Antimicrobial Therapy Program Research Articles

Review of the first comprehensive outpatient parenteral antimicrobial therapy program in a tertiary care hospital in Japan

ObjectivesThe infectious diseases team at Kameda Medical Center, Japan, implemented a new outpatient parenteral antimicrobial therapy (OPAT) program in July 2012 and expanded the program with the support of home care services. This study reviews the OPAT program after 5.5 years of operation. MethodsWe prospectively collected data about the age, sex, diagnoses, causative organisms, types of OPAT, modes of administration, selected antibiotics, treatment durations, bed days saved, outcomes, readmissions, and estimated cost reductions of all patients who were treated in the OPAT program from July 2012 to December 2017. ResultsOf the 66 patients treated under the OPAT program, 45 (68.2%) were treated using clinic OPAT, and 21 (31.8%) were treated using homecare OPAT. The most commonly targeted organism was methicillin-susceptible Staphylococcus aureus. Continuous infusion with elastomeric pumps was employed in 55 patients (83.3%). Cefazolin was the most frequently used antibiotic (39.4%), followed by penicillin G (24.2%). The median OPAT duration was 13 days (range, 3–51), and the total bed days saved was 923. The estimated medical cost reduction was approximately 87,000 US dollars. ConclusionsOur experience shows that OPAT is a safe and feasible practice not only for efficient bed utilization and medical cost savings but also for better antimicrobial stewardship.

Nephrotoxicity Risk and Clinical Effectiveness of Continuous versus Intermittent Infusion Vancomycin Among Patients in an Outpatient Parenteral Antimicrobial Therapy Program.

To compare rates of nephrotoxicity, time to nephrotoxicity onset, and clinical failure among patients who received continuous infusion (C-I) or intermittent infusion (I-I) vancomycin in an outpatient parenteral antimicrobial therapy (OPAT) program. Nephrotoxicity was defined as an increase in serum creatinine greater than 0.5mg/dl or a 50% increase from baseline for two consecutive measurements while receiving vancomycin during OPAT. Clinical failure was defined as unplanned readmission, extension of therapy, or change in antibiotics. Single-center propensity score-matched retrospective cohort study. OPAT clinic affiliated with two nearby hospitals. We identified 300 patients who received C-I or I-I vancomycin for at least 1week in the OPAT program between October 1, 2017, and March 31, 2019. Propensity score matching based on age, sex, and infection was performed to minimize differences in patient characteristics between groups. After propensity score matching and exclusion criteria, 74 patients were included in each cohort. Continuous infusion vancomycin was associated with a 3.22-fold decrease in nephrotoxicity risk (C-I 6.8% [5/74 patients] vs I-I 18.9% [14/74 patients]; odds ratio 3.22, 95% confidence interval 1.10-9.46, p=0.027) and a significantly slower onset to nephrotoxicity compared with I-I (p=0.035). No statistically significant difference in clinical failure rates was observed between the C-I and I-I groups (13.5% [10/74 patients] vs 23.0% [17/74 patients], p=0.147). In an OPAT setting, C-I vancomycin was associated with a lower risk of and slower onset to nephrotoxicity than I-I vancomycin; however, no statistically significant difference in clinical failure rates was observed with C-I versus I-I vancomycin.

Efficacy and safety of a Belgian tertiary care outpatient parenteral antimicrobial therapy (OPAT) program.

Evidence supports the implementation of outpatient parenteral antimicrobial therapy (OPAT) as standard of care. Until 2015 the overall experience with OPAT in Belgium remained limited. The aim of this study was to evaluate the efficacy and safety of a Belgian 'OPAT at home' program, which was implemented in University Hospitals Leuven starting from January 2017. A mono-centric, prospective, observational study was carried out. All OPAT cases discharged between 10 January 2017 and 10 January 2019 were included in the study. Relevant demographic and clinical patient data were collected. The outcomes were clinical cure rate, OPAT related readmission rate, adverse event rate and patients' satisfaction. Over the two-year study period, 152 OPAT episodes were started in 130 patients, resulting in 3153 avoided hospitalization days which corresponds to 5.4 freed hospital beds. Urinary tract infections accounted for 40.8% of OPAT courses and temocillin was the most frequently used antibiotic (24.3%). Cure was achieved in 97.9% of the OPAT episodes. During 22 (14.5%) OPAT episodes, patients experienced adverse events, including line related adverse events (7.9%) and adverse drug events (6.6%). An OPAT related readmission rate of 9.2% was observed, mostly related to line-associated adverse events. All patients who completed the satisfaction survey (n = 23) were very satisfied with their OPAT course. The University Hospitals Leuven OPAT program is associated with a high level of clinical cure and low all-cause readmission and adverse event rates. Improvement actions are described to further reduce the readmission rate to less than 5.0%.

