Parenteral Antimicrobial Therapy Research Articles

A Quality Initiative to Improve Postdischarge Care for Patients on Outpatient Parenteral Antimicrobial Therapy.

BackgroundPatients discharged from the hospital on outpatient parenteral antimicrobial therapy (OPAT) require close monitoring, including weekly blood tests and an early posthospital follow-up visit. However, because patients often receive OPAT in a separate healthcare system from where they received inpatient care, the OPAT plan often fails, with less than 75% of OPAT patients receiving the recommended laboratory monitoring. We sought to determine whether changing our inpatient OPAT documentation method would improve postdischarge care.MethodsAs a quality improvement initiative, we conducted 2 Plan-Do-Study-Act interventions on our OPAT documentation. Our first intervention was to create a standardized OPAT Progress Note, and our second was to turn that note into a SmartForm (Epic) with discrete fields for the key information. We examined the effects of these changes on the rate of completion of recommended laboratory monitoring, attendance at outpatient follow-up visits, and 30-day readmission rates.ResultsChanging our documentation to a standardized Progress Note and then to a SmartForm with discrete fields led to an increase in the proportion of patients with a serum creatinine checked within 10 days of discharge (from 63% to 71% to 73%) and who attended an infectious disease clinic visit within 3 weeks of discharge (from 21% to 36% to 47%). However, the rate of readmissions for OPAT-related problems did not change, nor did a composite outcome of 30-day mortality/unplanned readmission.ConclusionsChanges in how and where care plans are documented in the inpatient medical record can have significant effects on patient care outcomes after discharge.

Stability Studies of 16 Antibiotics for Continuous Infusion in Intensive Care Units and for Performing Outpatient Parenteral Antimicrobial Therapy.

The use of continuous infusion to improve the therapeutic efficacy of time-dependent antibiotics has been demonstrated. There is still a lack of data to safely perform these continuous infusions. The objectives in this study were to evaluate the stability by using stability-indicating methods (High-Performance Liquid Chromatography) of 16 antibiotics in concentrated solutions, especially for administration in intensive care units and solutions in elastomeric diffusers at 37 °C for outpatient parenteral antimicrobial therapy. The solutions were considered stable if the percentage of the drug was ≥90%, and the colour and clearness remained unchanged. In syringes, the stability data vary from 4 to 8 h (h) for meropenem in Dextrose 5% (D5W) and Normal Saline (NS), respectively, 6 h for cefotaxime, 12 h for cefoxitin, and 24 h for aztreonam, cefazolin, cefepime, cefiderocol, ceftazidime/avibactam, ceftolozane/tazobactam in NS and D5W, and in water for injection for cloxacillin. A stability period of 48 h has been validated for vancomycin (D5W), aztreonam, and piperacillin/tazobactam. Cefoxitin, cefazolin, cefepime, cefotaxime, cloxacillin, and piperacillin are unstable for diffuser administration. In diffusers, stability times vary from 6 h for cefiderocol, 8 h for ceftazidime, 12 h for ceftazidime/avibactam and ceftolozane/tazobactam (NS), 24 h for temocillin (NS) and piperacillin/tazobactam (D5W), up to 48 h for aztreonam and vancomycin. Solutions stored at 37 °C are less stable and allow the administration of seven antibiotics using diffusers.

Implementation of IV Push Antibiotics for Outpatients During a National Fluid Shortage Following Hurricane Maria.

BackgroundPrior to the introduction of intravenous (IV) drip infusion, most IV drugs were delivered in a syringe bolus push. However, intravenous drip infusions subsequently became the standard of care. Puerto Rico is the largest supplier of IV fluid bags and in the aftermath of Hurricane Maria, there was a nationwide fluid bag shortage. This shortage required stewardship measures to maintain the operation of the self-administered outpatient parenteral antimicrobial therapy (OPAT) program at Parkland Health.MethodsParkland pharmacists evaluated all self-administered antimicrobials for viability of administration as an IV syringe bolus push (IVP) instead of an IV-drip infusion. Medications deemed appropriate were transitioned to IVP. The hospital EMR was used to identify patients discharged to the OPAT clinic using all methods of parenteral drug delivery. Data was collected for patient demographics, patient satisfaction, and clinical outcomes. Finally cost of care was calculated for IVP and IV drip administration. ResultsOne-hundred and thirteen self-administered IVP and 102 self-administered IV drip treatment courses were identified during the study period. Individuals using IVP had a statistically significant decrease in hospital length of stay. Patient satisfaction was greater with IVP and IVP saved 504 liters of normal saline resulting in a savings of $43,652 over 6 months. The 30-day readmission rate and mortality were similar.ConclusionThe abrupt IV fluid shortage following a natural disaster led to implementation of a high value care model that improved efficiency, reduced costs, and did not affect safety or efficacy.

