Outpatient parenteral antimicrobial therapy is safe and effective for the treatment of infective endocarditis: a retrospective cohort study

Outpatient parenteral antibiotic treatment for infective endocarditis: A retrospective observational evaluation

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.

Use of Ceftriaxone and Benzylpenicillin in Outpatient Parenteral Antimicrobial Therapy: Spectrum vs Cost

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.

Outpatient Parenteral Antimicrobial Therapy for Infective Endocarditis-Model of Care

Infective endocarditis (IE) is a serious infectious disease with significant mortality and morbidity placing a burden on healthcare systems. Outpatient antimicrobial therapy in selected patients has been shown to be safe and beneficial to both patients and the healthcare system. In this article, we review the literature on the model of care for outpatient parenteral antimicrobial therapy in infective endocarditis and propose that systems of care be developed based on local resources and all patients admitted with infective endocarditis be screened appropriately for outpatient antimicrobial therapy.

Conventional Hospitalization versus Sequential Outpatient Parenteral Antibiotic Therapy for Staphylococcus aureus Bacteremia: Post-Hoc Analysis of a Multicenter Observational Cohort

It is not known whether sequential outpatient parenteral antimicrobial (OPAT) is as safe and effective as conventional hospitalization in patients with S. aureus bacteremia (SAB). A post-hoc analysis of the comparative effectiveness of conventional hospitalization versus sequential OPAT was performed in two prospective Spanish cohorts of patients with S. aureus bacteremia. The PROBAC cohort is a national, multicenter, prospective observational cohort of patients diagnosed in 22 Spanish hospitals between October 2016 and March 2017. The DOMUS OPAT cohort is a prospective observational cohort including patients from two university hospitals in Seville, Spain from 2012 to 2021. Multivariate regression was performed, including a propensity score (PS) for receiving OPAT, stratified analysis according to PS quartiles, and matched pair analyses based on PS. Four hundred and thirteen patients were included in the analysis: 150 in sequential OPAT and 263 in the full hospitalization therapy group. In multivariate analysis, including PS and center effect as covariates, 60-day treatment failure was lower in the OPAT group than in the full hospitalization group (p < 0.001; OR 0.275, 95%CI 0.129−0.584). In the PS-based matched analyses, sequential treatment under OPAT was not associated with higher 60-day treatment failure (p = 0.253; adjusted OR 0.660; % CI 0.324−1.345). OPAT is a safe and effective alternative to conventional in-patient therapy for completion of treatment in well-selected patients with SAB, mainly those associated with a low-risk source and without end-stage kidney disease.

Efficacy and safety of outpatient parenteral antibiotic therapy in patients with infective endocarditis: a meta-analysis

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.

Clinical predictors of outcome in patients with infective endocarditis receiving outpatient parenteral antibiotic therapy (OPAT)

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.

Infective Endocarditis in a Hospital-at-Home Setting: A Retrospective Analysis in a Peripheral Spanish Hospital

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.

Close Patient Follow-up Among Patients Receiving Outpatient Parenteral Antimicrobial Therapy

BACKGROUND

Outpatient parenteral antimicrobial therapy (OPAT) programs allow patients to receive intravenous treatment in the outpatient setting. We developed a predictive model of 30-day readmission among hospitalized patients discharged on OPAT from 2 academic medical centers with a dedicated OPAT clinic for management.

METHODS

A retrospective medical records review was performed and logistic regression was used to assess OPAT and other outpatient clinic follow-up in conjunction with age, sex, pathogen, diagnosis, discharge medication, planned length of therapy, and Charlson comorbidity score. We hypothesized that at least 1 follow-up visit at the Emory OPAT clinic would reduce the risk for hospital readmission within 30 days.

RESULTS

Among 755 patients, 137 (18%) were readmitted within 30 days. Most patients (73%) received outpatient follow-up care at Emory Healthcare within 30 days of discharge or prior to readmission, including 52% of patients visiting the OPAT clinic. The multivariate logistic regression model indicated that a follow-up OPAT clinic visit was associated with lower readmission compared to those who had no follow-up visit (odds ratio, 0.10 [95% confidence interval, .06-.17]) after adjusting for infection with enterococci, Charlson score, discharge location, and county of residence.

CONCLUSIONS

These results can inform potential interventions to prevent readmissions through OPAT clinic follow-up and to further assess factors associated with successful care transitions from the inpatient to outpatient setting.

