Outpatient Parenteral Antimicrobial Therapy
Joanna Allen
Leeds Teaching Hospitals NHS Trust
September 2016
OPAT
• ‘The administration of intravenous antimicrobial
therapy to patients in an outpatient facility or in
their home’
OPAT • Severe infections e.g. cellulitis
• Deep-seated infections e.g. infective endocarditis
• Resistant organisms with limited oral options e.g.
complicated UTI with ESBL-producing organisms
• Where oral therapy cannot be absorbed or
tolerated
Models of Service
• Community-based
• Hospital-based
• Self or carer administered Mixed
Leeds CIVAS • Email referral by specialty doctor
• Outpatient referrals via established pathways
• Review by CIVAS specialist nurse and senior ID
doctor
• Treatment plan
• Referral to community
nursing team
• Blood test monitoring
• Virtual Ward Round
• Follow-up
Leeds CIVAS Inclusion
• Clinically stable
• No other indication to remain in hospital/be admitted
• Feasible outpatient antimicrobial option
• Patient happy to be treated with OPAT
Exclusion
• Clinically unstable
• Non-compliant with
treatment
• Alcohol/drug abuse
• Homeless
• Outside of area
Indications Cellulitis
• Various different settings/models
• Doctor or nurse-led
• Requires daily clinical review
Indications Bone and joint infections
• Spinal infection
• Prosthetic joint infection
• Native septic arthritis
• Post-op infections
• Diabetic foot infection
Indications Infective endocarditis
• Low risk uncomplicated IE
• Native valve or low virulence organism
• Selected complex/prosthetic valve IE
Neurological infections
• Meningitis
• HSV Encephalitis
• Brain abscess
• Post op
Indications Respiratory
• MDR TB
• Non-TB mycobacterial
infections
• Cystic fibrosis/bronchiectasis
• Pulmonary aspergillosis
• Chronic empyema
• Actinomycosis
Indications • Necrotising otitis externa
• Resistant/complex UTI
• Prostatitis
• Line infections
• Vascular graft infections
• Complex post-operative infections
• Enteric fever
Antimicrobials •
Administration • Bolus – drug/dilutent mixed, given via syringe
• Bolus - pre-filled
• Short infusion - diluent bag and flow-restriction
device
• Prolonged infusion
o Infusion pump
o Elastomeric device
Elastomeric Devices
Benefits of OPAT • Comparable efficiency and safety to hospital-
based therapy
• Better patient satisfaction
• Reduced length of stay
• Admission avoidance
• Reduced HAI
• Reduced cost
• Infection specialist review
Corwin et al. BMJ 2005;330:129-32. Jones et al. JAC. Sharma , et al. Am J Med Sci 2005;330:60-4. Heintz BH, et al. Ann Pharmacother 2011;45:1329-37.Shrestha NK, J Hosp Med 2012;7:365-9.
Leeds CIVAS Q1 2016
• 86 patients referred
• 55 patients started CIVAS
• 1034 bed days saved (18.8 days/pt)
Antimicrobial Stewardship
Suitability Audit • 603 patients audited
• 109 (18% on antimicrobials)
• 3 referred, 15 not referred
0 10 20 30 40 50 60 70 80 90
Unclear diagnosis
Unstable patient
Unmet care needs
Substance abuse
Homeless/hostel resident
The Future • Lack of available stability data for drugs
• BSAC stability work stream - investigating up to 4
drugs/year
• Development of better pathways
• ?Telemedicine
Conclusions
• Think OPAT!
• Regimes can be constructed for most infections
• Talk to your OPAT service…..
Thank you • CIVAS team Leeds
• Jane Minton
• Fiona Byrne
• Kelly Atack