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Feasibility of an outpatient and home parenteral antibiotic therapy (OHPAT) programme in Tayside, Scotland
i
Feasibility of an Outpatient and Home Parenteral Antibiotic Therapy (OHPAT) Programme in Tayside, Scotland R. A. Seaton’,
D. Nathwani’,
F. L. R. Williams*
and A. C. BoytIer
‘Infection a17d Imnzunodeficienc~ unit. Dundee Teaching Hospitals L3JHSTrust, Kings Cross Hospital, Durtdee, “Departnlellt of E~iden7io1og;yand Public Health. Uni\lersity of Dundee Medical School. DLu?deeana ‘Department of Pharrnarebltiral Sciences, University of Strathclyde, Glasgow Outpatient and home parenteral antibiotic therapy (OHPAT) is under-utilized in the U.K. We performed a feasibility study over a S-month period in a regional U.K. infection unit. After exclusions, 183 antibiotic treatesd patients were evaluated. Ninety-five received intravenous (I\‘) therapy, of whom 32 received at least 4 days. Prolonged IV therapy was most frequent in soft tissue infections. In these patients, length of stay and duration of IV treatment were correlated (r = 0.74,0.51-0.87). Eighty-three (86%) of patients who received IV therapy judged OHPAT to be an acceptable alternative to hospitalization. Those who did not were older (mean age 64 vs. 46 years, P
Introduction In the U.K. patients who require intravenous antibiotic therapy are usually managed in hospital until it is appropriate to change to oral therapy. To our knowledge, outpatient and home parenteral antibiotic therapy (OHPAT) is only practiced by a small number of clinical enthusiasts.1-3 Despite the National Health Service (NHS) executive’s commitment to promoting high-quality care in the communily. clear national guidelines on the development, implementation or funding of an OHPAT programme have only recently been published.” Potentially an OHPAT programme should reduce hospital stay, improve patient lifestyle, reduce the risk of nosocomial infection and free up beds for other patients who require more intensive nursing or medical care. OHPAT is well established in the U.S.A and clear guidelines exist.j In the U.K. setting there are little data on the need or feasibility of a hospital-led OHPAT programme. We have previously outlined what we perceive as the key issues in developing such a programme.” The purpose of the present study was to describe the indications for intravenous antibiotic therapy within our Address all correspondence to: Dr RA Seaton. Infection and Immunodeficiency unit. Dundee Teaching Hospitals NHS Trust, Kings Cross Hospital, Clepington road. Dundee. DD3 8EA. U.T<. Accepted for publication 15 May 1999. Olh3-4433/99/020129
+ 05 $12.00/O
infection unit and to determine the feasibility of an OHPAT programme within such a setting. Specifically we wanted to determine whether typical patients with infection in our region thought that non-inpatient management of infection with parenteral agents would be an acceptable alternative to hospital admission. We have previously published an ad hoc analysis in a separate non-consecutive group of patients in our own and another regional infection unit.’ Here we present our findings of a consecutive group of patients referred to our infection unit.