Effectiveness and Safety of Ceftriaxone Compared to Standard of Care for Treatment of Bloodstream Infections Due to Methicillin-Susceptible Staphylococcus aureus: A Systematic Review and Meta-Analysis.

(1) Background: Ceftriaxone is a potential alternative for the treatment of methicillin-susceptible Staphylococcus aureus (MSSA) bloodstream infections (BSIs) in acute care and outpatient parenteral antimicrobial therapy (OPAT) settings. We evaluated the effectiveness and safety of ceftriaxone for the treatment of MSSA BSIs. (2) Method: We searched PubMed, Embase, and Cochrane Library from their inception to October 30th 2021. Our outcomes included clinical cure, microbiological cure, 30- and 90-day mortality, 90-day hospital readmission, and adverse drug reactions (ADRs). We compared ceftriaxone against standard of care (SOC) therapy. We used the random-effects model for the meta-analysis, and our estimated effects were reported as odds ratios (ORs) with 95% confidence intervals (CI). (3) Results: Twelve retrospective cohort studies were included, comprising 1037 patients in the ceftriaxone arms and 2088 patients in the SOC arms. The clinical cure rate of the ceftriaxone regimen was not statistically different from SOC: OR 0.65 (95% CI: 0.29–1.45). Ceftriaxone was also not statistically different from SOC in microbiological cure: OR 1.48 (95% CI: 0.29–7.51); 30-day mortality: OR 0.79 (95% CI: 0.14–4.65); 90-day mortality: OR 0.82 (95% CI: 0.38–1.80); 90-day hospital readmission: OR 1.20 (95% CI: 0.92–1.56); and ADRs: OR 0.92 (95% CI: 0.39–2.18). (4) Conclusion: Ceftriaxone could provide an alternative for the treatment of MSSA BSIs in acute care and OPAT settings (except in patients whose BSIs were due to infective endocarditis).

Implementation of a Collaborated Antimicrobial Stewardship Program and Outpatient Parenteral Antimicrobial Therapy (OPAT) Unit-driven Monoclonal Antibody Therapy Program for COVID-19 at an NYC Hospital

ObjectivesThis study aimed to assess the processes and clinical outcomes of a joint collaboration between Antimicrobial Stewardship Program (ASP) and the outpatient parenteral antimicrobial therapy (OPAT) unit for delivery of monoclonal antibody therapy for mild-to-moderate COVID-19. MethodsWe carried out a retrospective, interim analysis of our COVID-19 monoclonal antibody therapy program. Outcomes included clinical response, incidence of hospitalization, and adverse events. ResultsA total of 175 patients (casirivimab-imdevimab, n = 130; bamlanivimab, n = 45) were treated between December 2020 and March 1, 2021. The median time from symptom onset was 6 (IQR 4, 8) days at time of treatment. Of 135 patients available for follow-up, 71.9% and 85.9% of patients reported symptom improvement within 3 and 7 days of treatment, respectively. A total of 9 (6.7%) patients required COVID-19–related hospitalization for progression of symptoms, all within 14 days of treatment. A total of 7 (4%) patients experienced an infusion-related reaction. ConclusionsASP-OPAT collaboration is a novel approach to implement an efficient and safe monoclonal antibody therapy program for the treatment of mild-to-moderate COVID-19.

Simulated Cost-effectiveness and Long-term Clinical Outcomes of Addiction Care and Antibiotic Therapy Strategies for Patients With Injection Drug Use–Associated Infective Endocarditis

