Outpatient parenteral antimicrobial therapyBMJ 2013; 346 doi: https://doi.org/10.1136/bmj.f1585 (Published 26 March 2013) Cite this as: BMJ 2013;346:f1585
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Outpatient Parenteral Antibiotic Therapy (OPAT) aims to shorten or avoid hospitalisation in carefully selected patients with infection. In the Department of Health’s 2011 Antimicrobial stewardship position document “Start smart and then focus” , OPAT has been highlighted as one of five key antimicrobial stewardship decisions following the prescription of an antimicrobial in hospital, primarily to reduce potential risks associated with unnecessarily prolonged admission. OPAT’s cost-effectiveness is also a clear and related advantage of shortened/avoided admission. Despite these advantages and central support by the Department of Health, current funding mechanisms act as a relative barrier to wider development of OPAT services.
Chapman  highlights the central role of the core OPAT team with specialist knowledge of infection to design treatment regimes for individual patients and provide on-going care that is both safe and meets wider antibiotic stewardship goals. However, in only a small number of highly specialised settings is management of infection recognised for specific funding, while the bulk of infection consultations delivered by infectious disease physicians, medical microbiologists and antimicrobial pharmacists take place under the funding radar, seen as a hidden cost of acute care or as an unquantified component of diagnostic provision. Funding has traditionally been provided by acute trusts which recognise that such activity improves patient experience and outcome, provides essential antimicrobial stewardship and is highly cost-effective within their own organisation. Providing guidance for and stewardship of antibiotic use is increasingly complex and a lack of knowledge to underpin use by non-specialists is not fully appreciated.
Most OPAT services established in the UK to date have been developed by acute providers using in-house expertise. In England, OPAT strategies to achieve admission avoidance for conditions such as cellulitis can be funded by an acute ambulatory care tariff. However, OPAT services to achieve early discharge from hospital are currently funded by a variety of ad-hoc methods based around counting days on OPAT treatment as part of an extended in-patient episode and cost-savings realised have been retained by the acute provider. Commissioners have little incentive to invest in such services to support early discharge and the increased patient flow they create may actually put pressure on limited budget allocations where pent-up demand exists. Incentives do exist to commission OPAT services as part of the Department of Health agenda to offer closer healthcare in the community [1,3]. While community providers and commercial home healthcare providers can deliver elements of safe care, commissioners may be constrained in establishing community-based services because they lack the degree of access to infection expertise required to provide a safe service, which almost invariably resides within the acute hospital sector and lacks capacity to deal with this increased demand.
A national OPAT tariff is an essential next step to remove these funding barriers and would benefit the system as a whole. Commissioners would gain flexibility to commission the expertise required to design and deliver safe OPAT treatment either entirely from one provider or from a combination of local providers working in co-operation. Individual providers would be explicitly funded for access to the expertise they possess and the services they provide, and cost savings accrued would be equitably distributed between commissioners and providers. For OPAT to reach its full potential, consideration needs to be given to this important funding issue.
Graeme Jones, Consultant in Medical Microbiology, University Hospital Southampton SO16 6YD, UK
Debbie Cumming, Antibiotic Pharmacist, St Mary’s Hospital NHS Isle of Wight PO30 5TG, UK
Mark Gilchrist, Consultant Antimicrobial Pharmacist, Imperial College Healthcare NHS Trust W2 1NY, UK
RA Seaton, Consultant in Infectious Diseases and General Medicine, Gartnavel General Hospital, Glasgow, G12 0YN, UK
On behalf of British Society for Antimicrobial Chemotherapy UK OPAT Initiative Standing Committee
1.Department of Health: Advisory Committee on Antimicrobial Resistance 259 and Healthcare Associated Infection (ARHAI). Antimicrobial stewardship: 260 Start smart and then focus 2011: 261http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/documents/di262 gitalasset/dh_131181.pdf
2.Ann LN Chapman. Outpatient parenteral antimicrobial therapy. BMJ 2013;346:f1585
3. The King’s Fund. Transforming our healthcare system. 2011; 278
Competing interests: All authors are members of the British Society for Antimicrobial Chemotherapy UK OPAT Initiative Standing Committee
In addition to the conditions listed by Chapman, outpatient parenteral antimicrobial therapy (OPAT) also has potential application for infective exacerbations of non-CF bronchiectasis where often there may be a lack of effective suitable oral antimicrobial depending on the patient's sputum library. A previous feasibility study demonstrated the utility of single agent parenteral meropenem for ambulatory management of patients with infective flares of their bronchiectasis(1). This has been incorporated into the ambulatory management in appropriately selected patients presenting to a respiratory "hot" clinic with non-CF bronchiectasis in an ambulatory care area (2). We have found that at most 28% of all unselected "hot" patients require admission over the subsequent month (with proportions much lower for non-CF bronchiectasis alone) (2). One of the key design features is both the administration of OPAT and review of its effectiveness occur in the same ambulatory care unit allowing easy admission to secondary care if needed for escalated therapy. Another important design feature is that the assessment of effectiveness of OPAT review is undertaken by a specialist in the particular condition.