Outpatient Antimicrobial Therapy for Infective Endocarditis is Safe

Infective endocarditis (IE) is common and is associated with significant mortality, morbidity and health care burden. Outpatient antimicrobial therapy in carefully selected patients, supported by a multidisciplinary team is safe and beneficial for both the patient and the health care system. In this article, we review current literature of outpatient antimicrobial therapy in infective endocarditis and propose that most patients with IE should be considered and appropriate pathways developed to facilitate this.

Human Factors approaches to evaluating outpatient parenteral antimicrobial therapy services: A systematic review

BACKGROUND

The expansion in terms of available treatment options and models of care has led to a growing global momentum for outpatient antimicrobial therapy (OPAT) services. A systematic review was undertaken to explore Human Factors aspects relating to OPAT service delivery and to evaluate whether OPAT is amenable to description using the Systems Engineering Initiative for Patient Safety (SEIPS 2.0) model.

METHOD

Following a preliminary search, a search string was applied to four databases, including Medline, Cumulative Index of Nursing and Allied Health Literature, International Pharmaceutical Abstracts and PsychINFO. Inclusion criteria ensured only articles published after the year 2000 and written in English were accepted. The methodological quality of studies was assessed by three reviewers. Narrative synthesis was performed to uncover the key interactions between work system entities which underpin OPAT processes and outcomes as described using the SEIPS 2.0 model.

RESULTS

A total of twenty-seven studies were deemed eligible for the final review. Of these, most described sample populations representative of the population under study, while duration of the studies varied from a few months to years. Some studies evaluated a single model of care whilst others evaluated all three currently available models. The breadth and scope of the studies included enabled extraction of rich Human Factors data describing barriers and enablers to service provision.

CONCLUSION

OPAT is a service which offers significant benefits to both patients and care providers. These benefits include patient satisfaction and wellbeing, as well as financial performance. OPAT is a complex sociotechnical system, and a systems approach may offer the opportunity to enhance system design, maximising system performance. This review demonstrates that the service can be better understood using the SEIPS 2.0 model to identify key work system interactions that support performance.

Twice daily cefazolin is effective for treatment of serious methicillin-sensitive Staphylococcus aureus infection in an outpatient parenteral antimicrobial therapy program

Background:

The use of cefazolin for infections caused by Staphylococcus aureus has been demonstrated to be effective, and associated with fewer adverse effects compared with anti-staphylocccal penicillins; however, use of cefazolin on outpatient parenteral antimicrobial therapy (OPAT) programs often requires the use of continuous infusions. We report the outcomes of patients with serious infections caused by methicillin-sensitive S. aureus (MSSA) treated using twice daily cefazolin by a large tertiary hospital OPAT program. The aim of this study was to evaluate the safety, efficacy and outcomes after 90 days of follow up for patients with serious infections caused by MSSA treated with twice daily cefazolin by our OPAT program.

Methods:

A retrospective analysis of clinical outcomes of cases treated for a serious infection proven to be caused by MSSA treated with cefazolin monotherapy on the OPAT program at a tertiary hospital between January 2010 and July 2016 (6.5 years). Outcome measures included readmission rate, adverse drug reactions and clinical cure.

Results:

A total of 111 cases of serious MSSA infection were treated with cefazolin in the OPAT service during the study period, including 52 with peripheral or vertebral osteomyelitis and 13 with infective endocarditis; 56 patients had bacteraemia. Median duration of intravenous antibiotic therapy was 41 days, and the median proportion of intravenous therapy administered via OPAT was 69%. Two patients had recurrence of infection within 90 days, but were in the setting of retained prosthetic material. A total of 4% of patients experienced an adverse drug reaction. No cases of antibiotic failure were identified.

Conclusions:

The use of twice daily cefazolin for serious MSSA infection on an OPAT program is safe and effective. Further study is needed to assess for noninferiority to conventional treatment regimes.

Cost and Outcomes of Implantable Cardiac Electronic Device Infections in Victoria, Australia

BACKGROUND

Implantable cardiac electronic device (ICED) infections are associated with significant morbidity, mortality and cost. The aim of this study was to perform the first analysis for the cost of ICED infection in Australia. Secondary aims were to provide an update on the incidence, burden and outcomes of ICED infections and an analysis of the hospital ICD-10 codes used for ICED infection admissions.

METHODS

We performed a retrospective study of ICED implantations and infections in the Barwon Health region (BH) and the state of Victoria (Vic) from January 2010 to December 2015 inclusive.