Emerging evidence supports the use of outpatient parenteral antimicrobial therapy (OPAT) and, in many cases, partial oral antibiotic therapy for the treatment of injection drug use-associated infective endocarditis (IDU-IE); however, long-term outcomes and cost-effectiveness remain unknown. To compare the added value of inpatient addiction care services and the cost-effectiveness and clinical outcomes of alternative antibiotic treatment strategies for patients with IDU-IE. This decision analytical modeling study used a validated microsimulation model to compare antibiotic treatment strategies for patients with IDU-IE. Model inputs were derived from clinical trials and observational cohort studies. The model included all patients with injection opioid drug use (N = 5 million) in the US who were eligible to receive OPAT either in the home or at a postacute care facility. Costs were annually discounted at 3%. Cost-effectiveness was evaluated from a health care sector perspective over a lifetime starting in 2020. Probabilistic sensitivity, scenario, and threshold analyses were performed to address uncertainty. The model simulated 4 treatment strategies: (1) 4 to 6 weeks of inpatient intravenous (IV) antibiotic therapy along with opioid detoxification (usual care strategy), (2) 4 to 6 weeks of inpatient IV antibiotic therapy along with inpatient addiction care services that offered medication for opioid use disorder (usual care/addiction care strategy), (3) 3 weeks of inpatient IV antibiotic therapy along with addiction care services followed by OPAT (OPAT strategy), and (4) 3 weeks of inpatient IV antibiotic therapy along with addiction care services followed by partial oral antibiotic therapy (partial oral antibiotic strategy). Mean percentage of patients completing treatment for IDU-IE, deaths associated with IDU-IE, life expectancy (measured in life-years [LYs]), mean cost per person, and incremental cost-effectiveness ratios (ICERs). All modeled scenarios were initialized with 5 million individuals (mean age, 42 years; range, 18-64 years; 70% male) who had a history of injection opioid drug use. The usual care strategy resulted in 18.63 LYs at a cost of $416 570 per person, with 77.6% of hospitalized patients completing treatment. Life expectancy was extended by each alternative strategy. The partial oral antibiotic strategy yielded the highest treatment completion rate (80.3%) compared with the OPAT strategy (78.8%) and the usual care/addiction care strategy (77.6%). The OPAT strategy was the least expensive at $412 150 per person. Compared with the OPAT strategy, the partial oral antibiotic strategy had an ICER of $163 370 per LY. Increasing IDU-IE treatment uptake and decreasing treatment discontinuation made the partial oral antibiotic strategy more cost-effective compared with the OPAT strategy. When assuming that all patients with IDU-IE were eligible to receive partial oral antibiotic therapy, the strategy was cost-saving and resulted in 0.0247 additional discounted LYs. When treatment discontinuation was decreased from 3.30% to 2.65% per week, the partial oral antibiotic strategy was cost-effective compared with OPAT at the $100 000 per LY threshold. In this decision analytical modeling study, incorporation of OPAT or partial oral antibiotic approaches along with addiction care services for the treatment of patients with IDU-IE was associated with increases in the number of people completing treatment, decreases in mortality, and savings in cost compared with the usual care strategy of providing inpatient IV antibiotic therapy alone.

Survey of delivery of parenteral antimicrobials in non-inpatient settings across Europe

Delivery of parenteral antimicrobials in non-inpatient settings (DPANS) may be through a dedicated outpatient parenteral antimicrobial therapy (OPAT) service, co-ordinated by hospital- or community-based specialised teams, or via an infusion service involving community-based health professionals (nurses, general practitioners) without centralised hospital oversight, or through ad hoc arrangements. DPANS varies among countries. Our objective was to describe how DPANS is organised at a national level in European countries. A survey (65-item self-administered questionnaire) was conducted from February-June 2019 among infection specialists in 34 European countries on behalf of the ESCMID Study Group for Antimicrobial Stewardship (ESGAP) and the British Society for Antimicrobial Chemotherapy (BSAC) OPAT initiative. Most countries (28/34; 82.4%) participated in the survey. DPANS was available in almost all (27/28; 96.4%) responding countries. DPANS was predominantly provided either via specialised OPAT services (17/28; 60.7%) or via infusion services (16/28; 57.1%), with 11 countries (39.3%) providing both services. A formal OPAT team structure with specifically trained staff was reported in only six countries (6/17; 35.3%). Some countries (4/28; 14.3%) had no structured services but practiced DPANS via ad hoc arrangements. The costs of all stages of the process were covered for patients managed by specialised OPAT/infusion services, either completely, partially or for specific patient groups in the majority (20/28; 71.4%) of countries. The main barriers to implement OPAT/infusion services were lack of organisational structure or guidelines. In conclusion, DPANS with respect to availability and organisation is highly heterogeneous in Europe. National/European guidelines may help improve and standardise DPANS.

Outpatient parenteral antimicrobial therapy (OPAT) in the UK: findings from the BSAC National Outcomes Registry (2015-19).

