Outpatient Parenteral Antimicrobial Therapy Courses Research Articles

Quantifying the Time to Administer Outpatient Parenteral Antimicrobial Therapy: A Missed Opportunity to Compensate for the Value of Infectious Diseases.

Outpatient parenteral antimicrobial therapy (OPAT) relies on substantial uncompensated provider time. In this study of a large academic OPAT program, the median amount of unbilled OPAT management time was 27 minutes per week, per OPAT course. These data should inform benchmarks in pursuing novel payment approaches for OPAT.

2206. Using Day-Level Registry Data on Patients in OPAT to Assess Heterogeneous Patterns of Time-Varying Antimicrobial Exposure and Unplanned Stopping across Multiple Infection Diagnoses, 2015-2022

Abstract Background Patients receiving outpatient parenteral antimicrobial therapy (OPAT) are often medically complex and require carefully tailored treatments to address severe and often concomitant infections. Methods We conducted a cohort study of patients enrolled in the University of North Carolina Medical Center OPAT program between March 2015 and December 2022 (2358 OPAT courses among 2072 unique patients). Patients were followed from OPAT regimen initiation (day 0) until observed treatment stop date, based on a grace period of 5 days to confirm discontinuation. Using hierarchical and mutually exclusive categorization schema, we classified patients into 1 of 10 infection diagnosis groups (Figure 1A), and classified all observed antibiotic cocktails (64 distinct antimicrobial medications comprising 520 distinct cocktails) into 18 treatments (Figure 1B). For each patient, we assessed their planned OPAT duration to classify their observed discontinuation as “planned,” “unanticipated early stop,” or “unanticipated prolonged treatment.” Stratified by infection diagnosis and treatment classifications, we used stacked bar charts to describe treatment heterogeneity, and Aalen-Johansen-based cumulative incidence curves to estimate occurrence of each type of discontinuation amid competing events. Results The cohort was 59.7% male with median age 56 years (IQR 45-66); the most common infection diagnosis was osteomyelitis +/- diabetic foot infection (28.1%, Figure 1A). Medication exposures were heterogeneous within and across infection diagnoses (Figure 1A and 1B). Median planned OPAT duration was 36 days (middle 90% 15-44). Overall cumulative incidence of unanticipated early discontinuation was 11.9%; overall incidence of unanticipated prolonged treatment was 22.9% (Figure 2). Conclusion Day-level data on medication use in this registry provided evidence of heterogeneity in medication exposure and unplanned discontinuation from OPAT, within and across infection diagnoses. These data highlight the need for multi-layered ascertainment of medication exposure, microorganisms, and infection diagnosis in this medically complex patient population to inform surveillance for adverse effects and comparative effectiveness research for post-discharge antibiotic treatment. Disclosures Asher J. Schranz, MD, MPH, WoltersKluwer: Honoraria Alan C. Kinlaw, PhD, MSPH, Genentech: Grant/Research Support

Heterogeneous OPAT regimens within and across infection diagnoses: Day-level medication use patterns among 2072 OPAT patients