Methods Adult patients referred to the Tayside infection and immunodeficiency unit (a 22-bed ward) in the Dundee Teaching Hospitals NHS Trust, Scotland, U.K. over a 5 month period were included in this prospective study. The unit admits approximately 1200 patients annually with suspected community acquired infections, imported infections, HIV-related disease and accepts referrals from other units within the region (population approximately 400 000). Most patients with bone and joint infections and infective endocarditis are managed jointly with other specialists in other units. Patients were included in the study if they were: admitted between September 199 7 and February 1998; were treated with an antimicrobial agent (oral or parenteral) 8 1 Y 99 The British Tnfection Society
and were discharged with a clinical diagnosis OTan infectious disease. Patients were excluded if they were unable to give informed consent, if they were known intravenous drug users or if they had a history of poor drug compliance In addition. those who were readmitted during the study period were l:ot included again: those who died or were transferred !o other units were excluded. Patients were assessed to be appropriate for OHPAT if they met the inclusion criteria, had an infection that would be amenable to outpatient therapy, they received a parenteral antimicrobia! for more than 72 11 and did not require andary therapy that could only be provided in hospital. Patients who received 72 h or less parenteral antibiotic therapy were, at the time of the study. not judged to be suitable for SPAT as it was judged that such short-course parenteral therapy in hospital was necessary for proper assessment of response to treatment and suitability for oral switch therapy. Patients who required intermittent inksions (i.e. T-I!Ti-antibody patients receiving cidofovir) were included. All patients were under the care of an infectious disease physician. Route and duration of therapy were determined by the attending physician. This initially followed the unit’s sepsis protocol which was modified depending on the patients’ clinical response to antibiotics. Ethical appznoval for the study was granted by the Tayside Area Ethics Committee and informed consent was obtained from a!1 patients. Details were recorded on all patients including age, sex. date of admission and discharge, diagnosis, route and duration of the antibiotic therapy In addition patients were asked to complete a on admission detaiiing key ‘patient questionnaire factors’” which determined if parenteral therapy at home would be feasible and if they were willing to undergo therapy at home (Table I). Ail data were recorded on a standardised proforma. The Epi-info 5 statistical package was used for analysis. The correlation coefficient. r, with 9 5% confidence intervals was calculated for length of hospital stay and length of intravenous antimicrobial therapy Continuous data were compared using the Student’s t-test
and categorical data were compared with the cm-squared test with Yate’s correction. P values of CO.05 were regarded as significant.
hn the S-month study period there were a total of 436 admissions to the infection unit. One hundred and twenty-six patients (2 9 %) were excluded as. following assessment, they were judged not to have an infectious disease cr had an infection which did not require antibiotic therapy (e.g. viral pharyngitis). Of the remaining 3 10 (71%) patient-s. 17 were unable to consent (1 5 dementia, two learning or language difficulties), 12 were known intravenous drug misusers and one had documented poor adhe:-ence to anti-tuberculous therapy. Sixteen patients died. 3 2 were transferred to other units and there were 2 5 readmissions. Two patients refused to participate in the study. Thus, a total of 205 patients were eligible for the study. One hundred and eighty-three (90%) completed the questionnaire. There were 94 men and X5 women (gender was not recorded in folur patients). The ages ranged from 10 years to 96 years (mean 49 years). The most common diagnoses were lower respiratory tract infections and soft tissue infection (Table II). Length of admission ranged from 1 day (26 patients) to 22 days (mean 5 days, standard deviation 4.3 days). Eighty-five patients received only oral antibiotics whilst 9 5 received at least 1 day of intravenous therapy. The median length of intravenous therapy in hospital was 3 days (range l-14 days). Thirty two patients (I 7.5%) received at least 4 days of inpatient intravenous therapy: this was most common in patients with serious deep seated infections, e.g. extensive soft tissue infections. bone and joint infections and bacterial meningitis (Table II). In those patients who received intravenous therapy there was a clear correlation between length of stay and length of treatment with intravenous antibiotics (r = 0.71, 95% confidence interval 0.6-0.8).