OPAT in Switzerland: single-center experience of a model to treat complicated infections.

Outpatient parenteral antimicrobial therapy (OPAT) programmes are established in the minority of Swiss hospitals. We aimed to study the OPAT programme at the University Hospital Basel during a 3-year period to evaluate safety and outcome. All patients treated in the OPAT programme between 2015 and 2017 were included in the study. Demographic, clinical and OPAT outcome data were extracted from the hospital information system. Differences between treatment periods were analysed and risk factors for readmission and adverse events identified. In total, 462 patients were enrolled from 2015 to 2017. Patient numbers and total treatment days increased by 68% and 116%, respectively. Indications included many complicated infections such as bone and joint (23%) and intravascular infections (13%). Of the identified Gram-negative bacteria, 25% produced extended spectrum beta-lactamases. The percentage of antibiotics administrated with an elastomeric device increased from 11% in 2015 to 29% in 2017, whereas the use of once-daily antimicrobials (such as ceftriaxone) declined. Adverse events were rare (n = 67; 14.6%) including only two severe catheter-related events. Cure was noted in 98% of patients. 30-day unplanned readmission occurred in 46 (10.0%) patients, and intravascular infections and a higher Charlson comorbidity index were identified as independent predictors. This study demonstrates the successful implementation of a formal OPAT programme in a Swiss tertiary care hospital. Careful selection of patients and monitoring during treatment are crucial to avoid frequent readmissions. Hence, our data call for an expansion of OPAT services in Switzerland in the near future.

743. Evaluation of Adverse Drug Reactions due to Common β-Lactam Therapies Among Patients Enrolled in an Outpatient Parenteral Antimicrobial Therapy (OPAT) Program

BackgroundThe UNC Medical Center Outpatient Parenteral Antimicrobial Therapy (OPAT) program was started in 2015 to provide multidisciplinary monitoring and management of patients discharged on parenteral antimicrobials. Laboratory abnormalities and adverse drug reactions (ADRs) are potential complications of OPAT that may result in readmission and treatment changes. The purpose of this study was to evaluate the time to first ADR for OPAT patients treated with BL therapies for diabetic foot infections (DFI) and osteomyelitis (OM).MethodsThis was a retrospective cohort study of patients enrolled in the UNC OPAT program between January 2015 and September 2018 for treatment of DFI or OM. Included patients received one of the following BL: cefepime, ceftriaxone, ertapenem, meropenem, and piperacillin/tazobactam. The primary outcome was time to first ADR during OPAT. Secondary outcomes were estimation of risk of ADR during OPAT for each medication; and ADR types and frequencies observed among patients treated with BL alone or with concomitant vancomycin or daptomycin.ResultsIn this cohort, 178 OPAT patients received 193 OPAT courses, for a median duration of 42 days (IQR 38–50). The average patient age was 55 years, and 68% were male. Ertapenem was the most commonly prescribed BL (76 courses, 39%), followed by ceftriaxone (29, 15%), cefepime, (41, 21%), piperacillin/tazobactam (30, 16%) and meropenem (17, 9%). Approximately 40% (76) patients received concomitant vancomycin. ADR was documented in 48 patients (27%) and 56 courses of therapy (29%). Kaplan–Meier-estimated risk of at least one ADR in the first 8 weeks of therapy was 38.7% (95% CI 29.1% to 48.2%). ADR resulted in 32 therapy changes and 8 readmissions.ConclusionMore than one-third of patients treated with BL for treatment of DFI and/or OM are at risk of ADR within 8 weeks. ADR commonly resulted in treatment changes, and possible hospital readmission. BL therapy is associated with significant ADR risk, and careful selection and monitoring is essential for optimal patient safety during OPAT. Disclosures All authors: No reported disclosures.

