Outpatient Parenteral Antibiotic Therapy Research Articles

A case-control study of the clinical and economic impact of infections caused by Carbapenemase-producing Enterobacterales (CPE).

The aim was to analyse the clinical and economic impact of carbapenemase-producing Enterobacterales (CPE) infections. Case-control study. Adult patients with CPE infections were considered cases, while those with non-CPE infections were controls. Matching criteria were age (± 5years), sex, source of infection and microorganism (ratio 1:2). Primary outcome was 30-day mortality. Secondary outcomes were 90-day mortality, clinical failure, hospitalisation costs and resource consumption. 246 patients (82 cases and 164 controls) were included. Klebsiella pneumoniae OXA-48 was the most common microorganism causing CPE infections. CPE cases had more prior comorbidities (p = 0.007), septic shock (p = 0.003), and were more likely to receive inappropriate empirical and definitive antibiotic treatment (both p < 0.001). Multivariate analysis identified septic shock and inappropriate empirical treatment as independent predictors for 7-day and end-of-treatment clinical failure, whereas Charlson Index and septic shock were associated with 30- and 90-day mortality. CPE infection was independently associated with early clinical failure (OR 2.18, 95% CI, 1.03-4.59), but not with end-of-treatment clinical failure or 30- or 90-day mortality. In terms of resource consumption, hospitalisation costs for CPE were double those of the non-CPE group. CPE cases had longer hospital stay (p < 0.001), required more long-term care facilities (p < 0.001) and outpatient parenteral antibiotic therapy (p = 0.007). The CPE group was associated with worse clinical outcomes, but this was mainly due to a higher comorbidity burden, more severe illness, and more frequent inappropriate antibiotic treatment rather than resistance patterns as such. However, the CPE group consumed more healthcare resources and incurred higher costs.

Outpatient parenteral antibiotic treatment for infective endocarditis: A retrospective observational evaluation

BackgroundInfective endocarditis (IE) requires long courses of intravenous (IV) antibiotics. Outpatient parenteral antibiotic therapy (OPAT) saves resources, improves the patient experience and allows care in their preferred place; however, questions remain about safety when treating IE patients. This study evaluates OPAT management of IE patients in our region between 2006 and 2019. MethodsThis is a retrospective observational evaluation and description of outcomes and adherence to suitability criteria, according to British Society for Antimicrobial Chemotherapy (BSAC) guidelines. ResultsWe identified five models of OPAT delivery. The number of patients treated expanded significantly over time. Of 101 patients, six (6%) suffered poor outcomes, but each patient had contributing factors outside of the primary infection. Median OPAT duration was 12 days and 1,489 hospital bed days were saved. ConclusionsIn a setting where there was good adherence to BSAC criteria, treating IE patients using OPAT services was safe. Complications observed were likely independent of treatment location. Significant bed days were saved.

Stability of meropenem in portable elastomeric infusion devices: which protocol should be implemented in clinical practice?

Meropenem has an excellent activity against gram-positive and gram-negative bacteria, including multi-resistant microorganisms. Even though meropenem is a great candidate for outpatient parenteral antimicrobial therapy (OPAT), its physicochemical stability is a major challenge. This work aimed to demonstrate the suitability of including meropenem in OPAT by elucidating its physicochemical stability in a range of commonly prescribed concentrations within portable elastomeric infusion devices. Physical and chemical stability were evaluated at two concentrations commonly used in clinical practice (2 and 25 mg/mL), and three temperatures (2°C-8°C, 25°C, and 32°C) using Accufuser portable elastomeric infusion devices. Drug adsorption onto portable elastomeric infusion devices was also determined at the end of the experiment. Meropenem stability significantly decreased at higher temperatures and when higher drug solution concentrations were used. Meropenem solutions at 2 mg/mL kept the drug content above 95% over 24 h at 2°C-8°C but just for 8 h at 25°C. Nevertheless, solutions containing 25 mg/mL of meropenem showed a dramatic decrease in chemical stability after 8 h 2°C-8°C and just after 4 h at 25°C or 32°C. However, physical stability was kept favorable during this period. The drug adsorption on the material of the elastomeric infusion device was below 1%, indicating the suitability of the chosen device. We propose several administration protocols for meropenem in portable elastomeric infusion devices in clinical practice, according to the results obtained in our study. The results obtained in this study open up the possibility of administering meropenem in an OPAT setting despite its short stability.IMPORTANCEAlthough outpatient parenteral antibiotic therapy can be a good approach to treating infections, a lack of data regarding antibiotic stability in portable elastomeric infusion devices restricts its safe and effective use. Actually, meropenem is used for prolonged periods above 24 h, and it is not physicochemically stable, which can compromise efficacy and toxicity. This work is of high importance to show the clinicians the real shelf life of meropenem when administered in portable elastomeric infusion devices. We propose several administration protocols for meropenem in portable elastomeric infusion devices in clinical practice, according to the stability drug results obtained in our study.

