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Schwiebert DR, Atanze DS, Iroegbu DU, Wilkins DM, Sandoe DJAT. Outpatient parenteral antibiotic treatment for infective endocarditis: A retrospective observational evaluation. Clin Med (Lond) 2024; 24:100213. [PMID: 38643831 PMCID: PMC11101910 DOI: 10.1016/j.clinme.2024.100213] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2024] [Accepted: 02/23/2024] [Indexed: 04/23/2024]
Abstract
BACKGROUND Infective endocarditis (IE) requires long courses of intravenous (IV) antibiotics. Outpatient parenteral antibiotic therapy (OPAT) saves resources, improves the patient experience and allows care in their preferred place; however, questions remain about safety when treating IE patients. This study evaluates OPAT management of IE patients in our region between 2006 and 2019. METHODS This is a retrospective observational evaluation and description of outcomes and adherence to suitability criteria, according to British Society for Antimicrobial Chemotherapy (BSAC) guidelines. RESULTS We identified five models of OPAT delivery. The number of patients treated expanded significantly over time. Of 101 patients, six (6%) suffered poor outcomes, but each patient had contributing factors outside of the primary infection. Median OPAT duration was 12 days and 1,489 hospital bed days were saved. CONCLUSIONS In a setting where there was good adherence to BSAC criteria, treating IE patients using OPAT services was safe. Complications observed were likely independent of treatment location. Significant bed days were saved.
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Affiliation(s)
- Dr Ralph Schwiebert
- Department of Microbiology, Leeds Teaching Hospitals NHS Trust, Leeds, England, United Kingdom.
| | - Dr Sokolayam Atanze
- Department of Microbiology, Leeds Teaching Hospitals NHS Trust, Leeds, England, United Kingdom
| | - Dr Uchechika Iroegbu
- Department of Microbiology, Leeds Teaching Hospitals NHS Trust, Leeds, England, United Kingdom
| | - Dr Molly Wilkins
- Department of Anaesthesia and Intensive Care Medicine, Countess of Chester Hospital, Chester, England, United Kingdom
| | - Dr Jonathan A T Sandoe
- Department of Microbiology, Leeds Teaching Hospitals NHS Trust, Leeds, England, United Kingdom; Leeds Institute of Medical Research, University of Leeds, Leeds, England, United Kingdom
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2
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Kalatharan L, Ferman M, Kumar S, Rajendra S, Pripanapong S, Wu Y, Richards H, Rogers BA. Use of Ceftriaxone and Benzylpenicillin in Outpatient Parenteral Antimicrobial Therapy: Spectrum vs Cost. Open Forum Infect Dis 2023; 10:ofad505. [PMID: 37965641 PMCID: PMC10641299 DOI: 10.1093/ofid/ofad505] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2023] [Accepted: 10/04/2023] [Indexed: 11/16/2023] Open
Abstract
Background The application of antimicrobial stewardship (AMS) principles may entail increased cost to allow for narrower-spectrum therapy. Prescribing benzylpenicillin (BP) and ceftriaxone (CRO) for outpatient parenteral antimicrobial therapy (OPAT) demonstrates the complex challenge of this principle. The aim of this study is to analyze the use of BP and CRO in our OPAT program, including indications and relative cost. Methods We analyzed all adult patients in our OPAT program who received intravenous BP or CRO over 1 year. We identified a "crossover group" of patients who could have received either agent. Economic comparison was based on acquisition cost of the therapy (drug, infuser, and preparation costs). Results Of 105 eligible patients, 54 (51%) and 51 (49%) received BP and CRO, respectively. Forty (38%) patients were suitable for either agent; of these, the majority (n = 31, 78%) were treated with BP. Economic analysis demonstrated that the average daily cost of BP therapy was $93.76/d (AUD) vs $1.23/d for CRO. Thus, across our OPAT programs, we had an additional average cost of $92.53/patient/d to use BP instead of CRO. Program-wide the annual additional cost of using BP and thus applying this AMS strategy was $68 386.12. Conclusions BP is often selected over CRO by clinicians, where possible, as recommended by the Australian guidelines; however, BP is associated with higher daily acquisition costs. More broadly, a number of narrower-spectrum agents may involve significantly higher costs than comparators; as such, the $92.53/d to prevent CRO exposure can be considered when applying other antimicrobial-substitution AMS interventions in an acute health care setting.
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Affiliation(s)
- L Kalatharan
- Hospital in the Home, Monash Health, Clayton, Victoria, Australia
| | - M Ferman
- Hospital in the Home, Monash Health, Clayton, Victoria, Australia
| | - S Kumar
- Hospital in the Home, Monash Health, Clayton, Victoria, Australia
| | - S Rajendra
- Department of Pharmacy, Monash Health, Clayton, Victoria, Australia
| | - S Pripanapong
- Hospital in the Home, Monash Health, Clayton, Victoria, Australia
| | - Y Wu
- Hospital in the Home, Monash Health, Clayton, Victoria, Australia
| | - H Richards
- Hospital in the Home, Monash Health, Clayton, Victoria, Australia
| | - B A Rogers
- Hospital in the Home, Monash Health, Clayton, Victoria, Australia
- Centre for Inflammatory Diseases, School of Clinical Sciences at Monash Health, Monash University, Clayton, Victoria, Australia
- Monash Infectious Diseases, Monash Health, Clayton, Victoria, Australia
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3
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Campbell PO, Gallagher K, Dalton SC, Metcalf SCL, Douglas NM, Chambers ST. Safety and clinical outcomes of outpatient parenteral antibiotic therapy for infective endocarditis in Christchurch, New Zealand: A retrospective cohort study. Int J Infect Dis 2023; 134:172-176. [PMID: 37331565 DOI: 10.1016/j.ijid.2023.06.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2023] [Revised: 06/06/2023] [Accepted: 06/09/2023] [Indexed: 06/20/2023] Open
Abstract
OBJECTIVES We examined the safety and clinical outcomes of outpatient parenteral antibiotic therapy (OPAT) for patients with infective endocarditis (IE) in Christchurch, New Zealand. METHODS Demographic and clinical data were collected from all adult patients treated for IE over 5 years. Outcomes were stratified by receipt of at least partial OPAT vs entirely hospital-based parenteral therapy. RESULTS There were 172 episodes of IE between 2014 and 2018. OPAT was administered in 115 cases (67%) for a median of 27 days after a median of 12 days of inpatient treatment. In the OPAT cohort, viridans group streptococci were the commonest causative pathogens (35%) followed by Staphylococcus aureus (25%) and Enterococcus faecalis (11%). There were six (5%) antibiotic-related adverse events and 26 (23%) readmissions in the OPAT treatment group. Mortality in OPAT patients was 6% (7/115) at 6 months and 10% (11/114) at 1 year and for patients receiving wholly inpatient parenteral therapy was 56% (31/56) and 58% (33/56), respectively. Three patients (3%) in the OPAT group had a relapse of IE during the 1-year follow-up period. CONCLUSION OPAT can be used safely in patients with IE, even in selected cases with complicated or difficult-to-treat infections.
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Affiliation(s)
- Patrick O Campbell
- Department of Infectious Diseases, Christchurch Hospital, Te Whatu Ora Waitaha Canterbury, New Zealand.
| | - Kate Gallagher
- Department of Infectious Diseases, Christchurch Hospital, Te Whatu Ora Waitaha Canterbury, New Zealand
| | - Simon C Dalton
- Department of Infectious Diseases, Christchurch Hospital, Te Whatu Ora Waitaha Canterbury, New Zealand
| | - Sarah C L Metcalf
- Department of Infectious Diseases, Christchurch Hospital, Te Whatu Ora Waitaha Canterbury, New Zealand
| | - Nicholas M Douglas
- Department of Infectious Diseases, Christchurch Hospital, Te Whatu Ora Waitaha Canterbury, New Zealand; Division of Medicine, University of Otago, Christchurch, New Zealand; Division of Global and Tropical Health, Menzies School of Health Research, Charles Darwin University, Darwin, Australia
| | - Stephen T Chambers
- Department of Infectious Diseases, Christchurch Hospital, Te Whatu Ora Waitaha Canterbury, New Zealand; Department of Pathology and Biomedical Science, University of Otago, Christchurch, New Zealand
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Kilinc F, Setzer M, Behmanesh B, Jussen D, Gessler F, Keil F, Kempf VAJ, Kessel J, Czabanka M, Prinz V. Safety and feasibility of outpatient parenteral antimicrobial therapy for patients with spinal infection. Sci Rep 2023; 13:6863. [PMID: 37100824 PMCID: PMC10133347 DOI: 10.1038/s41598-023-33502-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2022] [Accepted: 04/13/2023] [Indexed: 04/28/2023] Open
Abstract
Outpatient parenteral antimicrobial therapy (OPAT) is a cost-effective method of administering intravenous antimicrobial therapy. Although OPAT is well established in the UK and US healthcare systems, few centres in Europe perform it. Here we analysed OPAT for the treatment of patients with spinal infections at our institution. In this retrospective study, patients with spinal infection who required intravenous (i.v.) antimicrobial treatment between 2018 and 2021 were analysed. The duration of short-term antimicrobial treatment for skin and soft tissue infections and complex infections requiring long-term antimicrobial treatment, such as spinal bone or joint infections, were analysed. All patients were discharged with a peripherally inserted central catheter (PICC) line. Prior to discharge, all patients received training in the safe administration of their medications via the PICC line. The duration of OPAT and the rate of readmission after OPAT were analysed. For this study a total of 52 patients who were treated via OPAT due to spinal infections were analyzed. In 35 cases (69.2%) complex spinal infection was reason for i.v. antimicrobial therapy. Surgery was required in 23 of these 35 patients (65.7%). The average hospital stay for these patients was 12 ± 6 days. The remaining 17 patients were treated for an infection of the soft tissue or the skin and hospital stay for these patients was on average 8 ± 4 days. Gram-positive organisms were isolated in 64.4%. Staphylococcus aureus followed by other Staphylococcus species, was the most common detected organism. After discharging i.v. antimicrobial treatment was given for an average of 20 ± 14 days. The duration of antimicrobial treatment for soft tissue was 10.8 ± 8 days, and for complex infections 25.1 ± 18 days. The mean follow-up was 21 ± 14 months. There was one case of readmission due to treatment failure. There were no difficulties encountered in implementing OPAT. OPAT is a feasible and effective option for delivering intravenous antimicrobial therapy to patients with spinal infections who can be managed without hospitalisation. OPAT offers patient-centred treatment at home while avoiding the risks associated with hospitalisation, with high levels of patient satisfaction.
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Affiliation(s)
- Fatma Kilinc
- Department of Neurosurgery, Goethe University Hospital, Schleusenweg 2-16, 60528, Frankfurt Am Main, Germany.
| | - Matthias Setzer
- Department of Neurosurgery, Goethe University Hospital, Schleusenweg 2-16, 60528, Frankfurt Am Main, Germany
| | - Bedjan Behmanesh
- Department of Neurosurgery, University Medicine of Rostock, Rostock, Germany
| | - Daniel Jussen
- Department of Neurosurgery, Goethe University Hospital, Schleusenweg 2-16, 60528, Frankfurt Am Main, Germany
| | - Florian Gessler
- Department of Neurosurgery, University Medicine of Rostock, Rostock, Germany
| | - Fee Keil
- Department of Diagnostic and Interventional Radiology, Goethe University Hospital Frankfurt, Frankfurt Am Main, Germany
| | - Volkhard A J Kempf
- Department of Medical Microbiology, Goethe University Hospital, Frankfurt Am Main, Germany
| | - Johanna Kessel
- Department of Medicine, Infectious Diseases Unit, Goethe University Hospital, Frankfurt Am Main, Germany
| | - Marcus Czabanka
- Department of Neurosurgery, Goethe University Hospital, Schleusenweg 2-16, 60528, Frankfurt Am Main, Germany
| | - Vincent Prinz
- Department of Neurosurgery, Goethe University Hospital, Schleusenweg 2-16, 60528, Frankfurt Am Main, Germany
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Pericàs JM, Llopis J, Muñoz P, González-Ramallo V, García-Leoni ME, de Alarcón A, Luque R, Fariñas MC, Goenaga MÁ, Hernández-Meneses M, Nicolás D, Ramos-Martínez A, Rodríguez-Esteban MÁ, Villoslada-Gelabert A, Miró JM. Outpatient Parenteral Antibiotic Treatment (OPAT) vs. Hospitalization for Infective Endocarditis: Validation of the OPAT-GAMES criteria. Open Forum Infect Dis 2022; 9:ofac442. [PMID: 36172059 PMCID: PMC9512706 DOI: 10.1093/ofid/ofac442] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2022] [Accepted: 08/27/2022] [Indexed: 11/13/2022] Open
Abstract
Abstract
Background
Outpatient parenteral antibiotic treatment (OPAT) programs are increasingly used to manage infective endocarditis (IE), but current criteria for indicating OPAT are markedly conservative. We aimed to investigate whether more liberal criteria for indicating OPAT in IE can be safely used.
