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 •

Intravenous access

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