Is the patienL willing to have oupaiiml parentera antibiotic therapy? Does the patient live m4th a person who would be willing to administer parenteral antibiotics? Does the palienl have a telephone al home? Does the patient have access to a car? Does the patient have access to public transport? Does the patient have a fridge; Has the patient had home antibiotics before.;
Outpatient
and Home Parenteral
Antibiotic
131
Therapy
Table II. Site of infection. frequency and duration of intravenous antibiotic chemotherapy and willingness to undergo OHPAT >72 hrs:~(%)
infection
NO’WJ)
Ivs-;-(%)
Lower respiratory tract Soft tiswe Gastroinlestinal tract Urinary lracl Lpper respiratory tract Malaria Rone-joint Ikcteraemia Herpes virus Meningitis Other
42 (23) 39 (21) 29 (16) 25 (14) 10 (6) 9 (5) 8 (4) 6 (3) 6 (3) 5 (3) 4 (2)
20 (48) 30 (77) 3 (10) 15 (60) 7 (70) 0 (0) 5 (631 5 (83) 3 (50) 4 (80) 3 (75)
6 (14) 13 (33) 0 (0) J 14) l(lO) 0 (0) 3 (38) 2 (33) cl (0) 4 (80) 2 (50)
95 (52)
32 (17)
To&l
J 83
Willingg(%) 35 (83) 31 (7’9) 24 (83) 20 (813) 9 (910) 9 (1100) 6 (75) 6 (1’00) 5 (83) 5 (100) 4 (100) 154 (84)
‘Total number (percentage) of patients sludied: jNumber (percentage) of patients receiving intravenous antibiotics: ZKumber (percentage) of patients with more than 72 h of intravenous antibiotics therapy: $Xumber (percentage) of patients willing to undergo outpatient or home parenteral antibiotic therapy
This was true for soft tissue infections (r = 0.74, 0.51LO.87) but not for lower respiratory tract infections (r = 0.45,0.01-0.74). A survey of patients attitudes towards outpatient parenteral therapy showed most (154. 84%) thought OHPAT would be an acceptable alternative to inpatient therapy. Of the 29 patients who did not think OHPAT was an acceptable alternative to inpatient therapy only three gave explanations: severe arthritis. fear of the intravascular device and disagreement in principle. Patients who thought OHPAT would not be an acceptable alternative to inpatient therapy were significantly older (mean age 64. standard deviation 22 years) compared to those who were willing to undergo intravenous therapy at home (mean age 46. standard deviation 22 years, P
three bone and joint infections (tota! 77 bed-days), three infective endocarditis/ bacteraemia (total 6X bed-days), two cytomegalovirus retinitis (total two bed-days) and one invasive aspergillosis (total 60 bed-days). Twenty-one other patients received prolonged (>72 hours) inpatient parenteral antibiotic therapy. Fourteen of these could have been managed after initial hospital management with OHPAT if the resource had been available (nine soft tissue infections, four patients with bacterial meningitis and one with bacteraemia). Of the remaining seven patients, five had complicated respiratory tract infections and required inpatient management and oxygen therapy. one had pyelonephritis and one had severe herpes stomatitis requiring intravenous fluids.
Discussion Several obstacles to OHPAT have been identified by hospital doctors in the U.K.: reluctance to try something new: lack of good clinical data relevant to the British healthcare system: practical organizational problems including funding and concern about reducing the number of hospital beds3 However, despite these reservations there is growing experience in the U.K. that OHPAT can be safe. efficient and acceptable to patients.1~“~8In addition, recent guidelines applicable to European models of healthcare have recently been published.‘The present study included patients with a broad spectrum of community-acquired infection but underestimated the numbers of patients with bone and joint infections, infective endocarditis and other deep seated infections, who are usually managed jointly with other specialists and who would probably
most benefit from OIIPAT~ We have also excluded some patients who received parenteral therapy but were unsuitable for OIZAT due to mental illness, behavioural problems, compliance problems and intravenous drug misuse irrespective of their home circumstances. this is in line with others’ practice.i Exclusion of some of these patients may have biased the results. despite these exceptions, prolonged (>72 11) parenteral therapy was common in the study group. In those patients with soft tissue infections requiring parenteral antibiotic therapy length of hospital stay was correlated with length of inpatient parenteral antibiotic therapy, highlighting potential for an OHPAT programme in this group of patients. This has been confirmed in a subsequent audit9 This was not true for community-acquired respiratory tract infections which are usually managed with oral antibiotics in our practice. Prolonged hospital admissions in patients with respiratory tract infections usually reflect lack of acute respiratory support at home although such infections are managed successfrdly by some home therapy teams in the U.S.A. Our study also demonstra!ed that OHPAT is viewed as both an acceptable and feasible