OUTPATIENT INTRAVENOUS ANTIBIOTIC THERAPY: REDUCES ECONOMIC BURDEN OF PATIENTS

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ABOUT AUTHORS
Mohd Altaf S*, Qadrie ZL, M Nagavamsidhar ,suman A,Saiteja D, Shivani P
Department of Pharmacy Practice,
Pratishta Institute of Pharmaceutical Sciences,
Suryapet, Hyderabad, Telangana

ABSTRACT:
OPAT it is a frequent source of questions and formal infectious diseases consultations. OPAT is always less expensive than inpatient therapy. Financial savings have been found with OPAT when compared with in hospital stays. The use of intravenous (IV) antibiotics for the treatment of serious infections has become common around the world. It is accepted as the standard treatment for many infectious diseases including other chronic infection like sepsis, meningitis, endocarditis etc. The goals of OPAT program are to provide expert care to patients on IV antibiotics, manage side effects and infections, reduces the need for hospital readmissions. The OPAT having a series of   program patient care team includes doctors, nurses, and clinical and hospital pharmacists who are skilled in management of infectious diseases. Intravenous therapy outside the hospital, has only recently become possible, with the introduction of new Antibiotics, better catheters for vascular access, and improved infusion devices. Health care professionals have pioneered the development of OPAT and worked together to  develop safe and effective programs. The antibiotics used for OPAT care are chosen for safety, effectiveness and ease of administration and money saving. The IV delivery system needed in the home is much simpler than the large, complicated IV pumps you see in the hospital. OPAT allows suitable patients on intravenous (IV) antibiotics to be discharged early from hospital and treated in their home or community setting by a team of specialist nurses.

Reference Id: PHARMATUTOR-ART-2610

PharmaTutor (Print-ISSN: 2394 - 6679; e-ISSN: 2347 - 7881)

Volume 6, Issue 9

Received On: 25/07/2018; Accepted On: 15/08/2018; Published On: 01/09/2018

How to cite this article: Mohammed, A., ZL, Q., Nagavamsidhar, M., Suman, A., Saiteja, D. and Shivani, P. 2018. Outpatient Intravenous Antibiotic Therapy: Reduces economic burden of patients. PharmaTutor. 6, 9 (Sep. 2018), 24-30. DOI:https://doi.org/10.29161/PT.v6.i9.2018.24

INTRODUCTION:
Outpatient parenteral antibiotic therapy (OPAT) is now the standard care for a wide range of infections in most communities. An outpatient approach to therapy allows patients to return home more quickly while providing substantial cost savings. Despite its widespread use, OPAT is a frequent source of curbside questions and formal infectious diseases consultations. This article answers some of the most common questions encountered in routine practice. Antibiotic therapy may be given at home, in an office-based setting or through a hospital-based infusion program.

OPAT offers several advantages to patients, health care providers, and insurers. Primarily, the length of hospital stays can be markedly reduced. Some patients may return home and resume their daily routine days or weeks before finishing therapy. In other cases, OPAT can be started as soon as the diagnosis is made, and hospitalization can be completely avoided. Secondary, OPAT is almost always less expensive than inpatient therapy. Substantial savings have been found with OPAT when compared with in hospital stays (Williams DN 1993, Bernard L 2001).

Types of OPAT:
There are 3 basic types of intravenous access used for OPAT:
a. Peripherally inserted central catheter (PICC) lines
b. Midline catheters
c. Peripheral lines

Peripherally Inserted Central Catheter: PICC lines are typically inserted into either the cephalic or basilica vein and terminate in the mid to distal superior vena cava (SVC). A PICC line should be considered for any treatment course lasting more than 2 weeks. A catheter that terminates in the SVC is mandatory for hyperosmolar solutions and medications with a pH of less than 5 or greater than 9. Penicillin G potassium, nafcillin, oxacillin, and vancomycin require central access if they are to be infused at standard concentrations. If these antibiotics are diluted, peripheral infusion may be possible.

Midline Catheter: A midline catheter is inserted in a manner similar to that of a PICC line but runs only 8 to 10 cm into the vein. Because the tip of the midline catheter rests in t he peripheral circulation, this type of catheter is best reserved for shorter courses (3 to 14 days) of less irritating antibiotics.

Short Peripheral Lines: Short peripheral lines can be used to temporize for brief periods (1 to 7 days). However, the frequent need to replace these lines makes them unwieldy for longer treatment courses. (Mortlock NJ 1998, Gilbert DN 1997)

Categories of Antibiotics used in Outpatient Parenteral Antibiotic Therapy:  These are categorized into 3 types and well are explained by using examples (Cohen E., 2002) in tabulated form below Table No. 1.

Table No. 1: Category of Antibiotics, Use and Examples


Catergory


Use


Example


Category 1


Can typically be dosed daily


Aminoglycosides

Amphotericin B

Caspofungin

Ceftriaxone

Daptomycin

Ertapenem

Vancomycin


Category 2


Are stable for more than 24 hours at room temperature or if refrigerated and can be used in syringe pumps or electronic infusion pumps


Aztreonam

Cefazolin

Cefepime

Ceftazidime

Clindamycin

Nafcillin


Category 3


Have limited stability and are difficult to use in the outpatient setting


Ampicillin

Imipenem

Meropenem

The use of intravenous (IV) antibiotics for the treatment of serious infections has become common around the world. It is accepted as the standard treatment for many infections including sepsis, meningitis, endocarditis, intra-abdominal infections, pneumonia, and osteomyelitis. Intravenous antibiotics have traditionally been given in the hospital but increasingly they are given at home or in a clinic or physician’s office. One of the few areas of medicine that offers the potential to save money as well as improve the quality of patient care is that of home and OPAT (Hindes R., 1995).