The success rate and complications of midline catheters in pediatric outpatient parenteral antibiotic therapy (OPAT)

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.

Making the EHR Work for You-Modifications of an Electronic Health Record System to Improve Tracking and Management of Patients Receiving Outpatient Parenteral Antibiotic Therapy.

Managing the complex needs of outpatient parenteral antibiotic therapy (OPAT) patients is challenging and time-consuming. We describe development of multimodal interventions to facilitate patient management within an Epic® (Epic Systems Corporation)-based electronic health record (EHR) platform. During 2016-2018, a multidisciplinary team created several modifications in our local EHR to improve gaps in OPAT care, including shared note templates, shared patient lists, automatically triggered notifications, and comprehensive order sets. A SmartForm was created, allowing collection of discrete, self-contained extractable data about each OPAT episode. We reviewed OPAT episodes from January 2019 through December 2022. The multimodal EHR interventions culminated in the creation of a patient report, the "OPAT Monitoring View" collating OPAT-relevant data from multiple sections of the chart onto 1 screen display. This view is accessible both within the patient chart and from multiple list-based, in-basket, and snapshot-anchored preview functions in the EHR. Implementation of the EHR bundle facilitated management of 3402 OPAT episodes from 2019 to 2022 (850 episodes/year), about 50% higher than anticipated based on 540 OPAT courses in 2016. The OPAT EHR bundle allowed efficient (<3 hours) multidisciplinary rounds for management of 130-145 patients each week, streamlining of care transitions, and increasing staff satisfaction. Bundled multimodal modifications to the local EHR increased patient care efficiency and staff satisfaction and facilitated data collection to support a large OPAT program. These modifications apply commonly available EHR functionalities to OPAT care and could be adapted to other settings with different EHR platforms.

Creation and Validation of an Automated Registry for Outpatient Parenteral Antibiotics.

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.

Experience with dalbavancin use in various gram-positive infections within Aberdeen Royal Infirmary OPAT service

PurposeDalbavancin, approved in 2014 for Gram-positive acute bacterial skin and skin structure infections (ABSSSI), has pharmacokinetics enabling treatment with one or two doses. Dalbavancin might be useful in outpatient parenteral antibiotic therapy (OPAT) of deep-seated infections, otherwise requiring inpatient admission. We documented our experience with pragmatic dalbavancin use to assess its effectiveness for varied indications, on- and off-label, as primary or sequential consolidation therapy.MethodsPatients prescribed dalbavancin between 1 December 2021 and 1 October 2022 were screened for demographics of age, sex, Charlson comorbidity index (CCI), allergies, pathogens, doses of dalbavancin, other antibiotics administered and surgery. Where available, infection markers were recorded. The primary outcome was a cure at the end of treatment. Secondary outcomes included any adverse events and for those with treatment failures, response to salvage antibiotics.ResultsSixty-seven per cent of patients were cured. Cure rates by indication were 93% for ABSSSI, 100% for bacteraemia, 90% for acute osteomyelitis, 0% for chronic osteomyelitis, 75% for native joint septic arthritis and 33% for prosthetic joint infection. Most bone and joint infections that were not cured did not have source control, and the goal of treatment was suppressive. Successful suppression rates were greater at 48% for chronic osteomyelitis and 66% for prosthetic joint infections. Adverse events occurred in 14 of 102 patients.ConclusionThis report adds to clinical experience with dalbavancin for off-label indications whilst further validating its role in ABSSSI. Dalbavancin as primary therapy in deep-seated infections merits investigation in formal clinical trials.