769. Comparison of Vancomycin Continuous and Intermittent Infusion Dosing Strategies Among Patients in an Outpatient Antimicrobial Therapy Program

BackgroundVancomycin may be administered via intermittent infusion (I-I) or continuous infusion (C-I). C-I vancomycin has advantages including the potential for less nephrotoxicity; however, available data are inconsistent and varies based on inpatient and outpatient settings. Thus, the primary objective of this study was to compare rates of nephrotoxicity in patients who received C-I or I-I vancomycin in an outpatient parenteral antimicrobial therapy (OPAT) program. Secondary objectives included time to onset of nephrotoxicity and clinical failure.MethodsThis was a single-center, propensity score-matched, retrospective cohort study of patients who received C-I or I-I vancomycin for at least one week in the OPAT program between October 1, 2017 and March 31, 2019. Exclusion criteria included patients lost to follow-up, age less than 18 years old, and those requiring renal replacement therapy. Nephrotoxicity was defined as a serum creatinine (Scr) increase of >0.5 mg/dL or >50% from baseline for two consecutive measurements. Clinical failure was defined as unplanned readmission, extension of planned therapy, or change in antibiotic therapy.ResultsThree hundred patients were identified who received C-I or I-I vancomycin. After propensity score matching and exclusion criteria were applied, 74 patients were included in each cohort. Demographic information was similar between cohorts including baseline Scr, age, gender, comorbidities, concurrent nephrotoxins, indication, and vancomycin duration. C-I was associated with a 3.22-fold decrease in nephrotoxicity risk when compared with I-I [C-I: 6.8% vs. I-I 18.9%; OR (95% CI): 3.22 (1.10–9.46), P =0.027]. C-I was associated with a significantly slower onset to nephrotoxicity compared with I-I (P = 0.035; Figure 1). A significant difference in clinical failure was not observed between C-I and I-I (10/74, 13.7% vs. 17/74, 23.0%; P = 0.147).ConclusionC-I vancomycin was associated with a lower nephrotoxicity risk and slower onset to nephrotoxicity, but no difference in clinical failure rates when compared with I-I. Disclosures All authors: No reported disclosures.

755. Outpatient Parenteral Antimicrobial Therapy Program Evaluation within a Large Veterans Affairs Healthcare System

BackgroundOutpatient parenteral antimicrobial therapy (OPAT) allows safe delivery of IV antibiotics in ambulatory settings to facilitate hospital discharge. Within the Veterans Affairs (VA) system, OPAT programs face the unique challenges of large geographic coverage areas and referrals for veterans from non-VA hospitals.MethodsPatients enrolled in the VA North Texas Health Care System OPAT program during fiscal years 2016 to 2018 had data collected on demographics, comorbidities, OPAT indications, antimicrobials used, pharmacist interventions, and complications during therapy. Data were collected from retrospective chart review as a quality improvement project. All enrolled OPAT patients required either an inpatient infectious disease (ID) consult or, for patients from non-VA facilities, required medical records review and telephone consultation with approval by a VA ID clinician. A third-party infusion company provided all medications and line care. Weekly laboratory monitoring and follow-up telephone visits were conducted by ID-trained pharmacists.ResultsDuring the evaluation period, 485 unique OPAT encounters (425 patients) were completed, with 164 patients (33%) directly admitted to OPAT upon referral from non-VA hospitals. Most common OPAT indications were osteomyelitis/diabetic foot infections (40.4%), bacteremia (17.3%), prosthetic joint infections/septic arthritis (12.4%), and urinary/intrabdominal infections (11.7%). Following standardization of pharmacist documentation, the volume and consistency of documented notes and interventions increased. Readmission rates while on therapy were similar, ranging from 13.4% to 13.7% each year. Patient demographics and OPAT outcomes demonstrated steady growth in the program (Table 1) with low rates of complications on therapy (Table 2). The program served patients in 35 counties and 158 zip codes across a broad geographic region in North Texas and southern Oklahoma (Figure 1). The most commonly used antibiotics are shown in Figure 2.ConclusionOur program has demonstrated the ability to safely and effectively provide OPAT across a large geographic region from a central location. ID-trained clinical pharmacists are critical to the care coordination and safety monitoring of OPAT in this unique setting. Disclosures All authors: No reported disclosures.