Methods
Prospective multi-center nationwide cohort study (2008-2018). Rates of readmission, significant sequelae, recurrences, and 1-year mortality were compared between hospital-based antibiotic treatment (HBAT) and OPAT. Risk factors for readmission and mortality in OPAT patients were investigated by logistic regression. Patients did not fulfill OPAT-GAMES (Grupos de Apoyo al Manejo de la Endocarditis en ESpaña) criteria if any of the following: cirrhosis, severe CNS emboli, undrained abscesses, severe conditions requiring cardiac surgery in non-operable patients, severe post-surgical complications, highly-difficult-to-treat microorganisms, and intravenous drug use.
Results
2279 HBAT patients and 1268 OPAT patients were included. Among OPAT patients, 307 (24.2%) did not fulfill OPAT-GAMES criteria. Overall, OPAT patients presented higher rates of readmissions than HBAT patients (18.2% vs.14.4%; P = 0.004), but no significant differences were found in the propensity analysis. Patients not fulfilling OPAT-GAMES criteria presented significantly higher rates of readmission than HBAT and OPAT-GAMES (23.8%, 14.4%, 16.4%; P < 0.001), whereas no significant differences were found in mortality (5.9%, 8%, 7.4%; P = 0.103) and recurrences (3.9%, 3.1%, 2.5%; P = 0.546). Not fulfilling OPAT-GAMES criteria was associated with higher risk of readmission (OR 1.43, 95%CI 1.03-1.97; P = 0.03), whereas cardiac surgery was associated to lower risk (OR 0.72, 95%CI 0.53-0.98; P = 0.03).
Conclusions
OPAT-GAMES criteria allow identifying IE patients at higher risk of long-term complications to whom OPAT cannot be safely adminitered.
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Affiliation(s)
- Juan M Pericàs
- Hospital Clínic de Barcelona, Institut de Recerca Augusti Pi i Sunyer, Universitat de Barcelona , Barcelona , Spain
- Liver Unit, Internal Medicine Deparment, Vall d’Hebron University Hospital, Vall d’Hebron Institute for Research, CIBER Enfermedades Hepáticas y Digestivas (CIBERehd) , Barcelona , Spain
| | - Jaume Llopis
- Hospital Clínic de Barcelona, Institut de Recerca Augusti Pi i Sunyer, Universitat de Barcelona , Barcelona , Spain
- Department of Genetics, Microbiology and Statistics, University de Barcelona , Spain
| | - Patricia Muñoz
- Hospital General Universitario Gregorio Marañón. Instituto de Investigación Sanitaria Gregorio Marañón. CIBER Enfermedades Respiratorias-CIBERES (CB06/06/0058) , Madrid , Spain
| | - Víctor González-Ramallo
- Hospital General Universitario Gregorio Marañón. Instituto de Investigación Sanitaria Gregorio Marañón. CIBER Enfermedades Respiratorias-CIBERES (CB06/06/0058) , Madrid , Spain
| | - M Eugenia García-Leoni
- Hospital General Universitario Gregorio Marañón. Instituto de Investigación Sanitaria Gregorio Marañón. CIBER Enfermedades Respiratorias-CIBERES (CB06/06/0058) , Madrid , Spain
| | - Arístides de Alarcón
- Clinical Unit of Infectious Diseases, Microbiology and Preventive Medicine Infectious Diseases Research Group. Institute of Biomedicine of Seville (IBIS), University of Seville/CSIC/University Virgen del Rocío and Virgen Macarena . Seville , Spain
| | - Rafael Luque
- Clinical Unit of Infectious Diseases, Microbiology and Preventive Medicine Infectious Diseases Research Group. Institute of Biomedicine of Seville (IBIS), University of Seville/CSIC/University Virgen del Rocío and Virgen Macarena . Seville , Spain
| | - M Carmen Fariñas
- Hospital Universitario Marqués de Valdecilla. Universidad de Cantabria , Santander , Spain
| | | | - Marta Hernández-Meneses
- Hospital Clínic de Barcelona, Institut de Recerca Augusti Pi i Sunyer, Universitat de Barcelona , Barcelona , Spain
| | - David Nicolás
- Hospital Clínic de Barcelona, Institut de Recerca Augusti Pi i Sunyer, Universitat de Barcelona , Barcelona , Spain
| | - Antonio Ramos-Martínez
- Unidad de Enfermedades Infecciosas. Servicio de Medicina Interna. Universitario Puerta de Hierro. Majadahonda . Madrid , Spain
| | | | - Aroa Villoslada-Gelabert
- Servicio de Medicina Interna-Enfermedades Infecciosas. Hospital Son Llàtzer, Palma de Mallorca, Balearic Islands , Spain
| | - José M Miró
- Hospital Clínic de Barcelona, Institut de Recerca Augusti Pi i Sunyer, Universitat de Barcelona , Barcelona , Spain
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6
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Wen W, Li H, Wang C, Chen C, Tang J, Zhou M, Hong X, Cheng Y, Wu Q, Zhang X, Feng Z, Wang M. Efficacy and safety of outpatient parenteral antibiotic therapy in patients with infective endocarditis: a meta-analysis. REVISTA ESPANOLA DE QUIMIOTERAPIA : PUBLICACION OFICIAL DE LA SOCIEDAD ESPANOLA DE QUIMIOTERAPIA 2022; 35:370-377. [PMID: 35652306 PMCID: PMC9333124 DOI: 10.37201/req/011.2022] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVE To investigate the clinical outcome of patients with infective endocarditis (IE) during and after outpatient parenteral antimicrobial treatment (OPAT), and to further clarify the safety and efficacy of OPAT for IE patients. METHODS Through December 20, 2021, a total of 331 articles were preliminarily searched in Pubmed, Web of Science, Cochrane Library and Embase, and 9 articles were eventually included in this study. RESULTS A total of 9 articles comprising 1,116 patients were included in this study. The overall mortality rate of patients treated with OPAT was 0.04 (95% CI, 0.02-0.07), that means 4 deaths per 100 patients treated with OPAT. Separately, mortality was low during the follow-up period after OPAT treatment, with an effect size (ES) of 0.03 (95%CI, 0.02-0.07) and the mortality of patients during OPAT treatment was 0.04 (95% CI, 0.01-0.12). In addition, the readmission rate was found to be 0.14 (95% CI, 0.09-0.22) during the follow-up and 0.18 (95% CI, 0.08-0.39) during treatment, and 0.16 (95% CI, 0.10-0.24) for patients treated with OPAT in general. Regarding the relapse of IE in patients, our results showed a low overall relapse rate, with an ES of 0.03 (95% CI, 0.01-0.05). In addition, we found that the incidence of adverse events was low, with an ES of 0.26 (95% CI, 0.19-0.33). CONCLUSIONS In general, the incidence of adverse events and mortality, readmission, and relapse rates in IE patients treated with OPAT are low both during treatment and follow-up period after discharge, indicating that OPAT is safe and effective for IE patients. However, our study did not compare routine hospitalization as a control group, so conclusions should be drawn with caution. In order to obtain more scientific and rigorous conclusions and reduce clinical risks, it is still necessary to conduct more research in this field and improve the patient selection criteria for OPAT treatment, especially for IE patients. Finally, clinical monitoring and follow-up of OPAT-treated patients should be strengthened.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | - M Wang
- Mingwei Wang, MD, PhD, Hangzhou Institute of Cardiovascular Diseases, Affiliated Hospital of Hangzhou Normal University, Hangzhou Normal University, Hangzhou, 310015, China.
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Durojaiye OC, Morgan R, Chelaghma N, Kritsotakis EI. Clinical predictors of outcome in patients with infective endocarditis receiving outpatient parenteral antibiotic therapy (OPAT). J Infect 2021; 83:644-649. [PMID: 34614400 DOI: 10.1016/j.jinf.2021.09.021] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2020] [Revised: 04/23/2021] [Accepted: 09/07/2021] [Indexed: 02/01/2023]
Abstract
OBJECTIVES Outpatient parenteral antimicrobial therapy (OPAT) is increasingly used to treat infective endocarditis (IE) with documented success. This study aims to identify risk factors for treatment failure and poor outcomes in patients with IE treated through OPAT. METHODS We conducted a retrospective analysis of all episodes of IE treated over 13 years (September 2006 - September 2019) at a large teaching hospital in Sheffield, UK. We defined OPAT failure as unplanned readmission or death within 30 days of discharge from the OPAT service. Major adverse cardiac events (MACE) were defined as a composite of IE-related death, cardiac surgery, and recurrence of IE within the first year of completion of OPAT. RESULTS Overall, 168 episodes of IE were reviewed. OPAT failure and MACE occurred in 44 episodes (26.2%) and 29 episodes (17.3%) respectively. On multivariable analysis, pre-existing renal failure (adjusted odds ratio [aOR], 3.00; 95% confidence interval [CI], 1.08-8.30; P = 0.034) and Charlson comorbidity score (aOR, 1.29 per unit increase; 95% CI, 1.06-1.57; P = 0.011) were associated with increased risk of failure. Previous endocarditis (aOR, 3.60; 95% CI, 1.49-8.70; P = 0.004) and cardiac complications (aOR, 3.85; 95% CI, 1.49-9.93; P = 0.005) were risk factors for MACE, whereas cardiac surgery during the initial hospitalisation for IE (aOR, 0.34; 95% CI, 0.12-0.22; P < 0.001) was a protective factor. CONCLUSIONS Our findings suggest that OPAT is safe and effective for completing antibiotic treatment for IE, including cases deemed to be at increased risk of complications. However, careful patient selection and monitoring of patients with pre-existing comorbidities and cardiac complications are recommended to optimise clinical outcomes.
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Affiliation(s)
- Oyewole Chris Durojaiye
- Department of Infection and Tropical Medicine, Royal Hallamshire Hospital, Sheffield S10 2JF, United Kingdom; Department of Microbiology, Royal Derby Hospital, Derby DE22 3NE, United Kingdom.
| | - Robin Morgan
- Department of Infection and Tropical Medicine, Royal Hallamshire Hospital, Sheffield S10 2JF, United Kingdom.
| | - Naziha Chelaghma
- Department of Cardiology, University Hospitals of Derby and Burton NHS Foundation Trust, Burton-on-Trent, Staffordshire DE13 0RB, United Kingdom.
| | - Evangelos I Kritsotakis
- Laboratory of Biostatistics, School of Medicine, University of Crete, Heraklion 71003, Greece; School of Health and Related Research, Faculty of Medicine, Dentistry and Health, The University of Sheffield, Sheffield, United Kingdom.
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8
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Cost minimization analysis of outpatient parenteral/oral antibiotic therapy at a trauma hospital: Public health system. Infect Control Hosp Epidemiol 2021; 42:1445-1450. [PMID: 33618784 DOI: 10.1017/ice.2021.22] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
OBJECTIVE To evaluate the impact of outpatient parenteral antimicrobial therapy (OPAT) on a public hospital in a middle-income country. DESIGN A retrospective, observational study analyzing the economic data retrieved on the dehospitalization of patients on antibiotic therapy. SETTING Public university trauma hospital. PATIENTS Data were collected from June 2017 to May 2020. Antibiotic cost, hospital length of stay, and risk of multidrug-resistant (MDR) infection or colonization were reviewed, along with the break-even point at which a balance occurs between OPAT antimicrobial costs and all in-hospital costs. A cumulative risk curve was constructed showing the incidence of MDR during the review period. RESULTS In total, 225 patients were studied. The implementation of OPAT resulted in a reduction of $156,681 (49.6%), which is equivalent to an average of $696 per patient, as well as a shortened length of stay, from 33.5 to 15.7 days. OPAT reduces the risk of acquiring infection by MDR bacteria by having the final treatments administered outside of the hospital environment. The breakeven curves, comparing the duration of the OPAT to daily medication costs, allowed for the prediction of the time and dollar costs of antibiotic therapy. CONCLUSIONS OPAT presented a significant cost savings, shortened length of stay, and reduced risk of contamination of patients by MDR.