Successful outpatient parenteral antibiotic therapy with cefiderocol for osteomyelitis caused by multi-drug resistant Gram-negative bacteria: a case report.

Post-traumatic osteomyelitis attributed to metallo-β-lactamase (MBL)-producing Gram-negative bacteria presents a challenging clinical scenario. Cefiderocol emerges as a viable treatment option within the limited therapeutic options available. In this brief report, we present a case of a Ukrainian patient with osteomyelitis caused by multi-drug resistant Pseudomonas aeruginosa, which was successfully treated with cefiderocol, facilitated in part by outpatient parenteral antibiotic therapy (OPAT). Administration of Cefiderocol via OPAT can present a safe and effective option for treatment of post-traumatic osteomyelitis with multi-drug resistant Pseudomonas aeruginosa. A possible effect on iron homeostasis of extended treatment duration with cefiderocol may be taken into consideration.

Development of quality indicators for antimicrobial stewardship in Belgian hospitals: a RAND – modified Delphi procedure

ABSTRACT Introduction Inappropriate antibiotic use is a major cause of antibiotic resistance. Therefore, optimizing antibiotic usage is essential. In Belgium, optimization of antimicrobials for the fight against multidrug resistant organisms (MDROs) is followed up by national surveillance by public health authorities. To improve appropriate antimicrobial use in hospitals, an effective national Antimicrobial Stewardship (AMS) program should include indicators for measuring both the quantity and quality of antibiotic use. Objectives The aim of this study was to develop a set of process quality indicators (QIs) to evaluate and improve AMS in hospitals. Methods A RAND-modified Delphi procedure was used. The procedure consisted of a structured narrative literature review to select the QIs, followed by two online questionnaires and an intermediate multidisciplinary panel discussion with experts in infectious diseases from general and teaching hospitals in Belgium. Results A total of 38 QIs were selected after the RAND-modified Delphi procedure, from which 11 QIs were selected unanimously. These QIs address compliancy of antibiotic therapy and prophylaxis with local guidelines, documentation of the rationale for antibiotic treatment in the medical record, the availability of AMS Programs and Outpatient Parenteral Antibiotic Therapy, resistance patterns and antimicrobial prescribing during focused ward rounds. Conclusion Our study selected 38 relevant process QIs, from which 11 were unanimously selected. The QIs can contribute to the improvement of quality of antibiotic use by stimulating hospitals to present better outcomes and by providing a focus on how to intervene and to improve prescribing of antimicrobials.

Stability of meropenem in portable elastomeric infusion devices: which protocol should be implemented in clinical practice?

Although outpatient parenteral antibiotic therapy can be a good approach to treating infections, a lack of data regarding antibiotic stability in portable elastomeric infusion devices restricts its safe and effective use. Actually, meropenem is used for prolonged periods above 24 h, and it is not physicochemically stable, which can compromise efficacy and toxicity. This work is of high importance to show the clinicians the real shelf life of meropenem when administered in portable elastomeric infusion devices. We propose several administration protocols for meropenem in portable elastomeric infusion devices in clinical practice, according to the stability drug results obtained in our study.