Background: Patients receiving outpatient parenteral antimicrobial therapy (OPAT) are often medically complex and require carefully tailored treatments to address severe and often concomitant infections. Our objective was to illustrate the heterogeneity in antimicrobials used for patients in OPAT, within and across infection diagnosis groups. Methods: We abstracted electronic health record data regarding day-level treatment into a registry of 2,358 OPAT courses (n = 2,072 unique patients) treated in the University of North Carolina Medical Center OPAT program during 2015–2022 (total, 11,861 person weeks; average, 7 OPAT weeks per patient). We classified infection diagnoses into 10 hierarchical or mutually exclusive categories (eg, bacteremia only, diabetic foot infection (DFI) only, osteomyelitis only) (Fig., vertical axes). Accounting for 64 antimicrobial medications and 520 cocktails administered for at least 1 patient day in our OPAT registry, we also defined 18 hierarchical or mutually exclusive classifications of treatment (eg, “daptomycin alone” or “daptomycin and any other antibiotic(s)” (Fig. key). We conducted 2 stratified analyses to describe the heterogeneity across infection diagnoses with respect (1) to medications used at OPAT initiation (patient as unit of analysis) and (2) to medications used throughout OPAT (person time as unit of analysis, allowing for differential OPAT course to other treatment classifications during follow-up). We present stacked bar charts to visualize the intersection between infection diagnosis and treatment group. Results: Among patients in this OPAT registry, 34.6% had osteomyelitis and/or DFI, 4.8% had bacteremia, and 44.6% had multiple infections (Fig. 1). The most common medications in initial OPAT regimens were vancomycin (30.8% of OPAT patients), ceftriaxone (15.0%), and daptomycin (10.9%). We observed overall similarity between the distribution of treatment groups at initiation compared to cumulative person-time during the OPAT course (Figs. 1 and 2). However, we observed heterogeneity in medications by infection diagnosis (Figs. 1 and 2); for example, vancomycin was used in 39% of osteomyelitis cases but only 14% for endocarditis (Fig. 2). For several infection groups (eg, osteomyelitis, DFI, multiple infections, “other” single infections), no treatment classification exceeded 20% use (Figs. 1 and 2). Conclusions: Day-level data on medication use in this monitored registry of patients provided evidence of heterogeneity in the types of medications used throughout treatment in OPAT, which varies within and across infection diagnoses. These data highlight the need for multilayered ascertainment of medication exposure in this medically complex patient population to inform surveillance for adverse effects and guide comparative effectiveness research for postdischarge antibiotic treatment.Disclosures: None

1007. Impact of an Interdisciplinary Outpatient Parenteral Antimicrobial Therapy (OPAT) Clinic During the COVID-19 Pandemic

Abstract Background At the Michael E. DeBakey Veterans Affairs Medical Center, an interdisciplinary outpatient parenteral antimicrobial therapy (OPAT) clinic was developed in August 2020 during the COVID-19 pandemic (Figure 1). Standardized weekly safety monitoring and clinical follow-up was implemented via tele-OPAT visits by an infectious diseases (ID) pharmacist or ID PA with ID physician oversight. This study aimed to describe the practices implemented through initiation of our OPAT clinic, and its impact on clinical outcomes. Figure 1:Description of intervention and clinic model Methods This retrospective cohort study compared clinical outcomes of veterans receiving home OPAT one year pre- and post-implementation of a dedicated OPAT clinic. OPAT episodes initiated during the intervention period, prescribed for less than 7 days, not completed at time of analysis, administered with hospice services, or at a hemodialysis center, infusion suite, skilled nursing facility or long-term care facility were excluded. The primary endpoint was treatment failure during or within 30 days of OPAT completion defined as requiring repeat OPAT course for the same infection, unplanned admission, unplanned surgical intervention or procedure for additional source control, or death from any cause. Results A total of 191 OPAT episodes were included in the analysis (pre-intervention group, n= 76 vs. post-intervention, n=115). The most common indications for OPAT included bone/joint infections (34%), bacteremia (24%), and endocarditis (13%). Treatment failure was lower in the post-intervention vs. pre-intervention group (29% vs 46%, p = 0.01) with a median time to treatment failure of 24 days. Treatment failures in both groups were primarily driven by unplanned hospital admissions (Table 3). The median time to ID follow-up from OPAT initiation was shorter in the post-intervention vs. pre-intervention arms (6 days vs. 9 days, p< 0.001). The adverse event rate was higher (13% vs. 4%, p= 0.06), and modifications were made more frequently in the post-intervention (49% vs. 29%, p=0.007). Table 1:Demographics and baseline characteristicsTable 2:OPAT indications, antimicrobials, and microbiologyTable 3:OPAT follow-up, complications, and treatment failure Conclusion Implementation of an interdisciplinary OPAT clinic led to shorter time to ID follow-up, more frequent OPAT modifications, and reduced treatment failure. The median time to treatment failure suggests the need for ongoing surveillance beyond the initial 2 weeks of OPAT. Disclosures All Authors: No reported disclosures.

Evaluation of Opportunities for Oral Antibiotic Therapy in Bone and Joint Infections.