Reporting of outpatient parenteral antimicrobial therapy (OPAT) outcomes with national benchmarking is key to informing service development and supporting quality improvement. To analyse and report on data collected by the BSAC OPAT National Outcomes Registry from 2015 to 2019. Quarterly data to 2020 was extracted from the BSAC National Outcomes Registry and analysed. 57 organizations submitted data on 27 841 patient episodes and 442 280 OPAT treatment days. A diverse range of infections and antimicrobials were reported with a mean OPAT treatment duration of 16.7 days (adults) and 7.7 days (paediatrics). In adults, the top five conditions treated were skin and soft tissue (27.6%), bronchiectasis (11.4%), urinary tract infections (7.6%), and diabetic foot infections (5.5%). Ceftriaxone followed by teicoplanin, ertapenem and piperacillin/tazobactam were the most-used antimicrobials. A median of 1.4 vascular-device-related complications were observed per 1000 OPAT treatment days (range 0.11 to 10.4) with device infections in 0.3 per 1000 OPAT days (range 0.1 to 1.7). Other adverse events (rash, blood dyscrasias, antibiotic-associated diarrhoea) were observed in a median of 1.9 per 1000 OPAT days. OPAT infection outcome (cured/improved) was 92.4% and OPAT outcome (success/partial success) was 90.7%. This report demonstrates the safety, breadth, and complexity of modern UK OPAT practice. Future analyses of OPAT data should focus on infection- and service-specific quality indicators. OPAT registries remain central to planning and assessing safe, effective, and efficient delivery of patient-centred care and should be an important focus for UK and global OPAT practice.

P15 Evaluation of the stability of temocillin in elastomeric infusion devices used for outpatient parenteral antimicrobial therapy in accordance with the requirements of the UK NHS Yellow Cover Document

BackgroundTo assess the feasibility of its use in OPAT via continuous infusion, the stability of temocillin solutions at clinically relevant concentrations in two elastomeric infusion devices (B. Braun Medical Ltd Easypump® II LT 270-27- S and Spirit Ltd Medical Dosi-Fuser® L25915-250D1) was evaluated during 14 days of (2°C–8°C) fridge storage followed by 24 h exposure in-use temperature at 32°C, when reconstituted with 0.3% citrate buffer at pH 7.MethodsStability testing was conducted in accordance with the standard protocols for deriving and assessment of stability of small molecule aseptic preparation as per the latest UK National Health Service Pharmaceutical Quality Assurance Committee Yellow Cover Document (YCD) requirements. A stability indicating assay method was developed with an ultra-HPLC (UHPLC) system using photodiode array detector. Temocillin concentrations corresponding to low (500 mg/240 mL), intermediate (4000 mg/240 mL) and high (6000 mg/240 mL) dose in triplicate devices were tested with duplicate samples at 11 timepoints during 14 days of fridge storage followed by 24 h in-use temperature exposure at 32°C.ResultsA total of 396 samples were collected and assayed. The percentage of temocillin remaining after 14 days of fridge storage was greater than 97% in both devices and at all concentrations tested. During in-use temperature, 95% stability limit was achieved for 12 h for all doses and devices tested except for the high concentration in the Dosi-Fuser® device, which met this criterion for only 10 h of in-use temperature exposure.ConclusionsTemocillin reconstituted with 0.3% citrate buffer at pH 7 in elastomeric infusion devices can be stored in a fridge (2°C–8°C) for 2 weeks, meeting the YCD acceptance criteria of <5% degradation. Within the UK, the current data supports twice daily dosing of temocillin with <5% degradation at in-use temperature of 32°C for 12 h, except at high dose (6000 mg/240 mL) in the Dosi-Fuser® device, which must be limited to 10 h. The limits of accepted degradation do vary in other countries. Temocillin is an important addition to the anti-Gram-negative OPAT armamentarium and may reduce reliance on other broader spectrum, higher consequence agents.

P33 Day 3 reviews led by pharmacy technicians—encouraging antimicrobial stewardship