alternative to inpatient therapy in the majority of patients with communityacquired infection. Those patients who were less enthusiastic about intravenous therapy at home were significantly older than those who were in favour and were significantly less likely to have a carer at home who would be willing to administer the antibiotic. This probably reflects many factors such as comorbidity, frailty, sense of vulnerability at home and perhaps reluctance to consider alternatives in view of previous positive hospital experiences. Thirteen patients were treated ad hoc as outpatients by ward staff with narenteral antibiotics. A!though there were significant savings in bed-days and patients were satisfied with their management, the extra workload for ward nursing staff was difficult to manage within existing resources. Fourteen other patients were appropriate for OHPAT but had to be managed in hospital because of pressures on ward nursing staff and lack of a dedicated nurse specialist. Hence 25/32 (79%) of patients who required prolonged parenteral antibiotic therapy or 27/95 (28%) of all patients who required any parenteral therapy were judged to be suitable candidates for OHPAT if the resource had been available. In a previous pilot study (involving mainly patients with soft tissue or orthopaedic infections) we treated 11% of inpatients requiring parenteral therapy as outpatients with either daily teicoplanin or ceftriaxone. At completion, 92% of patients were very much in favour of OHPAT, said they would
repeat this form of treatmen; again and Lt that treatment out of hospital improved their quality of life.” These findings have been instrumental in securing funding for a full-time nurse practitioner to coordinate an 3HPAT programme within our region. In the first year over IO0 patients have been treated with OHPAT and patient satisfaction has been high.‘” Oher units within the trust including internal medicine, orthopaedics, otolaryngology, neurosurgery and radiotherapy have utilized the service and have been satisfied with the service provided. The service has developed such that some patients (particularly those with soft tissue infections) are now managed solely in a non-inpatient setting without prior admission. Since this situation has evolved with our OHPAT experience it is clear that in the present study we have underestimated the proportion of patients who could be managed with OHPAT on a short term basis. These experiences show that OHPAT is acceptable both in theory and in practice to patients with communityacquired infections. The remaining issues which determine the feasibility of a European O?IPAT programme such as staffing and funding have recently been reviewed.4,6 A major issue is the co-operation and involvement of primary healthcare professionals. In Tayside the concept of OHPAT therapy is acceptable to most general practitioners as long as the programme is hospital lead and funded.“~” It is important for any healthcare provider to properly assess the need and feasibility of any new health care innative before significantly altering clinical practice. This applies particularly to loca!, community based intravenous antibiotic programmes in the ‘J.K. and elsewhere in Europe. Although many Trusts throughout the U.K. do not have a dedicated infection unit, this is not a prerequisite for an OHPAT programme. It would feasible for an interested physician or clinical microbiologist with suitable experience in managing infection to investigate the local need for an OHPAT service. We envisage that patient attitudes about the acceptability of community based therapy throughout the U.K. would not differ greatly from our experience in Tayside. As hospital admissions increase, nosocomial infections become more prevalent and the public become aware of opportunities for hospital care in the community, we encourage others to research and develop OHPAT programmes locally in the U.K. and Europe.
The authors are grateful to DE Cmelia Criyhton. Jonalhan McDevitt and Jason I’winn for help in colleclion of patient questionnaires.
Outpatient
and Home Parenteral
References 1 Kayley 1. I3erendt AR, Snelling MJnl. Moore H, Hamilton HC. l’eto TEA. Safe intravenous antibiotic therapy at home: experience of a LK based programme. 1 A~~Limi~n~h Chcm 1996: 37: 1023-I 03 1. 2 Wiskela MJ. Nicholson KG. Outpatient parenteral antimicrobial therapy: experience in a large teaching hospital. i I~lfrrt 19V7; 35: 73-76. 3 Nathwani D. Daueg I? Intravenous antimicrobial therapy in the community: underused. inadequately resourccd or irrelevant to health care in Britain. Mrii ~Mriif 1997; 313: 1541-1543. 4 Nathwani 1~and Cordon C. Outpatient and home parenteral antibiotic therapy IOHPAT) in the UK: a consensus slatement by a working party Cliil Mirrohiol h/?ct 1998: 4: 53 7-551 5 Williams DN. Rem SJ, Tice AD. Bradley JS. Kind AC. Craig WA. Practice guidelines for community-based parenteral anti-inCective therapy Cli11Inject Dis 1997; 25: 787-801.