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9
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Garcia-Carretero R, Vazquez-Gomez O, Rodriguez-Maya B, Naranjo-Mansilla G, Luna-Heredia E. Infective Endocarditis in a Hospital-at-Home Setting: A Retrospective Analysis in a Peripheral Spanish Hospital. HOME HEALTH CARE MANAGEMENT AND PRACTICE 2021. [DOI: 10.1177/1084822320988513] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Infective endocarditis (IE) is a severe condition with high morbidity and mortality, and it requires long-term suppressive antibiotic therapy. Outpatient parenteral antimicrobial therapy (OPAT) has been used for a range of infectious diseases for more than 30 years, and in Spain it is used in hospital-at-home (HaH) settings. Our objectives were to describe and characterize the demographic, clinical, and microbiological features of patients admitted to an HaH setting and to assess the safety and effectiveness of OPAT. We conducted a retrospective study that included patients diagnosed with IE over a period of 8 years (2011-2018). We collected demographic and clinical features, length of hospital stay, antimicrobial treatment, microbiological profiles, and outcomes. We included 26 patients during the observation period. Their mean age was 66.5 years, and 88.5% were male. The mean hospital stay was 10.5 days, and the mean stay in the HaH setting was 31 days. A total of 6 patients required readmission due to deterioration, of whom 3 had severe mitral insufficiency. The 8 patients had symptoms of heart failure, but they were treated at home and did not require readmission. Ultimately, 12 patients recovered and were referred to a surgical unit for valvular repair and replacement on a scheduled basis. OPAT is a useful and effective tool for the management of patients diagnosed with IE in HaH settings.
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Affiliation(s)
- Rafael Garcia-Carretero
- Department of Internal Medicine, Mostoles University Hospital, Rey Juan Carlos University, Mostoles, Spain
| | - Oscar Vazquez-Gomez
- Department of Internal Medicine, Mostoles University Hospital, Rey Juan Carlos University, Mostoles, Spain
| | - Belen Rodriguez-Maya
- Department of Internal Medicine, Mostoles University Hospital, Rey Juan Carlos University, Mostoles, Spain
| | - Gema Naranjo-Mansilla
- Department of Internal Medicine, Mostoles University Hospital, Rey Juan Carlos University, Mostoles, Spain
| | - Esther Luna-Heredia
- Department of Internal Medicine, Mostoles University Hospital, Rey Juan Carlos University, Mostoles, Spain
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10
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Wo S, Dubrovskaya Y, Siegfried J, Papadopoulos J, Jen SP. Clinical Outcomes of Ceftriaxone vs Penicillin G for Complicated Viridans Group Streptococci Bacteremia. Open Forum Infect Dis 2020; 8:ofaa542. [PMID: 33511221 PMCID: PMC7817077 DOI: 10.1093/ofid/ofaa542] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2020] [Accepted: 11/03/2020] [Indexed: 11/20/2022] Open
Abstract
Background Ceftriaxone (CTX) and penicillin G (PCN G) are considered reasonable treatment options for viridans group streptococci (VGS) bloodstream infections, but comparisons between these agents are limited. We evaluated clinical outcomes among patients treated with these agents for complicated VGS bacteremia. Methods This was a single-center retrospective study of adult patients with ≥1 positive VGS blood culture who were treated with either CTX or PCN G/ampicillin (both included in the PCN arm) between January 2013 and June 2019. The primary outcome was a composite of safety end points, including hospital readmission due to VGS bacteremia or adverse events (AEs) from therapy, Clostridioides difficile infections, treatment modification or discontinuation due to AEs from therapy, and development of extended-spectrum beta-lactamase resistance. Secondary outcomes included individual safety end points, VGS bacteremia recurrence, hospital readmission, and all-cause mortality. Results Of 328 patients screened, 94 met eligibility criteria (CTX n = 64, PCN n = 30). Streptococcus mitis was the most common isolate, and infective endocarditis was the predominant source of infection. CTX was not significantly associated with increased risk of the primary composite safety outcome (CTX 14% vs PCN 27%; P = .139). The driver of the composite outcome was hospital readmission due to VGS bacteremia or therapy complications. No secondary end points differed significantly between groups. On multivariate analysis, source removal was a protective factor of the primary composite safety outcome. Conclusions Despite potential safety concerns with the prolonged use of CTX in complicated VGS bacteremia, this study did not demonstrate higher rates of treatment failure, adverse events, or resistance.
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Affiliation(s)
- Stephanie Wo
- Department of Pharmacy, NYU Langone Health, New York, New York, USA
| | - Yanina Dubrovskaya
- Department of Pharmacy, NYU Langone Health, New York, New York, USA.,Department of Medicine, New York University School of Medicine, New York, New York, USA
| | - Justin Siegfried
- Department of Pharmacy, NYU Langone Health, New York, New York, USA
| | - John Papadopoulos
- Department of Pharmacy, NYU Langone Health, New York, New York, USA.,Department of Medicine, New York University School of Medicine, New York, New York, USA
| | - Shin-Pung Jen
- Department of Pharmacy, Newark Beth Israel Medical Center, Newark, New Jersey, USA
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11
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Vroon JC, Liesdek OCD, Boel CHE, Arends JE, Niessen FA, van Heusden HC, Cramer MJ, van der Spoel TIG, Chamuleau SAJ. Retrospective analysis of endocarditis patients to investigate the eligibility for oral antibiotic treatment in routine daily practice. Neth Heart J 2020; 29:105-110. [PMID: 32940869 PMCID: PMC7843713 DOI: 10.1007/s12471-020-01490-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Background According to the current guidelines of the European Society of Cardiology, patients with left-sided infective endocarditis are treated with intravenous antibiotics for 4–6 weeks, leading to extensive hospital stay and high costs. Recently, the Partial Oral Treatment of Endocarditis (POET) trial suggested that partial oral treatment is effective and safe in selected patients. Here, we investigated if such patients are seen in our daily clinical practice. Methods We enrolled 119 adult patients diagnosed with left-sided infective endocarditis in a retrospective, observational study. We identified those that would be eligible for switching to partial oral antibiotic treatment as defined in the POET trial (e.g. stable clinical condition without signs of infection). Secondary objectives were to provide insight into the time until each patient was eligible for partial oral treatment, and to determine parameters of longer hospital stay and/or need for extended intravenous antibiotic treatment. Results Applying the POET selection criteria, the condition of 38 patients (32%) was stable enough to switch them to partial oral treatment, of which 18 (47.3%), 8 (21.1%), 9 (23.7%) and 3 patients (7.9%) were eligible for switching after 10, 14, 21 days or 28 days of intravenous treatment, respectively. Conclusion One-third of patients who presented with left-sided endocarditis in routine clinical practice were possible candidates for switching to partial oral treatment. This could have major implications for both the patient’s quality of life and healthcare costs. These results offer an interesting perspective for implementation of such a strategy, which should be accompanied by a prospective cost-effectiveness analysis. Electronic supplementary material The online version of this article (10.1007/s12471-020-01490-2) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- J C Vroon
- Department of Cardiology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - O C D Liesdek
- Department of Cardiothoracic Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - C H E Boel
- Department of Microbiology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - J E Arends
- Department of Internal Medicine and Infection Diseases, University Medical Center Utrecht, Utrecht, The Netherlands
| | - F A Niessen
- Department of Microbiology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - H C van Heusden
- Department of Cardiology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - M J Cramer
- Department of Cardiology, University Medical Center Utrecht, Utrecht, The Netherlands
| | | | - S A J Chamuleau
- Department of Cardiology, Amsterdam University Medical Center, AMC/University of Amsterdam, Amsterdam, The Netherlands.
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12
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Briquet C, Cornu O, Servais V, Blasson C, Vandeleene B, Yildiz H, Stainier A, Yombi JC. Clinical characteristics and outcomes of patients receiving outpatient parenteral antibiotic therapy in a Belgian setting: a single-center pilot study. Acta Clin Belg 2020; 75:275-283. [PMID: 31023169 DOI: 10.1080/17843286.2019.1608396] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND Outpatient parenteral antibiotic therapy (OPAT) was not used in Belgium before 2013, except for patients with cystic fibrosis. Thus, we have performed a pilot study to evaluate clinical characteristics and outcomes of patient receiving OPAT in a Belgian setting. METHODS The study was a prospective observational single-center study of patients receiving OPAT between 1 September 2013 and 31 December, 2017. RESULTS We included 218 OPATs. The median age was 58 years and 71% were men. At the end of the treatment, 92% of the patients on OPAT were cured. Risk factors for treatment failure were obesity, diabetes and diabetic foot infections, longer duration of hospitalization before OPAT, and duration of OPAT >16 days. An average of 24 days of hospitalization per patient discharge was saved, which amounted to 5205 days saved during the project. During the OPAT and 30 days thereafter, 71 (32.6%) of patients were readmitted, but only 26 (12%) readmissions were directly related to OPAT. Risk factors for readmissions were diabetes and diabetic foot infections, endovascular infections, longer duration of hospitalization before OPAT, duration of OPAT >30 days, and history of hospitalizations in the year before OPAT. There were 2.3 intravenous catheter-related events per 1000 days of catheter use. Patients' level of satisfaction was high (99.5%). CONCLUSIONS In this pilot study, OPAT is found to be efficacious in saving hospitalization's days, with a low rate of readmissions and complications and a high patients' level of satisfaction. We therefore conclude that OPAT is feasible and safe. BACKGROUND Outpatient parenteral antibiotic therapy (OPAT) was not used in Belgium before 2013, except for patients with cystic fibrosis. Thus, we have performed a pilot study to evaluate clinical characteristics and outcomes of patient receiving OPAT in a Belgian setting. METHODS The study was a prospective observational single-center study of patients receiving OPAT between 1 September 2013 and 31 December, 2017. RESULTS We included 218 OPATs. The median age was 58 years and 71% were men. At the end of the treatment, 92% of the patients on OPAT were cured. Risk factors for treatment failure were obesity, diabetes and diabetic foot infections, longer duration of hospitalization before OPAT, and duration of OPAT >16 days. An average of 24 days of hospitalization per patient discharge was saved, which amounted to 5205 days saved during the project. During the OPAT and 30 days thereafter, 71 (32.6%) of patients were readmitted, but only 26 (12%) readmissions were directly related to OPAT. Risk factors for readmissions were diabetes and diabetic foot infections, endovascular infections, longer duration of hospitalization before OPAT, duration of OPAT >30 days, and history of hospitalizations in the year before OPAT. There were 2.3 intravenous catheter-related events per 1000 days of catheter use. Patients' level of satisfaction was high (99.5%). CONCLUSIONS In our study, OPAT is found to be efficacious in saving hospitalization's days, with a low rate of readmissions and complications and a high patients' level of satisfaction. We therefore conclude that OPAT is feasible and safe.