BackgroundA documented 72 h antimicrobial review is a national target that we are expected to achieve at the Leeds Teaching Hospital. Current practice within LTHT provides a pharmacist-led antimicrobial stewardship ward round where IV antimicrobials are reviewed at Day 3 (72 h). Patients prescribed IV antimicrobials are reviewed within 72 h and a decision is made to continue, stop, switch to oral or refer to the outpatient parenteral antimicrobial therapy (OPAT) service. The Healthcare Associated Infection (HCAI) Annual Programme for this year highlights the importance of expanding antimicrobial stewardship within the pharmacy team. This presented an opportunity to develop a new antimicrobial stewardship strategy by leading a virtual pharmacy technician-led antimicrobial stewardship ward round. This allowed for a greater number of patients that were prescribed IV antimicrobials to reviewed and the potential for less patients to remain on broad-spectrum IV antimicrobials for extended durations.ProblemClinicians and pharmacists struggle to undertake this review due to the demands of the daily ward rounds and other reviews that take priority that are needed to ensure patients safety. The electronic prescribing system used within the trust prompts users to undertake Day 3 reviews; however, this is not utilized. This often leads to a greater number of patients remaining on broad-spectrum IV antimicrobials, alongside a lack of justification for remaining on IV antimicrobials despite robust, easily accessible guidelines, education, training and electronic systems.Assessment of problem and analysis of causesFirstly, it is a large teaching hospital that has a variation of different specialities and departments, a lot of patients and fewer people to do the reviews and large turnover of staff and patients. Antimicrobial stewardship is complex, everybody has a role to play in making sure that we use antibiotics appropriately and effectively as IV antibiotics can delay discharge, they are costly, the patients are at risk of line infection, they require IV access and they require more nursing time, so it is necessary to embed antimicrobial stewardship good practice principles throughout the trust and promote that everyone needs to play an active role in this. On identifying the problem, I gained feedback from the pharmacy technicians as to why this review could not be done by them; they reported a lack of knowledge of how to review eligibility of patients for oral switch and with the appropriate training this would be something that they would be happy to do within their daily tasks.MethodsOne pharmacy technician (specializing with infectious disease/pharmacy infection team) was appropriately trained to complete virtual reviews, utilizing an electronic LTHT IV antimicrobial reviewing tool which is available to upload to the patient's electronic records. Patients were identified using a daily antimicrobial prescribing list and filtered for those that had been prescribed IV antimicrobials for 3 days. This allowed for a variety of specialities to be included within the audit. Inclusion criteria: patients aged >16 years, inpatients prescribed IV antibiotics for 72 h. Exclusion criteria: patient aged <16 years, antimicrobial prescribed for the treatment of cystic fibrosis, patients prescribed directed antimicrobial therapy based on an infection specialist recommendation (not empirical treatment), those on oral antibiotics, prophylactic antimicrobials. Data were collected throughout the improvement projected as a baseline audit to understand the impact the intervention made, and results were collated and recorded into an Excel spreadsheet and processed:ResultsA total of 38 patients were included in the audit as having had IV antimicrobial reviews completed. Of these, 28 patients fitted the criteria for a switch from IV to oral antimicrobials and therefore recommendations reflecting this were documented. Advice to de-escalate to oral antimicrobials was followed for 20 patients resulting in a hospital discharge after 24 h. The other 10 patients were advised to continue IV treatment until more clinically stable (advice was followed for 9 patients). Overall recommendations were followed in 76% of cases.ConclusionsOverall, pharmacy technician-led antimicrobial virtual reviews have shown a positive impact on antimicrobial stewardship, by reducing the number of inappropriate IV antimicrobial continued beyond 3 days and ensuring that a greater number of clinical reviews have been documented for the empirical prescribing of IV antimicrobials. This project highlights the potential for a greater number of pharmacy technicians to get involved with IV antimicrobial reviews (once appropriately trained) to complete a small number of reviews weekly, which in turn could provide a reduction of inpatient bed days, decrease harm to patients through the prescribing of antimicrobials, decrease medication costs and improve patient care by facilitating discharge and safeguarding antimicrobials. Additionally, this could help to upskill staff, allowing for greater job satisfaction alongside improved antimicrobial stewardship within the trust.

Risk factors for readmission among patients receiving outpatient parenteral antimicrobial therapy: a retrospective cohort study

Background In the Netherlands, home treatment with intravenous antimicrobial therapy is a relatively new concept. Although several studies have shown that outpatient parenteral antimicrobial therapy (OPAT) can be administered safely, people receiving antimicrobials at home remain at risk for adverse events, including readmission. Aim The aim of our retrospective study was to identify risk factors for readmission in patients discharged with OPAT. Method Patients who were at least 18 years or older, discharged with OPAT between January 2016–December 2018 were included. Variables that were collected consisted of baseline demographics, complications, readmission within 30 days and treatment failure. Multivariate logistic regression analysis was performed to identify risk factors for readmission. Results A total of 247 patients were included; the most common reason for OPAT was bone and joint infections (17%). Penicillin (37%), cephalosporin (26%) and vancomycin/aminoglycoside (15%) were the most commonly prescribed antimicrobials. Among patients receiving medication subject to therapeutic drug monitoring (i.e. aminoglycosides or vancomycin), 51% (19/37) received weekly therapeutic drug monitoring. Receiving aminoglycosides or vancomycin (adjusted OR 2.05; 95% CI 1.30–3.25, p < 0.05) and infection of prosthetic material (adjusted OR 2.92, 95% CI 1.11–7.65, p < 0.05) were independent risk factors associated with readmission. Conclusion Although patients receiving medication subject to therapeutic drug monitoring are at higher risk of readmission, only half of the patients discharged with aminoglycosides or vancomycin were monitored according to IDSA guidelines. A specialized team in charge of monitoring patients with OPAT is more likely to increase the rate of monitoring to prevent readmissions and complications.