Antibiotic
Therapy
133
6 Kathwani D, Seaton X. Davey I? Key issues in the development of a non-inpatient intravenous (NIPIT’) antibiotic therapy programme a European perspeclive. Rw Med Mici- 1997; 8: 1-I 1. 7 Seaton RA. Boyter AC. Williams FLR. Laing R, Nathmani D. ,icceptability of non-inpatient intravenous antibiotic therapy in patients with infection in the North-East of Scotland. i Antimicroh Chem 19 9 7: 40: 9 7 2-9 13. 8 Parker SE. Nathwani D, O’Reillp DO, Parkinson S. Davey PG. Evaluation of the impact of non-inpatient iv antibiotic treatment for acule infections on the hospital. primary care services and Ihe patient. JHnlimici-ob Chen~ 1998: 42: 373-380. 9 Nathwani I>, Moitra S. Dunbar J et oi. Skin and soft tissue infectionsdevelopment of a collaborative management plan between communily and hospital care. 111t1 Ciirl Piuct 199 8. 10 Nathwani D. Morrison J. Gray I< et al. Outpatient and home parenleral antibiotic therapy (OHPAT). Evaluation of the impact of one year’s experience in Tayside. Henitll Blilletirl (in press).
Feasibility of an Outpatient and Home Parenteral Antibiotic Therapy (OHPAT) Programme in Tayside, Scotland R. A. Seaton’,
D. Nathwani’,
F. L. R. Williams*
and A. C. BoytIer
‘Infection a17d Imnzunodeficienc~ unit. Dundee Teaching Hospitals L3JHSTrust, Kings Cross Hospital, Durtdee, “Departnlellt of E~iden7io1og;yand Public Health. Uni\lersity of Dundee Medical School. DLu?deeana ‘Department of Pharrnarebltiral Sciences, University of Strathclyde, Glasgow Outpatient and home parenteral antibiotic therapy (OHPAT) is under-utilized in the U.K. We performed a feasibility study over a S-month period in a regional U.K. infection unit. After exclusions, 183 antibiotic treatesd patients were evaluated. Ninety-five received intravenous (I\‘) therapy, of whom 32 received at least 4 days. Prolonged IV therapy was most frequent in soft tissue infections. In these patients, length of stay and duration of IV treatment were correlated (r = 0.74,0.51-0.87). Eighty-three (86%) of patients who received IV therapy judged OHPAT to be an acceptable alternative to hospitalization. Those who did not were older (mean age 64 vs. 46 years, P
Introduction In the U.K. patients who require intravenous antibiotic therapy are usually managed in hospital until it is appropriate to change to oral therapy. To our knowledge, outpatient and home parenteral antibiotic therapy (OHPAT) is only practiced by a small number of clinical enthusiasts.1-3 Despite the National Health Service (NHS) executive’s commitment to promoting high-quality care in the communily. clear national guidelines on the development, implementation or funding of an OHPAT programme have only recently been published.” Potentially an OHPAT programme should reduce hospital stay, improve patient lifestyle, reduce the risk of nosocomial infection and free up beds for other patients who require more intensive nursing or medical care. OHPAT is well established in the U.S.A and clear guidelines exist.j In the U.K. setting there are little data on the need or feasibility of a hospital-led OHPAT programme. We have previously outlined what we perceive as the key issues in developing such a programme.” The purpose of the present study was to describe the indications for intravenous antibiotic therapy within our Address all correspondence to: Dr RA Seaton. Infection and Immunodeficiency unit. Dundee Teaching Hospitals NHS Trust, Kings Cross Hospital, Clepington road. Dundee. DD3 8EA. U.T<. Accepted for publication 15 May 1999. Olh3-4433/99/020129
+ 05 $12.00/O
infection unit and to determine the feasibility of an OHPAT programme within such a setting. Specifically we wanted to determine whether typical patients with infection in our region thought that non-inpatient management of infection with parenteral agents would be an acceptable alternative to hospital admission. We have previously published an ad hoc analysis in a separate non-consecutive group of patients in our own and another regional infection unit.’ Here we present our findings of a consecutive group of patients referred to our infection unit.