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Affiliation(s)
- Caroline Briquet
- Department of Pharmacy and Groupe de Gestion de l’antibiothérapie Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, Brussels, Belgium
| | - Olivier Cornu
- Department of Orthopaedic surgery, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, Brussels, Belgium
| | - Valerie Servais
- Service social, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, Brussels, Belgium
| | - Chloe Blasson
- Service social, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, Brussels, Belgium
| | - Bernard Vandeleene
- Department of endocrinology and Diabetes, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, Brussels, Belgium
| | - Halil Yildiz
- Department of Internal medicine and infectious diseases, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, Brussels, Belgium
| | - Annabelle Stainier
- Depertment of Urology, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, Brussels, Belgium
| | - Jean Cyr Yombi
- Department of Internal medicine and infectious diseases, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, Brussels, Belgium
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13
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Tattevin P, Revest M. Outpatient Parenteral Antibiotic Treatment for Infective Endocarditis: Insights From Real Life. Clin Infect Dis 2020; 69:1701-1702. [PMID: 30649207 DOI: 10.1093/cid/ciz027] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2018] [Accepted: 01/09/2019] [Indexed: 11/13/2022] Open
Affiliation(s)
- Pierre Tattevin
- Infectious Diseases and Intensive Care Unit, Pontchaillou University Hospital, Rennes, France
| | - Matthieu Revest
- Infectious Diseases and Intensive Care Unit, Pontchaillou University Hospital, Rennes, France
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14
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Shoai-Tehrani M, Pilmis B, Maury MM, Robineau O, Disson O, Jouvion G, Coulpier G, Thouvenot P, Bracq-Dieye H, Valès G, Leclercq A, Lecuit M, Charlier C. Listeria monocytogenes-associated endovascular infections: A study of 71 consecutive cases. J Infect 2019; 79:322-331. [DOI: 10.1016/j.jinf.2019.07.013] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2019] [Revised: 06/19/2019] [Accepted: 07/26/2019] [Indexed: 10/26/2022]
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15
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Heriot GS, Tong SYC, Cheng AC, Liew D. Benefit of Echocardiography in Patients With Staphylococcus aureus Bacteremia at Low Risk of Endocarditis. Open Forum Infect Dis 2018; 5:ofy303. [PMID: 30555848 PMCID: PMC6288770 DOI: 10.1093/ofid/ofy303] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2018] [Accepted: 11/22/2018] [Indexed: 12/12/2022] Open
Abstract
Background The risk of endocarditis among patients with Staphylococcus aureus bacteremia is not uniform, and a number of different scores have been developed to identify patients whose risk is less than 5%. The optimal echocardiography strategy for these patients is uncertain. Methods We used decision analysis and Monte Carlo simulation using input parameters taken from the existing literature. The model examined patients with S aureus bacteremia whose risk of endocarditis is less than 5%, generally those with nosocomial or healthcare-acquired bacteremia, no intracardiac prosthetic devices, and a brief duration of bacteremia. We examined 6 echocardiography strategies, including the use of transesophageal echocardiography, transthoracic echocardiography, both modalities, and neither. The outcome of the model was 90-day survival. Results The optimal echocardiography strategy varied with the risk of endocarditis and the procedural mortality associated with transesophageal echocardiography. No echocardiography strategy offered an absolute benefit in 90-day survival of more than 0.5% compared with the strategy of not performing echocardiography and treating with short-course therapy. Strategies using transesophageal echocardiography were never preferred if the mortality of this procedure was greater than 0.5%. Conclusions In patients identified to be at low risk of endocarditis, the choice of echocardiography strategy appears to exert a very small influence on 90-day survival. This finding may render test-treatment trials unfeasible and should prompt clinicians to focus on other, more important, management considerations in these patients.
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Affiliation(s)
- George S Heriot
- School of Public Health and Preventative Medicine, Monash University Victoria, Australia.,Victorian Infectious Diseases Service, The Royal Melbourne Hospital, and The University of Melbourne, at the Peter Doherty Institute for Infection and Immunity, Victoria, Australia
| | - Steven Y C Tong
- Victorian Infectious Diseases Service, The Royal Melbourne Hospital, and The University of Melbourne, at the Peter Doherty Institute for Infection and Immunity, Victoria, Australia.,Menzies School of Health Research, Royal Darwin Hospital, Northern Territory, Australia
| | - Allen C Cheng
- School of Public Health and Preventative Medicine, Monash University Victoria, Australia.,Department of Infectious Diseases, Alfred Health, Victoria, Australia.,Infection Prevention and Healthcare Epidemiology Unit, Alfred Health, Victoria, Australia
| | - Danny Liew
- School of Public Health and Preventative Medicine, Monash University Victoria, Australia
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16
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Smismans A, Vantrappen A, Verbiest F, Indevuyst C, Van den Poel B, von Winckelmann S, Peeters A, Ombelet S, Lybeert P, Heremans A, Frans E, Ho E, Frans J. OPAT: proof of concept in a peripheral Belgian hospital after review of the literature. Acta Clin Belg 2018; 73:257-267. [PMID: 29385901 DOI: 10.1080/17843286.2018.1424503] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Since its introduction in the 1970s in the United States, outpatient parenteral antibiotic/antimicrobial therapy (OPAT) has been adopted internationally for long-term intravenous (IV) treatment of stable infectious diseases. The aim is to provide a safe and successful completion of IV antimicrobial treatment at the ambulatory care center or at home without complications and costs associated with hospitalization. OPAT implementation has been accelerated by progress in vascular access devices, newly available antibiotics, the emphasis on cost-savings, as well as an improved patient comfort and a reduced incidence of health care associated infections with a similar outcome. OPAT utilization is supported by an extensive published experience and guidelines of the British Society of Antimicrobial Chemotherapy and the Infectious Diseases Society of America for adults as well as for children. Despite these recommendations and its widespread adoption, in Belgium OPAT is only fully reimbursed and established for cystic fibrosis patients. Possible explanations for this unpopularity include physician unfamiliarity and a lack of uniform funding arrangements with higher costs for the patient. This article aims to briefly review benefits, risks, indications, financial impact for supporting OPAT in a non-university hospital as standard of care. Our experience with OPAT at the ambulatory care center of our hospital and its subsequent recent introduction in the home setting is discussed.
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Affiliation(s)
- Annick Smismans
- Laboratory of Clinical Biology, Imelda Hospital, Bonheiden, Belgium
| | | | | | | | - Bea Van den Poel
- Laboratory of Clinical Biology, Imelda Hospital, Bonheiden, Belgium
| | | | | | - Sara Ombelet
- Internal Medicine, Imelda Hospital, Bonheiden, Belgium
| | - Peter Lybeert
- Internal Medicine, Imelda Hospital, Bonheiden, Belgium
| | | | - Eric Frans
- Internal Medicine, Imelda Hospital, Bonheiden, Belgium
| | - Erwin Ho
- Laboratory of Clinical Biology, Imelda Hospital, Bonheiden, Belgium
| | - Johan Frans
- Laboratory of Clinical Biology, Imelda Hospital, Bonheiden, Belgium
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17
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Pajarón M, Lisa M, Fernández-Miera MF, Dueñas JC, Allende I, Arnaiz AM, Sanroma-Mendizábal P, De Berrazueta JR, Fariñas MC. Efficiency of a self-administered outpatient parenteral antimicrobial therapy (s-opat) for infective endocarditis within the context of a shortened hospital admission based on hospital at home program. Hosp Pract (1995) 2017; 45:246-252. [PMID: 29090606 DOI: 10.1080/21548331.2017.1398588] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
OBJECTIVE This study aimed to evaluate the efficiency of treatment of infectious endocarditis (IE) via Self-administered Outpatient Parenteral Antimicrobial Therapy (S-OPAT) supported by a shortening hospital admission program in a hospitalization-at-home unit (HAH), including a short review of the literature. METHODS Ambispective cohort study of 57 episodes of IE in 54 patients treated in an HAH unit between 1988 and 2014 who receive S-OPAT after prior intra-hospital clinical stabilization. Characteristics of each episode of IE, safety and efficiency of the care model, were analyzed. RESULTS Forty-three (76%) patients were males with a median age of 61 years (SD = 16.5). A total of 37 (65%) episodes affected the native valve (42% the aortic valve). In 75%, a micro-organism was isolated, of which 88% were Gram-positive bacteria. No deaths occurred during HAH program, clinical complications appeared in 30% of episodes, only 6 patients were re-admitted to hospital although no patient died. In the 12 months' follow-up 3 cases had a recurrence. The average cost of a day stay in HAH was €174 while in traditional cardiology hospitalization was €1100. The total average cost of treatment of each episode of IE managed entirely in hospital was calculated as €54,723. Application of the S-OPAT model based on HAH meant a cost reduction of 32.72%. CONCLUSIONS In suitably selected patients, treatment of IE based on S-OPAT supported by a shortening hospital admission care program by means of referral to a HAH unit is a safe and efficient care model which entails a significant cost saving for the public healthcare system.
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Affiliation(s)
- Marcos Pajarón
- a Domiciliary Hospitalisation Unit , Hospital Universitario Marqués de Valdecilla , Santander , Spain
| | - Marta Lisa
- b Internal Medicine Unit , Hospital Universitario Marqués de Valdecilla , Santander , Spain
| | - Manuel F Fernández-Miera
- a Domiciliary Hospitalisation Unit , Hospital Universitario Marqués de Valdecilla , Santander , Spain
| | - Juan C Dueñas
- c Financial Management , Hospital Universitario Marqués de Valdecilla , Santander , Spain
| | - I Allende
- d Primary Care and Community Medicine , Santa Cruz de Bezana Health Center , Santander , Spain
| | - Ana M Arnaiz
- e Infectious Disease Unit , Hospital Universitario Marqués de Valdecilla , Santander , Spain
| | - Pedro Sanroma-Mendizábal
- a Domiciliary Hospitalisation Unit , Hospital Universitario Marqués de Valdecilla , Santander , Spain
| | - José R De Berrazueta
- f Service of Cardiology , Hospital Universitario Marqués de Valdecilla, University of Cantabria , Santander , Spain
| | - María C Fariñas
- g Infectious Disease Unit, Hospital Universitario Marqués de Valdecilla , University of Cantabria , Santander , Spain
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18
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Durojaiye OC, Bell H, Andrews D, Ntziora F, Cartwright K. Clinical efficacy, cost analysis and patient acceptability of outpatient parenteral antibiotic therapy (OPAT): a decade of Sheffield (UK) OPAT service. Int J Antimicrob Agents 2017; 51:26-32. [PMID: 28673610 DOI: 10.1016/j.ijantimicag.2017.03.016] [Citation(s) in RCA: 67] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2016] [Revised: 03/10/2017] [Accepted: 03/15/2017] [Indexed: 10/19/2022]
Abstract
Outpatient parenteral antimicrobial therapy (OPAT) has evolved relatively slowly in the UK. This study describes the OPAT service based in a large UK teaching hospital in Sheffield, and examines the clinical efficacy, patient acceptability and costs saved over a 10-year period. Data on 3812 episodes of OPAT administered between January 2006 and January 2016 were retrieved from a prospectively maintained electronic database. This study compared the real costs of the OPAT service with estimated costs of conventional inpatient care for these patient episodes, and analysed patient feedback questionnaires that were administered randomly between January 2014 and January 2015. A wide range of infections were managed during the 10-year period. Skin and soft tissue infections accounted for 57% of OPAT episodes. The total number of bed-days saved was 49,854. A successful outcome (cure or improvement) was found in 3357 (88%) episodes. Re-admission occurred in 265 (7%) episodes. The rates of healthcare-associated infections were low: 15 intravenous-line-related infections were recorded (0.3 per 1000 OPAT patient-days). Patient acceptance and satisfaction with OPAT were high. OPAT cost 15%, 39%, 40% and 44% of inpatient costs for an infectious diseases unit, national average costs, other departments (non-infectious diseases unit), and the minimum national average costs for each diagnostic category, respectively. This study shows that OPAT is safe, clinically efficacious and acceptable for treating a wide range of infections with high levels of patient satisfaction and substantial cost savings.
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Affiliation(s)
| | - Helen Bell
- School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Dawn Andrews
- Department of Infection and Tropical Medicine, Royal Hallamshire Hospital, Sheffield, UK
| | - Fotinie Ntziora
- Department of Infection and Tropical Medicine, Royal Hallamshire Hospital, Sheffield, UK
| | - Katharine Cartwright
- Department of Infection and Tropical Medicine, Royal Hallamshire Hospital, Sheffield, UK
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19
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Mitchell ED, Czoski Murray C, Meads D, Minton J, Wright J, Twiddy M. Clinical and cost-effectiveness, safety and acceptability of community intra venous antibiotic service models: CIVAS systematic review. BMJ Open 2017; 7:e013560. [PMID: 28428184 PMCID: PMC5775457 DOI: 10.1136/bmjopen-2016-013560] [Citation(s) in RCA: 70] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Abstract
OBJECTIVE Evaluate evidence of the efficacy, safety, acceptability and cost-effectiveness of outpatient parenteral antimicrobial therapy (OPAT) models. DESIGN A systematic review. DATA SOURCES MEDLINE, EMBASE, CINAHL, Cochrane Library, National Health Service (NHS) Economic Evaluation Database (EED), Research Papers in Economics (RePEc), Tufts Cost-Effectiveness Analysis (CEA) Registry, Health Business Elite, Health Information Management Consortium (HMIC), Web of Science Proceedings, International Pharmaceutical Abstracts, British Society for Antimicrobial Chemotherapy website. Searches were undertaken from 1993 to 2015. STUDY SELECTION All studies, except case reports, considering adult patients or practitioners involved in the delivery of OPAT were included. Studies combining outcomes for adults and children or non-intravenous (IV) and IV antibiotic groups were excluded, as were those focused on process of delivery or clinical effectiveness of 1 antibiotic over another. Titles/abstracts were screened by 1 reviewer (20% verified). 2 authors independently screened studies for inclusion. RESULTS 128 studies involving >60 000 OPAT episodes were included. 22 studies (17%) did not indicate the OPAT model used; only 29 involved a comparator (23%). There was little difference in duration of OPAT treatment compared with inpatient therapy, and overall OPAT appeared to produce superior cure/improvement rates. However, when models were considered individually, outpatient delivery appeared to be less effective, and self-administration and specialist nurse delivery more effective. Drug side effects, deaths and hospital readmissions were similar to those for inpatient treatment, but there were more line-related complications. Patient satisfaction was high, with advantages seen in being able to resume daily activities and having greater freedom and control. However, most professionals perceived challenges in providing OPAT. CONCLUSIONS There were no systematic differences related to the impact of OPAT on treatment duration or adverse events. However, evidence of its clinical benefit compared with traditional inpatient treatment is lacking, primarily due to the dearth of good quality comparative studies. There was high patient satisfaction with OPAT use but the few studies considering practitioner acceptability highlighted organisational and logistic barriers to its delivery.
