Ann Chapman

Good practice recommendations for outpatient parenteral antimicrobial therapy (OPAT) in adults in the UK: a consensus statement

These good practice recommendations for outpatient parenteral antimicrobial therapy (OPAT) are an update to a previous consensus statement on OPAT in the UK published in 1998. They are based on previous national and international guidelines, but have been further developed through an extensive consultation process, and are underpinned by evidence from published literature on OPAT. They provide pragmatic guidance on the development and delivery of OPAT services, looking at all aspects of service design, care delivery, outcome monitoring and quality assurance, with the aim of ensuring that OPAT services provide high-quality, low-risk care, whatever the healthcare setting. They will provide a useful resource for teams developing new services, as well as a practical set of quality indicators for existing services.

Ertapenem administered as outpatient parenteral antibiotic therapy for urinary tract infections caused by extended-spectrum-β-lactamase-producing Gram-negative organisms

OBJECTIVES Infections with extended-spectrum-beta-lactamase-producing organisms are an increasing public health concern. We reviewed the use of an outpatient parenteral antibiotic therapy (OPAT) programme to facilitate the early discharge from hospital of patients with ESBL-associated urinary tract infections. METHODS A retrospective review of patients treated for urinary tract infections caused by ESBL-producing organisms through the OPAT programme at the Royal Hallamshire Hospital, Sheffield, UK over a 4 year period to January 2010 was conducted. Data on patient demographics, clinical presentation and laboratory results were collected. RESULTS Twenty-four OPAT episodes involving 11 patients were identified. Six patients (54.5%) had an underlying urological abnormality on presentation to OPAT. All patients were treated with parenteral ertapenem. Two patients had multiple infections treated by OPAT. The mean duration of the OPAT episodes was 9.9 days (range 3-42). A total of 238 inpatient bed days were avoided, with resultant cost savings. CONCLUSIONS Ertapenem administration through OPAT may help to decrease the costs associated with ESBL infections by reducing the number of inpatient bed days required for their successful treatment.

Outpatient parenteral antimicrobial therapy

#### Summary points Outpatient parenteral antimicrobial therapy (OPAT) allows patients to be given intravenous antibiotics in the community rather than as an inpatient. First developed in the 1970s in the US for the treatment of children with cystic fibrosis,1 OPAT has expanded substantially and is now standard practice in many countries.2 3 In the UK, uptake has been much slower, although OPAT is now being increasingly used in both primary and secondary care, driven by a national focus on efficiency savings in healthcare, improving patient experience, and provision of care closer to home. It is important that medical practitioners are aware both of the opportunities that OPAT presents and of the potential risks of treatment outside hospital for patients with serious and often complex infections. This article aims to describe the clinical practice of OPAT, highlight potential risks, and explore how these may be reduced. OPAT is the administration of intravenous antimicrobial therapy to patients in an outpatient setting or in their own home. It can be used for patients with severe or deep seated infections who require parenteral treatment but are otherwise stable and well enough not to be in hospital; these patients may be discharged early to an OPAT service or may avoid hospital admission altogether. ### Cellulitis OPAT is most widely used …

Outpatient parenteral antibiotic therapy for infective endocarditis: a review of 4 years' experience at a UK centre

Objectives To review the role of outpatient parenteral antibiotic therapy (OPAT) in the management of infective endocarditis (IE) with the aim to guide further development of the service modality both locally and at other centres, in light of the evolving recommendations on patient suitability in international guidelines. Methods A retrospective case review of all patients receiving OPAT for IE in Sheffield between January 2006 and October 2010 was conducted. Data were collected on site and microbiology of infection, antibiotic regimens, adverse events during OPAT therapy and outcomes were studied. Results A total of 36 episodes of IE were treated in 34 patients. All patients received initial treatment as inpatients. Treatment was successful in 34/36 episodes (94.4%) with no evidence of recurrence at a median of 30 months follow-up. One patient had a relapse 2 months after completion of OPAT for enterococcal endocarditis and was found to have concurrent chronic prostatitis. One patient died of a ruptured pulmonary root abscess while receiving OPAT. Adverse events occurred in 12 episodes (33.3%), of which seven were line associated. In four cases adverse events resulted in re-hospitalisation. A successful outcome was achieved in 22/24 episodes (91.7%) deemed to be less suitable for OPAT due to higher risk of complications by Infectious Diseases Society of America guidelines. Conclusions OPAT is a safe and effective means of completing therapy for IE, including prosthetic valve endocarditis and other cases at a higher risk of complicated disease. However, the relatively high rate of adverse events highlights the need for well-developed protocols and policies for patient selection and follow-up within the context of a formal OPAT service.