Methods Adult patients referred to the Tayside infection and immunodeficiency unit (a 22-bed ward) in the Dundee Teaching Hospitals NHS Trust, Scotland, U.K. over a 5 month period were included in this prospective study. The unit admits approximately 1200 patients annually with suspected community acquired infections, imported infections, HIV-related disease and accepts referrals from other units within the region (population approximately 400 000). Most patients with bone and joint infections and infective endocarditis are managed jointly with other specialists in other units. Patients were included in the study if they were: admitted between September 199 7 and February 1998; were treated with an antimicrobial agent (oral or parenteral) 8 1 Y 99 The British Tnfection Society
and were discharged with a clinical diagnosis OTan infectious disease. Patients were excluded if they were unable to give informed consent, if they were known intravenous drug users or if they had a history of poor drug compliance In addition. those who were readmitted during the study period were l:ot included again: those who died or were transferred !o other units were excluded. Patients were assessed to be appropriate for OHPAT if they met the inclusion criteria, had an infection that would be amenable to outpatient therapy, they received a parenteral antimicrobia! for more than 72 11 and did not require andary therapy that could only be provided in hospital. Patients who received 72 h or less parenteral antibiotic therapy were, at the time of the study. not judged to be suitable for SPAT as it was judged that such short-course parenteral therapy in hospital was necessary for proper assessment of response to treatment and suitability for oral switch therapy. Patients who required intermittent inksions (i.e. T-I!Ti-antibody patients receiving cidofovir) were included. All patients were under the care of an infectious disease physician. Route and duration of therapy were determined by the attending physician. This initially followed the unit’s sepsis protocol which was modified depending on the patients’ clinical response to antibiotics. Ethical appznoval for the study was granted by the Tayside Area Ethics Committee and informed consent was obtained from a!1 patients. Details were recorded on all patients including age, sex. date of admission and discharge, diagnosis, route and duration of the antibiotic therapy In addition patients were asked to complete a on admission detaiiing key ‘patient questionnaire factors’” which determined if parenteral therapy at home would be feasible and if they were willing to undergo therapy at home (Table I). Ail data were recorded on a standardised proforma. The Epi-info 5 statistical package was used for analysis. The correlation coefficient. r, with 9 5% confidence intervals was calculated for length of hospital stay and length of intravenous antimicrobial therapy Continuous data were compared using the Student’s t-test
and categorical data were compared with the cm-squared test with Yate’s correction. P values of CO.05 were regarded as significant.
hn the S-month study period there were a total of 436 admissions to the infection unit. One hundred and twenty-six patients (2 9 %) were excluded as. following assessment, they were judged not to have an infectious disease cr had an infection which did not require antibiotic therapy (e.g. viral pharyngitis). Of the remaining 3 10 (71%) patient-s. 17 were unable to consent (1 5 dementia, two learning or language difficulties), 12 were known intravenous drug misusers and one had documented poor adhe:-ence to anti-tuberculous therapy. Sixteen patients died. 3 2 were transferred to other units and there were 2 5 readmissions. Two patients refused to participate in the study. Thus, a total of 205 patients were eligible for the study. One hundred and eighty-three (90%) completed the questionnaire. There were 94 men and X5 women (gender was not recorded in folur patients). The ages ranged from 10 years to 96 years (mean 49 years). The most common diagnoses were lower respiratory tract infections and soft tissue infection (Table II). Length of admission ranged from 1 day (26 patients) to 22 days (mean 5 days, standard deviation 4.3 days). Eighty-five patients received only oral antibiotics whilst 9 5 received at least 1 day of intravenous therapy. The median length of intravenous therapy in hospital was 3 days (range l-14 days). Thirty two patients (I 7.5%) received at least 4 days of inpatient intravenous therapy: this was most common in patients with serious deep seated infections, e.g. extensive soft tissue infections. bone and joint infections and bacterial meningitis (Table II). In those patients who received intravenous therapy there was a clear correlation between length of stay and length of treatment with intravenous antibiotics (r = 0.71, 95% confidence interval 0.6-0.8).