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Affiliation(s)
- E D Mitchell
- Centre for Health Services Research, Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - C Czoski Murray
- Centre for Health Services Research, Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - D Meads
- Academic Unit of Health Economics, Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - J Minton
- Department of Infection and Travel Medicine, Leeds Teaching Hospitals NHS Trust, St James's Hospital, Leeds, UK
| | - J Wright
- Academic Unit of Health Economics, Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - M Twiddy
- Centre for Health Services Research, Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
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20
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Minton J, Murray CC, Meads D, Hess S, Vargas-Palacios A, Mitchell E, Wright J, Hulme C, Raynor DK, Gregson A, Stanley P, McLintock K, Vincent R, Twiddy M. The Community IntraVenous Antibiotic Study (CIVAS): a mixed-methods evaluation of patient preferences for and cost-effectiveness of different service models for delivering outpatient parenteral antimicrobial therapy. HEALTH SERVICES AND DELIVERY RESEARCH 2017. [DOI: 10.3310/hsdr05060] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
BackgroundOutpatient parenteral antimicrobial therapy (OPAT) is widely used in most developed countries, providing considerable opportunities for improved cost savings. However, it is implemented only partially in the UK, using a variety of service models.ObjectivesThe aims of this research were to (1) establish the extent of OPAT service models in England and identify their development; (2) evaluate patients’ preferences for different OPAT service delivery models; (3) assess the cost-effectiveness of different OPAT service delivery models; and (4) convene a consensus panel to consider our evidence and make recommendations.MethodsThis mixed-methods study included seven centres providing OPAT using four main service models: (1) hospital outpatient (HO) attendance; (2) specialist nurse (SN) visiting at home; (3) general nurse (GN) visiting at home; and (4) self-administration (SA) or carer administration. Health-care providers were surveyed and interviewed to explore the implementation of OPAT services in England. OPAT patients were interviewed to determine key service attributes to develop a discrete choice experiment (DCE). This was used to perform a quantitative analysis of their preferences and attitudes. Anonymised OPAT case data were used to model cost-effectiveness with both Markov and simulation modelling methods. An expert panel reviewed the evidence and made recommendations for future service provision and further research.ResultsThe systematic review revealed limited robust literature but suggested that HO is least effective and SN is most effective. Qualitative study participants felt that different models of care were suited to different types of patient and they also identified key service attributes. The DCE indicated that type of service was the most important factor, with SN being strongly preferred to HO and SA. Preferences were influenced by attitudes to health care. The results from both Markov and simulation models suggest that a SN model is the optimal service for short treatment courses (up to 7 days). Net monetary benefit (NMB) values for HO, GN and SN services were £2493, £2547 and £2655, respectively. For longer treatment, SA appears to be optimal, although SNs provide slightly higher benefits at increased cost. NMB values for HO, GN, SN and SA services were £8240, £9550, £10,388 and £10,644, respectively. The simulation model provided useful information for planning OPAT services. The expert panel requested more guidance for service providers and commissioners. Overall, they agreed that mixed service models were preferable.LimitationsRecruitment to the qualitative study was suboptimal in the very elderly and ethnic minorities, so the preferences of patients from these groups might not be represented. The study recruited from Yorkshire, so the findings may not be applicable nationally.ConclusionsThe quantitative preference analysis and economic modelling favoured a SN model, although there are differences between sociodemographic groups. SA provides cost savings for long-term treatment but is not appropriate for all.Future workFurther research is necessary to replicate our results in other regions and populations and to evaluate mixed service models. The simulation modelling and DCE methods used here may be applicable in other health-care settings.FundingThe National Institute for Health Research Health Service and Delivery Research programme.
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Affiliation(s)
- Jane Minton
- Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | | | - David Meads
- Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - Stephane Hess
- Institute of Transport Studies, University of Leeds, Leeds, UK
| | | | | | - Judy Wright
- Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - Claire Hulme
- Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | | | | | - Philip Stanley
- Bradford Teaching Hospitals NHS Foundation Trust, Bradford, UK
| | - Kate McLintock
- Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | | | - Maureen Twiddy
- Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
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21
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Cervera C, Sanroma P, González-Ramallo V, García de la María C, Sanclemente G, Sopena N, Pajarón M, Segado A, Mirón M, Antón F, Basterretxea A, Cuende A, Miró JM. Safety and efficacy of daptomycin in outpatient parenteral antimicrobial therapy: a prospective and multicenter cohort study (DAPTODOM trial). Infect Dis (Lond) 2016; 49:200-207. [PMID: 27820968 DOI: 10.1080/23744235.2016.1247292] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
Abstract
BACKGROUND Daptomycin is an optimal choice for outpatient parenteral antibiotic therapy (OPAT) because of its safety, once-daily administration and its activity against Gram-positive bacteria. Although daptomycin is increasingly being used in OPAT, limited information about its safety in this scenario is available. METHODS We performed a prospective multicentre pilot study to evaluate the safety of daptomycin in outpatients with proved or suspected Gram-positive infections (DAPTODOM). The primary objective was to evaluate the safety and the secondary objective to evaluate the efficacy in OPAT. We also looked at the development of daptomycin resistance in those cases with microbiological failure. RESULTS We included 54 patients from 12 Spanish hospitals, 67% male with a mean age of 67.1 years. Most patients (87%) had chronic underlying diseases. The main reason for inclusion was skin and soft-tissue infections in 52%, followed by bacteremia or endocarditis in 34%. Staphylococcus aureus accounted for 44% of the isolates (24% were methicillin-resistant), coagulase-negative staphylococci 15% and enterococci 7%. Two patients (4%) had to be readmitted because of complications; only one patient had an adverse effect related to daptomycin (increase in serum creatine kinase levels), which disappeared after discontinuation (2%). At the end of follow-up, 96% of patients had good outcome and only 4% of patients did not have a clinical or microbiological cure. The use of a 2-minute bolus in 18 cases was not associated with adverse effects. CONCLUSIONS Daptomycin was safe and efficacious in outpatients with Gram-positive bacterial infections and can be administered in 2-minute bolus infusion.
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Affiliation(s)
- Carlos Cervera
- a Hospital Clinic-IDIBAPS , Universidad de Barcelona , Barcelona , Spain.,b Department of Medicine , University of Alberta , Edmonton , Canada
| | - Pedro Sanroma
- c Hospital Universitario Marqués de Valdecilla , Santander , Spain
| | | | | | - Gemma Sanclemente
- a Hospital Clinic-IDIBAPS , Universidad de Barcelona , Barcelona , Spain
| | - Nieves Sopena
- e Hospital Universitari Germans Trias i Pujol , Badalona , Spain
| | - Marcos Pajarón
- c Hospital Universitario Marqués de Valdecilla , Santander , Spain
| | - Antonio Segado
- d Hospital Universitario Gregorio Marañón , Madrid , Spain
| | - Manuel Mirón
- f Hospital Universitario de Torrejón , Torrejón de Ardoz , Spain
| | | | | | - Ana Cuende
- i Hospital Universitario Donostia , San Sebastián , Spain
| | - José M Miró
- a Hospital Clinic-IDIBAPS , Universidad de Barcelona , Barcelona , Spain
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22
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Chung EK, Beeler CB, Muloma EW, Osterholzer D, Damer KM, Erdman SM. Development and implementation of a pharmacist-managed outpatient parenteral antimicrobial therapy program. Am J Health Syst Pharm 2016; 73:e24-33. [PMID: 26683676 DOI: 10.2146/ajhp150201] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
PURPOSE The development and implementation of a pharmacist-managed outpatient parenteral antimicrobial therapy (OPAT) program in a county teaching hospital are described. SUMMARY A pharmacist-managed OPAT program was developed and implemented at a county teaching hospital to provide consistent evaluation, approval, and monitoring of patients requiring OPAT for the treatment of infection. The developmental and implementation stages of the OPAT program included (1) a needs assessment, (2) the identification of resources necessary for program operation, (3) delineation of general OPAT program operations and activities of individual OPAT clinicians, (4) the development of patient selection criteria, including a plan of care algorithm, and (5) acquisition of administrative support to approve the program. In this program, the OPAT pharmacist plays an integral role in the management and oversight of OPAT patients, working under a collaborative agreement with infectious diseases physicians. The OPAT pharmacist assists with appropriate patient and regimen selection, confirmation of orders on discharge, assuring that laboratory tests for safety surveillance are performed and evaluated, performing routine monitoring for adverse events and line complications, and assuring the removal of the vascular access device upon the completion of OPAT. CONCLUSION The OPAT program provides structured monitoring, patient follow-up, and led to improvements in patient outcome with minimization of treatment and line-related adverse events.