342. Evaluation of Patient Satisfaction with Outpatient Parenteral Antibiotic Therapy (OPAT) at a University Medical Center

Abstract Background With the expansion of OPAT care over recent years, new devices such as elastomeric balls have been added to the available drug delivery options, which also include syringe, electronic pumps and gravity bags. The primary objective of this study was to evaluate the experience of patients (and their caregivers) on OPAT, ease of use with various delivery methods, and barriers to outpatient care. Methods The survey included questions on IV antibiotic received, delivery method, who administered the medicines, effect on daily activities, ease of access to staff, and thoughts on various aspects of the process and experience. Questions were multiple choice, based on Likert scale, or open-ended. Patients were recruited in person during infectious diseases (ID) clinic visits, or by phone, just before or around the time OPAT ended. Results We had 51 responses from 130 patients from 10/1/22 thru 3/31/23. Median age group was 55-64 years, 45% were women, for 78% it was first OPAT episode, and 23% received &amp;gt; one IV drug. Syringe push was used for 37%, elastomeric ball for 38%, gravity bag for 18% and electronic pump for 7% of agents. Most (76%) received help in administering treatment by friend or family (spouse=75%). 44% of infusions were once/day and 27% were 3 or more times/day. Home nursing services were received by 94% (5 different agencies) and &amp;gt; 6 different infusion pharmacies supplied the medicines. Medicine was always delivered on time for 38 of 45 respondents. All patients found IV push and elastomeric ball easy to use; 25% disagreed with this about gravity bag or electronic pump. Overall satisfaction was 94% with OPAT course and 94% felt instructions on how to administer medicines at home were clear and easy. Financial hardships were noted by 9 of 48 respondents (12 responded “neutral”) and 77% had to curtail some or most of their daily activities while on OPAT. Conclusion Overall, patients’ responses were positive of our OPAT program. However, the large portion of patients needing to curtail their usual activities highlights the need for more study on how regimen details such as delivery device and infusion frequency impact patient and caregiver experience. Financial hardships may be underestimated as final bills may not yet have been received by patients. Disclosures All Authors: No reported disclosures

1293. Efficacy of Doxycycline in Staphylococcal Prosthetic Joint Infection Treated with Debridement, Antibiotics and Implant Retention (DAIR) or Revision with Destination Spacer Placement

Abstract Background Prosthetic joint infection (PJI) is common, limb-threatening, and often warrants extended antibiotic durations. Intravenous (IV) glycopeptide, lipopeptide, and beta-lactam antibiotics have been the de facto US standard of care for staphylococcal PJI for decades, while the preponderance of (mostly European) published clinical data for PJI involves fluoroquinolone and rifampin combinations. However, these antibiotic strategies carry substantial adverse effects. In contrast, tetracyclines are less-studied for treatment of staphylococcal PJIs, but offer ease of administration and a favorable side effect profile. Methods We retrospectively evaluated the characteristics and outcomes of patients with staphylococcal PJI treated with doxycycline from March 2019 to April 2021 who received some period of outpatient parenteral antibiotic therapy (OPAT) and were included in our medical center’s OPAT database. We included patients with hip, knee, or shoulder PJIs managed with either debridement, antibiotics and implant retention (DAIR) or revision to a permanent “destination” spacer who received doxycycline within the first 12 weeks of therapy. Diagnosis of staphylococcal PJI was based on the documentation of the treating ID team plus identification of staphylococci in surgical tissue or synovial fluid cultures. Our primary outcome of interest was treatment failure, defined as reoperation for infection in the affected joint within one year of initial surgery. Results Of 24 patients switched to doxycycline after a mean 42 days, 17 underwent DAIR and 7 had destination spacers placed. 15 of 17 patients (88.2%) who underwent DAIR and 7 of 7 patients (100%) who received destination spacers remained free of treatment failure at one year; two patients had recurrent infections and none died. Conclusion These findings suggest that doxycycline is a safe and efficacious option for treatment of PJI. A key limitation of this study is patient identification via the OPAT database, meaning patients with short IV lead-in therapy (i.e. switch to PO at discharge) were not included, and that the efficacy of doxycycline is likely exaggerated by immortal time. Disclosures Angela Hewlett, MD, MS, Forcast Orthopedics: Advisor/Consultant|Mapp Biopharmaceutical: Grant/Research Support

346. Evaluation of the Safety Profile of Cefazolin Monotherapy in Outpatient Parenteral Antibiotic Antimicrobial Therapy at a Large Academic Medical Center