Is the patienL willing to have oupaiiml parentera antibiotic therapy? Does the patient live m4th a person who would be willing to administer parenteral antibiotics? Does the palienl have a telephone al home? Does the patient have access to a car? Does the patient have access to public transport? Does the patient have a fridge; Has the patient had home antibiotics before.;
Outpatient
and Home Parenteral
Antibiotic
131
Therapy
Table II. Site of infection. frequency and duration of intravenous antibiotic chemotherapy and willingness to undergo OHPAT >72 hrs:~(%)
infection
NO’WJ)
Ivs-;-(%)
Lower respiratory tract Soft tiswe Gastroinlestinal tract Urinary lracl Lpper respiratory tract Malaria Rone-joint Ikcteraemia Herpes virus Meningitis Other
42 (23) 39 (21) 29 (16) 25 (14) 10 (6) 9 (5) 8 (4) 6 (3) 6 (3) 5 (3) 4 (2)
20 (48) 30 (77) 3 (10) 15 (60) 7 (70) 0 (0) 5 (631 5 (83) 3 (50) 4 (80) 3 (75)
6 (14) 13 (33) 0 (0) J 14) l(lO) 0 (0) 3 (38) 2 (33) cl (0) 4 (80) 2 (50)
95 (52)
32 (17)
To&l
J 83
Willingg(%) 35 (83) 31 (7’9) 24 (83) 20 (813) 9 (910) 9 (1100) 6 (75) 6 (1’00) 5 (83) 5 (100) 4 (100) 154 (84)
‘Total number (percentage) of patients sludied: jNumber (percentage) of patients receiving intravenous antibiotics: ZKumber (percentage) of patients with more than 72 h of intravenous antibiotics therapy: $Xumber (percentage) of patients willing to undergo outpatient or home parenteral antibiotic therapy
This was true for soft tissue infections (r = 0.74, 0.51LO.87) but not for lower respiratory tract infections (r = 0.45,0.01-0.74). A survey of patients attitudes towards outpatient parenteral therapy showed most (154. 84%) thought OHPAT would be an acceptable alternative to inpatient therapy. Of the 29 patients who did not think OHPAT was an acceptable alternative to inpatient therapy only three gave explanations: severe arthritis. fear of the intravascular device and disagreement in principle. Patients who thought OHPAT would not be an acceptable alternative to inpatient therapy were significantly older (mean age 64. standard deviation 22 years) compared to those who were willing to undergo intravenous therapy at home (mean age 46. standard deviation 22 years, P
three bone and joint infections (tota! 77 bed-days), three infective endocarditis/ bacteraemia (total 6X bed-days), two cytomegalovirus retinitis (total two bed-days) and one invasive aspergillosis (total 60 bed-days). Twenty-one other patients received prolonged (>72 hours) inpatient parenteral antibiotic therapy. Fourteen of these could have been managed after initial hospital management with OHPAT if the resource had been available (nine soft tissue infections, four patients with bacterial meningitis and one with bacteraemia). Of the remaining seven patients, five had complicated respiratory tract infections and required inpatient management and oxygen therapy. one had pyelonephritis and one had severe herpes stomatitis requiring intravenous fluids.