The OVIVA trial suggests oral antibiotics are an alternative to intravenous antibiotics to treat bone and joint infections (BJI). A shift in practice to treatment with oral antibiotics would eliminate the need for central vascular access, improve patient satisfaction, and reduce overall healthcare costs. The primary objective was to identify the proportion of patients treated for BJIs with outpatient parenteral antimicrobial therapy (OPAT) who would have qualified for oral antibiotics based on microbiological data. The secondary objective was to conduct a cost-analysis to estimate potential cost-savings had eligible patients been treated with oral antibiotics. This was a single-center, retrospective study of adult patients in the United States treated with intravenous antibiotics for BJIs from January 2018 to April 2020. Inclusion and exclusion criteria matched the OVIVA trial. Patients with Staphylococcus aureus bacteremia, endocarditis, or other high-risk features were excluded. 281 patients met the inclusion criteria. Most had prosthetic joint infections (56%). Infections caused by coagulase-negative staphylococci (25%) were most common, followed by S. aureus (23%) and polymicrobial infections (22%). 69 (25%) patients required a switch during their OPAT course to an alternate antibiotic agent. Thirteen patients (5%) experienced vascular access complications, and 6 patients (2%) developed Clostridiodes difficile infections. Oral therapy could have resulted in an estimated average savings per patient of $3,270.69 USD. Most patients treated with OPAT for BJIs were candidates for oral antibiotics. A change in practice would result in cost-savings to the U.S. healthcare system.

Outpatient parenteral antimicrobial therapy: how young is too young?

ObjectiveTo report the use, and assess the efficacy and outcomes of outpatient parenteral antimicrobial therapy (OPAT) in neonates (≤28 days of age), compared with older infants (1–12 months of age).DesignA...

607. Identifying Intervention Opportunities to Prevent Readmissions during OPAT

BackgroundPatients receiving outpatient parenteral antimicrobial therapy (OPAT) experience high rates of unplanned readmissions. To inform interventions that may reduce risk of unplanned readmissions during OPAT, we examined the frequency and reasons for readmission in a large cohort of OPAT patients.MethodsWe analyzed data on all patients enrolled in UNC’s OPAT program from February 2015-February 2020. Patients were evaluated by an infectious diseases (ID) physician prior to OPAT enrollment, discharged with >14 remaining days of prescribed therapy, and received care coordination and systematic monitoring by an ID pharmacist. We abstracted EHR data into a REDCap database to ascertain information on each patient’s OPAT course and readmission details: length of stay, primary ICD-9-CM/ICD-10-CM diagnosis code associated with readmission, and reason for readmission from clinical notes. Diagnosis codes and notes were adjudicated and summarized by a multidisciplinary team.ResultsAmong 1,165 OPAT courses, 19% resulted in at least one readmission during therapy, lasting for a median length of stay of 5 days. Among those patients who were readmitted during OPAT, the median time from OPAT start to readmission was 17 days (interquartile range, IQR: 8-29 days). 66% of readmissions preceded the scheduled follow-up appointment during OPAT (median time to scheduled follow-up was 27 days, IQR: 15-35 days). 55% of readmissions were unrelated to OPAT diagnosis. Based on ICD-9-CM/ICD-10-CM code classifications, the most common infectious diseases-related reasons for readmission were worsening OPAT infection (18%), OPAT-related adverse drug reaction (12%), and new infection (11%).ConclusionOne-fifth of OPAT courses resulted in readmission during therapy. Half of readmissions were associated with OPAT or other infection, and half were for other reasons. Earlier post-discharge follow-up by a multidisciplinary team (including primary care providers, case management, and OPAT) might prevent infection-related readmissions for OPAT patients. Future work should also address the need for enhanced care coordination with non-infectious disease providers to manage OPAT patients.Disclosures All Authors: No reported disclosures

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%.

Evaluation of Inpatient Antimicrobial Regimens for Readmitted Outpatient Parenteral Antimicrobial Therapy Patients Receiving Daptomycin or Ertapenem for Ease of Administration.

