Outpatient Parenteral Antimicrobial Therapy Program Research Articles

Managing an outpatient parenteral antibiotic therapy team: challenges and solutions.

Outpatient parenteral antimicrobial therapy (OPAT) programs should strive to deliver safe, cost effective, and high quality care. One of the keys to developing and sustaining a high quality OPAT program is to understand the common challenges or barriers to OPAT delivery. We review the most common challenges to starting and managing an OPAT program and give practical advice on addressing these issues.

Tolerability of Cefazolin after Immune-Mediated Hypersensitivity Reactions to Nafcillin in the Outpatient Setting

The objective of the present study was to assess the safety and tolerability of cefazolin therapy among patients with methicillin-sensitive Gram-positive bacterial infections who develop non-IgE-mediated hypersensitivity reactions (HSRs) to nafcillin. In this retrospective cohort analysis of the Outpatient Parenteral Antimicrobial Therapy program at the Massachusetts General Hospital from 2007 through 2013, we identified patients switched from nafcillin to cefazolin after an immune-mediated HSR. We reviewed patient demographics, details about the original HSR, and outcomes after the switch to cefazolin therapy. HSRs were classified by reaction type and likely mechanism. There were 467 patients treated with nafcillin, of which 60 (12.8%) were switched to cefazolin during their prescribed course. Of the 60 patients who transitioned to cefazolin, 17 (28.3%) were switched because of non-IgE-mediated HSRs. HSRs included maculopapular rash (n = 10), immune-mediated nephritis (n = 3), isolated eosinophilia (n = 2), immune-mediated hepatitis (n = 1), and a serum sickness-like reaction (n = 1). All but one patient (94.1%) who switched to cefazolin tolerated the drug with resolution of the HSR and completed their therapy with cefazolin. No patient experienced worsening of their rash or progressive organ dysfunction. With appropriate monitoring, therapy with cefazolin after non-IgE-mediated HSRs to nafcillin appears to be safe.

Outcomes from global adult outpatient parenteral antimicrobial therapy programmes: A review of the last decade

Outpatient parenteral antimicrobial therapy (OPAT) has become a global treatment modality since its advent in 1974. The multicentre outcome registries that were employed at the turn of the century to demonstrate the benefits and challenges in this treatment setting have been discontinued. In the intervening years, trends in clinical, patient satisfaction, programmatic and economic outcomes have been shown in sporadic cohort analyses from around the globe. These outcomes are generally reassuring and compare well with previous registry data. However, meaningful comparison of a range of key outcomes is hampered by a lack of uniformity to outcome reporting. In addition to ‘whole programme’ outcome reports, several studies have detailed real-world outcomes in OPAT pertaining to specific conditions and populations. This work has shown how prospective data collection in the OPAT setting can yield valuable insights into the effectiveness and safety of the management of many conditions, such as osteoarticular infection and endocarditis, in a diverse range of populations and increasingly from different countries. Enhanced and perhaps more uniform outcome surveillance in this fashion now constitutes good practice and will enable the benefits and risks of this treatment modality to be shared both in novel and established OPAT arenas.

Association of laboratory test result availability and rehospitalizations in an outpatient parenteral antimicrobial therapy programme

Laboratory tests are usually requested for monitoring during outpatient parenteral antimicrobial therapy (OPAT), but these recommendations are not always followed. The purpose of this study was to determine whether rehospitalization during the OPAT course is associated with the availability of these test results to the treating physician. Electronic health records (EHRs) from all patients in the Cleveland Clinic OPAT registry with start dates from 1 January to 28 February 2011 were reviewed in a retrospective cohort study. Comprehensive data on patient and OPAT characteristics were obtained for the first OPAT course per patient. Availability of laboratory test results was defined as documentation of results of at least one recommended test in the health system's EHR. Proportions of patients rehospitalized were compared for OPAT courses with test results available and non-available. Adjustments were made for patient age, hospital length of stay, anticipated OPAT duration, OPAT site and Charlson comorbidity index score. Four hundred patients received OPAT during the study period; 60% at home, 36% in skilled nursing facilities or long-term acute care facilities and 4% in other settings. Recommended monitoring laboratory test results were available to infectious disease physicians in 291 (73%) OPAT episodes. There were 82 patient readmissions (21%) while on OPAT. In a multivariable logistic regression model, non-availability of recommended test results was independently associated with readmissions while on OPAT (adjusted OR 2.53; 95% CI 1.36-4.73). Non-availability of recommended test results to treating physicians for patients on OPAT is associated with increased readmissions during OPAT.

