Graham E Home treatment of cytomegalovirus retinitis with intravenous Ganciclovir.Genitourin Med. 1990; 66: 460PubMed Google Scholar,22Wood G Whitby M Hogan P Frazer I Foscarnet infusion at home.Lancet. 1989; i: 156Abstract Google Scholar]. This is best achieved in an outpatient setting, largely because of the indefinite duration of therapy. The advent of oral ganciclovir and intravitreal treatments, however, has reduced the need for intravenous therapy. Paradoxically, new drugs may still need to be given by the intravenous route, though the intermittent-dosing schedule is best suited to the outpatient setting. An example of this is cidofovir for AIDS CMV retinitis. Also, more effective anti-HIV drugs may reduce the incidence of CMV retinitis.2.CMV disease as it occurs in organ transplantation may, from time to time, require intravenous therapy with the caveats above.3.Varicella zoster virus (VZV) infections in immunocompromised hosts, such as those undergoing cancer chemotherapy, may need prolonged antiviral treatment to heal skin lesions and prevent dissemination. Initially, intravenous acyclovir was the only reasonable treatment option and could be administered at home or in the clinic. Foscarnet has been used in the outpatient setting for acyclovir-resistant herpes simplex infections. The introduction of valaciclovir and famciclovir, both of which are well absorbed orally and give good plasma antiviral levels, has reduced the requirement for intravenous acyclovir.4.Herpes simplex virus (HSV) encephalitis should be treated with intravenous acyclovir for 3 weeks. Mild cases with rapid responses to therapy could be managed partly as outpatients. The role of the newer oral agents in this setting is as yet unclear. 1.Some fungal infections that occur in the setting of AIDS and oncology require an initial period of intravenous amphotericin B (including lipid-associated preparations) to maximize outcomes. This has primarily been shown for HIV-related cryptococcal meningitis, but could equally apply to histoplasmosis or coccidioides infections. It also applies to the longer-term management of Aspergillus and Candida infections in oncology patients (e.g. invasive aspergillosis and hepatosplenic candidosis).2.Pneumocystis carinii pneumonia (PCP) may be treated with intravenous pentamidine, and mild cases may not need admission. Equally, monthly PCP prophylaxis can be given as regular infusions of intravenous pentamidine to outpatients. When the suitability of patients for OHPAT is considered, a complex set of overlapping and interdependent issues is uncovered. These include: •clinical issues;•non-clinical issues. An early and thorough assessment of any patient being considered for OHPAT is essential, to ascertain if the patient is suitable and the treatment is manageable and appropriate for the community. The assessment and discharge planning process should be multidisciplinary and should include the following people [5Nathwani D Seaton W Davey P Key issues in the development of a non-inpatient intravenous (NIPIV) antibiotic therapy programme—a European perspective.Rev Med Microbiol. 1997; 8: 137-147Crossref Scopus (6) Google Scholar]: •clinician;•hospital nurse;•microbiologist;•pharmacist;•community liaison nurse;•general practitioners;•community nurse;•patient and carer;•social worker. This is ideally done through an integrated care pathway [30Campbell H Hotchkiss R Bradshaw N Porteous M Integrated care pathways.Br Med J. 1998; 316: 133-137Crossref PubMed Scopus (622) Google Scholar]. Such a pathway has been developed in Dundee and is currently being piloted in Dundee (D. Nathwani, personal communication). There should be clear documentation of assessment and discharge planning in the medical and nursing notes. The general practitioner (GP) should be contacted at the assessment stage to approve the patient being discharged into the community. To ensure good service delivery, the GP/primary healthcare team needs to be: •broadly positive towards this form of service delivery;•aware of any patient receiving home-based therapy;•technically competent to advise and assist. Important considerations at this stage include the following: •Does the patient want to be at home while having this treatment?•Does the patient/carer/family understand the implications of the treatment, the vascular access device, how to recognize and deal with any complications and who to contact throughout the night and day?•Is there any relevant past medical history? How long has the patient been on the treatment and have there been any problems/side effects so far?•Is the treatment appropriate and manageable for the community? Is there a treatment plan, including a start and finish date?•Will any blood monitoring be required, for what and how often, and who will assimilate the results?•What equipment and supplies are required and from where will they be supplied?•What are the hospital follow-up arrangements?•Is the GP happy to accept the patient being at home for this treatment?•What level of support and involvement are the community nurses and GPs able to provide? The patient's home circumstances should be taken into account. There should be basic sanitation with running water and power for heating and lighting. The patient should be able to maintain a reasonable standard of personal hygiene at home so that the infusion and line are not compromised. Drug or alcohol dependency may militate against home therapy. All patients should be registered with a GP and have access to a community nurse. The patient should have access to a telephone, ideally on the premises, for use in emergencies and for accessing help. In many but not all circumstances, access to a refrigerator is helpful, particularly if pre-diluted drugs are supplied. Some form of family support or onsite carer is a clear benefit, though not absolutely necessary. However, for the old or frail patient, such support is mandatory. Finally, the patient's home must be within reasonable reach of the hospital for easy outpatient attendance and rapid assessment in case of emergencies. Ideally, the home should be less than an hour's travel by road from the hospital or clinic. When non-clinical issues relevant to determining which patients are suitable for OHPAT are considered, a complex set of attitudes, preferences and values is uncovered, mainly centered around two issues: •Attitudes and preferences about hospitalization in patient groups. These include the individual patient's desire to go home for treatment, their competence and ability to support themselves at home, the presence of an appropriate home environment to support this and, above all, their belief that home therapy provides quality of care that is equivalent to hospitalization.•Cultural and professional values and interest among local healthcare groups. For example, hospital specialists may view OHPAT as a threat to their beds, i.e early discharge may reduce the need for and, possibly, the funding for some hospital beds. GPs may, in turn, feel that the hospital is putting an added burden on the community for high-technology care that they cannot manage. There is also a risk that patients may be discharged early on inappropriate oral therapy to reduce bed pressure, or patients and community health groups may be forced to accept non-inpatient parenteral therapy without sufficient education, planning or infrastructure. 1.The patient being considered for OHPAT must have a disease that requires intravenous antibiotics.2.The antibiotic regimen should be feasible for outpatient use (some complicated regimens can only be administered if programmable infusion pumps are available, for example).3.The patient should be clinically stable, so that the likelihood of emergencies or deterioration is low.4.Apart from the requirement for intravenous antibiotics, the patient should be medically and psychologically fit for discharge. He or she should understand and consent to the discharge plans.5.The views and agreement of the GP and community nurse (if applicable) should be obtained. Effective pharmacy services play a key role in the successful development, planning, provision and monitoring of an OHPAT program. The availability of the right drug, in the right form, and in the right place, is crucial. Pharmacy services may be provided by the hospital, community, or both. Pharmacy issues in OHPAT can be divided into three areas. The pharmacist should be integral to the development and/or assessment of an appropriate treatment plan for each infection managed by an OHPAT program, and for each individual patient. The pharmacist's role includes input in selecting the appropriate drug, the appropriate dose, and the appropriate route and means of administration. Drug properties that should influence selection by the pharmacist for an OHPAT antibiotic regimen include: •antimicrobial activity;•efficacy in clinical trials;•half-life and/or duration of therapeutic agent;•side effects;•cost-effectiveness. Appropriate delivery of the drug to and into the patient are integral to drug delivery. Properties that the pharmacist should consider for an OHPAT antibiotic regimen include: •chemical stability—to minimize dispensing frequency and storage/transportation problems;•compatibility with other drugs and admixtures;•suitable administration devices;•ease of administration.