Antibiotic Clinic: Two Years' Experience in Outpatient Parenteral Antimicrobial Therapy in a Portuguese Hospital.

Outpatient antimicrobial therapy programs have been in place for more than four decades. They provide safe and effective treatment for a selected group of patients while reducing costs. In Europe in general, and in Portugal in particular, these programsare still a relatively new phenomenon. The aim of this study is to describe our center's two years' experience with such a program(Antibiotic Clinic). The cohort of treatments administered by the Antibiotic Clinic in its first two years of existence (September 12th2016 to September 11th 2018) was analyzed and data pertaining to patients, infections, infectious agents, antimicrobials and outcomes(infection resolution, adverse events and death) were characterized. The Antibiotic Clinic treated 231 patients in 250 episodes, providing a total of 2357 days of antibiotic treatment. The urinarytract was the most common site (39.2%) and Enterobacteriaceae the most common agents (63.7% of isolates). Infections were resolved in 90.8% of treatments (95.6% of patients), adverse events were few (1.2%) and direct mortality was not found. The dropoutrate was 1.6%. Infection resolution and adverse event rates were comparable to other centers. High treatment and low dropout rates pointto high physician and patient acceptance. Our experience with this program suggests it is a safe and effective alternative to inpatient admission. This is in line withcurrent literature which suggests efforts should be made to expand this treatment modality.

Outpatient Parenteral Antimicrobial Treatment for Non-Cystic Fibrosis Bronchiectasis Exacerbations: A Prospective Multicentre Observational Cohort Study

Background: The recently published guidelines of the Spanish Society of Pulmonology and Thoracic Surgery encourage physicians to use outpatient antimicrobial therapy to treat exacerbations in patients with non-cystic fibrosis bronchiectasis (NCFB). The published literature on this topic, however, is scarce. Methods: We report a prospective observational cohort study of patients with NCFB who received treatment at home for at least one exacerbation episode between September 2012 and September 2017 as part of an outpatient parenteral antimicrobial therapy (OPAT) program. Patients were included in the analysis if they fulfilled all of the following criteria: established diagnosis of bronchiectasis according to current guidelines criteria, clinical exacerbation, requiring intravenous antibiotics because of failure to respond to oral antibiotics, or isolation of a microorganism resistant to oral options. Objectives: To evaluate the effectiveness and safety of the treatment of patients with NCFB exacerbations in an OPAT program under “real-world” conditions. Results: Sixty-seven patients were treated in the OPAT program due to bacterial exacerbations of NCFB. Forty-five (67.2%) patients were admitted to hospital for a median of 7 days before starting OPAT. Sixty-three (94%) patients achieved resolution of the exacerbation at the end of therapy. Four patients needed hospital readmission, and one died. The OPAT program saved 11,586 days of hospital admission, equivalent to EUR 7,866,904. Conclusions: OPAT appears to be a safe, effective, and efficient strategy for treating patients with exacerbations of NCFB.

Close Patient Follow-up Among Patients Receiving Outpatient Parenteral Antimicrobial Therapy.

Outpatient parenteral antimicrobial therapy (OPAT) programs allow patients to receive intravenous treatment in the outpatient setting. We developed a predictive model of 30-day readmission among hospitalized patients discharged on OPAT from 2 academic medical centers with a dedicated OPAT clinic for management. A retrospective medical records review was performed and logistic regression was used to assess OPAT and other outpatient clinic follow-up in conjunction with age, sex, pathogen, diagnosis, discharge medication, planned length of therapy, and Charlson comorbidity score. We hypothesized that at least 1 follow-up visit at the Emory OPAT clinic would reduce the risk for hospital readmission within 30 days. Among 755 patients, 137 (18%) were readmitted within 30 days. Most patients (73%) received outpatient follow-up care at Emory Healthcare within 30 days of discharge or prior to readmission, including 52% of patients visiting the OPAT clinic. The multivariate logistic regression model indicated that a follow-up OPAT clinic visit was associated with lower readmission compared to those who had no follow-up visit (odds ratio, 0.10 [95% confidence interval, .06-.17]) after adjusting for infection with enterococci, Charlson score, discharge location, and county of residence. These results can inform potential interventions to prevent readmissions through OPAT clinic follow-up and to further assess factors associated with successful care transitions from the inpatient to outpatient setting.