BackgroundOutpatient parenteral antimicrobial therapy (OPAT) allows for long-course intravenous treatment of infections without lengthy hospital stays. Upon discharge, antimicrobial therapy may be broadened for “ease” of once-daily administration (EOA). Patients requiring subsequent readmission can be tailored to pre-OPAT regimens to minimize adverse effects. This study assessed continuation of EOA regimens upon hospital readmission during or immediately after OPAT.MethodsThis was a retrospective review of adults enrolled in OPAT and discharged on ertapenem or daptomycin for EOA, defined by the terms “convenience” or “EOA” in OPAT notes or by switching to ertapenem or daptomycin upon OPAT enrollment despite adequate therapy with narrower-spectrum agents. The primary outcome was the percentage of patients readmitted during or after their OPAT course and maintained on an EOA regimen. Secondary outcomes included inpatient therapy cost, rates of Clostridioides difficile infection, and adverse events.ResultsOf 188 patients receiving an OPAT EOA regimen, 71 were readmitted, representing 113 unique readmissions. Patients were mostly males (81%) aged 57 years. The EOA regimens were continued in 27% of hospital readmissions. The Infectious Diseases (ID) team was consulted in 48% of readmissions, and the Antimicrobial Stewardship Program (ASP) intervened in 26%. Combined, this resulted in de-escalation in 28% of cases. Clostridioides difficile infections and adverse events occurred in 7% and 12% of readmissions, respectively. The median acquisition cost of inpatient EOA regimens was $150 per readmission.ConclusionsThe OPAT EOA regimens were continued in 27% of hospital readmissions indicating a role for improved indication documentation and collaboration between ID services, ASPs, and OPAT teams.

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.

788. Outcomes of Multidisciplinary Care Conferences for Patients with Substance Use Disorders Requiring Prolonged Antimicrobial Therapy for Severe Infections

BackgroundInfectious complications in people with substance use disorders (SUD) are rising, and while outpatient parenteral antimicrobial therapy (OPAT) is widely used in the general population, OPAT failure rates in SUD are high. Due to perceived PICC risks and OPAT safety, serious infections in people with SUD at our institution often resulted in hospitalization for the duration of treatment. Prolonged inpatient treatment is difficult to tolerate and increases healthcare costs. Our OPAT and addiction medicine teams initiated multidisciplinary discharge planning conferences (OPTIONS-DC) for inpatients with SUD requiring prolonged antimicrobials. The goal was to prioritize patient preferences regarding OPAT setting while incorporating harm-reduction principles. The goal of this study is to assess the impact and outcomes of the OPTIONS-DC.MethodsWe prospectively recorded comprehensive notes at OPTIONS-DC and retrospectively performed chart review for conferences held from February 2018 to March 2019.We performed a content analysis of OPTIONS-DC notes and patient records to identify ways that OPTIONS-DC modified care plans and prioritized patient preferences.ResultsThirty-one conferences were held during the study period. Twenty-eight patients reported substance use within 90 days, 24 used intravenous substances, 12 were homeless, 24 had a mental health diagnosis, and 20 started medication-assisted treatment during hospitalization (Table 1). For 16 patients the conference altered the definitive treatment plan to align with patient preferences while emphasizing safety, and 13 of those were changed to an outpatient setting. A total of 10 patients had a decreased length of stay, with a total of 238 hospital days saved overall. OPAT was planned at discharge for 15 patients, 11 of whom completed their OPAT course. Overall, 21/31 (68%) completed their recommended antimicrobial course and 3 were lost to follow-up.ConclusionA multidisciplinary conference that prioritizes patient preferences and uses harm reduction strategies to optimize infection treatment plans is feasible and effective. The OPTIONS-DC model has potential to expand treatment options for infections in SUD, reduce hospital days, and may serve as an example for other institutions. Disclosures All authors: No reported disclosures.

Selected Children With Complicated Acute Urinary Tract Infection May Be Treated With Outpatient Parenteral Antibiotic Therapy at Home Directly From the Emergency Department.