RESULTS

Sensitivity of ICD-10 code T82.7 was 63.4% (95% CI 46.9-77.8) and specificity was 14.5% (95% CI 9.9-21.1). Infection rates were 1.4 admissions/100,000 persons/year (SD 0.7) in BH and estimated to be 7.9 admissions/100,000 persons/year (95% CI 6.8-9.0) in Vic. Average cost of infection was $670,334/year in BH and estimated to be $14,879,979/year in Vic.

CONCLUSION

Rates of ICED infection are decreasing in Victoria. Infections are associated with significant morbidity and cost.

Outpatient Parenteral Antibiotic Treatment for Infective Endocarditis: A Prospective Cohort Study From the GAMES Cohort

BACKGROUND

Outpatient parenteral antibiotic treatment (OPAT) has proven efficacious for treating infective endocarditis (IE). However, the 2001 Infectious Diseases Society of America (IDSA) criteria for OPAT in IE are very restrictive. We aimed to compare the outcomes of OPAT with those of hospital-based antibiotic treatment (HBAT).

METHODS

Retrospective analysis of data from a multicenter, prospective cohort study of 2000 consecutive IE patients in 25 Spanish hospitals (2008-2012) was performed.

RESULTS

A total of 429 patients (21.5%) received OPAT, and only 21.7% fulfilled IDSA criteria. Males accounted for 70.5%, median age was 68 years (interquartile range [IQR], 56-76), and 57% had native-valve IE. The most frequent causal microorganisms were viridans group streptococci (18.6%), Staphylococcus aureus (15.6%), and coagulase-negative staphylococci (14.5%). Median length of antibiotic treatment was 42 days (IQR, 32-54), and 44% of patients underwent cardiac surgery. One-year mortality was 8% (42% for HBAT; P < .001), 1.4% of patients relapsed, and 10.9% were readmitted during the first 3 months after discharge (no significant differences compared with HBAT). Charlson score (odds ratio [OR], 1.21; 95% confidence interval [CI], 1.04-1.42; P = .01) and cardiac surgery (OR, 0.24; 95% CI, .09-.63; P = .04) were associated with 1-year mortality, whereas aortic valve involvement (OR, 0.47; 95% CI, .22-.98; P = .007) was the only predictor of 1-year readmission. Failing to fulfill IDSA criteria was not a risk factor for mortality or readmission.

CONCLUSIONS

OPAT provided excellent results despite the use of broader criteria than those recommended by IDSA. OPAT criteria should therefore be expanded.

Benefit of Echocardiography in Patients With Staphylococcus aureus Bacteremia at Low Risk of Endocarditis

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.

Start-up of a Cardiology Day Hospital: Activity, Quality Care and Cost-effectiveness Analysis of the First Year of Operation

INTRODUCTION AND OBJECTIVES

The cardiology day hospital (CDH) is an alternative to hospitalization for scheduled cardiological procedures. The aims of this study were to analyze the activity, quality of care and the cost-effectiveness of a CDH.

METHODS

An observational descriptive study was conducted of the health care activity during the first year of operation of DHHA. The quality of care was analyzed through the substitution rate (outpatient procedures), cancellation rates, complications, and a satisfaction survey. For cost-effectiveness, we calculated the economic savings of avoided hospital stays.

RESULTS

A total of 1646 patients were attended (mean age 69 ± 15 years, 60% men); 2550 procedures were scheduled with a cancellation rate of 4%. The most frequently cancelled procedure was electrical cardioversion. The substitution rate for scheduled invasive procedures was 66%. Only 1 patient required readmission after discharge from the CDH due to heart failure. Most surveyed patients (95%) considered the care received in the CDH to be good or very good. The saving due to outpatient-converted procedures made possible by the CDH was € 219 199.55, higher than the cost of the first year of operation.

CONCLUSIONS

In our center, the CDH allowed more than two thirds of the invasive procedures to be performed on an outpatient basis, while maintaining the quality of care. In the first year of operation, the expenses due to its implementation were offset by a significant reduction in hospital admissions.

What risk of endocarditis is low enough to justify the omission of transoesophageal echocardiography in Staphylococcus aureus bacteraemia? A narrative review

BACKGROUND

Recent criteria which can identify patients with Staphylococcus aureus bacteraemia (SAB) who are at very low risk of endocarditis raise the question of whether transoesophageal echocardiography (TOE) is appropriate for these patients.

AIMS

To estimate the probability of occult endocarditis complicating SAB below which a TOE-guided treatment strategy no longer offers the best 180-day survival, and to examine the key uncertainties affecting this result.

