Antimicrobial Stewardship- Focus on Clostridium difficile Infection

Report
Transition from Hospital to Home
Outpatient Parenteral
Antimicrobial Therapy (OPAT)
Karri A. Bauer, PharmD, BCPS
Specialty Practice Pharmacist Infectious Diseases
January 16, 2013
Objectives
 Understand combined benefits to provider and
patient of outpatient parenteral antibiotic therapy
(OPAT)
 List key components of a successful OPAT program
 Review OSUWMC data regarding transition of
patients from hospital to home on OPAT
 Discuss the potential role of an infusion center at
OSUWMC
Background
 1970s- Outpatient parenteral antimicrobial therapy
introduced
 Minneapolis-Canada
 Community hospital reported successful treatment of > 150
patients with invasive infections
 1998- 250,000 people treated, generates $2 billion
in revenue
 Growth rate > 10% annually
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Emphasis on cost containment
Availability of antibiotics administered once or twice daily
Advances in vascular access
Increased acceptance
Increased availability of structured services
Background
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Facilitate early discharge
Avoid hospital readmission
Provide safe, effective, and cost-effective therapy
Improve hospital throughput
Improve patient satisfaction
• Numerous studies have confirmed the safety with
appropriate antimicrobial selection and monitoring
Key Components
 Medical director/advisor
 Defined roles
 Physician, nurse, pharmacist, and patient
 Standards
 Physician, nurse, and pharmacist
 Accreditation or certification (JCAHO)
 Experience
 Policies
 Reporting of laboratory results
 Willingness to share local quality assurance and
outcomes
 Willingness to share charge/cost information
Key Elements
ID Specialist
ID Pharmacist
Primary care
Patient
Case manager
Nurse
Delivery of OPAT
 Infusion centers
 Visiting nurse
 Self or caretaker
 Long term care facility
Selection of Outpatient
Antimicrobials
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Dosage schedules
Long-term toxicity
Drug stability
Drug half-life
Patient population
Anticipated duration of therapy
Patient tolerance
Low incidence of side effects
Cost effectiveness
Home IV Antimicrobial
Infusion Therapy
 205 patients discharged from a VA
 Outpatient IV infusion team
 July 2000-December 2003
 230 courses of IV antimicrobials
 Most patients ≥ 60 years of age
 DM, CAD, PVD
 IV therapy team verified that patients could perform
infusion at home and provided instructions
 Osteoarticular (52%), bacteremia (14%), and skin
and soft tissue infections (13%)
 Mostly PICCs
Cox Am, Malani PN, Wiseman SW, Kauffman, CA. Home intravenous antimicrobial infusion therapy: a viable option in older adults.
J Am Geriatr Soc 2007; 55:645-650.
Home IV Antimicrobial
Infusion Therapy
 Vancomycin (46%) and cefazolin, ceftriaxone, and
ertapenem used for other infections
 Nephrotoxicity observed in 10 courses (4.3%)
 PICC complications common
 Failures:
 9 cases (8%) in patients ≥ 60 years of age and
 7 (6%) of patients < 60 years of age
 Overall, 70 (65%) courses in patients ≥ 60 years of age
and 89 (72%) courses in patients < 60 years of age
resulted in stable or improved infections
Cox Am, Malani PN, Wiseman SW, Kauffman, CA. Home intravenous antimicrobial infusion therapy: a viable option in older adults.
J Am Geriatr Soc 2007; 55:645-650.
OPAT Outcomes Registry
• Provided information regarding treated infections,
pathogens, and antibiotics
• Allowed sites to compare programs and experience
• 24 contributing US sites- >8000 patients, >11000 courses
• Osteomyelitis
• Vancomycin
• Most patients (93%) did not have repeat cultures
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266 patients analyzed
3 experienced therapy failure
4 showed no change
Overall adjusted failure rate of 2.5%
Tice A. The use of outpatient parenteral antimicrobial therapy in the management of osteomyelitis: data from the Outpatient
Parenteral Antimicrobial Therapy Outcomes Registries. Chemotherapy 2001;47(Suppl 1): 5-16.
