24hourinfusion-anewOPATpathwayfordiabeticfoot?

PaulaGrannonDiabeticSpecialistPodiatristNaomiFlemingAntimicrobialPharmacist

Context

Thereare17000peoplewithdiabetesinNorthandEastNorthamptonshire,7%willhavediabeticfootproblems.

DiabeticfootulcersareoftencomplicatedbyosteomyelitisrequiringlongtermIVantibiotics.

Infectionscausedbypseudomonasormulti-resistantcoliformsareoftenprescribedpiperacillin/tazobactam(PT),threetimesaday,asaninpatient.

ContinuousinfusionofPTover24hoursenablespatientstohavethisantibioticconvenientlyathome.

ImprovementIssuePatientscanbetreatedathomeorontheambulatorycareunitratherthanstayingasinpatients.Thishasthreebenefits

PatientcareisdeliveredclosertohomeReducedadmissionsEarlierdischarge

CapacityforOPATcanbemaximisedaspatientsonlyrequireoncedailyvisitsandthesetup/changeisquickerthansettingupintermittentinfusionsormultiplebolusregimes.Asonlyonceadaydosing,lessriskofbreakingaseptictechniqueandlessriskoflineinfection

Penicillinsandcontinuousinfusions

•  Aspenicillinsshowtimedependentratherthandosedependantbactericidaleffects,pharmacokineticstudiesshowatleastasgoodifnotbetteroutcomeswith24hourcontinuousinfusions.

•  ThisfulfilsgoodpracticerecommendationsforOPATthattherapyisatleastequivalenttothatgivenasaninpatient.

Process

WepilotedPT24hourinfusionsfortwomonthstoenableearlydischargeoradmissionavoidancefordiabeticfootpatientsselectedbasedonmicrobiologyresultsandsuitabilityforhomeIVtherapy.

PatientswereidentifiedeitheronthewardoratjointMDTthatincludesconsultantendocrinologist,diabetesspecialistpodiatristandantimicrobialpharmacist.

Dosesbasedonrenalfunction(9gor13.5gover24hours).

Aims:ToevaluatetheuseofPT24hourinfusionindiabeticfootpatients.

Datawascollectedonbeddayssaved,reductioninantibioticdoses,infectionoutcome,adverseeffects,costoftreatment,issuesencountered.

ResultsEvidence7patientsweretreated.

265dayswereadministered,saving265beddaysor530homevisitsforIVdoses.

AllpatientshadasimilaroutcomeaspredictedfromPTthreetimesadayadministration.

Patientsatisfactionwasimprovedasthetreatmentregimewaslessobtrusivetodailylife.

Cost24hourinfusionbag13.5g:£55+VAT

CosttdsPT£2.73+VAT/day

Nosignificantpatientadverseeffectsreported.

MrsA.March2016

MrsA.May2016

MrsA.June2016

MrPFeb2016

MrP.Feb2016

MrPApril2016

MrK.March2016

MrsH.March2016

MrsH.May2016

MrM.March2016

MrM.May2016

MrC.March1st2016

MrW.March2016

MrW.May2016

IssuesEncountered•  Supplyissuesfromthemanufacturerasdemandroserapidly

•  Staffingforpharmacyprocesses(unlicensedproductrequirements,instalmentdispensingduetoshortshelflifeandhomestorageissues).

•  Productremainingintheinfusiondeviceattheendofthe24hours.

•  Onepatientremovinglines.

Conclusion

Theuseof24hourinfusiondevicesenablespatientstohaveconvenientIVtherapyathomereleasingbeddaysandhomeIVslots.Thecostofmedicationisgreater,butmitigatedbysavingsinbeddaysorhomeIVslots.

FutureStepsFunding from the National Diabetes Treatment and CareProgramme to introduce a diabetes foot OPAT service foradmissionavoidanceandreducing lengthofstayusing24hourinfusiondeviceantibioticshasbeenapproved.

Piperacillin/tazobactam and flucloxacillin have been identifiedasoptions.

Patientswill be reviewed by the antimicrobial pharmacist andthe specialist podiatrist team weekly or fortnightly to ensurepromptmicrobiologicalandclinicalreviewofpatients.

Clinical governance will be carried out as per OPAT goodpractice guidelines by the antibiotic pharmacist and patientsrecordedontheofficialnationalOPATregistrysystem.

ThankyouandQuestions?

•  ThankyoutoDrPierides,thediabetesspecialistpodiatrists,podiatryassistants,ICTandpharmacyteam.