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Affiliation(s)
- Eun Kyoung Chung
- Eun Kyoung Chung, Pharm.D., Ph.D., is Assistant Professor, Clinical Pharmacy/Pharmacotherapy, Department of Pharmacy, Kyung Hee University College of Pharmacy, Seoul, South Korea; at the time of writing she was a graduate student, Department of Pharmacy Practice, Purdue University College of Pharmacy, West Lafeyette, IN. Cole B. Beeler, M.D., is Infectious Diseases Fellow, Indiana University School of Medicine, Indianapolis; at the time of writing he was Chief Internal Medical Resident, Eskenazi Health (formerly Wishard Health Services), Indianapolis. Eva W. Muloma, M.D., is Infectious Diseases Physician, Indiana University Medical Group, and Co-Director, Outpatient Parenteral Antimicrobial Therapy (OPAT) Program, Eskenazi Health. Danielle Osterholzer, M.D., is Infectious Diseases Faculty, Hurley Medical Center, Flint, MI; at the time of writing she was Assistant Clinical Professor of Medicine and Pediatrics, Division of Infectious Diseases, Indiana University School of Medicine, and Section Chief of Infectious Diseases, Eskenazi Health. Kendra M. Damer, Pharm.D., is Associate Professor, Department of Pharmacy Practice, Butler University College of Pharmacy and Health Sciences, Indianapolis; at the time of writing she was Assistant Professor of Pharmacy Practice, Butler University College of Pharmacy and Health Sciences, and Infectious Diseases Clinical Pharmacy Specialist, Eskenazi Health. Sharon M. Erdman, Pharm.D., is Clinical Professor, Department of Pharmacy Practice, Purdue University College of Pharmacy, and Infectious Diseases Clinical Pharmacist and Co-Director, OPAT Program, Eskenazi Health
| | - Cole B Beeler
- Eun Kyoung Chung, Pharm.D., Ph.D., is Assistant Professor, Clinical Pharmacy/Pharmacotherapy, Department of Pharmacy, Kyung Hee University College of Pharmacy, Seoul, South Korea; at the time of writing she was a graduate student, Department of Pharmacy Practice, Purdue University College of Pharmacy, West Lafeyette, IN. Cole B. Beeler, M.D., is Infectious Diseases Fellow, Indiana University School of Medicine, Indianapolis; at the time of writing he was Chief Internal Medical Resident, Eskenazi Health (formerly Wishard Health Services), Indianapolis. Eva W. Muloma, M.D., is Infectious Diseases Physician, Indiana University Medical Group, and Co-Director, Outpatient Parenteral Antimicrobial Therapy (OPAT) Program, Eskenazi Health. Danielle Osterholzer, M.D., is Infectious Diseases Faculty, Hurley Medical Center, Flint, MI; at the time of writing she was Assistant Clinical Professor of Medicine and Pediatrics, Division of Infectious Diseases, Indiana University School of Medicine, and Section Chief of Infectious Diseases, Eskenazi Health. Kendra M. Damer, Pharm.D., is Associate Professor, Department of Pharmacy Practice, Butler University College of Pharmacy and Health Sciences, Indianapolis; at the time of writing she was Assistant Professor of Pharmacy Practice, Butler University College of Pharmacy and Health Sciences, and Infectious Diseases Clinical Pharmacy Specialist, Eskenazi Health. Sharon M. Erdman, Pharm.D., is Clinical Professor, Department of Pharmacy Practice, Purdue University College of Pharmacy, and Infectious Diseases Clinical Pharmacist and Co-Director, OPAT Program, Eskenazi Health
| | - Eva W Muloma
- Eun Kyoung Chung, Pharm.D., Ph.D., is Assistant Professor, Clinical Pharmacy/Pharmacotherapy, Department of Pharmacy, Kyung Hee University College of Pharmacy, Seoul, South Korea; at the time of writing she was a graduate student, Department of Pharmacy Practice, Purdue University College of Pharmacy, West Lafeyette, IN. Cole B. Beeler, M.D., is Infectious Diseases Fellow, Indiana University School of Medicine, Indianapolis; at the time of writing he was Chief Internal Medical Resident, Eskenazi Health (formerly Wishard Health Services), Indianapolis. Eva W. Muloma, M.D., is Infectious Diseases Physician, Indiana University Medical Group, and Co-Director, Outpatient Parenteral Antimicrobial Therapy (OPAT) Program, Eskenazi Health. Danielle Osterholzer, M.D., is Infectious Diseases Faculty, Hurley Medical Center, Flint, MI; at the time of writing she was Assistant Clinical Professor of Medicine and Pediatrics, Division of Infectious Diseases, Indiana University School of Medicine, and Section Chief of Infectious Diseases, Eskenazi Health. Kendra M. Damer, Pharm.D., is Associate Professor, Department of Pharmacy Practice, Butler University College of Pharmacy and Health Sciences, Indianapolis; at the time of writing she was Assistant Professor of Pharmacy Practice, Butler University College of Pharmacy and Health Sciences, and Infectious Diseases Clinical Pharmacy Specialist, Eskenazi Health. Sharon M. Erdman, Pharm.D., is Clinical Professor, Department of Pharmacy Practice, Purdue University College of Pharmacy, and Infectious Diseases Clinical Pharmacist and Co-Director, OPAT Program, Eskenazi Health
| | - Danielle Osterholzer
- Eun Kyoung Chung, Pharm.D., Ph.D., is Assistant Professor, Clinical Pharmacy/Pharmacotherapy, Department of Pharmacy, Kyung Hee University College of Pharmacy, Seoul, South Korea; at the time of writing she was a graduate student, Department of Pharmacy Practice, Purdue University College of Pharmacy, West Lafeyette, IN. Cole B. Beeler, M.D., is Infectious Diseases Fellow, Indiana University School of Medicine, Indianapolis; at the time of writing he was Chief Internal Medical Resident, Eskenazi Health (formerly Wishard Health Services), Indianapolis. Eva W. Muloma, M.D., is Infectious Diseases Physician, Indiana University Medical Group, and Co-Director, Outpatient Parenteral Antimicrobial Therapy (OPAT) Program, Eskenazi Health. Danielle Osterholzer, M.D., is Infectious Diseases Faculty, Hurley Medical Center, Flint, MI; at the time of writing she was Assistant Clinical Professor of Medicine and Pediatrics, Division of Infectious Diseases, Indiana University School of Medicine, and Section Chief of Infectious Diseases, Eskenazi Health. Kendra M. Damer, Pharm.D., is Associate Professor, Department of Pharmacy Practice, Butler University College of Pharmacy and Health Sciences, Indianapolis; at the time of writing she was Assistant Professor of Pharmacy Practice, Butler University College of Pharmacy and Health Sciences, and Infectious Diseases Clinical Pharmacy Specialist, Eskenazi Health. Sharon M. Erdman, Pharm.D., is Clinical Professor, Department of Pharmacy Practice, Purdue University College of Pharmacy, and Infectious Diseases Clinical Pharmacist and Co-Director, OPAT Program, Eskenazi Health
| | - Kendra M Damer
- Eun Kyoung Chung, Pharm.D., Ph.D., is Assistant Professor, Clinical Pharmacy/Pharmacotherapy, Department of Pharmacy, Kyung Hee University College of Pharmacy, Seoul, South Korea; at the time of writing she was a graduate student, Department of Pharmacy Practice, Purdue University College of Pharmacy, West Lafeyette, IN. Cole B. Beeler, M.D., is Infectious Diseases Fellow, Indiana University School of Medicine, Indianapolis; at the time of writing he was Chief Internal Medical Resident, Eskenazi Health (formerly Wishard Health Services), Indianapolis. Eva W. Muloma, M.D., is Infectious Diseases Physician, Indiana University Medical Group, and Co-Director, Outpatient Parenteral Antimicrobial Therapy (OPAT) Program, Eskenazi Health. Danielle Osterholzer, M.D., is Infectious Diseases Faculty, Hurley Medical Center, Flint, MI; at the time of writing she was Assistant Clinical Professor of Medicine and Pediatrics, Division of Infectious Diseases, Indiana University School of Medicine, and Section Chief of Infectious Diseases, Eskenazi Health. Kendra M. Damer, Pharm.D., is Associate Professor, Department of Pharmacy Practice, Butler University College of Pharmacy and Health Sciences, Indianapolis; at the time of writing she was Assistant Professor of Pharmacy Practice, Butler University College of Pharmacy and Health Sciences, and Infectious Diseases Clinical Pharmacy Specialist, Eskenazi Health. Sharon M. Erdman, Pharm.D., is Clinical Professor, Department of Pharmacy Practice, Purdue University College of Pharmacy, and Infectious Diseases Clinical Pharmacist and Co-Director, OPAT Program, Eskenazi Health
| | - Sharon M Erdman
- Eun Kyoung Chung, Pharm.D., Ph.D., is Assistant Professor, Clinical Pharmacy/Pharmacotherapy, Department of Pharmacy, Kyung Hee University College of Pharmacy, Seoul, South Korea; at the time of writing she was a graduate student, Department of Pharmacy Practice, Purdue University College of Pharmacy, West Lafeyette, IN. Cole B. Beeler, M.D., is Infectious Diseases Fellow, Indiana University School of Medicine, Indianapolis; at the time of writing he was Chief Internal Medical Resident, Eskenazi Health (formerly Wishard Health Services), Indianapolis. Eva W. Muloma, M.D., is Infectious Diseases Physician, Indiana University Medical Group, and Co-Director, Outpatient Parenteral Antimicrobial Therapy (OPAT) Program, Eskenazi Health. Danielle Osterholzer, M.D., is Infectious Diseases Faculty, Hurley Medical Center, Flint, MI; at the time of writing she was Assistant Clinical Professor of Medicine and Pediatrics, Division of Infectious Diseases, Indiana University School of Medicine, and Section Chief of Infectious Diseases, Eskenazi Health. Kendra M. Damer, Pharm.D., is Associate Professor, Department of Pharmacy Practice, Butler University College of Pharmacy and Health Sciences, Indianapolis; at the time of writing she was Assistant Professor of Pharmacy Practice, Butler University College of Pharmacy and Health Sciences, and Infectious Diseases Clinical Pharmacy Specialist, Eskenazi Health. Sharon M. Erdman, Pharm.D., is Clinical Professor, Department of Pharmacy Practice, Purdue University College of Pharmacy, and Infectious Diseases Clinical Pharmacist and Co-Director, OPAT Program, Eskenazi Health.
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23
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Forestier E, Fraisse T, Roubaud-Baudron C, Selton-Suty C, Pagani L. Managing infective endocarditis in the elderly: new issues for an old disease. Clin Interv Aging 2016; 11:1199-206. [PMID: 27621607 PMCID: PMC5015881 DOI: 10.2147/cia.s101902] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
The incidence of infective endocarditis (IE) rises in industrialized countries. Older people are more affected by this severe disease, notably because of the increasing number of invasive procedures and intracardiac devices implanted in these patients. Peculiar clinical and echocardiographic features, microorganisms involved, and prognosis of IE in elderly have been underlined in several studies. Additionally, elderly population appears quite heterogeneous, from healthy people without past medical history to patients with multiple diseases or who are even bedridden. However, the management of IE in this population has been poorly explored, and international guidelines do not recommend adapting the therapeutic strategy to the patient's functional status and comorbidities. Yet, if IE should be treated according to current recommendations in the healthiest patients, concerns may rise for older patients who suffer from several chronic diseases, especially renal failure, and are on polypharmacy. Treating frailest patients with high-dose intravenous antibiotics during a prolonged hospital stay as recommended for younger patients could also expose them to functional decline and toxic effect. Likewise, the place of surgery according to the aging characteristics of each patient is unclear. The aim of this article is to review the recent data on epidemiology of IE and its peculiarities in the elderly. Then, its management and various therapeutic approaches that can be considered according to and beyond guidelines depending on patient comorbidities and frailty are discussed.
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Affiliation(s)
- Emmanuel Forestier
- Infectious Diseases Department, Centre Hospitalier Métropole Savoie, Chambéry, France
- Correspondence: Emmanuel Forestier, Service de maladies infectieuses, Centre Hospitalier Métropole Savoie, BP 1125, 73011 Chambery Cedex, France, Tel +33 4 7996 5847, Fax +33 4 7996 5171, Email
| | - Thibaut Fraisse
- Acute Geriatric Department, Centre Hospitalier, Alès, France
| | | | | | - Leonardo Pagani
- Infectious Diseases Department, Centre Hospitalier Annecy-Genevois, Annecy, France
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24
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Pajarón M, Fernández-Miera MF, Allende I, Arnaiz AM, Gutiérrez-Cuadra M, Cobo-Belaustegui M, Armiñanzas C, de Berrazueta JR, Fariñas MC, Sanroma P. Self-administered outpatient parenteral antimicrobial therapy (S-OPAT) for infective endocarditis: a safe and effective model. Eur J Intern Med 2015; 26:131-6. [PMID: 25596808 DOI: 10.1016/j.ejim.2015.01.001] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2014] [Revised: 01/01/2015] [Accepted: 01/04/2015] [Indexed: 01/11/2023]
Abstract
The safety and efficacy of treatment of infectious endocarditis (IE) was evaluated within a program of hospital-in-home (HIH) based on self-administered outpatient parenteral antimicrobial therapy (S-OPAT). IE episodes (n=48 in 45 patients; 71% middle-aged males) were recruited into the HIH program between 1998 and 2012. Following treatment stabilization at the hospital they returned home for HIH in which a physician and/or a nurse supervised the S-OPAT. Safety and efficacy were evaluated as mortality, re-occurrence, and unexpected re-admission to hospital. Of the episodes of IE, 83.3% had comorbidities with a mean score of 2.3 on the Charlson index and 1.5 on the Profund index; 60.4% had pre-existing valve disease (58.6% having had surgical intervention); 8.3% of patients had suffered a previous IE episode; 62.5% of all episodes affected a native valve; 45.8% being mitral; 70.8% of infection derived from the community. In 75% of the episodes there was micro-organism growth, of which 83.3% were Gram positive. Overall duration of antibiotic treatment was 4.8 weeks; 60.4% of this time corresponding to HIH. Re-admission occurred in 12.5% of episodes of which 33.3% returned to HIH to complete the S-OPAT. No deaths occurred during HIH. One year after discharge, 2 patients had recurrence and 5 patients died, in 2 of whom previous IE as cause-of-death could not be excluded. In conclusion, the S-OPAT schedule of hospital-in-home is safe and efficacious in selected patients with IE.
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Affiliation(s)
- Marcos Pajarón
- Unidad de Hospitalización a Domicilio Hospital Universitario Marqués de Valdecilla, Avda. Valdecilla s/n, 39008 Santander, Spain.
| | - Manuel F Fernández-Miera
- Unidad de Hospitalización a Domicilio Hospital Universitario Marqués de Valdecilla, Avda. Valdecilla s/n, 39008 Santander, Spain.
| | - Iciar Allende
- Dept. Medicina de Atención Primaria y Comunitaria, Area de Salud I. C/ San Fernando 15 Sta. Cruz de Bezana, 39100 Cantabria, Spain.
| | - Ana M Arnaiz
- Dept. Medicina Interna, Unidad de Enfermedades Infecciosas, Hospital Universitario Marqués de Valdecilla, Avda. Valdecilla s/n, 39008 Santander, Spain.
| | - Manuel Gutiérrez-Cuadra
- Dept. Medicina Interna, Unidad de Enfermedades Infecciosas, Hospital Universitario Marqués de Valdecilla, Avda. Valdecilla s/n, 39008 Santander, Spain.
| | - Manuel Cobo-Belaustegui
- Intensive Care Unit, Dept. Cardiología, Hospital Universitario Marqués de Valdecilla, Avda. Valdecilla s/n, 39008 Santander, Spain.
| | - Carlos Armiñanzas
- Dept. Medicina Interna, Unidad de Enfermedades Infecciosas, Hospital Universitario Marqués de Valdecilla, Avda. Valdecilla s/n, 39008 Santander, Spain.
| | - Jose R de Berrazueta
- Dept. Cardiology Universidad de Cantabria, Hospital Universitario Marqués de Valdecilla, Avda. Valdecilla s/n, 39008 Santander, Spain.
| | - Maria C Fariñas
- Dept. Medicina Interna, Unidad de Enfermedades Infecciosas, Hospital Universitario Marqués de Valdecilla, Avda. Valdecilla s/n, 39008 Santander, Spain.
| | - Pedro Sanroma
- Unidad de Hospitalización a Domicilio Hospital Universitario Marqués de Valdecilla, Avda. Valdecilla s/n, 39008 Santander, Spain.