Are We Ready for an Outpatient Parenteral Antimicrobial Therapy Bundle? A Critical Appraisal of the Evidence

Healthcare "bundles" have been developed to help providers improve the reliability and delivery of essential healthcare processes. Bundles have been shown to be effective in reducing healthcare-associated infection rates and are increasingly used to ensure the quality of patient care. Outpatient parenteral antimicrobial therapy (OPAT) is now standard medical practice in the treatment of a wide variety of infections. We review 6 components that we believe comprise an OPAT bundle and the evidence supporting each: patient selection, infectious disease consultation, patient/caregiver education, discharge planning, outpatient monitoring/tracking, and OPAT program review. To ensure that patients are receiving optimal care, further program development and outcomes research should target these bundle components to bring the evidence base up to date with current medical practices.

Outpatient Parenteral Antimicrobial Therapy for Surgery Patients: A Comparison with Previous Standard of Care

Current literature reports that outpatient parenteral antimicrobial therapy (OPAT) programs improve cure rates, and reduce length of hospitalization and costs. OPAT programs are still relatively new in Canada. To evaluate the benefits of an OPAT program initiated at a multispecialty tertiary care facility in Toronto, Ontario, compared with the previous standard of care. The present retrospective observational study was conducted using data from a group of surgical patients who were treated for active infections. Between February 1, 2010 and November 30, 2010, a total of 108 surgical patients were enrolled in the OPAT program. Patients were matched 1:1 with historical controls discharged between January 1, 2001 and January 1, 2010 according to age, sex, type of surgery, infection and comorbidities (Charlson Comorbidity Index). Cure rate, 30-day rehospitalization and length of stay were evaluated as primary end points. Of 108 eligible OPAT patients, 21 were matched to the control group using the prespecified criteria. For this cohort, the OPAT program was associated with improved cure rates (OPAT 61.7% versus control 57.1%; P>0.10), reduction in rehospitalization rate (14.3% versus 28.6%; P>0.10) and reduced length of stay (10.7 versus 13.9 days, P>0.10) compared with the control group. For this cohort of surgery patients, the OPAT program demonstrated a trend toward improved outcomes but did not achieve statistical significance. Due to the lack of statistical power, further evaluation is required to determine the full benefit of OPAT to patients and the health care system.

Outpatient Parenteral Antimicrobial Therapy

We have witnessed major shifts in the delivery of health care from the hospital to community settings during the past decades, in part, due to technological improvements, medical cultural changes, cost-containment efforts and patient preferences. Central to this changing environment has been the development of outpatient parenteral antimicrobial therapy (OPAT) clinics and services. A wide range of OPAT treatment models have been adopted in many jurisdictions worldwide, and these have been shown to be safe and highly cost saving compared with inpatient management (1-10). In many regions, OPAT has become a significant part of the job description of adult infectious diseases specialists. Extensive reviews of OPAT program development and requirements have been published (11-13). In the present note, we briefly review the development, potential benefits and challenges associated with OPAT, and focus on contemporary issues relevant to adult infectious diseases specialists.

Developments in outpatient parenteral antimicrobial therapy (OPAT) for Gram-positive infections in Europe, and the potential impact of daptomycin

Parenteral antimicrobial therapy is traditionally offered in the inpatient setting in many parts of the world. In the USA, the past three decades have seen an unprecedented increase in the delivery of these therapies in the non-inpatient setting, and outpatient parenteral antibiotic therapy (OPAT) is now an established standard of care in North America. However, the uptake of OPAT within Europe has been more gradual, owing to a number of clinical, fiscal, logistical and cultural considerations. In particular, physicians who are not currently engaged in OPAT programmes frequently cite concerns over patient safety as a major barrier. However, where OPAT programmes have been established, high levels of satisfaction are reported by both patients and physicians, suggesting that many anxieties concerning the introduction of OPAT stem from a lack of patient and physician education regarding the key potential benefits associated with OPAT. As the burden of serious Gram-positive infections grows, so does the need to offer clinicians, administrators and patients alternative treatment programmes that are equally effective and safe compared with inpatient treatment, while promoting optimal use of limited healthcare resources. This article will review the European experience of OPAT, discussing the associated benefits and the potential antibiotic options, with an emphasis on the evolving experience with daptomycin.