Community delivered outpatient parenteral antimicrobial therapy in Qatar

Background: For some time, paramedics and nurses of the National Ambulance Service in Qatar provided outpatient parenteral antimicrobial therapy (OPAT) to patients with the support of Family Physicians. Like in many other countries of the Middle East, there is a high prevalence of antimicrobial resistance which makes treating infectious conditions challenging. Methods: This is a retrospective cohort study of patients referred to the Ambulance Service – Mobile Healthcare Service from a public hospital acute facility for OPAT over 6 months in 2015. The study&apos;s primary aim is to determine whether the OPAT service had comparable outcomes to international reports with respect to unplanned hospital visits for acute care within 30 days of OPAT referral. A secondary aim of this work is to determine the effect of body fluid culture results on that outcome by comparing subgroups within the OPAT population, and the documentation of prevalence and types of antimicrobial resistance. Results: Between the 1st of March and the 30th of August 2015, 232 OPAT referrals were received. The most common referral diagnoses are reported in Table 1. Within 30 days of OPAT referral, 24.1% - 30.7% of patients required an unplanned hospital visit. This is at the high end of the range reported internationally for OPAT services.1,2 Patients with resistant bacterial infections isolated from body fluid cultures experienced the worst outcomes. The prevalence of significant drug resistance among OPAT referrals was 28.0%, mostly extended-spectrum β-lactamase (ESBL) production. Conclusion: OPAT can be provided in the community.3 The rate of return to hospital for acute care within 30 days of OPAT referral was relatively high, however much of this can be accounted for by patients with resistant infections. They had worse outcomes than patients with non-resistant infections or those treated on an empiric basis. The prevalence of antimicrobial resistance was comparable with other recent Middle Eastern reports.

Safety of prolonged outpatient courses of intravenous antibiotics: a prospective cohort study

ObjectivesThe perceived need for prolonged intravenous antibiotic courses has become a major driver behind the growth of outpatient parenteral antimicrobial therapy (OPAT) services. Several recent randomized controlled trials demonstrate noninferiority of an early switch to oral therapy and highlight the need to accurately quantify harms associated with OPAT. MethodsWe conducted a 10-year prospective cohort study in a tertiary hospital OPAT service. Adults admitted to the service between 1 June 2009 and 30 June 2019 who received an intravenous antimicrobial agent were included. Adverse events (AEs) attributable to intravenous antibiotics or intravenous access were recorded in a prospectively maintained database and analyzed. ResultsThere were 4160 admissions (median length of stay: 20 days) and a total of 88 432 patient-days of observation; 135 patients (3.3% of admissions) experienced at least one major AE (1.54 per 1000 patient-days; 95% CI, 1.29–1.82). The risk of a major AE peaked in the second week of OPAT admission, with acute kidney injury (43 of 136; 32%) and severe cytopenia (42 of 136; 31%) being the most common. At least one minor AE occurred in 38.3% of admissions (1592 of 4160; 26.4 per 1000 patient-days; 95% CI, 25.4–27.5), with central venous catheter-related complications accounting for 71% of AEs (1658 of 2338). DiscussionThe incidence of major AEs during long courses of intravenous antibiotics is low, peaking in week 2 and tailing off thereafter. These results should inform decisions concerning the choice of intravenous versus oral antimicrobials.

Survey of pharmacists on their roles and perceptions of outpatient parenteral antimicrobial therapy in the United States.