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25
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Lacroix A, Revest M, Patrat-Delon S, Lemaître F, Donal E, Lorléac'h A, Arvieux C, Michelet C, Tattevin P. Outpatient parenteral antimicrobial therapy for infective endocarditis: a cost-effective strategy. Med Mal Infect 2014; 44:327-30. [PMID: 25022891 DOI: 10.1016/j.medmal.2014.05.001] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2014] [Revised: 04/08/2014] [Accepted: 05/09/2014] [Indexed: 12/13/2022]
Abstract
OBJECTIVES We evaluated the benefit/risk ratio of outpatient parenteral antimicrobial therapy (OPAT) in infective endocarditis (IE). METHOD We performed an observational retrospective study of definite IE (Duke criteria) treated in an infectious diseases unit in 2012. We compared patients having completed the treatment in hospital (H), and those deemed sufficiently stable, and with adequate home environment, for OPAT. The costs were estimated through hospital bills, and, for OPAT, through the costs of drugs and their administration (material, staff), transportation, and outpatient visits. RESULTS Eighteen out of 39 consecutive patients presenting with IE received OPAT, with a mean hospital stay of 23.5days (vs 34.7days for H group, P=0.014). No severe adverse event related to OPAT was reported. The global saving was estimated at 267,307euros, or 14,850euros per patient. CONCLUSIONS OPAT in selected patients presenting with IE seems effective, safe, and reduces costs by approximately 15,000euros per patient.
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Affiliation(s)
- A Lacroix
- Service des maladies infectieuses et réanimation médicale, CHU Pontchaillou, 2, rue Le-Guilloux, 35033 Rennes cedex, France
| | - M Revest
- Service des maladies infectieuses et réanimation médicale, CHU Pontchaillou, 2, rue Le-Guilloux, 35033 Rennes cedex, France; CIC-Inserm 0203, faculté de médecine, université Rennes 1, IFR140, 35000 Rennes, France
| | - S Patrat-Delon
- Service des maladies infectieuses et réanimation médicale, CHU Pontchaillou, 2, rue Le-Guilloux, 35033 Rennes cedex, France
| | - F Lemaître
- Département de pharmacologie clinique, CHU Pontchaillou, 35033 Rennes cedex, France; CIC-Inserm 0203, faculté de médecine, université Rennes 1, IFR140, 35000 Rennes, France
| | - E Donal
- Département de cardiologie et maladies vasculaires, CHU Pontchaillou, 35033 Rennes cedex, France
| | - A Lorléac'h
- Service des maladies infectieuses et réanimation médicale, CHU Pontchaillou, 2, rue Le-Guilloux, 35033 Rennes cedex, France
| | - C Arvieux
- Service des maladies infectieuses et réanimation médicale, CHU Pontchaillou, 2, rue Le-Guilloux, 35033 Rennes cedex, France
| | - C Michelet
- Service des maladies infectieuses et réanimation médicale, CHU Pontchaillou, 2, rue Le-Guilloux, 35033 Rennes cedex, France; CIC-Inserm 0203, faculté de médecine, université Rennes 1, IFR140, 35000 Rennes, France
| | - P Tattevin
- Service des maladies infectieuses et réanimation médicale, CHU Pontchaillou, 2, rue Le-Guilloux, 35033 Rennes cedex, France; CIC-Inserm 0203, faculté de médecine, université Rennes 1, IFR140, 35000 Rennes, France; Inserm U835, faculté de médecine, université Rennes 1, IFR140, 35000 Rennes, France.
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26
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Goenaga MA, Kortajarena X, Ibarguren O, García R, Bustinduy MJ, Azkune H. Outpatient parenteral antimicrobial therapy (OPAT) for infectious endocarditis in Spain. Int J Antimicrob Agents 2014; 44:89-90. [DOI: 10.1016/j.ijantimicag.2014.04.009] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2014] [Accepted: 04/10/2014] [Indexed: 11/28/2022]
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27
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Outpatient parenteral antimicrobial therapy. CANADIAN JOURNAL OF INFECTIOUS DISEASES & MEDICAL MICROBIOLOGY 2014; 24:9-11. [PMID: 24421785 DOI: 10.1155/2013/205910] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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28
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MacKenzie M, Rae N, Nathwani D. Outcomes from global adult outpatient parenteral antimicrobial therapy programmes: A review of the last decade. Int J Antimicrob Agents 2014; 43:7-16. [DOI: 10.1016/j.ijantimicag.2013.09.006] [Citation(s) in RCA: 67] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2013] [Accepted: 09/21/2013] [Indexed: 12/16/2022]
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29
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Allison GM, Muldoon EG, Kent DM, Paulus JK, Ruthazer R, Ren A, Snydman DR. Prediction model for 30-day hospital readmissions among patients discharged receiving outpatient parenteral antibiotic therapy. Clin Infect Dis 2013; 58:812-9. [PMID: 24357220 DOI: 10.1093/cid/cit920] [Citation(s) in RCA: 96] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Factors associated with readmission for patients prescribed outpatient parenteral antibiotic therapy (OPAT) at hospital discharge have not been definitively identified. The study aim was to develop a model of 30-day readmissions for OPAT patients. METHODS A database comprising 782 OPAT patients treated between 2009 and 2011 at a single academic center was created. Variables collected included patient demographics, comorbidities, infections, and antibiotic classes. Final model discrimination was assessed using the c-statistic, and calibration was examined graphically. RESULTS Mean patient age was 58 years (range, 18-95 years), 43% were women, and the most common diagnoses were bacteremia (24%), osteomyelitis (20%), and pyelonephritis (13%). The unplanned 30-day readmission rate was 26%. The leading indications for readmission were non-infection related (30%), worsening infection (29%), and new infection (19%). The final regression model consisted of age (odds ratio [OR], 1.09 per decade; 95% confidence interval [CI], 0.99-1.21), aminoglycoside use (OR, 2.33; 95% CI, 1.17-4.57), resistant organisms (OR, 1.57; 95% CI, 1.03-2.36), and number of prior hospital discharges without intravenous antibiotics in the past 12 months (OR, 1.20 per prior admission; 95% CI, 1.09-1.32). The c-statistic was 0.61 and the highest-risk quintile of patients had almost a 3-fold higher rate of readmission compared to the lowest. CONCLUSIONS Patients prescribed OPAT are at risk for readmission. A subgroup of patients at especially high risk can be identified using easily obtainable clinical characteristics at the time of hospital discharge. More intensive interventions to prevent OPAT readmissions should be targeted and tested with those at highest risk.
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Affiliation(s)
- Genève M Allison
- Division of Geographic Medicine and Infectious Diseases, Tufts Medical Center, Boston, Massachusetts
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30
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Affiliation(s)
- DA Barr
- Brownlee Centre for Infectious diseases, Gartnavel General Hospital, Glasgow, UK
| | - RA Seaton
- Brownlee Centre for Infectious diseases, Gartnavel General Hospital, Glasgow, UK
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31
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Htin AKF, Friedman ND, Hughes A, O'Brien DP, Huffam S, Redden AM, Athan E. Outpatient parenteral antimicrobial therapy is safe and effective for the treatment of infective endocarditis: a retrospective cohort study. Intern Med J 2013; 43:700-5. [DOI: 10.1111/imj.12081] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2012] [Accepted: 01/11/2013] [Indexed: 11/30/2022]
Affiliation(s)
| | | | | | | | | | | | - E. Athan
- Barwon Health; Geelong; Australia
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32
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Pericás JM, Aibar J, Soler N, López-Soto A, Sanclemente-Ansó C, Bosch X. Should alternatives to conventional hospitalisation be promoted in an era of financial constraint? Eur J Clin Invest 2013; 43:602-15. [PMID: 23590593 DOI: 10.1111/eci.12087] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2012] [Accepted: 03/10/2013] [Indexed: 11/29/2022]
Abstract
BACKGROUND Because the current economic crisis has led to austerity in health policies, with severe restrictions on public health care, avoiding unnecessary admissions and shortening hospital stays is rapidly becoming an urgent priority. Alternatives to hospitalisation replace or shorten hospital processes, including diagnosis, monitoring, treatment and follow-up. This review aims to present the available evidence on alternatives to conventional hospitalisation for medical disorders; options for surgery, psychiatry and palliative care are largely excluded. MATERIALS AND METHODS Narrative review. RESULTS The main alternatives to conventional hospitalisation include day centres (DC), quick diagnosis units (QDU), hospital at home (HaH) and, in some circumstances, telemonitoring. DC increase patient comfort, reduce costs and can improve efficiency. In generally healthy patients with suspected severe disease, QDU may be a good alternative to hospitalisation for diagnostic procedures. However, their cost-effectiveness remains to be clearly proven. Randomised controlled trials have shown that hospital-at-home (HaH) can lead to earlier hospital discharges, improve outcomes and reduce costs in patients with prevalent chronic diseases. Although telemonitoring seems to be promising and its use is increasing, methodologically sounder studies with a higher level of evidence are needed to assess its clinical effectiveness. CONCLUSIONS Factors such as ageing, the need for an earlier diagnosis of suspected severe disease, the increasing complexity of medical care and the increasing costs of hospitalisation mean that, whenever possible, giving priority to less expensive alternatives to hospital admission, such as QDU, DC, HaH and telemedicine, is an urgent task in the current economic crisis.
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Affiliation(s)
- Juan M Pericás
- Department of Internal Medicine, Hospital Clínic, Institut d'Investigacions Biomèdiques August Pi i Sunyer, University of Barcelona, Barcelona, Spain
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Bor DH, Woolhandler S, Nardin R, Brusch J, Himmelstein DU. Infective endocarditis in the U.S., 1998-2009: a nationwide study. PLoS One 2013; 8:e60033. [PMID: 23527296 PMCID: PMC3603929 DOI: 10.1371/journal.pone.0060033] [Citation(s) in RCA: 206] [Impact Index Per Article: 18.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2012] [Accepted: 02/22/2013] [Indexed: 01/16/2023] Open
Abstract
Background Previous studies based on local case series estimated the annual incidence of endocarditis in the U.S. at about 4 per 100,000 population. Small-scale studies elsewhere have reported similar incidence rates. However, no nationally-representative population-based studies have verified these estimates. Methods and Findings Using the 1998–2009 Nationwide Inpatient Sample, which provides diagnoses from about 8 million U.S. hospitalizations annually, we examined endocarditis hospitalizations, bacteriology, co-morbidities, outcomes and costs. Hospital admissions for endocarditis rose from 25,511 in 1998 to 38, 976 in 2009 (12.7 per 100,000 population in 2009). The age-adjusted endocarditis admission rate increased 2.4% annually. The proportion of patients with intra-cardiac devices rose from 13.3% to 18.9%, while the share with drug use and/or HIV fell. Mortality remained stable at about 14.5%, as did cardiac valve replacement (9.6%). Other serious complications increased; 13.3% of patients in 2009 suffered a stroke or CNS infection, and 5.5% suffered myocardial infarction. Amongst cases with identified pathogens, Staphylococcus aureus was the most common, increasing from 37.6% in 1998 to 49.3% in 2009, 53.3% of which were MRSA. Streptococci were mentioned in 24.7% of cases, gram-negatives in 5.6% and Candida species in 1.0%. We detected no inflection in hospitalization rates after changes in prophylaxis recommendations in 2007. Mean age rose from 58.6 to 60.8 years; elderly patients suffered higher rates of myocardial infarction and death, but slightly lower rates of Staphylococcus aureus infections and neurologic complications. Our study relied on clinically diagnosed cases of endocarditis that may not meet strict criteria. Moreover, since some patients are discharged and readmitted during a single episode of endocarditis, our hospitalization figures probably slightly overstate the true incidence of this illness. Conclusions Endocarditis is more common in the U.S. than previously believed, and is steadily increasing. Preventive efforts should focus on device-associated and health-care-associated infections.