Abstract Background The Infectious Diseases Society of America recommends serial safety lab monitoring during outpatient parenteral antimicrobial therapy (OPAT) to assess treatment response and prevent adverse events. However, these recommendations do not address the safety profile of specific antimicrobial agents or the ideal frequency of monitoring. Previous studies, using cohorts of fewer than 300 patients, report adverse event rates of less than 5% with outpatient cefazolin. It is possible that serial lab monitoring for patients on cefazolin monotherapy may represent unnecessary work and increase costs with minimal patient benefit. Methods A retrospective chart review was performed on patients treated with cefazolin monotherapy in the OPAT program of Brigham and Women’s Hospital (Boston, MA, USA) from February 2018 to February 2023. Data from weekly safety labs were examined during OPAT for the following abnormalities: change in creatinine (absolute increase of 0.5 mg/dL or relative increase ≥50%), ALT &amp;gt; 100 units/L, neutropenia (absolute neutrophil count &amp;lt; 1000 cells/mm3), eosinophilia ( &amp;gt;500 cells/mm3), and thrombocytopenia (&amp;lt; 100K/uL or relative decrease ≥50%). Other treatment complications adjudicated from chart review included antibiotic treatment changes, readmission, or mortality during OPAT. Results Among the 420 patients receiving cefazolin in OPAT, the median age was 62 (IQR: 49-71) years; 168 patients (40%) were women, and 62 (15%) were referred from oncology or transplant services. Twenty-four (6%) patients had at least one lab abnormality. Of these, 13 (3%) required a treatment change or had readmission or death. Eight (2%) cases were related to a lab abnormality, while five were due to other factors either unrelated to antibiotic therapy or apparent on clinical examination (e.g., rash). Conclusion In an OPAT program at a large academic medical center, weekly lab monitoring altered clinical decision-making for 2% of patients on cefazolin monotherapy. It may be reasonable to reduce the frequency of or eliminate routine lab monitoring for these patients to reduce the cost of healthcare services. Future studies are indicated to evaluate the clinical impact of less frequent lab monitoring for OPAT patients on cefazolin monotherapy. Disclosures David W. Kubiak, PharmD, BCPS, BCIDP, FIDSA, Astellas Pharma, Inc.: Advisor/Consultant|AVIR Pharma Inc: Advisor/Consultant|Cidara Therapeutics: Advisor/Consultant|Shionogi Inc: Grant/Research Support

351. Factors Predicting Readmission within 90 days in Patients Receiving Outpatient Parenteral Antibiotic Therapy

Abstract Background Outpatient Parenteral Antibiotic Therapy (OPAT) involves administering antibiotics outside hospitals via non-oral routes. Success depends on well-reasoned selection of patients for this treatment modality and proper antibiotic stewardship to avoid serious complications. Methods We created a de-identified dataset (n=295) from a retrospective chart review of veterans receiving OPAT at the Orlando VA Medical Center (ORL-VAMC) in 2020. We included patients aged 18 or older who underwent OPAT therapy at ORL-VAMC with at least one antibiotic administration between January 1 and December 31, 2020. Inclusion also required compliance with follow-up and laboratory monitoring for at least 90 days after starting outpatient antibiotics. Of 364 patients receiving OPAT during 2020, 295 met the full criteria, with loss to follow-up and absent labs as common reasons for exclusion. We examined patient demographics, medical history, diagnosis, and elements of treatment for associations with unplanned hospital visits within 90-days of OPAT initiation using Binary Logistic Regression modeling. Results The average age within the dataset was 67.37 (SD=±11.38) years. Common treatment indications included Osteomyelitis (80/295, 27.12%) and Bacteremia (64/295, 21.69%). 40.96% (119/295) of patients had an unplanned hospital visit within 90 days, primarily due to unresolved symptoms. Our regression model identified Pyelonephritis/UTI (OR 2.26; 95% CI 1.02-5.41), Intra-Abdominal Infection (OR 3.81, 95% CI 1.15-17.45), Cephalosporin Antibiotics (OR 2.57, 1.39-4.91), Liver Disease (OR 2.26, 95% CI 1.02-5.41), and psychiatric illness (OR 1.74, 95% CI 1.06-2.87) as being significantly associated with unplanned hospital visits within 90 days. Conclusion A majority (177/295, 60%) of patients did not need further care in the hospital setting after starting OPAT. Our study supports OPAT as an effective option for delivering IV antibiotic therapy when indicated. This study's external validity is limited by the overrepresentation of males in the sample. Nevertheless, these findings can help physicians better anticipate successful outcomes and select suitable patients for OPAT. Further research aimed at understanding the associations identified may offer improved clinical utility. Disclosures All Authors: No reported disclosures

