Nestor Sosa MD FACP Infectious Diseases Division Chief Outline History of OPAT Why OPAT Pros and Cons Who does OPAT How are patient and antibiotics selected OPAT Complications Monitoring and Future ID: 931127
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Slide1
Outpatient Antimicrobial Therapy (OPAT)
Nestor Sosa MD FACP
Infectious Diseases Division Chief
Slide2Outline
History of OPAT
Why OPAT: Pros and Cons
Who does OPAT
How are patient and antibiotics selected
OPAT Complications, Monitoring and Future
Slide3OPAT
Initiated in the 70’s,
250,000 OPAT in USA per year
Growing demand:
Technologic and Pharmacologic AdvancesMinimization of Hospital Stay
Slide4OPAT Evolution
1974
First Publication by Rucker and Harrison
who treated children with CF for exacerbation
of lung infections
1980 Ceftriaxone: long half life, broad spectrum1983 DRG models of payment were adopted by CMMS (Health Care Financing Administration)Prolonged hospital stay=financial liability2004 Publication of IDSA Guidelines (CID, Tice AD, et al.)
2018 New OPAT IDSA Guidelines (CID Norris A, et al.)
Slide5Slide6Slide7Slide8OPAT Pros and Cons
Pros
Safety and efficacy, decreased LOS and health care costs
Avoidance of nosocomial complications (C. diff, MRSA) and
Improved Quality of Life
Cons:Vascular Access related complicationsDrug-related complications: rash, GI side effects, nephrotoxicity and cytopeniasOutcomes less well studied
Slide9Slide10OPAT Team and Setting
Multidisciplinary:
Patient and Caregivers
Physician
Infusion Nurse
PharmacistCase Manager or Social WorkerSetting:Self Administration at HomeVisiting Nurse Service
Infusion CenterSkilled Nursing Facility
PHARMACY
PAYER
Home Health Care Company
Slide11Patient Selection (8 Key Questions)
Is Parenteral Needed?
Do the patient’s medical needs exceed resources available in the community?
Is home environment safe and adequate to support care?
Are the patient and caregiver willing and able to safely and effectively and reliably deliver parenteral antimicrobial therapy?
Are rapid and reliable communication mechanisms in place for monitoring of complications?Do the patient and caregiver understand benefits, risk and financial costs of OPAT?
Slide12Patient Selection
Is the microorganism, sensitivity and therapeutic plan clear?
Are all surgical and radiological interventions completed?
Slide13Patient Selection
Is OPAT needed?
Does the patient needs to be hospitalized
Patient and/or caregiver
knows OPAT
Disease Process
Microorganism and sensitivity
It is safe at home?
Do we have a good
communication plan?
Slide14OPAT Antibiotic Selection
Age,
Comorbid conditions,
Allergies
Slide15Table 5.
Slide16Indications for OPAT
Bone and Joint Infections
Endocarditis
Skin and Soft Tissue Infections
Bacteremia
Other: Pyelonephritis, Intra-abdominal, Prosthetic Device-related, and CNS infections, AIDS related OI’sID Consult prior to OPAT: Cost Saver, Improved Antimicrobial Utilization and Enhanced Safety. In one study 27% of OPAT was not necessary
Slide17Not “Candidates” for OPAT
Absolute
Hemodynamic instability
Hyperpyrexia
Altered mental status
Poor Performance statusRelativeEmpirical or multiple antibioticsPolymicrobial processInfections that required combined Surgical-MedicalPWID (debatable)
Slide18OPAT may be safe and effective, with comparable success,
mortality, catheter-related complication, but higher
re-admission rates than not IDU
Slide19OPAT Complications
≈20%
Drug related AE’s
Most common drug-related AE’s: rash, nephrotoxicity, GI adverse events,
cytopenias
3-10% Discontinuation due to medication-related AEs≈ 20% Catheter related complication Hospital Readmission 6-50%
Slide20OPAT monitoring
Monitoring:
Weekly Clinical and Laboratory monitoring:
CBC, renal and liver function tests
Daptomycin: CK, Vancomycin: drug levels Aminoglycosides: levels, renal and vestibular functionBone and Joint infections: CRP, ESR and imaging studies
Slide21OPAT Bundle: 6 components
Patient identification/selection
ID Consultation
Patient family education
Care transition
Outpatient monitoringOPAT program measures
Slide22Future of OPAT
Growing demand
Opiod
epidemic
Newer antibiotics:
Oritavancin once weekly antibioticDalbavancin: weekly injection (2 doses for osteo)Ceftaroline/Ceftobiprole: MRSA activityTelemedicine
Slide23References
Rucker R, Harrison G. Outpatient intravenous medications fin management
fo
cystic fibrosis. Pediatrics. 1974;54:358-360
Tice AD,
Rehm SJ, Dalovisio JR, et al: Practice guidelines for outpatient parenteral antimicrobial therapy. Clin Infect Dis 2004; 38: pp. 1651-1671Norris Anne, Shrestha Nabin et al: 2018 IDSA Practice Guideline for the Management of OPAT. CID 2019;68 (1):e1/e35.Chapman A.L., Dixon S., Andrews D., et al: Clinical efficacy and cost-effectiveness of outpatient parenteral antibiotic therapy (OPAT): a UK perspective. J
Antimicrob Chemother 2009; 64:1316-1324
Paladino
J.A., and
Poretz
D.: Outpatient parenteral antimicrobial therapy today.