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Affiliation(s)
- David H. Bor
- Department of Medicine and Division of Infectious Diseases, Cambridge Health Alliance/Harvard Medical School, Cambridge, Massachusetts, United States of America
| | - Steffie Woolhandler
- School of Public Health, City University of New York, New York, New York, United States of America; and Department of Medicine, Cambridge Health Alliance/Harvard Medical School, Cambridge, Massachusetts, United States of America
| | - Rachel Nardin
- Department of Medicine and Division of Neurology, Cambridge Health Alliance/Harvard Medical School, Cambridge, Massachusetts, United States of America
| | - John Brusch
- Department of Medicine and Division of Infectious Diseases, Cambridge Health Alliance/Harvard Medical School, Cambridge, Massachusetts, United States of America
| | - David U. Himmelstein
- School of Public Health, City University of New York, New York, New York, United States of America; and Department of Medicine, Cambridge Health Alliance/Harvard Medical School, Cambridge, Massachusetts, United States of America
- * E-mail:
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Duncan CJA, Barr DA, Ho A, Sharp E, Semple L, Seaton RA. Risk factors for failure of outpatient parenteral antibiotic therapy (OPAT) in infective endocarditis. J Antimicrob Chemother 2013; 68:1650-4. [PMID: 23475647 PMCID: PMC3682687 DOI: 10.1093/jac/dkt046] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Objectives To identify risk factors for failure of outpatient antibiotic therapy (OPAT) in infective endocarditis (IE). Patients and methods We identified IE cases managed at a single centre over 12 years from a prospectively maintained database. ‘OPAT failure’ was defined as unplanned readmission or antibiotic switch due to adverse drug reaction or antibiotic resistance. We analysed patient and disease-related risk factors for OPAT failure by univariate and multivariate logistic regression. We also retrospectively collected follow-up data on adverse disease outcome (defined as IE-related death or relapse) and performed Kaplan–Meier survival analysis up to 36 months following OPAT. Results We identified 80 episodes of OPAT in IE. Failure occurred in 25/80 episodes (31.3%). On multivariate analysis, cardiac or renal failure [pooled OR 7.39 (95% CI 1.84–29.66), P = 0.005] and teicoplanin therapy [OR 8.69 (95% CI 2.01–37.47), P = 0.004] were independently associated with increased OPAT failure. OPAT failure with teicoplanin occurred despite therapeutic plasma levels. OPAT failure predicted adverse disease outcome up to 36 months (P = 0.016 log-rank test). Conclusions These data caution against selecting patients with endocarditis for OPAT in the presence of cardiac or renal failure and suggest teicoplanin therapy may be associated with suboptimal OPAT outcomes. Alternative regimens to teicoplanin in the OPAT setting should be further investigated.
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Affiliation(s)
- Christopher J A Duncan
- Glasgow OPAT Service, Brownlee Centre for Infectious Diseases, Tropical Medicine and Counselling, Gartnavel General Hospital, 1053 Great Western Rd, Glasgow G12 0YN, UK.
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Neurologic Implications of Critical Illness and Organ Dysfunction. TEXTBOOK OF NEUROINTENSIVE CARE 2013. [PMCID: PMC7119948 DOI: 10.1007/978-1-4471-5226-2_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Critical illness has consequences for the nervous system. Patients experiencing critical illness are at risk for common global neurologic disturbances, such as delirium, long-term cognitive dysfunction, ICU-acquired weakness, sleep disturbances, recurrent seizures, and coma. In addition, complications related to specific organ dysfunction may be anticipated. Cardiovascular disease presents the possibility for CNS injury after cardiac arrest, sequelae of endocarditis, aberrancies of blood flow autoregulation, and malperfusion. Respiratory disease is known to cause short-term effects of hypoxia and long-term effects after ARDS. Sepsis encephalopathy and sickness behavior syndrome are early signs of infection in patients. In addition, commonly encountered organ dysfunction including uremia, hepatic failure, endocrine, and metabolic disturbances present with neurologic findings which may manifest in the critically ill patient as well.
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Cervera C, Mestres CA. [Daptomycin in outpatient antimicrobial parenteral therapy]. Enferm Infecc Microbiol Clin 2012; 30 Suppl 1:59-63. [PMID: 22541978 DOI: 10.1016/s0213-005x(12)70074-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Daptomycin is a cyclic lipopeptide with a rapid bactericidal effect against Gram-positive bacteria. The pharmacokinetic properties of this drug allow once-daily intravenous infusion as the best posology (including a 2-minute bolus). Because of its ease of administration and excellent safety profile, daptomycin is a first-line agent for use as outpatient antimicrobial parenteral therapy (OPAT). The best evidence supporting this indication exists for the treatment of complicated and uncomplicated skin and soft tissue infections, as well as osteoarticular infections caused by Gram-positive bacteria. For the remaining indications, the use of daptomycin as OPAT should be analyzed in each patient. Information from the EUCORE Registry in Spain indicates that daptomycin has high rates of treatment success in both hospitalized patient and in those included in OPAT programs.
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Affiliation(s)
- Carlos Cervera
- Servicio de Enfermedades Infecciosas, Hospital Clínic de Barcelona-IDIBAPS, Universitat de Barcelona, Barcelona, España.
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Outpatient parenteral antimicrobial therapy with ceftriaxone, a review. Int J Clin Pharm 2012; 34:410-7. [PMID: 22527482 DOI: 10.1007/s11096-012-9637-z] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2011] [Accepted: 03/29/2012] [Indexed: 10/28/2022]
Abstract
BACKGROUND More than 30 years since it was developed for clinical use, the third-generation cephalosporin ceftriaxone remains the most commonly used agent for outpatient parental antimicrobial therapy (OPAT). Recent antimicrobial stewardship programmes have tended to restrict ceftriaxone use in hospitals to control antibiotic resistance and outbreaks of Clostridium difficle infection (CDI). Considering the expansion of OPAT programmes both in the UK and worldwide, revisiting the role of ceftriaxone in OPAT in the context of changing antimicrobial prescribing practices is timely. AIM OF THE REVIEW To identify the evidence base for OPAT, review current and historical data on indications for, and safety of ceftriaxone within the OPAT setting, and to provide some perspectives on the future role of ceftriaxone. METHOD We searched PubMed and Scopus for articles published in English, and hand searched reference lists. We also conducted a complementary descriptive analysis of prospectively acquired data on the use of ceftriaxone in more than 1,300 OPAT episodes over a 10-year period in our UK centre. RESULTS Ceftriaxone has an excellent safety profile in the OPAT setting, and its broad spectrum of activity makes it an established agent in a wide range of clinical infection syndromes, such as skin and soft-tissue infection, bone and joint infection, streptococcal endocarditis and several others. Intriguingly, in contrast to the inpatient setting, liberal use of ceftriaxone in OPAT has not been strongly linked to CDI, suggesting additional patient and environmental factors may be important in mediating CDI risk.
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Barr DA, Semple L, Seaton RA. Self-administration of outpatient parenteral antibiotic therapy and risk of catheter-related adverse events: a retrospective cohort study. Eur J Clin Microbiol Infect Dis 2012; 31:2611-9. [DOI: 10.1007/s10096-012-1604-z] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2012] [Accepted: 03/05/2012] [Indexed: 01/14/2023]
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Cervera C, del Río A, García L, Sala M, Almela M, Moreno A, Falces C, Mestres CA, Marco F, Robau M, Gatell JM, Miró JM. Efficacy and safety of outpatient parenteral antibiotic therapy for infective endocarditis: a ten-year prospective study. Enferm Infecc Microbiol Clin 2011; 29:587-92. [PMID: 21723004 DOI: 10.1016/j.eimc.2011.05.007] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2011] [Revised: 05/12/2011] [Accepted: 05/13/2011] [Indexed: 10/18/2022]
Abstract
BACKGROUND The length of treatment of infective endocarditis (IE) with parenteral antibiotics varies from 2 to 6 weeks. Although several studies indicate that outpatient parenteral antibiotic treatment (OPAT) could be safe for uncomplicated viridans-group streptococci (VGS) IE, the experience in Spain is limited and data on other types of endocarditis and OPAT are scarce worldwide. METHODS Prospective single center study of a cohort including all patients with IE admitted to the Hospital Clinic of Barcelona OPAT program from January 1997 to December 2006. RESULTS During the study period, 392 consecutive episodes of IE in non-drug abusers were attended to. Of these, 73 episodes (42 native-valve, 23 prosthetic-valve, and 8 pacemaker-lead) were admitted to the OPAT program (19%). The percentage of inclusion was higher for viridans group streptococci (VGS) or Streptococcus bovis (S. bovis) IE (32% of all VGS or S. bovis IE episodes diagnosed vs. 14% of the remaining etiologies, P<.001). Twelve patients (16%) were readmitted due to complications, of which 3 died (4%). Glycopeptides use was the only predictor factor of hospital readmission (OR 4.5, 95% confidence interval 1.2; 16.8, P=.026). No differences in OPAT outcome were found between VGS plus S. bovis IE and Staphylococcus aureus (S. aureus) plus coagulase-negative staphylococci IE. Patients spent a median of 17 day on OPAT (interquartile range 11-26.5), which enabled 1,466 days of hospital stay to be saved. CONCLUSIONS These data suggest that OPAT for IE may be a safe and effective therapeutic approach in the treatment of selected patients with types of endocarditis other than uncomplicated VGS or S. bovis endocarditis, although patients taking glycopeptides need close clinical OPAT monitoring.
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Affiliation(s)
- Carlos Cervera
- Service of Infectious Diseases, Hospital Clínic-IDIBAPS, University of Barcelona, Barcelona, Spain
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Cervera C, Castañeda X, Pericas JM, Del Río A, de la Maria CG, Mestres C, Falces C, Marco F, Moreno A, Miró JM. Clinical utility of daptomycin in infective endocarditis caused by Gram-positive cocci. Int J Antimicrob Agents 2011; 38:365-70. [PMID: 21420835 DOI: 10.1016/j.ijantimicag.2010.11.038] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2010] [Accepted: 11/23/2010] [Indexed: 10/18/2022]
Abstract
Gram-positive bacteria account for >80% of all cases of endocarditis. Currently, staphylococci are the leading cause of endocarditis worldwide. Daptomycin is the drug of choice for empirical antibiotic therapy of staphylococcal endocarditis due to its optimal activity both against meticillin-susceptible Staphylococcus aureus and meticillin-resistant S. aureus (MRSA) strains. Daptomycin has not been proven to be superior to vancomycin in the treatment of MRSA endocarditis. However, daptomycin should be considered the drug of choice for the treatment of MRSA endocarditis caused by strains with a vancomycin minimum inhibitory concentration (MIC) of 2μg/mL, for heterogeneous vancomycin-intermediate S. aureus (hVISA) phenotypes and for glycopeptide-intermediate S. aureus (GISA) strains. Daptomycin is the drug of choice for rescue therapy in cases of MRSA endocarditis in which vancomycin has failed. The appropriate dose of daptomycin has not yet been established; however, for treatment of left-sided endocarditis the dose of daptomycin should be higher than the recommended dose of 6mg/kg/day. Combination antibiotic therapy with daptomycin (e.g. combined with fosfomycin) is a promising treatment for MRSA endocarditis and warrants further investigation. In vivo studies show that daptomycin is superior to vancomycin in the treatment of meticillin-resistant coagulase-negative staphylococci experimental endocarditis, although clinical data are required. Daptomycin could represent an efficacious treatment for vancomycin-resistant Enterococcus faecium endocarditis. Finally, the pharmacokinetic profile of daptomycin makes it an excellent drug for outpatient parenteral antimicrobial therapy.
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Affiliation(s)
- Carlos Cervera
- Infectious diseases Service, Hospital Clínic, Institut d'Investigacions Biomèdiques August Pi i Sunyer, University of Barcelona School of Medicine, Barcelona, Catalunya, Spain
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Current awareness: Pharmacoepidemiology and drug safety. Pharmacoepidemiol Drug Saf 2010. [DOI: 10.1002/pds.1853] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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Kommentierte Zusammenfassung der Leitlinien der European Society of Cardiology zur Infektiösen Endokarditis (Neuauflage 2009). KARDIOLOGE 2010. [DOI: 10.1007/s12181-010-0282-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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