Outpatient Parenteral Antimicrobial Therapy in Vulnerable Populations-- People Who Inject Drugs and the Homeless.

Outpatient parenteral antimicrobial therapy (OPAT) programs can provide high-value care but may be challenging in people who inject drugs (PWID) and homeless individuals. We conducted a single-center, retrospective, cohort study of adults who received OPAT at an urban, public health hospital from January 1, 2015 to April 30, 2016, grouped by PWID and housing status. Outcomes included clinical cure, length of stay, secondary bacteremia, line-tampering, and readmission. A total of 596 patients (homeless PWID (9%), housed PWID (8%), homeless non-PWID (8%), and housed non-PWID (75%), received OPAT. Assuming that patients lost to follow-up failed therapy, homeless PWID were least likely to achieve cure compared with housed non-PWID, (odds ratio [OR] = 0.33, 95% CI 0.18-0.59; P < .001). Housed PWID were also less likely to achieve cure (OR = 0.37, 95% CI 0.20-0.67; P = .001). Cure rates did not differ in patients not lost to follow-up. OPAT can be effective in PWID and the homeless, but loss to follow-up is a significant barrier.

Twice daily cefazolin is effective for treatment of serious methicillin-sensitive Staphylococcus aureus infection in an outpatient parenteral antimicrobial therapy program.

Background:The use of cefazolin for infections caused by Staphylococcus aureus has been demonstrated to be effective, and associated with fewer adverse effects compared with anti-staphylocccal penicillins; however, use of cefazolin on outpatient parenteral antimicrobial therapy (OPAT) programs often requires the use of continuous infusions. We report the outcomes of patients with serious infections caused by methicillin-sensitive S. aureus (MSSA) treated using twice daily cefazolin by a large tertiary hospital OPAT program. The aim of this study was to evaluate the safety, efficacy and outcomes after 90 days of follow up for patients with serious infections caused by MSSA treated with twice daily cefazolin by our OPAT program.Methods:A retrospective analysis of clinical outcomes of cases treated for a serious infection proven to be caused by MSSA treated with cefazolin monotherapy on the OPAT program at a tertiary hospital between January 2010 and July 2016 (6.5 years). Outcome measures included readmission rate, adverse drug reactions and clinical cure.Results:A total of 111 cases of serious MSSA infection were treated with cefazolin in the OPAT service during the study period, including 52 with peripheral or vertebral osteomyelitis and 13 with infective endocarditis; 56 patients had bacteraemia. Median duration of intravenous antibiotic therapy was 41 days, and the median proportion of intravenous therapy administered via OPAT was 69%. Two patients had recurrence of infection within 90 days, but were in the setting of retained prosthetic material. A total of 4% of patients experienced an adverse drug reaction. No cases of antibiotic failure were identified.Conclusions:The use of twice daily cefazolin for serious MSSA infection on an OPAT program is safe and effective. Further study is needed to assess for noninferiority to conventional treatment regimes.

295. Outcomes of Orthopedic Hardware-Related Osteomyelitis Treated Via a County Hospital Outpatient Parenteral Antimicrobial Therapy (OPAT) Program

BackgroundOrthopedic hardware-related osteomyelitis (OHRO) is associated with high morbidity and cost from prolonged courses of antibiotics and additional surgery. There is limited published data describing OPAT for the treatment of OHRO.MethodsElectronic medical records of patients receiving OPAT for OHRO between July 1, 2009 and March 1, 2015 at Eskenazi Hospital were retrospectively reviewed. Data were collected using a standardized data collection form for 24 months after OPAT completion. Cure was defined as lack of clinical signs/symptoms of infection, CRP < 5 mg/L, absence of radiologic signs infection with hardware removal as planned (negative intraoperative cultures). Failure was defined as persistent clinical/laboratory signs of infection during/at the end of OPAT, unanticipated repeat surgery, isolation of new organism from removed hardware, or extension of OPAT due to continued infection. Safety of OPAT was evaluated through adverse event and line complication monitoring.ResultsOverall, 53 patients (57% male) with OHRO were included (mean age of 50.5 ± 13.2 years). Two patients were excluded due to refusal of OPAT and death after a decision for comfort care. Of 30 evaluable patients who received OPAT with retained hardware, 14/30 (47%) achieved clinical cure. Five patients had failure requiring surgery during OPAT from worsening infection. 23/25 (92%) remaining patients with retained hardware received PO suppressive antibiotics until hardware removal; three failures were observed in patients noncompliant with PO suppression. Of 21 patients who received OPAT after hardware removal, 16 (76%) achieved clinical cure; five patients had failure due to extension of OPAT for 2–3 weeks due to continued features of infection. Three patients (6%) had an adverse event during OPAT (one each thrombocytopenia, vertigo, acute kidney injury) while three patients (6%) had line-related complications (2 bacteremias, one deep vein thrombosis).ConclusionOPAT is a viable treatment option for ORHO when utilized in appropriate patients. Patients with retained hardware or noncompliance with oral suppressive therapy may be associated with increased failure. Further study is needed to validate these and other potential risk factors for treatment failure.Disclosures All authors: No reported disclosures.