Pediatric Outpatient Parenteral Antimicrobial Therapy (OPAT): Experience of Families During Implementation of the Program

Abstract Background Experience with ambulatory intravenous antimicrobial therapy in pediatrics is reported since 1973. This modality avoids hospitalization or helps for early discharge in a patient who, in addition to antibiotics, has no other criteria to remain hospitalized. Even though it reduces the risks and costs that hospitalization entails and allows the patient to remain inserted in his family its use is not widespread in Latin America. We report the experience of families during the implementation of outpatient parenteral antibiotic therapy (OPAT) in pediatric oncologic patients at Solca Guayaquil. Methods A pilot program for outpatient parenteral antibiotic therapy (OPAT) was started in March 2022. We included patients with a permanent central venous access (port-a-cath) who were otherwise clinical stable (afebrile &amp;gt; 48h, increasing absolute neutrophil count (&amp;gt;500 in hematologic malignancies, &amp;gt;100 in solid tumors), no transfusion requirement) and completed a social questionnaire described previously (SUAU C, Thelma et al) with a score &amp;gt; 9. Patients had follow up with pediatric infectious diseases once a week during therapy and received a certificate of completion on their last day with a QR code to complete an anonymous online survey regarding their experience with the program. Results From March to November 2022 there were 6 patients enrolled. Their mean age 9.6 years, 3 (50%) were male and mean duration of therapy 7.7 days. Response rate was 100%. Ronald Mc. Donald's house hosted 5 (83%) patients while 1 (17%) was staying at home. There was 1 (16.7%) readmission 72h after completion of the program. No disfunction of catheter, secondary infection or deaths were reported. Return to regular activities was possible for 4 (67%) of patients. The experience was considered excellent, good or average in 3(50%), 2(33%) and 1(17%) cases. Quality of care during OPAT was perceived as exceeding expectations, meeting expectations and no opinion in 2(33%), 3(50%), and 1(17%) respectively. Support received by hospital staff was pondered excellent and good in 3 (50%) each. All of the patients agreed that OPAT was better than staying admitted however 1 (17%) declared that would not take this modality again (referred as "stressful"). Conclusion The newly implemented OPAT program was perceived overall as a positive experience for patients and their families, there were no major complications. The feedback provided helped to improve the logistics of the program.

Dalbavancin utilization registry investigating value and effectiveness (DRIVE): Outcomes report on real-world use

ObjectivesDalbavancin has potent activity against Gram-positive pathogens, including methicillin-resistant Staphylococcus aureus, and is approved for treatment of acute bacterial skin and skin structure infections (ABSSSI). We describe real-world use of dalbavancin in patients with ABSSSI, bloodstream infection (BSI), bone and joint infection (BJI), or other infection (OI). MethodsDalbavancin Utilization Registry Investigating Value and Effectiveness (DRIVE) was a phase 4 observational, multicenter, retrospective study of the real-world use of dalbavancin in adults across the United States. Data collected March 2017 – November 2018, at hospitals, intensive care units, and outpatient parenteral antibiotic therapy units, included patient demographics, diagnosis, microbiology, antibiotic use, clinical outcome, and adverse events up to 60 days after the last dose of dalbavancin. Patients were treated entirely at the physicians’ discretion. All patients who received ≥ 1 dose of dalbavancin between February 2016 and the end of the data collection period were included in the safety population. Patients with clear clinical success or failure of dalbavancin treatment, according to definitions similar to those used in the dalbavancin phase 3 trials, were included in the evaluable population and the post-hoc analysis. ResultsThe safety population comprised 1168 patients treated at 31 healthcare sites. Median cumulative dalbavancin dose was 1500 mg for all infection categories, most commonly as 1 infusion; 36.9 % of BSI patients and 58.6 % of BJI patients received ≥ 2 infusions; most were treated as outpatients. Serious adverse drug reactions were reported in 0.7 % of patients overall. Clinical success was achieved in 747/815 (91.7 %) evaluable patients with ABSSSI (BSI, 43/48 [89.6 %]; BJI, 75/87 [86.2 %]; OI, 7/7 [100 %]). ConclusionsDalbavancin demonstrated high rates of real-world clinical success and safety when treating patients for suspected or confirmed Gram-positive infections.

