Outpatient Antimicrobial Therapy (OPAT) - PowerPoint Presentation

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Outpatient Antimicrobial Therapy (OPAT)

Nestor Sosa MD FACP

Infectious Diseases Division Chief

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Outline

History of OPAT

Why OPAT: Pros and Cons

Who does OPAT

How are patient and antibiotics selected

OPAT Complications, Monitoring and Future

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OPAT

Initiated in the 70’s,

250,000 OPAT in USA per year

Growing demand:

Technologic and Pharmacologic AdvancesMinimization of Hospital Stay

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OPAT 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.)

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OPAT 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

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OPAT 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

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Patient 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?

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Patient Selection

Is the microorganism, sensitivity and therapeutic plan clear?

Are all surgical and radiological interventions completed?

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Patient 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?

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OPAT Antibiotic Selection

Age,

Comorbid conditions,

Allergies

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Table 5.

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Indications 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

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Not “Candidates” for OPAT

Absolute

Hemodynamic instability

Hyperpyrexia

Altered mental status

Poor Performance statusRelativeEmpirical or multiple antibioticsPolymicrobial processInfections that required combined Surgical-MedicalPWID (debatable)

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OPAT may be safe and effective, with comparable success,

mortality, catheter-related complication, but higher

re-admission rates than not IDU

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OPAT 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%

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OPAT 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

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OPAT Bundle: 6 components

Patient identification/selection

ID Consultation

Patient family education

Care transition

Outpatient monitoringOPAT program measures

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Future of OPAT

Growing demand

Opiod

epidemic

Newer antibiotics:

Oritavancin once weekly antibioticDalbavancin: weekly injection (2 doses for osteo)Ceftaroline/Ceftobiprole: MRSA activityTelemedicine

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References

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)

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Thank You

NRSosa@salud.unm.edu

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OPAT at UNM

25

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ID 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

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OPAT 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

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InPAT

Currently on Thursday and Friday only

Patients seen weekly on Thurs or Fri

Pager 380-0901

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InPAT

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

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OPAT

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

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OPAT

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

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OPAT

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

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OPAT

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

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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

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OPAT

Ideal future

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OPAT

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

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OPAT 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

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OPAT

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

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Comprehensive 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

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OPAT Bundle: 6 components

Patient identification/selection

ID Consultation

Patient family education

Care transition

Outpatient monitoringOPAT program measures

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Questions