1931. Health-Related Social Vulnerabilities in a Pediatric Outpatient Antimicrobial Therapy (OPAT) Program

BackgroundSerious pediatric infections are treated safely with outpatient parenteral or prolonged oral antibiotic therapy (OPAT). The OPAT delivery system can be complex with outcomes complicated by social vulnerabilities in the lives of children on OPAT. Our goal was to better understand the psycho-social challenges pediatric families face undergoing OPAT.MethodsCaregivers of patients discharged on parenteral or prolonged oral antibiotics and referred to Doernbecher Children’s Hospital OPAT program between July 1, 2017 and December 31, 2017 were eligible for enrollment. We assessed health-related social vulnerabilities using a pre-discharge survey of pediatric caregivers. Child-specific medical information was collected by EMR review. Descriptive statistics were used to characterize social challenges.ResultsTwenty-six caregivers completed the survey. Mean patient age was 7.7 years. Infections included osteomyelitis (31%), endocarditis or infectious thrombophlebitis (19%), brain abscess or meningitis (15%), complicated pneumonia (12%), device-related infections (12%), or other (12%). Combined, patients spent 1,150 days on OPAT (390 parenteral; 760 prolonged oral antibiotic days). Of the social vulnerabilities endorsed, economic hardship featured prominently with 31% of caregivers having difficulty paying for food, housing or utilities and 12% having problems with appliances working at home. Among the caregivers, 23% reported inadequate social support, 42% reported psychological problems (31% anxiety; 19% depression), 15% reported involvement with child protective services, and 19% reported other legal concerns. 27% had difficulty getting time off work and 31% requested extra help with coordination of healthcare services. 58% of caregivers had a high school degree or less.ConclusionWe identified a large number of social vulnerabilities that likely impact pediatric OPAT care after discharge. Identifying social vulnerabilities for pediatric OPAT patients prior to discharge, such as health literacy or barriers to return visits, could better enable treatment customization or prompt care coordination that better supports pediatric OPAT patients.Disclosures All authors: No reported disclosures.

