OPATandStewardship–theLeedsExperience

JaneMintonConsultantinInfec?ousDiseases

Summary

•  WhatisOPAT?•  OPATinLeeds– CommunityIVAn?bio?cService

•  OPATStewardship– Generalissues– WhathappensinLeeds– Sugges?onsforfuturework

OPAT=Outpa?entParenteralAn?microbialTherapy

•  ProvidingIVan?bio?cstopa?entslivingoutsidehospital– Simplecommoninfec?onse.g.celluli?s– Complexunusualinfec?onse.g.endocardi?s

•  Standardinmostdevelopedcountries•  Variableimplementa?oninUK•  Widevarietyofmodelsofcareinexistence

DriversforOPAT

•  Freesupbedcapacity– BeQer‘pa?entflow’foremergencyadmissions–  Increasedelec?vecapacity/income

•  Pa?entdemand•  Poten?allylessriskofHCAI

Indica?onsforIVratherthanoralAn?bio?cs

•  Severeinfec?ons– Meningi?s,endocardi?s

•  Failureoforaltherapy– celluli?s

•  Nootherroutefeasible– e.g.nilbymouth

•  Nooralalterna?ve– Somemul?-resistantinfec?ons

Assessingpa?entsforOPAT

Inclusioncriteria•  IVan?bio?csclinically

necessary–  Failureoforaltherapy–  Noeffec?veoralregimen

•  Feasiblean?bio?cregimen•  Nootherindica?onto

remaininhospital•  Pa?enthappytobetreated

athome

Exclusioncriteria•  Uncleardiagnosis•  Unstablepa?ente.g.

tachycardia,hypotension,newhypoxia,confusedpa?entwithoutcarer

•  Substanceabuse•  Homeless/home

environmentunsuitableforIVadministra?on

Varia?oninOPAT:modelsofservicedelivery

•  DailyaQendanceathospital•  Visi?ngnurse(generalorspecialist)•  Selforcareradministra?on

BSAC(Bri?shSocietyforAn?microbialChemotherapy)OPATProject

•  GoodPrac?ceGuidelines

•  Conferences•  Na?onaloutcomesregistry

•  Workstreamsonkeyissuese.g.DrugStabilityandTes?ng

ModelsofcareinLeeds

•  CommunityIVAn?bio?cService-CIVAS–  Visi?ngspecialistnurse,aliQlehospitalOP,occasionalselfadministra?on

–  JointservicebetweenLeedsCommunityHealth&LeedsTeachingHospitals

–  ProvidedinLTHTbyInfec?ousDiseaseswithhugeinputfromMicrobiologyandthePharmacyInfec?onTeam

•  LTHTEmergencyDepartment–  Celluli?s,pa?entsaQenddaily

•  Cys?cfibrosis–  Self-administra?onwithspecialisednursesupervision

Infec?onsreferredtoLeedsCIVASn=931,over3years6months

Bone&jointinfec?on

Skin&soe?ssue

Urinarytract

Endovascular

Intra-abdominal

Others

BSACOPATstrategy:an?microbialstewardship

•  PromoteOPATasanimportantaspectofan7microbialstewardshipacrosstheBSACporfolio

•  EngagewithallintheOPATclinicalcommunitye.g.acutemedicine,ambulatorycare,surgery–toinform,supportandenhancethedeliveryofsafeandeffec7veservicesacrossallsectors

•  DevelopanonlineaccreditedOPATstewardshiptrainingmodulerelevantforOPATandotherhealthcareprac??oners

•  Recommendalllocalan7microbialmanagementteams,stewardshipcommiQeesortheirequivalentsappointamemberoftheOPATservicetotheirmembership.

•  RecommendthatOPATan7microbialuseisreviewedwithinthean?microbialstewardshipprogrammeasinotherclinicalspecial?es

TheidealOPATan?bio?c

•  Administeredonceadayorless–  Canbegivenasabolusinjec?on–  Infusiondeviceover24hours

•  Canbequicklypreparedanddoesn’tneedrefrigera?on

•  Doesnotcausesideeffectsincludingphlebi?s•  Doesnotrequiretherapeu?cdrugmonitoring•  Narrowspectrumtarge?ngjustthepathogenbeingtreated

ControversiesaroundOPATandstewardship

•  More‘broadspectrumthannecessary’an?bio?cssome?mesusedastheyareconvenient–  RiskofAMR&CDI

•  IVan?bio?csmaybecon?nuedlongerthannecessary,ratherthanoralswitch–  Clinicaldesiretogivewhatisseenasthemosteffec?vetreatment

–  Possiblyfinancialincen?ves“Thereareperverseincen?vesfortheuseofOPAT;paymentstohospitalstoprovideOPATasanalterna?vetoinpa?entIVtherapyandthusanincen?vetorecommendIVtherapyinsteadoforal.”

Top6an?bio?csusedforCIVASinLeeds(n=707courses)

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StewardshipinLeedsinprac?ce•  An?bio?cguidelines:celluli?sintheED–  Currentlyteicoplaninfirstchoice;daptomycinasalterna?ve

–  Abouttotrialorallinezolidwhereappropriate•  Restric?onsonan?bio?cuseoutsideTrustguidelines(‘code’system)

•  Infec?onspecialistreviewpriortoacceptanceforCIVAS– Microbiology/Infec?ousDiseases,includingclinicalreview

•  Challenges: •  Admissionavoidancepa?ents•  Referralsfromotherins?tu?ons

Levelsofan?bio?cstewardship

•  Clinical–  Isitaninfec?on?–  Isitaninfec?onwhichneedsan?microbialtreatment?

•  Microbiological– Choiceofan?microbialfollowingiden?fica?on&sensi?vi?es

– Ensuringsourcecontrol/adviceonlengthoftreatmentandoralswitch

Furtherwork

•  AuditofOPATprescribing-couldthesebyna?onal,ledbyBSAC?– Agentused– Dura?onoftherapy

•  Researchoneffectofuseofbroad-spectruman?bio?csincommunitye.g.– Surveillanceforacquisi?onofan?bio?cresistancebypa?entsonOPAT

– Againscopeformul?-centreprojectsledbyBSAC

AVeryBigThankYouto•  Infec?ousDiseasesincluding

LizzieWareDebbieBookerShonaCaltonJoAllenPennyLewthwaiteHughMcGann

•  MicrobiologyincludingNickFosterJonSandoe

•  PharmacyincludingKellyAtackJoeSpencerPhilipHowardLizKay

•  LeedsCommunityHealthincludingAngelaGregsonKateO’HalloranAnnaGreenRenataO'DonovanRonLinsaoAndrewRobertsCharloQeWardLeeMaloneyAnneObwar

Thankyouforlistening!Anyques?onsorcomments?