Stability Study of Fosfomycin in Elastomeric Pumps at 4 °C and 34 °C: Technical Bases for a Continuous Infusion Use for Outpatient Parenteral Antibiotic Therapy.

Fosfomycin acts against aerobic Gram-/+ bacteria by blocking the synthesis of peptidoglycan. Its use has been currently re-evaluated for intravenous administration for the treatment of systemic infections by multidrug-resistant bacteria. Concentration-/time-dependent activity has been suggested, with potential clinical advantages from prolonged or continuous infusion. Nevertheless, little is known about Fosfomycin stability in elastomeric pumps. The aim of the present work was stability investigation before administration at 4 °C and during administration at 34 °C. InfectoFos® (InfectoPharm s.r.l., Milan, Italy) preparation for intravenous use in elastomeric pumps at 4 °C and 34 °C was analyzed following EMA guidelines for drug stability. Samples were analyzed with an ultra-high performance liquid chromatography coupled with tandem mass spectrometry method on a LX50® UHPLC system equipped with a QSight 220® (Perkin Elmer, Milan, Italy) tandem mass spectrometer. Fosfomycin in elastomeric preparation is stable for at least 5 days at a storage temperature of 4 °C and 34 °C. The results suggest Fosfomycin eligibility for continuous infusion even in the context of outpatient parenteral antibiotic therapy. Therefore, this approach should be tested in clinical and pharmacokinetic studies, in order to evaluate the possible gains in the pharmacokinetic profile and the clinical effectiveness.

Intravenous versus Partial Oral Antibiotic Therapy in the Treatment of Uncomplicated Bloodstream Infection Due to Streptococcus Species.

This retrospective cohort study examines effectiveness of partial oral antibiotic regimens in uncomplicated bloodstream infections (BSIs) due to Streptococcus species compared to standard intravenous therapy. Adult patients with uncomplicated streptococcal BSIs from April 2016 to June 2020 in seven hospitals in South Carolina, USA, were evaluated. Multivariate Cox proportional hazards regression was used to examine the time to treatment failure within 90 days of a BSI after adjustment for the propensity to receive partial oral therapy. Multivariate linear regression was used to examine the hospital length of stay (HLOS). Among the 222 patients included, 99 received standard intravenous antibiotics and 123 received partial oral therapy. Of the standard intravenous therapy group, 46/99 (46.5%) required outpatient parenteral antibiotic therapy (OPAT). There was no difference in the risk of treatment failure between partial oral and standard intravenous therapy (hazards ratio 0.53, 95% CI 0.18, 1.60; p = 0.25). Partial oral therapy was independently associated with a shorter HLOS after adjustments for the propensity to receive partial oral therapy and other potential confounders (-2.23 days, 95% CI -3.53, -0.94; p < 0.001). Transitioning patients to oral antibiotics may be a reasonable strategy in the management of uncomplicated streptococcal BSIs. Partial oral therapy does not seem to have a higher risk of treatment failure and may spare patients from prolonged hospitalizations and OPAT complications.