1925. Vancomycin Treatment and Time to Adverse Drug Reactions During Outpatient Parenteral Antimicrobial Therapy (OPAT)

BackgroundThe UNC Medical Center Outpatient Parenteral Antimicrobial Therapy (OPAT) program was started in 2015 to provide multidisciplinary monitoring and management of patients discharged on parenteral antimicrobials. Laboratory abnormalities are a frequent complication of antimicrobial therapy, as are drug reactions such as rash and diarrhea. We examined characteristics of incident adverse drug reactions (ADRs) observed among patients receiving parenteral vancomycin therapy over a two year period.MethodsThis was a retrospective cohort study of patients enrolled in the UNC OPAT program who received vancomycin July 2015–August 2017. Patients with end-stage renal disease receiving hemodialysis were excluded. The primary outcome was time-to-first ADR during the first 42 days of vancomycin therapy, estimated using Kaplan–Meier methods. Secondary outcomes included type of ADR and time-to-first nephrotoxicity ADR (>50% increase in serum creatinine). We also assessed indication for OPAT, comorbidities, and concomitant medications among patients with an ADR.ResultsOne hundred sixteen patients were followed on vancomycin therapy for 3,367 person-days (~111 person-months). Risk of any ADR within the first 42 days of vancomycin therapy was 33% (95% CI 24%–42%) (Figure 1); risk increased steadily by 6%–8% during the first 4 weeks on vancomycin therapy. The 42-day risk of nephrotoxicity was 18% (95% CI 10%–26%) (Figure 1), and followed a similar trajectory to overall ADR risks over time on OPAT. Other ADR risks (%) were: neutropenia (<1,000 cells/mm3), 5%; rash, 4%; thrombocytopenia (<100 × 103 cells/mm3 and decrease >50%), 2%; and other, 7%. The most common indications for OPAT vancomycin were osteomyelitis (53%), joint infection (16%), and bacteremia (10%). The most common comorbidities were hypertension (54%) and diabetes (40%). Among patients who experienced an ADR, the most frequent concomitant medications included: NSAID, 62%; ertapenem, 27%; ACE-I, 24%; loop diuretic, 17%; and ARB, 12%.ConclusionRisk of ADR increases with duration of parenteral vancomycin therapy during OPAT. Nephrotoxicity was the most common type of ADR during vancomycin therapy. Use of concomitant nephrotoxins during OPAT vancomycin therapy should be evaluated. Disclosures All authors: No reported disclosures.

Resumen Ejecutivo del tratamiento antibiótico domiciliario endovenoso: Directrices de la Sociedad Española de Enfermedades Infecciosas y la Sociedad Española de Hospitalización a Domicilio

Los programas de tratamiento antibiótico domiciliario endovenoso (TADE) permiten iniciar o completar el tratamiento antimicrobiano por vía endovenosa de prácticamente cualquier tipo de infección en el domicilio, siempre y cuando se realice una selección del paciente acorde al tipo de programa de TADE que se dispone. Aunque hay aspectos del manejo clínico de las infecciones en el domicilio que son superponibles en la mayoría de los casos a la realizada en la hospitalización convencional (selección de la antibioterapia, duración del tratamiento, etc.), existen numerosos aspectos que son específicos de esta modalidad asistencial. Resulta imprescindible conocerlos para que el TADE siga siendo igual de eficaz y seguro que la hospitalización convencional. El objetivo de esta guía clínica es por tanto proporcionar recomendaciones basadas en la evidencia realizadas por expertos para homogeneizar la práctica clínica de esta modalidad asistencial y contribuir a que se incremente progresivamente el número de pacientes que pueden ser atendidos y recibir tratamiento endovenoso en su propio domicilio.

Outcomes According to Discharge Location for Persons Who Inject Drugs Receiving Outpatient Parenteral Antimicrobial Therapy.

BackgroundOpioid use disorder poses a significant public health risk. Persons who inject drugs (PWID) suffer from high mortality and morbidity secondary to serious infectious diseases, often requiring prolonged courses of outpatient parenteral antibiotics. The goal of this study was to determine the outcomes of PWID discharged to home or to a skilled nursing or rehabilitation facility (SNF/rehab) with parenteral antibiotic treatment under an outpatient parenteral antimicrobial therapy (OPAT) program.MethodsThis is a retrospective observational study. The study population was identified via hospital and OPAT databases using substance use disorder diagnoses and confirmed through chart review. The study population included hospitalized PWID with injection drug use in the preceding 2 years who were discharged between 2010 and 2015 to complete at least 2 weeks of parenteral antibiotics and monitored by the OPAT program. Retrospective chart review was used to describe patient characteristics and outcomes.ResultsFifty-two patients met inclusion criteria, 21 of whom were discharged to home and 31 were discharged to a SNF/rehab. Of the patients discharged to home, 17 (81%) completed their planned antibiotic courses without complication. Twenty (64%) patients discharged to a SNF/rehab completed the antibiotic courses without complication. Six (11%) patients had line infections, 6 (11%) had injection drug use relapse, and 12 (23%) required readmission.ConclusionsPersons who inject drugs discharged home were not more likely to have complications than those discharged to a SNF/rehab. Home OPAT may be a safe discharge option in carefully selected patients.

An Assessment of an Outpatient Antimicrobial Therapy Program in a Rural Medical Center : A Retrospective Chart Review.