To define outpatient parenteral antimicrobial therapy (OPAT) clinical pharmacy practice across the United States, specifically pharmacist functions, design of pharmacist involvement, and to compare pharmacist training of those who practice in OPAT to infectious diseases pharmacists who do not. A survey of a possible 32 questions was emailed to the American College of Clinical Pharmacists (ACCP) Infectious Diseases Practice and Research Network (PRN) e-mail list. Results were focused on US-based respondents. In total, 87 pharmacists responded; 27 of these pharmacists (31%) practiced in OPAT. Training background did not differ between groups. Programs with an OPAT pharmacist were more likely to have a formal OPAT team compared to those without an OPAT pharmacist (P < .001). OPAT pharmacists were early in their careers with 66.7% practicing <5 years in OPAT. Most OPAT pharmacists (66.7%) practiced at an academic medical center with a median full-time equivalent (FTE) of 0.6. Moreover, 63% utilized a collaborative practice agreement and 81.5% shared job functions with other pharmacist roles, most commonly antimicrobial stewardship. Few OPAT programs involved a dispensing component (28%). The median daily census was 43 patients followed by an OPAT pharmacist. Pharmacists performed a variety of tasks in OPAT. Pharmacist nondispensing involvement in OPAT is an emerging trend in the United States with wide variability in program structure and pharmacist tasks. A ratio of 1 OPAT pharmacist for every 45-70 OPAT patients is proposed to facilitate expansion of pharmacist clinical practice in OPAT.

Improving care for individuals with serious infections who inject drugs.

Hospitalizations for serious infections requiring long-term intravenous (IV) antimicrobials related to injection drug use have risen sharply over the last decade. At our rural tertiary care center, opportunities for treatment of underlying substance use disorders were often missed during these hospital admissions. Once medically stable, home IV antimicrobial therapy has not traditionally been offered to this patient population due to theoretical concerns about misuse of long-term IV catheters, leading to discharges with suboptimal treatment regimens, lengthy hospital stays, or care that is incongruent with patient goals and preferences. A multidisciplinary group of clinicians and patients set out to redesign and improve care for this patient population through a health care innovation process, with a focus on increasing the proportion of patients who may be discharged on home IV therapy. Baseline assessment of current experience was established through retrospective chart review and extensive stakeholder analysis. The innovation process was based in design thinking and facilitated by a health care delivery improvement incubator. The components of the resulting intervention included early identification of hospitalized people who inject drugs with serious infections, a proactive psychiatry consultation service for addiction management for all patients, a multidisciplinary care conference to support decision making around treatment options for infection and substance use, and care coordination/navigation in the outpatient setting with a substance use peer recovery coach and infectious disease nurse for patients discharged on home IV antimicrobials. Patients discharged on home IV therapy followed routine outpatient parenteral antimicrobial therapy (OPAT) protocols and treatment protocols for addiction with their chosen provider. An intervention developed through a design-thinking-based health care redesign process improved patient-centered care for people with serious infections who inject drugs.

Current Status of Outpatient Parenteral Antimicrobial Therapy in Korea: Experience of a Single University-Affiliated Acute-Care Hospital.

Systematic protocols for the management of outpatient parenteral antimicrobial therapy (OPAT) and information on the current status of a prescription of parenteral antibiotics for outpatients and referred patients are lacking in the Korea. This study aimed to describe the current status of OPAT at a tertiary care hospital in Korea. This was a retrospective study of outpatients and referral patients who were prescribed parenteral antibiotics from July to December 2019. We reviewed the prescribed antimicrobials, indications for antimicrobial therapy, institution administering the antimicrobial injections, and pre- and post-prescription management. Of the 577 prescriptions assessed in this study, 399 (69.2%) and 178 (30.8%) were delivered using the referral and outpatient models, respectively. About 70% of OPATs were prescribed in the pulmonology, infectious diseases, orthopedics, gastroenterology, and hematology departments. Five antibiotics (ertapenem [26.0%], ceftriaxone [12.8%], kanamycin [11.8%], amikacin [10.1%], and cefazolin [8.5%]) accounted for 69.2% of the total OPATs. Urinary tract (27.3%), respiratory (20.8%), and intra-abdominal (15.9%) infections were the most frequent indications for OPAT. After prescription, there were 295 (73.9%) and 150 (84.3%) follow-up visits in the referral and outpatient models, respectively (P <0.05). Laboratory tests necessary for monitoring were fully performed for 274 (47.5%) prescriptions. We found that a significant number of OPATs were prescribed, follow-up visits were not performed in the case of about a quarter of prescriptions, and laboratory monitoring was not fully conducted in more than half of the cases. Therefore, it is necessary to establish an appropriate management program for OPAT. Considering the limited resources and the distribution of OPAT prescriptions, an effective strategy may be to select the frequently-used antibiotics or frequently-prescribing departments and start the program with them.