Economics of OPAT
 IV antibiotic treatment is ~$1000-2500,compared
with $200-300 for OPAT/day
 Benefits
 Ability to return to work
 Reduction in cost of nosocomial infections
 ~5% of hospitalized patients develop an infection during
hospitalization
 Estimate total cumulative cost of >$2 billion annually
 Outpatient care may reduce expenses, morbidity, and
mortality
Antimicrobial Stewardship at
Transition of Care
• Retrospective study 2/14/10-5/14/10
• Cleveland Clinic CoPAT Registry
• Structured data entry form (CoPAT form)
• No patient can leave the hospital on OPAT without CoPAT filled out
• Electronic form requesting ID consultation
• CoPAT request
• CoPAT approved in 72% and avoided in 28%
• 17% oral antibiotics; 11% no antibiotics
• No significant differences in ED visits or readmissions when
comparing CoPAT avoided vs CoPAT approved
Shrestha NK, Bhaskaran A, Scalera NM, et al. Antimicrobial stewardship at transition of care from hospital to
community. Infect Control Hosp Epidemiol 2012; 33:401-404.
Impact of a Multidisciplinary Team
Review of Potential OPAT
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2000- Multidisciplinary OPAT team
Independent from ASP
Review antibiotic care plans at hospital discharge
ID physicians, ID pharmacists, and case managers
Receive therapy at a variety of non-acute care settings
Interventions provided and documented
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Patient safety
Regimen simplification
Clinical efficacy
Decreased healthcare expenditures
Heintz BH, Halilovic J, Christensen CL. Impact of a multidisciplinary team review of potential outpatient parenteral antimicrobial
therapy prior to discharge at an academic medical center. Ann Pharmacother 2011; 45:1329-1337.
Impact of a Multidisciplinary Team
Review of Potential OPAT
• Analysis of impact of OPAT between 7/1/09-6/30/10
• 613 bed academic tertiary care hospital
• Electronic form requesting ID consultation
• Safety, efficacy, and complexity
• Economic benefits (total number of hospital days avoided)
Heintz BH, Halilovic J, Christensen CL. Impact of a multidisciplinary team review of potential outpatient parenteral antimicrobial
therapy prior to discharge at an academic medical center. Ann Pharmacother 2011; 45:1329-1337.
Impact of a Multidisciplinary Team
Review of OPAT
• Interventions
• Regimen safety- 56.1%
• Simplification- 40.6%
• Efficacy- 28.6%
• OPAT was avoided in 13.2% referrals
Heintz BH, Halilovic J, Christensen CL. Impact of a multidisciplinary team review of potential outpatient parenteral antimicrobial
therapy prior to discharge at an academic medical center. Ann Pharmacother 2011; 45:1329-1337.
Impact of a Multidisciplinary Team
Review of Potential OPAT
Heintz BH, Halilovic J, Christensen CL. Impact of a multidisciplinary team review of potential outpatient parenteral antimicrobial
therapy prior to discharge at an academic medical center. Ann Pharmacother 2011; 45:1329-1337.
Impact of a Multidisciplinary Team
Review of OPAT
Heintz BH, Halilovic J, Christensen CL. Impact of a multidisciplinary team review of potential outpatient parenteral antimicrobial
therapy prior to discharge at an academic medical center. Ann Pharmacother 2011; 45:1329-1337.
Impact of a Multidisciplinary Team
Review of OPAT
• Discharge delays avoided
• 6.2% referrals, resulting in total of 228 days (mean 6.5 days)
and $366,000 in hospital bed cost savings
• CVC placement prevented in 48 referrals, represents an
additional $58,080 in cost savings
• $424,080 of direct inpatient care-related costs was
avoided over 1-year study period
• Mean 27 minutes of ID pharmacist time was required
Heintz BH, Halilovic J, Christensen CL. Impact of a multidisciplinary team review of potential outpatient parenteral antimicrobial
therapy prior to discharge at an academic medical center. Ann Pharmacother 2011; 45:1329-1337.