Current literature supports outpatient parenteral antimicrobial therapy (OPAT). This article presents results from a research study that evaluated an OPAT program that treated community-acquired pneumonia. If patients had the opportunity to receive outpatient intravenous antibiotics for community-acquired pneumonia, would this prevent future hospitalization? Was there a decrease in hospital admissions? An informal cost-benefit analysis comparing OPAT with inpatient hospital admissions for the same disease was also reviewed to provide evidence whether there was a change. What was the overall health care cost savings? The medical charts of 50 patients with confirmed pneumonia who had received OPAT in a 3-month period were reviewed. A retrospective medical record review was performed. All patients were evaluated by the in-house OPAT team. The resulting analysis provided evidence that an estimated savings of approximately $2100 per day would be achieved by decreasing hospital readmissions for patient who had been treated with OPAT. The conclusion of this study provides evidence that the implement of an OPAT program was, and is, essential for patient care and evidence-based best practice adherence.

Incidence and risk factors for healthcare utilisation among patients discharged on outpatient parenteral antimicrobial therapy.

Outpatient parenteral antimicrobial therapy (OPAT) programmes facilitate hospital discharge, but patients remain at risk of complications and consequent healthcare utilisation (HCU). Here we elucidated the incidence of and risk factors associated with HCU in OPAT patients. This was a retrospective, single-centre, case-control study of adult patients discharged on OPAT. Cases (n = 63) and controls (n = 126) were patients that did or did not utilise the healthcare system within 60 days. Characteristics associated with HCU in bivariate analysis (P ≤ 0.2) were included in a multivariable logistic regression model. Variables were retained in the final model if they were independently (P < 0.05) associated with 60-day HCU. Among all study patients, the mean age was 55 ± 16, 65% were men, and wound infection (22%) and cellulitis (14%) were common diagnoses. The cumulative incidence of 60-day unplanned HCU was 27% with a disproportionately higher incidence in the first 30 days (21%). A statin at discharge (adjusted odds ratios (aOR) 0.23, 95% confidence intervals (CIs) 0.09-0.57), number of prior admissions in past 12 months (aOR 1.48, 95% CIs 1.05-2.10), and a sepsis diagnosis (aOR 4.62, 95% CIs 1.23-17.3) were independently associated with HCU. HCU was most commonly due to non-infection related complications (44%) and worsening primary infection (31%). There are multiple risk factors for HCU in OPAT patients, and formal OPAT clinics may help to risk stratify and target the highest risk groups.

Efficacy and Cost Comparison of Ertapenem as Outpatient Parenteral Antimicrobial Therapy in Acute Pyelonephritis due to Extended-spectrum Beta-lactamase-producing Enterobacteriaceae.

Outpatient parenteral antimicrobial therapy (OPAT) programs are becoming an increasingly popular trend in clinical practice as they offer several benefits to both patients and health-care setups. While OPAT is an established clinical practice in the Western world, the concept itself is alien to patients in India as they prefer the security of hospitals to receive antibiotics over OPAT. We evaluated the clinical response and cost comparison of ertapenem under OPAT versus inpatient settings in patients with extended-spectrum beta-lactamase (ESBL)-positive acute pyelonephritis (APN) given the increasing importance of optimizing both hospital beds and overall cost of patient care in India. APN was chosen as the indication to be studied as it is one of the common complicated urinary tract infections treated in our OPAT unit requiring 10–14 days of parenteral therapy with an agent active against various Gram-negative bacilli and multidrug-resistant organisms. One hundred patients were retrospectively studied based on whether antibiotics were administered during hospital stay alone (hospital only), during both hospital stay, and also as OPAT post discharge (hospital/OPAT) or as OPAT alone (OPAT only). Response to ertapenem and cost of treatment in inpatient versus OPAT settings were compared using Pearson's Chi-square or Fisher's exact test for categorical variables. ANOVA (or Kruskal–Wallis) was used for continuous variables. Baseline urine cultures were ESBL positive with 98% prevalence of Gram-negative bacilli (GNB). Colony counts were ≥100,000 in 74% patients. Only ertapenem, imipenem, and meropenem showed 100% sensitivity to ESBL-positive GNB in baseline urine culture and sensitivity reports. Ertapenem showed 100% sensitivity and complete clinical resolution for 96% patients with APN due to ESBL Enterobacteriaceae. It was administered as OPAT in 90% patients and significantly reduced overall treatment costs.