Clinical outcomes following dalbavancin administration in patients with barriers to outpatient parenteral antimicrobial therapy.

Between 2016 and 2021, we retrospectively identified 42 patients receiving ≥1 dose of dalbavancin for osteomyelitis, skin and soft-tissue infection, endocarditis or bacteremia, or septic arthritis. Median antibiotic duration prior to dalbavancin administration was 7 days. Within 90 days, 93% achieved clinical cure, 12% were readmitted, 12% developed hepatotoxicity, and 5% died.

A Single Centre Experience of Prosthetic Joint Infection Outcomes with Outpatient Parenteral Antimicrobial Therapy

A Single Centre Experience of Prosthetic Joint Infection Outcomes with Outpatient Parenteral Antimicrobial Therapy

Assessment of risk factors associated with outpatient parenteral antimicrobial therapy (OPAT) complications: A retrospective cohort study

To characterize factors associated with increased risk of outpatient parenteral antimicrobial therapy (OPAT) complication. Retrospective cohort study. Four hospitals within NYU Langone Health (NYULH). All patients aged ≥18 years with OPAT episodes who were admitted to an acute-care facility at NYULH between January 1, 2017, and December 31, 2020, who had an infectious diseases consultation during admission. Overall, 8.45% of OPAT patients suffered a vascular complication and 6.04% suffered an antimicrobial complication. Among these patients, 19.95% had a 30-day readmission and 3.35% had OPAT-related readmission. Also, 1.58% of patients developed a catheter-related bloodstream infection (CRBSI). After adjusting for key confounders, we found that patients discharged to a subacute rehabilitation center (SARC) were more likely to develop a CRBSI (odds ratio [OR], 4.75; P = .005) and to be readmitted for OPAT complications (OR, 2.89; P = .002). Loss to follow-up with the infectious diseases service was associated with increased risks of CRBSI (OR, 3.78; P = .007) and 30-day readmission (OR, 2.59; P < .001). Discharge to an SARC is strongly associated with increased risks of readmission for OPAT-related complications and CRBSI. Loss to follow-up with the infectious diseases service is strongly associated with increased risk of readmission and CRBSI. CRBSI prevention during SARC admission is a critically needed public health intervention. Further work must be done for patients undergoing OPAT to improve their follow-up retention with the infectious diseases service.

Design and protocol of the Buprenorphine plus Outpatient Parenteral Antimicrobial Therapy (B-OPAT) study: a randomized clinical trial of integrated outpatient treatment of opioid use disorder and severe, injection-related infections.

Introduction:A marked increase in hospitalizations for severe, injection-related infections (SIRI) has been associated with the opioid epidemic. Outpatient parenteral antibiotic therapy (OPAT) is typically not offered to persons with opioid use disorder (OUD) and SIRI, though increasing evidence suggests it may be feasible and safe. This study evaluates the efficacy and cost-effectiveness of an integrated care model combining Buprenorphine treatment of OUD with OPAT for SIRI (B-OPAT) compared with treatment as usual on key OUD, infectious disease, and health economic outcomes. B-OPAT expands and incorporates key elements of established clinical models, including inpatient initiation of buprenorphine for OUD, inpatient infectious disease consultation for SIRI, office-based treatment of OUD, and OPAT, and includes more frequent clinical outpatient visits than standard OPAT. A qualitative evaluation is included to contextualize effectiveness outcomes and identify barriers and facilitators to intervention adoption and implementation.Methods:B-OPAT is a single-site, randomized, parallel-group, superiority trial recruiting 90 adult inpatients hospitalized with OUD and SIRI who require at least 2 weeks of intravenous (IV) antibiotic therapy. After screening, eligible participants are randomized 1:1 to either discharge once medically stable to an integrated outpatient treatment care model combining Buprenorphine and OPAT (B-OPAT) or to Treatment As Usual (TAU). The primary outcome measure is the proportion of urine samples negative for illicit opioids in the 12 weeks after discharge from the hospital. Key secondary OUD outcomes include self-reported number of days of illicit opioid abstinence and 12-week retention in buprenorphine treatment. The infection outcomes are completion of recommended IV antibiotic therapy, peripherally inserted central catheter (PICC) complications, and readmission related to primary SIRI.Conclusions:The B-OPAT study will help address the important question of whether it is clinically effective and cost-effective to discharge persons with OUD and SIRI to an integrated outpatient care model combining OUD treatment with OPAT relative to TAU (Clinicaltrials.gov Identifier: NCT04677114).