Tuberculous vertebral osteomyelitis: findings of a 10-year review of experience in a UK centre.

During any outbreak of a widespread febrile illness, alternative diagnoses accounting for the fever are likely to be missed. This is seen each ‘flu’ season, when patients may either present ‘atypically’ with non-pulmonary manifestations of influenza, or when diagnosis of a more severe co-existent underlying illness or complication, such as pneumonia or meningitis is delayed. This difficulty will be augmented with escalation of the potential ‘swine’ influenza pandemic due to the numbers involved, and to the degree of trepidation at exposing patients and staff to a potentially severe infectious agent. It is important that those involved with the care of patients given a diagnosis of ‘swine’ influenza are prepared to re-consider the diagnosis as symptoms develop and progress. The three cases presented above occurred during a relatively low intensity period, and thus many more serious near misses are to be expected in the forthcoming months. All three cases tested negative for respiratory viruses including (H1N1) 2009 influenza. Falciparum malaria is associated with significant morbidity and mortality, which is increased by even short delays in diagnosis and treatment. The presenting symptoms of malaria are often non-specific and difficult to distinguish from influenza, particularly if a travel history is not taken. It is likely that some of the complications of severe malaria described in this case could have been avoided if the diagnosis had been made earlier. We suggest that a travel history is added to the algorithm used by the National Pandemic Flu Service. Those who have visited the malaria endemic area should be assessed by medical staff and have blood taken to exclude the diagnosis before being assumed to have ‘swine’ influenza. In each case above the presumed diagnosis was made using the national algorithm, in 2 cases following telephone consultation. We share the concern of Bourke et al. regarding the use of decision support systems particularly when operated by non-medically trained personnel. These are highlighted by the fact none of the cases described had coryzal symptoms and yet were still eligible for antiviral medication, which in turn, supports concern regarding the development of oseltamivir resistance. The risks to patients in misdiagnosing ‘swine’ influenza, even once in the hospital setting, may include delay in diagnosis resulting in longer in-patient stays, more severe illness and even death. In analysing the cost of the pandemic, both in terms of medical and human cost, the expense of these cases must be borne in mind.

Tuberculosis in UK cities: workload and effectiveness of tuberculosis control programmes

BackgroundTuberculosis (TB) has increased within the UK and, in response, targets for TB control have been set and interventions recommended. The question was whether these had been implemented and, if so, had they been effective in reducing TB cases.MethodsEpidemiological data were obtained from enhanced surveillance and clinics. Primary care trusts or TB clinics with an average of > 100 TB cases per year were identified and provided reflections on the reasons for any change in their local incidence, which was compared to an audit against the national TB plan.ResultsAccess to data for planning varied (0-22 months). Sputum smear status was usually well recorded within the clinics. All cities had TB networks, a key worker for each case, free treatment and arrangements to treat HIV co-infection. Achievement of targets in the national plan correlated well with change in workload figures for the commissioning organizations (Spearmans rank correlation R = 0.8, P < 0.01) but not with clinic numbers. Four cities had not achieved the target of one nurse per 40 notifications (Birmingham, Bradford, Manchester and Sheffield). Compared to other cities, their loss to follow-up during treatment was usually > 6% (χ2 = 4.2, P < 0.05), there was less TB detected by screening and less outreach. Manchester was most poorly resourced and showed the highest rate of increase of TB. Direct referral from radiology, sputum from primary care and outreach workers were cited as important in TB control.ConclusionTB control programmes depend on adequate numbers of specialist TB nurses for early detection and case-holding.Please see related article: http://www.biomedcentral.com/1741-7015/9/127

Abdominal pain in acute infectious mononucleosis.