Models for Delivery:
The most common models for delivery of outpatient infusion therapy may be classified as
a. The visiting nurse model
b. The infusion center model
c. The self-administration model (Tice AD.1995)

a. The visiting nurse model: A visiting nurse service is already established and well developed in a country and this model may work well to provide parenteral antibiotic therapy, especially if it needs to be given only once a day. The nurse simply visits the home and gives an intra-muscular injection or uses an intravenous line to infuse the antibiotic. This model offers the safety of supervised administration by a nurse and is a particular advantage for a patient who is confined to bed (Kravitz RL1994).

b. The infusion center model: The infusion center model is an easy one to establish. Patients travel to the infusion center for therapy. In this model, the infusion center may be located in a hospital clinic, a doctor’s office, an emergency room, nursing home, or a free-standing infusion center. This model offers the advantages of ready access to professional staff as well as medical equipment, medications, and often laboratory and x-ray facilities as well. The center may also be used for other intravenous therapies such as chemotherapy, blood transfusions and fluid therapy. In this model it is convenient for the doctor to observe and diagnosis the patients. Again, the ability to use a once-a-day antibiotic is an advantage. The major limitation to the model is difficulty for the patient and often the family to travel to the facility. In some countries, pharmacists may administer parenteral medications in pharmacy stores, especially if there are no restrictions on medication use and ordering. An interesting variation is the use of a mobile health services to move towards the patient to provide parenteral medication in the home or inside the ambulance (Tice AD.1995, Poretz DM 1993)

c. The self-administration model: This model of self-administration has the advantage of avoiding even the once-a-day travel. Patients who are stable on IV antibiotic therapy usually need to be seen only once or twice a week by the physician if they can administer their own medications. Infusions are given by the patient or family member using a gravity drip system or with an automatic system such as a battery-driven, computer-operated pump that can be easily carried around. Generally, patients can be trained to be efficient in self-administration and may do as good job as hospital nurses (Stivers HG., 1978).

Intravenous treatment at home:
Patients were provided with a printed information sheet explaining about the drugs to be used and the duration of treatment. Patients or their careers were trained to prepare and administer the injections on the ward and observed to ensure correct practice on two occasions. They were provided with instructions to take home. These instructions listed the supplies required, provided a quick reference reminder followed by detailed instructions for preparation and administration, outlined possible complications to watch out for and provided a list of contact telephone numbers. Patients were asked to return to the ward at least weekly to review IV access and clinical condition. Support for patients while at home. Patients were advised to communicate with one of the Infectious diseases wards or to ask the receptionist to connect a call to doctor for Infectious diseases. The Infectious diseases unit is maintained a 24/7 on-call service with no cross-cover (Malek 1992).

Intravenous Antibiotic Use: Antibiotics given intravenously are commonly used in both high-income and low-income countries. Available evidence from well-established antibiotic stewardship programmes in high-income settings suggests this is frequently unnecessary Intravenous therapy may result in harmful complications such as phlebitis, extravasation injury, thrombosis, and local or systemic infection including bacteraemia (Boyles TH., 2013). Intravenous therapy also prolongs the duration of inpatient stay, causing pain and inconvenience to the patient and financial cost to the health care system. The risk of bacteraemia in intravenously i.e., peripherally inserted or central venous catheters can be as high as 0.1%, 2.4%, and 4.4%, respectively (Maki DG., 2006).

Present and future challenges:
While OPAT has provided many patients with improved satisfaction in care, saved health care resources, and helped to offload emergency departments and inpatient beds, a number of challenges and controversies remain compared with inpatient care. OPAT is clearly cost saving, however issues remain with respect to its funding because it may shift costs from hospitals to patients (Fisher DA., 2006).

OPAT programs can help manage many types of infections, such as:
a. Heart infections (endocarditis).
b. Bone infections (osteomyelitis).
c. Skin and soft tissue infections.
d. Brain (CNS) infections.

The goals of OPAT program are to:
 a. Provide expert care to patients on IV antibiotics.
 b. Manage side effects and infections.
 c. Reduce the need for hospital readmissions.

Patient Information
Patients and their families should have a basic knowledge of health care to allow safe, effective outpatient therapy. It is also important that they have a positive attitude toward this and be willing and able to learn about out-patient therapy (Chrijvens G., 1995).

Outside the hospital IV Therapy
Intravenous therapy outside the hospital, has only recently become possible, with the introduction of new Antibiotics, better catheters for vascular access, and improved infusion devices. Health care professionals have pioneered the development of OPAT and worked together to develop safe and effective programs. The involvement of a team of health care workers, including a physician, nurse, and often a pharmacist and social worker is particularly important (Rehm SJ 1983).

Intravenous (IV) Antibiotics
The antibiotics used for OPAT care are chosen for safety, effectiveness and ease of administration. The IV delivery system needed in the home is much simpler than the large, complicated IV pumps you see in the hospital. A few pharmacies have been licensed to provide OPAT antibiotics and IV supplies. These pharmacies may not be located at your home medical center. However, the delivery procedures are in place to make sure you get the medication in a timely fashion. For example, a pharmacy at Kaiser Permanente San Francisco (the French Campus pharmacy on Geary St.) provides the IV medications for much of the surrounding Bay Area. Delivery of the antibiotics and other needed supplies is usually made directly to either your home or to your nearby Kaiser medical office.

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