Transition from Hospital to Home
Outpatient Parenteral
Antimicrobial Therapy (OPAT)
Karri Bauer, PharmD, BCPS
Jessica Johnston, MSPH
Debbie Goff, PharmD, FCCP
OSUWMC and University Optioncare
Background
• Audit in 2009 completed by Jen Severing, PharmD, BCPS
• Evaluate home regimens of nafcillin and piperacillin
• Patients discharged with incorrect or ambiguous orders
• 30% of nafcillin orders; 24% of piperacillin orders
• 26% readmitted for suspected or confirmed ongoing infection
63
70
60
Incorrect/Ambiguous
50
Total
40
30
19
20
17
4
10
0
Nafcillin
Piperacillin
Background
• At OSUWMC, approximately 200 patients per year are
discharged to University Optioncare on OPAT
• Currently, not every patient discharged on OPAT is seen
by an ID physician or ID pharmacist
• Collaboration between ID specialists at OSUWMC and
pharmacists at University Optioncare provides an unique
opportunity to study outcomes
• Relationship provides a method for prompt identification
of patient care issues and improved access to
communication
Methods
• All patients who received inpatient antimicrobial therapy
and were discharged on OPAT (ertapenem +/- additional
antibiotic) through University Optioncare between 1/1/1112/31/11
• Patients < 18 or > 89 years of age, prisoners, and
pregnant females were excluded
• Data obtained from the electronic medical record and
University Optioncare database
• IRB approved for all patients discharged on OPAT
through University Optioncare
Results
n=100
Age
48 (39-60)
Male
53
Service*
--UH hospitalist
--Colorectal surgery
--Gen surgery
--Inpatient ID
--Urology
9
5
5
5
5
Comorbidities
--Diabetes
--Chronic renal disease
--Malignancy
--Chronic respiratory disease
--Immunosuppression
--Liver disease
18
15
16
15
10
3
*Top 5 services presented
Data presented as % unless otherwise stated
Results
n=100
Infectious diagnosis*
--Osteomyelitis
--Intra-abdominal
--UTI/pyelonephritis
--Pneumonia
--Bacteremia
21
21
12
7
6
IV access
--PICC
--Groshong
99
1
ID follow-up upon discharge
60
Combination therapy
31
Median antibiotic duration, days
*Top 5 diagnoses presented
Data presented as % unless otherwise stated
21 (14-42)
Results
Organism
%
Polymicrobial
33
Culture negative
26
MRSA*
6
MSSA
5
Gram negatives**
52
Antimicrobial Agent#
%
Ertapenem
100
Vancomycin
15
Daptomycin
11
Penicillins
2
Fluoroquinolones
1
*1 patient had MRSA identified as the only organism
**8 patients had E coli; 6 patients had ESBL E coli; 6 patients had K pneumoniae
#30 patients received combination therapy
Results
Outcome
n=100
Line-related complication
0
Antibiotic-related complication
--Intolerance*
--Compatibility
--Allergy
2
0
0
Change in antibiotic therapy
4
Post discharge antibiotic additions
12
Transition to oral therapy
--Osteomyelitis
9
5
Clinical cure
80
Infection-related readmission**
19
*1 patient elevated liver enzymes; 1 patient elevated vancomycin level
**Median time to readmission was 50 days (11-133)
Data presented as % unless otherwise stated
Results
• 20 patients did not achieve a clinical cure
• 19 patients had an infection-related readmission
Infectious Diagnosis
n=20
Intraabdominal
6 (20)
Osteomyelitis
4 (20)
UTI/pyelonephritis
3 (15)
Soft tissue
3 (15)
Pneumonia
2 (10)
Bacteremia
1 (5)
LVAD
1 (5)
Organism
n=20
Gram negative
14 (70)
Culture negative
5 (25)
Polymicrobial
5 (25)
MRSA
3 (15)
Results
• 20 patients could have potentially received oral
antibiotics
• 17 patients- no ID consult
• 3 patients- ID consult
• 3 patients could have potentially received
ceftriaxone instead of ertapenem
• 3 patients- no ID consult
Conclusions
• Currently, there is a great emphasis on methods to
improve hospital throughput and patient satisfaction
while minimizing health care-associated costs
• Administration of IV antimicrobials on an outpatient basis
has been shown to be safe, efficacious, practical and
cost-effective
• Future direction of the study is to complete review of all
patients discharged on OPAT through University
Optioncare and economic analysis
• OPAT presents a future direction for OSUWMC and
“Create the Future Now”
Transition from Hospital to Home
Outpatient Parenteral
Antimicrobial Therapy (OPAT)
Karri A. Bauer, PharmD, BCPS
Specialty Practice Pharmacist Infectious Diseases
January 16, 2013

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