Abdominal pain in patients with infectious mononucleosis may signal splenic rupture Abdominal pain and tachycardia are unusual in patients with acute infectious mononucleosis. We present a case in which abdominal pain and tenderness signalled the presence of a potentially fatal complication of infectious mononucleosis. A previously fit 20 year old man was admitted with a three day history of fever, sore throat, dyspnoea, and malaise. Ten days before admission he had fallen on to his left side and had attended the casualty department with pain over the left chest wall. A chest radiograph did not show a fracture, but the pain had been sufficiently severe to warrant overnight observation in the casualty department. On admission he was feverish, with a temperature of 39.7°C, and had generalised lymphadenopathy, non-exudative pharyngitis, mild hepatomegaly, and splenomegaly of 2 cm. He looked pale but well, and his blood pressure was 115/95 mm Hg, with a pulse rate of 96 beats/min. He had mild left and right hypochondrial tenderness without guarding. Initial investigations showed a haemoglobin concentration of 10.9 g/dl, and a total leukocyte …

How is income generated by outpatient parenteral antibiotic treatment (OPAT) in the UK? Analysis of payment tariffs for cellulitis

OBJECTIVES We determined the available mechanisms to generate income from outpatient parenteral antimicrobial therapy (OPAT) in the UK and calculated the revenue generated from treatment of an episode of cellulitis. METHODS Revenue was calculated for patients receiving treatment for cellulitis as an inpatient and for patients receiving OPAT by a series of different payment pathways. Selected established OPAT services in Northern Ireland, Scotland and Wales, where Payment-by-Results (PbR) does not operate, were contacted to determine individual national funding arrangements. RESULTS In England, a traditional inpatient episode for uncomplicated cellulitis requiring 7 days of treatment generated £1361 of revenue, while OPAT generated revenue ranging from £773 to £2084 for the same length of treatment depending on the payment pathway used. Treatment using OPAT to avoid admission entirely generated £2084, inpatient admission followed by transfer to a virtual OPAT ward at day 2 generated £1361 and inpatient admission followed by discharge from hospital to OPAT at day 2 generated £773. In Northern Ireland, Scotland and Wales block contracts were used and no income was calculable for an individual episode of cellulitis. CONCLUSIONS No single funding mechanism supports OPAT across the UK. In England, revenue generated by OPAT providers from treatment of cellulitis varied with the OPAT payment pathway used, but equalled or exceeded the income generated from equivalent inpatient care. Cost savings for OPAT and reuse of released inpatient beds will increase revenue further. A single OPAT tariff is proposed.

Managing and monitoring tuberculosis using web-based tools in combination with traditional approaches

Tuberculosis (TB) remains a global health emergency. Ongoing challenges include the coordination of national and international control programs, high levels of drug resistance in many parts of the world, and availability of accurate and rapid diagnostic tests. The increasing availability and reliability of Internet access throughout both affluent and resource-limited countries brings new opportunities to improve TB management and control through the integration of web-based technologies with traditional approaches. In this review, we explore current and potential future use of web-based tools in the areas of TB diagnosis, treatment, epidemiology, service monitoring, and teaching and training.

A controlled trial of the knowledge impact of tuberculosis information leaflets among staff supporting substance misusers: pilot study.

Background Information leaflets are widely used to increase awareness and knowledge of disease. Limited research has, to date, been undertaken to evaluate the efficacy of these information resources. This pilot study sought to determine whether information leaflets developed specifically for staff working with substance mis-users improved knowledge of tuberculosis (TB). Method Staffs working with individuals affected by substance mis-use were recruited between January and May 2008. All participants were subjectively allocated by their line manager either to receive the TB-specific leaflet or a control leaflet providing information on mental health. Level of knowledge of TB was assessed using questionnaires before and after the intervention and data analysed using McNemars exact test for matched pairs. Results The control group showed no evidence of a change in knowledge of TB, whereas the TB questionnaire group demonstrated a significant increase in knowledge including TB being curable (81% correct before to 100% correct after), length of treatment required (42% before to 73% after), need to support direct observation (18% to 62%) and persistent fever being a symptom (56% to 87%). Among key workers, who have a central role in implementing a care plan, 88% reported never receiving any TB awareness-raising intervention prior to this study, despite 11% of all respondents having TB diagnosed among their clients. Conclusion Further randomized controlled trials are required to confirm the observed increase in short-term gain in knowledge and to investigate whether knowledge gain leads to change in health status.