Outpatient parenteral antimicrobial therapy offers the option of treating children requiring intravenous antibiotics for acute urinary tract infection (UTI)/pyelonephritis at home. We aimed to determine the outcomes of treating patients with UTI/pyelonephritis using outpatient parenteral antimicrobial therapy directly from the emergency department (ED) without admission to hospital. This was a retrospective study (August 2012-July 2016) of children with UTI/pyelonephritis treated with parenteral antibiotics via a peripheral cannula directly from ED to home under a hospital-in-the home (HITH) program. Data collection included demographics, clinical features, length of stay, complications, and readmissions to hospital. There were 62 patient episodes of UTI/pyelonephritis transferred directly from ED to HITH. Fifty-eight (94%) had systemic features including fever, vomiting and/or tachycardia. Eighteen (29%) patients had an underlying condition. Nine (15%) received intravenous fluids and 8 (13%) antiemetics in ED. The outpatient parenteral antimicrobial therapy course was successfully completed in 56 (90%) patients. Of 6 (10%) patients who were readmitted, 2 were discharged within 24 hours, and none were severely unwell. Two (3%) had a blocked cannula, with no antibiotic complications. HITH patients were treated for a combined total of 142 days at home resulting in a cost saving of Australian dollar 108,914 (US dollar 82,775). However, only 8% of children deemed to require a course of intravenous antibiotics were transferred directly home from ED. Compared with patients concurrently admitted to hospital, fewer on HITH were less than 1 year of age (13% vs. 33%; odds ratio: 0.3; P < 0.01). Selected patients presenting to ED with UTI/pyelonephritis may be treated directly via HITH, including some with underlying conditions and/or systemic features.

1854. Effective Antimicrobial Stewardship for Outpatient Parenteral Antimicrobial Therapy (OPAT): Nationwide Experience in Infectious Disease Physician Infusion Centers

BackgroundAntimicrobial stewardship (AS) is an important factor in combatting antimicrobial resistance and optimizing clinical outcomes, especially in the outpatient setting. With no AS guidelines in the United States for OPAT, we developed an antimicrobial stewardship program (ASP) for OPAT in 2016, which was piloted and applied to Infectious Disease practices and infusion centers. The program was expanded and assessed nationally in additional centers in 2017, adding appropriateness of empiric therapy (tx), supervision of first doses of antimicrobials, compliance with tx regimen, appropriate tx changes and staff education.MethodsAn assessment instrument was developed through literature review, expert opinion and validated with a logistic model. Patients receiving OPAT in 2017 were randomly selected and retrospectively reviewed based on annual patient volume from 14 OPAT practices. The table shows the ASP assessment tool consisting of 7 Core Elements (CE) scored at 10 points each and 6 Other Elements (OE) scored at 5 points each. Logistic regression was used to validate the relationship between the composite outcome elements and all other elements (aOR = 0.929, P = 0.0005, c = 0.704). Appropriateness of empiric tx and tx length was evaluated using evidence-based guidelines. Each patient OPAT course was assessed and scored for compliance to required elements with an achievable score per patient of 100 points (100%). IV to PO conversion was evaluated secondarily. Descriptive statistics were used.ResultsA total of 200 OPAT courses were scored for compliance to each ASP element as noted in the table. The overall compliance rate for CE and OE was 93.0% and 93.3%, respectively. All CEs were ≥90% compliant, except for duration of tx. This exceeded guidelines in 15% of patient courses due to severe disease presentation. For the OEs, all achieved ≥90% compliance except laboratories performed as ordered. Early conversion from IV to PO resulted in a reduction of 240 IV days for 1.2 days per patient.ConclusionWe successfully developed an OPAT ASP with national expansion. Opportunities were identified for improvement in laboratory processes and enhanced evaluation regarding tx durations. This validated ASP provides a valuable tool for OPAT, incorporating key elements for stewardship success. Disclosures R. V. Nathan, Merck & Co.: Scientific Advisor and Speaker’s Bureau, Consulting fee and Speaker honorarium. The Medicines Company: Speaker’s Bureau, Speaker honorarium. Allergan: Speaker’s Bureau, Speaker honorarium. R. L. Hengel, Merck & Co.: Scientific Advisor, Consulting fee. K. A. Couch, Allergan: Speaker’s Bureau, Speaker honorarium. Merck: Speaker’s Bureau, Speaker honorarium. Melinta: Speaker’s Bureau, Speaker honorarium. L. J. Van Anglen, Merck & Co.: Grant Investigator, Research grant.

Emergency department visits during outpatient parenteral antimicrobial therapy: a retrospective cohort study.