SOURCES

Estimates of the parameters required to calculate the Pauker-Kassirer testing threshold were identified from studies published prior to 1 June 2017 using a composite search strategy that involved a systematic search for relevant controlled trials and guidelines, followed by a non-systematic iterative search of the observational literature.

CONTENT

Estimates of the necessary parameters were generally consistent across the literature with the exception of the procedural mortality of TOE. In our base-case scenario (TOE mortality 0.1%), the testing threshold for TOE in apparently uncomplicated SAB was a 1.1% probability of occult endocarditis. Sensitivity analyses revealed that the procedural mortality of TOE was a key uncertainty affecting estimates of the testing threshold.

IMPLICATIONS

None of the available clinical tools can place patients with SAB below this probability of endocarditis with 95% confidence. Future work in this area should concentrate on improving the precision of these tools and on exploring the value of alternative echocardiography strategies. In addition, a better understanding of the harms of TOE is required to ensure that recommendations regarding the role of this investigation in the management of patients with SAB are appropriate.

Outpatient parenteral antibiotic therapy in a suburban tertiary referral centre in Australia over 10 years

PURPOSE

Outpatient parenteral antibiotic therapy (OPAT) is a widely accepted and safe therapeutic option for carefully selected patients. This study reviewed the practice of an OPAT service in a large Australian tertiary teaching hospital in Western Sydney over a 10-year period.

METHOD

Data were retrieved from a prospectively maintained electronic database which included information on patient demographics, clinical diagnosis, microbiological identity, antimicrobial therapy, complications and readmissions. Data were analysed using descriptive statistics.

RESULTS

There were 3435 referrals made to the service between January 2004 and June 2014, amounting to 25,289 antibiotic days. The most frequent referral was for Skin and Soft Tissue Infections (SSTIs), 61.28%, followed by Bone and Joint Infections (BJIs), 15.30%. The most common organism identified was methicillin-sensitive Staphylococcus aureus. Readmission was uncommon (5.15%), with the highest rate of readmission noted for Cardiovascular System Infections (16.67%) followed by BJIs (10.31%). Line infection, aseptic thrombophlebitis and drug hypersensitivity or reaction were the cause of 68.55% of all complications. There was a decline in line-related complications throughout the study period.

CONCLUSION

OPAT service is in increasing demand in Australia, providing a significant relief in in-hospital days. Growth in referrals was seen not only with SSTIs and BJIs, but also a diverse range of other infective entities with limited literature in its treatment in an OPAT setting. This study highlights the need to improve data collection, develop risk stratification strategies and standardisation of OPAT services in Australia.

Clinical efficacy, cost analysis and patient acceptability of outpatient parenteral antibiotic therapy (OPAT): a decade of Sheffield (UK) OPAT service

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.

Clinical and cost-effectiveness, safety and acceptability of community intravenous antibiotic service models: CIVAS systematic review

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.

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

Background

Outpatient 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.

Objectives

The 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.

Methods

This 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.

Results

The 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.

Limitations

Recruitment 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.

Conclusions

The 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 work

Further 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.

Funding

The National Institute for Health Research Health Service and Delivery Research programme.

The epidemiology and outcomes of infective endocarditis in a tertiary care hospital in Oman

OBJECTIVES

We undertook this study to describe the epidemiological and clinical features of infective endocarditis (IE) and to study the complications and management of IE in a tertiary care hospital in Oman.

METHODS

This is a retrospective study of 58 adult patients (>13 years of age) admitted to the Royal Hospital with IE from June 2006 to June 2011.

RESULTS

Of the 58 patients, 40 (69%) were males, and 18 (31%) were females (ratio 2.2). The median age was 43.6 years (range: 14-85). Forty-eight cases (82.7%) had native valves, nine patients (15.6%) had prosthetic valves, and one case (1.7%) had a pacemaker. The most commonly involved valves were mitral (33, 56.9%) and aortic (23, 39.7%). The blood cultures were positive in 47 (81%) patients, and the most commonly isolated organisms were Streptococci spp., which were found in 20 (34.5%) patients, and Staphylococci spp., which were found in 19 (32.8%) patients. The complication rate was 21%. A total of 15 (25.9%) patients underwent surgical intervention, and the in-hospital mortality rate was 27.6%.

CONCLUSIONS

Native-valve IE is the predominant type of endocarditis and is more of an acute disease. The prevalence of Staphylococci spp. IE is similar to that of Streptococci spp. IE, and its associated mortality remains high.