Terapia antimicrobiana endovenosa ambulatoria: Alternativa a la hospitalización en un servicio de urgencia pediátrico

Outpatient parenteral antimicrobial therapy (OPAT) was first introduced in 1973 as an alternative treatment. Since then, there have been numerous international case based studies including both children and adults with significant bacterial infections using this strategy. The protocol requires a careful screening and evaluation process of the patient. There must be no other motive for hospitalization other than the need for parenteral antibiotics.To describe the results of OPAT during a period of 26 months in emergency department of a Chilean pediatric public hospital.During the study period 228,144 patients received medical care in the Emergency Department (ED) and 380 patients were admitted to the OPAT program after clinical evaluation and based on the socioeconomic and cultural conditions of their parents. The major indications of OPAT were skin and soft tissues infections (50%) and pneumonia (28%) respectively. (beta-lactamic antibiotics the were most commonly prescribed. Thirty eight patients (10%) required hospitalization, mostly because of clinical deterioration. There were no deaths.In our public hospital OPAT for treatment of significant bacterial infections constitutes an efficient and safe alternative to hospitalization allowing the child to remain in his home.

Outpatient parenteral antimicrobial therapy: an alternative to hospitalization in a pediatric emergency department

Outpatient parenteral antimicrobial therapy (OPAT) was first introduced in 1973 as an alternative treatment. Since then, there have been numerous international case based studies including both children and adults with significant bacterial infections using this strategy. The protocol requires a careful screening and evaluation process of the patient. There must be no other motive for hospitalization other than the need for parenteral antibiotics. To describe the results of OPAT during a period of 26 months in emergency department of a Chilean pediatric public hospital. During the study period 228,144 patients received medical care in the Emergency Department (ED) and 380 patients were admitted to the OPAT program after clinical evaluation and based on the socioeconomic and cultural conditions of their parents. The major indications of OPAT were skin and soft tissues infections (50%) and pneumonia (28%) respectively. (beta-lactamic antibiotics the were most commonly prescribed. Thirty eight patients (10%) required hospitalization, mostly because of clinical deterioration. There were no deaths. In our public hospital OPAT for treatment of significant bacterial infections constitutes an efficient and safe alternative to hospitalization allowing the child to remain in his home.

Outpatient parenteral antimicrobial therapy (OPAT) for the treatment of osteomyelitis: evaluation of efficacy, tolerance and cost.

To evaluate the feasibility, efficacy, and cost of outpatient parenteral antimicrobial therapy (OPAT) in the treatment of osteomyelitis. 39 patients with an osteomyelitis requiring parenterally administered antibiotics for more than 4 weeks, and able to receive antibiotics at home. All patients had a totally implanted catheter. Antibiotics were administered by continuous infusion using a portable elastomeric infusion system, which was changed every day by the patient or by the home-care nurse. Laboratory monitoring and surveillance were performed weekly. Clinical efficacy, adverse effects and quality of life were recorded. The most commonly used antibiotics were vancomycin (51%) and beta-lactam (44%) antibiotics. Thirty patients were available for follow-up for a minimum of 12 months after completion of therapy. Twenty-eight (93%) were considered cured of their infection with a mean of 24 +/- 4 months after completion of antibiotic therapy. Adverse effects among the study patients were rare. The 39 patients in our OPAT programme resulted in a potential saving of US $1 873 885 relative to conventional therapy. OPAT is practicable and effective and may be the best alternative treatment for patients suffering from osteomyelitis requiring intravenous therapy.

Ambulatory use of parenteral antibacterials: contemporary perspectives.

Outpatient parenteral antimicrobial therapy (OPAT) offers increased patient comfort and convenience in appropriately selected patients who require parenteral antibacterial therapy, as well as opportunity for cost savings. Home-based programmes, with drugs being administered by the patient or the caregiver, have become the norm in the USA. Choice of drugs for OPAT is based on antimicrobial spectrum, dosage regimen, drug stability, toxicity profile, and cost. Over the past decade, availability of sophisticated programmable pumps has allowed a wider range of antimicrobial agents to be used in the ambulatory setting. The most popular antibacterial agents in OPAT programmes in the USA are vancomycin and beta-lactams.