Patients receiving outpatient parenteral antimicrobial therapy (OPAT) may require emergency department (ED) visits to manage complications. This study's purpose was to identify risk factors for ED visits during OPAT and risk factors for hospitalization among patients with ED visits. All OPAT courses initiated between 1 January 2013 and 1 January 2017 at Cleveland Clinic were identified. The first OPAT course per patient was included. For these, ED visits within 30 days were identified. Reasons and risk factors for these visits were sought, as were risk factors for hospitalization among patients visiting the ED. Among 8263 patients on OPAT, 381 (4.6%) had at least one ED visit, an additional 1133 (14%) were hospitalized and an additional 50 (0.6%) died, within 30 days. One hundred and ninety-three ED visits (51%) were OPAT related. In a multivariable subdistribution proportional hazards competing risks regression model, prior ED visit (preceding year) was most strongly associated with ED visits (HR 2.29, 95% CI 1.76-2.98, P = 8.1 × 10-10). Eighty-five visits (22%) led to hospitalization. Compared with non-OPAT-related reasons, visits for vascular access complications were associated with lower odds of hospitalization (OR 0.36, 95% CI 0.14-0.83, P = 0.022) and visits for worsening infection with higher odds (OR 18.95, 95% CI 5.50-79.85, P = 1.2 × 10-7). Compared with patients without, patients with prior ED visit have a 2.3-fold higher hazard of an ED visit within 30 days of OPAT initiation. Visits for worsening infection are much more likely to result in hospitalization than those for vascular access complications.

Adverse Drug Reactions Among Patients Enrolled in an Outpatient Parenteral Antimicrobial Therapy (OPAT) Program 2015–2016 at UNC Medical Center

BackgroundThe UNC Medical Center OPAT program was started in 2015 to provide multidisciplinary monitoring and management of patients discharged on parenteral antimicrobials. We examined characteristics of incident adverse drug reactions (ADRs) observed in our initial cohort of OPAT patients.MethodsWe abstracted electronic health records for the first 250 patients enrolled in the OPAT program. 223 patients with sufficient recorded data for entire OPAT course were included in the analysis. ADRs meeting criteria as detailed in Table 1 were collected and further stratified by antimicrobial regimen.Results57 patients (26%) experienced at least one ADR during OPAT therapy. The frequency of specific ADRs associated with OPAT therapies are provided in Figure 1. Β-lactam regimens were most frequently associated with liver dysfunction, while combinations of β-lactams and vancomycin were associated with kidney dysfunction. Median days on OPAT regimen was 19 days (IQR: 10–29) for patients who experienced an ADR compared with 39 (IQR: 30–44) for patients who did not experience an ADR.ConclusionADRs were most commonly observed within the first three weeks of therapy, particularly for patients receiving vancomycin and a β-lactam antimicrobial in combination. These results underscore the critical role of a multidisciplinary team in providing laboratory monitoring and response to abnormal results for OPAT patients. In addition, closer monitoring within the first three weeks of therapy may provide opportunities for regimen changes or dose adjustment to avoid toxicities.Table 1. Type of ADR experienced by OPAT patientsa at UNCMC, 2015–16 Type of ADR No. of Patients (n = 57) % of ADRs Liver dysfunction (ALT>100)2030Kidney dysfunction (SCr increase >50%)2436Neutropenia (<1000 cells/mm3)1015Eosinophilia (>500 cells/mm3)812Thrombocytopenia (<100 x 103and decrease >50%)11Rash46a166/223 (74%) OPAT patients did not experience an ADROf 57 patients with at least 1 ADR during OPAT, 8 had 2 types, and 1 had 3 types; ADR patient counts therefore sum to 67.Figure 1Type of ADR experienced by OPAT drug class 2015–16.Disclosures All authors: No reported disclosures.