1. Darley ES, Bowker KE, Lovering AM, Harvey JE, Macgowan AP. Use of meropenem 3 g once daily for outpatient treatment of infective exacerbations of bronchiectasis. J Antimicrob Chemother. 2000;45(2):247-50.
2. Khan A, Smith DL, Whittaker J, Williams A, Khan D, Harvey JE, Plummeridge MJ, A Millar, Calvert J, T Rawlings, Maskell NA. Effectiveness of direct GP referrals to hospital specialist respiratory teams in avoiding acute admissions. Thorax 2008; 63: A15.
Competing interests: No competing interests
As Chapman states  outpatient parenteral antibiotic treatment (OPAT) is increasingly seen as a viable management option for high-risk patients with infective endocarditis (IE), and several case series have reported successful treatment in the OPAT setting [2-5]. An important factor concerns how success of OPAT is judged: in most studies OPAT outcome assessment is clinically focussed (e.g. cure of infection) and performed by the treating clinician. However since the benefits of OPAT derive largely from avoiding hospitalisation whilst providing high standards of care to patients assessed as ‘low risk’ for failure, judgement on the process of OPAT (e.g. readmission to hospital, change in antibiotics due to adverse events) should also be included in outcome assessment .
We previously devised a conservative definition of OPAT failure that includes an assessment of ‘process failure’, defined as unplanned readmission, antibiotic resistance or failure to complete the initial antibiotic regimen. Using this composite outcome measure we have identified important clinical risk factors for OPAT failure in common conditions such as cellulitis and bone and joint infection [7, 8].
However risk factors for OPAT failure in IE are unknown, and it is unclear if high-risk factors identified in inpatients also apply to carefully selected OPAT populations. To address this we recently analysed first-patient IE episodes in the Glasgow OPAT programme to identify patient and disease-related risk factors for failure of OPAT in the treatment of IE and other cardiac device-related infections . We found pre-existing renal or cardiac failure (pooled OR 7.39 [95% CI: 1.84-29.66] P = 0.005), as well as treatment with teicoplanin (OR 8.69 [95% CI: 2.01-37.47] P = 0.004), were significant independent risk factors for OPAT failure. Importantly, we also observed that OPAT failure predicted longer-term adverse clinical outcomes such as death and disease recurrence (P = 0.016, log-rank).
With such emerging data on OPAT outcomes, we would like to reinforce the importance of careful selection of patients for the outpatient treatment of complex infection (in particular IE) and to reiterate the need for a structured approach to patient management . OPAT adverse events should be anticipated and the capacity and expertise to respond to such events should be an inherent part of the service. Based on our experience in the management of IE in the OPAT setting we would advise particular caution in selecting patients with pre-existing cardiac or renal dysfunction for OPAT management. Similarly alternatives to teicoplanin in the OPAT setting must be carefully considered.
1. Chapman, A. L., Outpatient parenteral antimicrobial therapy. BMJ 2013, 346, f1585.
2. Amodeo, M. R.; Clulow, T.; Lainchbury, J.; Murdoch, D. R.; Gallagher, K.; Dyer, A.; Metcalf, S. L.; Pithie, A. D.; Chambers, S. T., Outpatient intravenous treatment for infective endocarditis: safety, effectiveness and one-year outcomes. The Journal of infection 2009, 59, 387-393.
3. Cervera, C.; del Rio, A.; Garcia, L.; Sala, M.; Almela, M.; Moreno, A.; Falces, C.; Mestres, C. A.; Marco, F.; Robau, M.; Gatell, J. M.; Miro, J. M., Efficacy and safety of outpatient parenteral antibiotic therapy for infective endocarditis: a ten-year prospective study. Enfermedades infecciosas y microbiologia clinica 2011, 29, 587-592.
4. Larioza, J.; Heung, L.; Girard, A.; Brown, R. B., Management of infective endocarditis in outpatients: clinical experience with outpatient parenteral antibiotic therapy. Southern medical journal 2009, 102, 575-579.
5. Partridge, D. G.; O'Brien, E.; Chapman, A. L., Outpatient parenteral antibiotic therapy for infective endocarditis: a review of 4 years' experience at a UK centre. Postgraduate medical journal 2012, 88, 337-381.
6. Chapman, A. L.; Seaton, R. A.; Cooper, M. A.; Hedderwick, S.; Goodall, V.; Reed, C.; Sanderson, F.; Nathwani, D., Good practice recommendations for outpatient parenteral antimicrobial therapy (OPAT) in adults in the UK: a consensus statement. The Journal of antimicrobial chemotherapy 2012, 67, 1053-1062.