Clin
Infect Dis 2010; 51: pp. S198-S208
Shrestha N.K.,
Bhaskaran
A.,
Scalera
N.M., et al: Contribution of infectious disease consultation toward the care of inpatients being considered for community-based parenteral anti-infective therapy. J
Hosp
Med 2012; 7: pp. 365-369
Cox A.M.,
Malani
P.N., Wiseman S.W., et al: Home intravenous antimicrobial infusion therapy: a viable option in older adults. J Am
Geriatr
Soc
2007; 55: pp. 645-650
Pulcini
C,
Couadau
T, Bernard E, et al: Adverse effects of parenteral antimicrobial therapy for chronic bone infections.
Eur
J
Clin
Mcrobio
Infect Dis 2008
dec
27 (12)
Thank You
NRSosa@salud.unm.edu
Slide25OPAT at UNM
25
Slide26ID Consult
Admission
Discharge
OPAT Criteria:
1. I.V. Antibiotics needed >10d
2. No Oral or
Long acting IV alternative
OPAT
InPAT
ID Sign-off
OPAT
Slide27OPAT at UNM
Due to space and provider limitations OPAT is currently scheduled only Mondays and Wednesdays
5ACC clinic A and infusion suite
Annual the OPAT clinic manages 500 unique
patients and 2000
patient encounters.No-show rate has historically been low (<10%).27
Slide28InPAT
Currently on Thursday and Friday only
Patients seen weekly on Thurs or Fri
Pager 380-0901
Slide29InPAT
After Team 1 or Team 2 sign-off
Monitor for new infections or signs of worsening infection, look for any side effects from
abx
, new culture data
Help the case managers with discharge
Slide30OPAT
Have to have been seen by ID
Have to have a sign-off note from ID with OPAT recommendations
Have more than 10 days of antibiotics in treatment course at time of discharge
Slide31OPAT
Have to have ad hoc to OPAT
Case Managers need to call to schedule
appt
OPAT DC script needs to be filled out and given to the case manager
Case manager is responsible for faxing it to the facility and to OPAT. If on HD then script is faxed to HD center. HD center needs to be called to make sure they have the medication or can get the medication
Slide32OPAT
We will see patients with IV or PO
abx
, or on HD
Most
appts are weekly, if on IV abx then weekly appts, if on PO abx then appts can ben every two weeks or longerWe will see pts on oral suppression ideally for a yr and then turn over care to their PCP
Slide33OPAT
If a patient has an IR placed drain, prior to DC an ad hoc for IR follow-up must be placed
In ad hoc MUST SAY THE FACILITY WHERE PT HAS BEEN DISCHARGED
Labs
All patients must have weekly safety labs : CBC w/Diff,
Chem
7, LFT
If
pt is being treated for osteo must include an ESR and CRPIf patient is on Vancomycin, blood draw should come from a peripheral draw and not the PICC or Midline if at all possibleDaptomycin pt needs to have a CK An “Azole” and Fluoroquinolone needs a baseline EKG
Slide35OPAT
Ideal future
Slide36OPAT
Currently staffed to meet the need of two days of clinic
Many issues arise not during clinic hours
Limited ability to review clinic process retrospectively or plan prospectively
Majority of communications are outside of the UNM system
Slide37OPAT Structure
Current
4 half days of clinic
1.0 FTE APPs
0.5 FTE MD support
3.0 FTE OPAT RNs1.0 FTEOPAT MAShared RN CM & SWIdeal
8-10 half day of clinic2.0 FTE APPs1.0 FTE OPAT MD 4.0
FTE OPAT RNs
2.0
FTE OPAT MAs
1.0
FTE OPAT Case Manager
1.0 FTE Social Worker
Slide38OPAT
Not uncommon for OPAT to complete IV antibiotics before patients can follow-up with PCP and/or other specialties
Future state should be focused on a multidisciplinary approach to treatment
Slide39Comprehensive Clinic Model
Ideally clinics would be divided by specialties/ infection type
Allocations of resources and providers to meet specific needs (
i.e
CDE for DFI,
suboxone for PWID)
Patient
Slide40OPAT Bundle: 6 components
Patient identification/selection
ID Consultation
Patient family education
Care transition
Outpatient monitoringOPAT program measures
Slide41Questions