Safety and Effectiveness of Outpatient Parenteral Antimicrobial Therapy (OPAT) in the Aged Population

BackgroundThe aged population (≥75 years) have multiple comorbidities and are at increased risk of adverse events associated with intravenous antimicrobial therapy. Hospitalization (hosp) occurs frequently. This group presents challenges for site of care and reimbursement, which may be met with provision of OPAT through a physician office infusion center (POIC). This setting allows treatment immediately following hosp or directly from the community, thus avoiding hosp. For the aged patient (pt) population, we evaluated safety and effectiveness of OPAT in a POIC.MethodsRecords from 13 POICs were queried for patients ≥75 years receiving OPAT courses from January to July 2016. Data included demographics, therapy, disease characteristics, effectiveness and safety. Effectiveness was assessed as completion of therapy and no unplanned hosp related to the underlying infection. Safety assessment included adverse drug reactions (ADRs), catheter complications (CC) and hosp admissions for causes other than those related to the underlying infection. Descriptive statistics and regression analyses were performed.ResultsThere were 260 OPAT patient courses provided. Mean age was 81 ± 5 years, 64% male. 51% were treated directly from the community and 49% post hosp. The most common infections were bone and joint (32%), genitourinary (21%), skin and skin structure (20%) and respiratory (12%). OPAT met criteria for effectiveness in 95%, with 247/260 completing therapy and avoiding infection-related hosp. Antimicrobials most frequently used were vancomycin (n = 59), ceftriaxone (n = 43), cefepime (n = 35) and ertapenem (n = 32). Median length of OPAT was 14 days (range 1–79). OPAT was assessed as safe in 81% of patients (211/260). 49 patients reported ≥1 safety events including ADRs (40; 15%), CC (6; 2.3%), and hosp (17; 6.5%). 9 hosp patients completed OPAT following discharge. Most common ADRs were diarrhea (n = 9), fatigue (n = 9) and nausea (n = 8) with 4 hosp for serious ADRs. All CCs resolved and there were no mortalities. Significant risk factors associated with safety events were drug allergies (OR=2.47, CI=1.31–4.65, P = 0.005), ≥3 comorbidities (OR=3.92, CI=1.16–13.23, P = 0.027) and hypertension (OR=2.19, CI=1.04–4.64 P = 0.039).ConclusionProvision of OPAT through a POIC demonstrated to be exceptionally safe and effective in the aged population.Disclosures L. J. Van Anglen, Theravance: Scientific Advisor, Consulting fee R. V. Nathan, Merck: Speaker’s Bureau, Speaker honorarium Allergan: Speaker’s Bureau, Speaker honorarium The Medicines Company: Speaker’s Bureau, Speaker honorarium K. A. Couch, Merck: Speaker’s Bureau, Speaker honorarium Allergan: Speaker’s Bureau, Speaker honorarium

Characterization of Readmissions Among Patients Enrolled in an Outpatient Parenteral Antimicrobial Therapy (OPAT) Program Over a 2-Year Period at UNC Medical Center

BackgroundThe UNC Medical Center OPAT program was started in 2015 to provide multidisciplinary management of medically complex patients referred by the infectious diseases (ID) inpatient services and discharged on parenteral antimicrobials. A primary aim of the program is to avert avoidable readmissions during OPAT therapy through protocolized laboratory monitoring, case review and streamlined access to ID urgent care services.MethodsWe abstracted electronic health records for the first 250 patients enrolled in the OPAT program. 223 patients with sufficient recorded data for entire OPAT course were included. All-cause readmission events during OPAT therapy were collected, and cause for readmission was adjudicated by a multidisciplinary committee.ResultsOf the 223 patients, 62% were male with median age 53 years (20–88). 39 (17%) experienced a readmission (Table 1). Most readmissions occurred among patients not seen in our OPAT urgent care for the admitting complaint. 57 patients (26%) experienced at least one adverse drug reaction (ADR), e.g., laboratory abnormality, rash, or diarrhea; 7 of these required readmission. ADR was the most common reason for ID urgent care visit. Almost half of readmissions were unrelated to OPAT therapy or OPAT-related diagnosis. Less than 10% of OPAT patients utilized ID urgent care services; none of these visits resulted in readmission.ConclusionOur OPAT program represents a medically complex cohort that may be at higher risk of readmission at baseline. The availability of providers and pharmacists for urgent care services is effective in avoiding readmission for OPAT-related causes. Future interventions to address common causes of readmission include expanded access to urgent care servvices and close interval follow-up after discharge for particularly high-risk patients.Table 1. Reason for readmission of OPAT patientsa Reason No. (n = 39) % of readmissions Unrelated to OPAT-indicated diagnosisb1744Clinical failure923OPAT drug-related adverse eventc718New infectiond513Unspecified13a 184 out of 223 (83%) OPAT patients were not readmitted. b e.g., myocardial infarction, stroke, alcohol consumption. c e.g., kidney or liver dysfunction. d e.g., OPAT for endocarditis subsequent urinary tract infectionDisclosures All authors: No reported disclosures.