7. Mackintosh, C. L.; White, H. A.; Seaton, R. A., Outpatient parenteral antibiotic therapy (OPAT) for bone and joint infections: experience from a UK teaching hospital-based service. The Journal of antimicrobial chemotherapy 2011, 66, 408-415.
8. Seaton, R. A.; Sharp, E.; Bezlyak, V.; Weir, C. J., Factors associated with outcome and duration of therapy in outpatient parenteral antibiotic therapy (OPAT) patients with skin and soft-tissue infections. International journal of antimicrobial agents 2011, 38, 243-248.
9. Duncan, C. J.; Barr, D. A.; Ho, A.; Sharp, E.; Semple, L.; Seaton, R. A., Risk factors for failure of outpatient parenteral antibiotic therapy (OPAT) in infective endocarditis. The Journal of antimicrobial chemotherapy 2013. epub ahead of print
Competing interests: R.A.S. has received research funding and honoraria for consultancy and speaking at educational events for Novartis and Pfizer. All other authors: none to declare.
evidently there is so much to be gained via an opat that suitably complements overall treatment strategies; it is about hospital 'away' from Hospital with all the merits that can attend such schemes.
but it also illustrates how overall level of social development/infrastructures allows positive elastication of clinical strategies;
for the opat to work with maximum benefits and minimum risks, the environment outside of formal hospital must approximate in mood, cleanliness, access, communication and even microbial population/colonies etc to that of the average hospital;
and the pt is assumed will not be too dumb to be effective part of the team.
and these factors sadly come between opat and its applicability in most developing countries where opat in fact could have been otherwise far more salvaging given the constraints in these parts, of formal hospital structures and most times,capacity saturation.
plucking patients out of familiar ambience to the sometimes intimidating environments of hospitals can be disorienting for some patients particularly the very aged and the very un-aged.
novelty of the wards becomes a confounding factor in their managements, often unable to hit the ground running with regards to the home-hospital transition.
i can see an opat taking easy control of these potentially rocky instances were all the stars able to line up behind the goals.
increasing exteriorisation of management away from dominantly intramural hospital based approach to home based is easy to anticipate as confidence builds up in small steps at a time.
this may extend to many other therapies including parenteral cancer therapy.
i just wonder if one day, extramural structures will become so well developed that even a surgeon at the head of a phalanx of personnel will confidently carry his blade into the homes to oblige patients who need and demand and can be obliged.
Competing interests: No competing interests
Outpatient antibiotic therapy (OPAT) performed through a formal person can be welcomed as it ensures patient wellbeing. As the patient receives the treatment at home or in a non-hospital environment they can carry out their routine works. This can also reduce the risk of hospital borne infections. For the OPAT recommended infections may require long term therapy. OPAT will help to reduce the period of hospital stay and the financial burden due to this.
By performing a randomized controlled trail, Paul Corwin and coworkers stated that there is no significant change in the required duration of antibiotic therapy between OPAT and inpatient antibiotic therapy except in the case of mental satisfaction the patient enjoys which is more in case of OPAT . Elderly and diabetic people are more vulnerable to urinary tract infections, bacterial skin infections, bone and joint infections etc. . Usually people of an older age prefer to stay at home rather than hospitalization. Long hospitalization may alter their mood also. Psychoneuroimmunology explains that a person’s mental state influences his health either by influencing his immune system or indirectly by influencing how he takes care of himself [3-5].
The level of supervision an outpatient may get is lower compared to an inpatient. Considering the potential risks associated with OPAT such as chances of adverse reactions, antibiotic over use of broad spectrum antibiotics etc. It should be done under the guidance and monitoring of an infection specialist. Otherwise this may also promote development of antibiotic resistance and other complications.
1. Corwin P, Toop L, McGeoch G, et al. Randomised controlled trial of intravenous antibiotic treatment for cellulitis at home compared with hospital. BMJ 2005;330(7483):129
2. Muller L, Gorter KJ, Hak E, et al. Increased risk of common infections in patients with type 1 and type 2 diabetes mellitus. Clinical infectious diseases 2005;41(3):281-88
3. Beaton DB. Effects of Stress and Psychological Disorders on the Immune System. Secondary Effects of Stress and Psychological Disorders on the Immune System 2003. http://www.personalityresearch.org/papers/beaton.html.
4. Cohen S, Herbert TB. Health psychology: Psychological factors and physical disease from the perspective of human psychoneuroimmunology. Annual review of psychology 1996;47(1):113-42
5. Kiecolt-Glaser JK, McGuire L, Robles TF, Glaser R. Psychoneuroimmunology: psychological influences on immune function and health. Journal of consulting and clinical psychology 2002;70(3):537
Competing interests: No competing interests