Discussion Several obstacles to OHPAT have been identified by hospital doctors in the U.K.: reluctance to try something new: lack of good clinical data relevant to the British healthcare system: practical organizational problems including funding and concern about reducing the number of hospital beds3 However, despite these reservations there is growing experience in the U.K. that OHPAT can be safe. efficient and acceptable to patients.1~“~8In addition, recent guidelines applicable to European models of healthcare have recently been published.‘The present study included patients with a broad spectrum of community-acquired infection but underestimated the numbers of patients with bone and joint infections, infective endocarditis and other deep seated infections, who are usually managed jointly with other specialists and who would probably
most benefit from OIIPAT~ We have also excluded some patients who received parenteral therapy but were unsuitable for OIZAT due to mental illness, behavioural problems, compliance problems and intravenous drug misuse irrespective of their home circumstances. this is in line with others’ practice.i Exclusion of some of these patients may have biased the results. despite these exceptions, prolonged (>72 11) parenteral therapy was common in the study group. In those patients with soft tissue infections requiring parenteral antibiotic therapy length of hospital stay was correlated with length of inpatient parenteral antibiotic therapy, highlighting potential for an OHPAT programme in this group of patients. This has been confirmed in a subsequent audit9 This was not true for community-acquired respiratory tract infections which are usually managed with oral antibiotics in our practice. Prolonged hospital admissions in patients with respiratory tract infections usually reflect lack of acute respiratory support at home although such infections are managed successfrdly by some home therapy teams in the U.S.A. Our study also demonstra!ed that OHPAT is viewed as both an acceptable and feasible alternative to inpatient therapy in the majority of patients with communityacquired infection. Those patients who were less enthusiastic about intravenous therapy at home were significantly older than those who were in favour and were significantly less likely to have a carer at home who would be willing to administer the antibiotic. This probably reflects many factors such as comorbidity, frailty, sense of vulnerability at home and perhaps reluctance to consider alternatives in view of previous positive hospital experiences. Thirteen patients were treated ad hoc as outpatients by ward staff with narenteral antibiotics. A!though there were significant savings in bed-days and patients were satisfied with their management, the extra workload for ward nursing staff was difficult to manage within existing resources. Fourteen other patients were appropriate for OHPAT but had to be managed in hospital because of pressures on ward nursing staff and lack of a dedicated nurse specialist. Hence 25/32 (79%) of patients who required prolonged parenteral antibiotic therapy or 27/95 (28%) of all patients who required any parenteral therapy were judged to be suitable candidates for OHPAT if the resource had been available. In a previous pilot study (involving mainly patients with soft tissue or orthopaedic infections) we treated 11% of inpatients requiring parenteral therapy as outpatients with either daily teicoplanin or ceftriaxone. At completion, 92% of patients were very much in favour of OHPAT, said they would
repeat this form of treatmen; again and Lt that treatment out of hospital improved their quality of life.” These findings have been instrumental in securing funding for a full-time nurse practitioner to coordinate an 3HPAT programme within our region. In the first year over IO0 patients have been treated with OHPAT and patient satisfaction has been high.‘” Oher units within the trust including internal medicine, orthopaedics, otolaryngology, neurosurgery and radiotherapy have utilized the service and have been satisfied with the service provided. The service has developed such that some patients (particularly those with soft tissue infections) are now managed solely in a non-inpatient setting without prior admission. Since this situation has evolved with our OHPAT experience it is clear that in the present study we have underestimated the proportion of patients who could be managed with OHPAT on a short term basis. These experiences show that OHPAT is acceptable both in theory and in practice to patients with communityacquired infections. The remaining issues which determine the feasibility of a European O?IPAT programme such as staffing and funding have recently been reviewed.4,6 A major issue is the co-operation and involvement of primary healthcare professionals. In Tayside the concept of OHPAT therapy is acceptable to most general practitioners as long as the programme is hospital lead and funded.“~” It is important for any healthcare provider to properly assess the need and feasibility of any new health care innative before significantly altering clinical practice. This applies particularly to loca!, community based intravenous antibiotic programmes in the ‘J.K. and elsewhere in Europe. Although many Trusts throughout the U.K. do not have a dedicated infection unit, this is not a prerequisite for an OHPAT programme. It would feasible for an interested physician or clinical microbiologist with suitable experience in managing infection to investigate the local need for an OHPAT service. We envisage that patient attitudes about the acceptability of community based therapy throughout the U.K. would not differ greatly from our experience in Tayside. As hospital admissions increase, nosocomial infections become more prevalent and the public become aware of opportunities for hospital care in the community, we encourage others to research and develop OHPAT programmes locally in the U.K. and Europe.
The authors are grateful to DE Cmelia Criyhton. Jonalhan McDevitt and Jason I’winn for help in colleclion of patient questionnaires.
Outpatient
and Home Parenteral
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