Setting up an outpatient parenteral antimicrobial therapy (OPAT) unit in Switzerland: review of the first 18 months of activity

Outpatient parenteral antimicrobial therapy (OPAT) has been recognised as a useful, cost-effective and safe alternative to inpatient treatment, but no formal OPAT unit existed in Switzerland until recently. In December 2013 an OPAT unit was established at Lausanne University Hospital. We review here the experience of this new OPAT unit after 18 months of activity. Patient characteristics, clinical activities and outcomes were recorded prospectively. Need and acceptance was evaluated as number of OPAT courses administered and number of patients refusing OPAT. Safety and efficacy were evaluated as: (1) adverse events linked to antimicrobials and catheters, (2) re-admission to hospital, (3) rate of treatment failures and (4) mortality. Over 18 months, 179 courses of OPAT were administered. Acceptance was high with only four patients refusing OPAT. Urinary tract infections with resistant bacteria and musculoskeletal infections were the most common diagnoses. Self-administration of antibiotics using elastomeric pumps became rapidly the most frequently used approach. Sixteen patients presented with adverse events linked to antimicrobials and catheters. OPAT-related readmissions occurred in nine patients. The overall cure rate was 94 %. This study shows that OPAT is very well accepted by patients and medical staff, even in a setting which has not used this type of treatment approach until now. Self-administration using elastomeric pumps proved to be particularly useful, safe and efficient. OPAT offers a good alternative to hospitalisation for patients presenting with infections due to resistant bacteria that cannot be treated orally anymore and for difficult to treat infections.

Vascular access complications during outpatient parenteral antimicrobial therapy at home: a retrospective cohort study.

The need for indwelling vascular access for outpatient parenteral antimicrobial therapy (OPAT) places patients at risk of vascular access complications. The purpose of this study was to describe vascular access complications during OPAT at home, and identify factors associated with their occurrence. All OPAT courses carried out at home for patients at Cleveland Clinic in 2013 were identified from the institution's OPAT registry. The first OPAT course per patient was included. Vascular access complications that occurred during the treatment course were abstracted from the electronic medical record. Only complications that triggered a clinical intervention were included. The 1461 included OPAT courses encompassed 33,579 OPAT days of treatment. One-hundred-and-forty-four vascular access complications occurred in 131 OPAT courses (9% of OPAT courses, 4.29 complications per 1000 OPAT days). The most common complication was occlusion (53% of all complications). Hickman catheters [incidence rate ratio (IRR) 0.20, 95% CI 0.03-0.63] and indwelling ports (IRR 0.25, 95% CI 0.04-0.78) were associated with lower complication rates than peripherally inserted central catheters, as was increasing age (IRR 0.99, 95% CI 0.98-1.00). Log OPAT duration (IRR 1.60, 95% CI 1.28-2.03), female sex (IRR 1.62, 95% CI 1.16-2.28) and injection drug use (IRR 3.32, 1.16-7.46) were associated with increased risk of vascular access complications. Nine percent of OPAT courses at home have at least one vascular access complication requiring clinical intervention. Longer OPAT duration, younger age, female sex and injection drug use are associated with increased risk of vascular access complications.

Evaluation of Outpatient Parenteral Antimicrobial Therapy at a Veterans Affairs Hospital.

We reviewed outpatient parenteral antimicrobial therapy at a Veterans Affairs Medical Center to identify opportunities for antimicrobial stewardship intervention. A definite or possible modification would have been recommended in 60% of courses. Forty-one percent of outpatient parenteral antimicrobial therapy courses were potentially avoidable, including 22% involving infectious diseases consultation.