Outpatient parenteral antibiotic therapy (OPAT) for the management of bronchiectasis

BackgroundPatients with bronchiectasis often require hospitalisation for the administration of intravenous antibiotics for the management of acute exacerbations. Increasingly, Outpatient Parenteral Antibiotic Therapy (OPAT) services have become available as a potential alternative for domiciliary management. AimsThis study assessed outcomes in both cystic fibrosis (CF) and non-CF bronchiectasis patients who received OPAT for the management of an acute exacerbation of bronchiectasis. MethodsA retrospective study of consecutive subjects was done in both CF and non-CF groups in a large metropolitan Health Service in Australia from 2016 to 2022. ResultsThere were 51 episodes of care in the non-CF group (22 subjects) and 73 episodes in the CF group (13 subjects). The non-CF group were nearly all treated with once daily domiciliary intravenous (IV) ceftriaxone (49/51 episodes) for a duration of 9.1 ± 3.0 days (mean and standard deviation (SD)) via a peripherally inserted venous canula (84% of episodes). In contrast, the CF group generally received dual IV antibiotics (64% of episodes), with an average duration of 16.8 ± 6.3 days via central venous access (100%). In the non-CF group, the admission rate to hospital after 1 month was 9.6% and in the CF group was 0%. At 3 and 6 months the readmission rate for the non-CF group was 15.7% and 19.6% and CF group was 21.9% and 31.5%. There was a low rate of complications for the OPAT admissions (2% for the non-CF group and 7% for CF group). ConclusionsOPAT is a viable alternative for the management of bronchiectasis exacerbations.

Electronic health record-based readmission risk model performance for patients undergoing outpatient parenteral antibiotic therapy (OPAT).

Outpatient Parenteral Antibiotic Therapy (OPAT) provides coordinated services to deliver parenteral antibiotics outside of the acute care setting. However, the reduction in monitoring and supervision may impact the risks of readmission to the hospital. While identifying those at greatest risk of hospital readmission through use of computer decision support systems could aid in its prevention, validation of such tools in this patient population is lacking. The primary aim of this study is to determine the ability of the electronic health record-embedded EPIC Unplanned Readmission Model 1 to predict all-cause 30-day hospital unplanned readmissions in discharged patients receiving OPAT through the Duke University Heath System (DUHS) OPAT program. We then explored the impact of OPAT-specific variables on model performance. This retrospective cohort study included patients ≥ 18 years of age discharged to home or skilled nursing facility between July 1, 2019 -February 1, 2020 with OPAT care initiated inpatient and coordinated by the DUHS OPAT program and with at least one Epic readmission score during the index hospitalization. Those with a planned duration of OPAT < 7 days, receiving OPAT administered in a long-term acute care facility (LTAC), or ongoing renal replacement therapy were excluded. The relationship between the primary outcome (unplanned readmission during 30-day post-index discharge) and Epic readmission scores during the index admission (discharge and maximum) was examined using multivariable logistic regression models adjusted for additional predictors. The performance of the models was assessed with the scaled Brier score for overall model performance, the area under the receiver operating characteristics curve (C-index) for discrimination ability, calibration plot for calibration, and Hosmer-Lemeshow goodness-of-fit test for model fit. The models incorporating maximum or discharge Epic readmission scores showed poor discrimination ability (C-index 0.51, 95% CI 0.45 to 0.58 for both models) in predicting 30-day unplanned readmission in the Duke OPAT cohort. Incorporating additional OPAT-specific variables did not improve the discrimination ability (C-index 0.55, 95% CI 0.49 to 0.62 for the max score; 0.56, 95% CI 0.49 to 0.62 for the discharge score). Although models for predicting 30-day unplanned OPAT-related readmission performed slightly better, discrimination ability was still poor (C-index 0.54, 95% CI 0.45 to 0.62 for both models). EPIC Unplanned Readmission Model 1 scores were not useful in predicting either all-cause or OPAT-related 30-day unplanned readmission in the DUHS OPAT cohort. Further research is required to assess other predictors that can distinguish patients with higher risks of 30-day unplanned readmission in the DUHS OPAT patients.