The Early Bird Gets to Stay Home: Early OPAT Follow-Up Reduces 30-Day Readmissions

Highlighted Study: Early infectious disease outpatient follow-up of outpatient parenteral antimicrobial therapy patients reduces 30-day readmission.

Saini E, Ali M, Du P, Crook T, Zurlo J. Clin Infect Dis. 2019;69(5):865-868. doi: 10.1093/cid/ciz073.

Outpatient parenteral antimicrobial therapy (OPAT) programs offer support for patients who require prolonged intravenous antibiotic therapy outside of an acute care setting. These programs aim to reduce hospital readmissions and allow patients to safely complete antibiotic therapy at home or in a skilled nursing facility. The 2004 Infectious Diseases Society of America OPAT guidelines recommend weekly follow-up with an infectious diseases (ID) provider as best practice.¹ Despite this recommendation, most programs report less frequent patient follow-up.² Readmission rates for patients receiving OPAT are reported to be as high as 20%, mostly due to catheter-related problems, adverse drug reactions, or worsening of the primary infection.^3,4

Recently, Saini et al aimed to determine the impact of early outpatient ID follow-up on all-cause 30-day hospital readmission rates for patients enrolled in the PennState Health OPAT program.⁵ Patients were included if they were enrolled in the OPAT program between January 2012 and December 2014, then pair-matched in a case-control manner relative to 30-day readmission. Patients were excluded from the study if the OPAT course was never started, if OPAT was managed primarily by providers at the patient’s facility, or if the OPAT course included only oral agents. Case (ie, readmission occurred)—control (ie, readmission did not occur) pairs were matched based on age, sex, discharge year, and discharge diagnosis category. Both bivariable and multivariable conditional logistic regression analyses were performed. Patients were followed weekly, with laboratory tests dependent on the antimicrobial regimen.

During the study period, 1102 patients were enrolled in the OPAT program and 201 (18%) were readmitted within 30 days of discharge. A total of 388 patients (194 case—control pairs) were included in the study. The Table shows patient demographics and indications for OPAT. The average age was 59.6 years; past medical histories of diabetes, renal failure, and immune compromise were present in 32.2%, 10%, and 12.1%, respectively. The most commonly administered antibiotic was vancomycin (36% of the case group and 29% of the control group). Antifungal use (9% vs 2%), fluoroquinolone use (17% vs 10%), and metronidazole use (13% vs 6%) were more common in the case compared with the control group, respectively. More case patients received 3 or more antimicrobials relative to their control counterparts (21% vs 7%).

Approximately 40% of the readmissions occurred within 7 days of discharge and 97 of 201 (46%) of readmissions were attributed to OPAT-related issues, including worsening infection and acute kidney injury. Of the patients who were readmitted, 13% were seen by an ID provider within 14 days of discharge, compared with 33% of patients in the control group (P = .0001). This finding suggests that early outpatient ID follow-up may reduce the risk of 30-day readmission. On multivariable analysis, immunosuppression was significantly more common in the case group (17% vs 6%; P = .0015; OR, 2.79; 95% CI, 1.17-6.64). Ceftriaxone use, however, was more common in the control group (11% vs 20%; P = .02; OR, 0.49; 95% CI, 0.26-0.92).

This study has some notable limitations, including that microbiologic data were not assessed. Specific pathogens, such as Staphylococcus aureus, may have further stratified complex patients who may have benefited from early ID follow-up. Additionally, a limited number of patient comorbidities were characterized, preventing identification of any other patient-specific factors that may be associated with readmission.

Although not the central focus of the study, these findings reinforce the challenges surrounding early OPAT follow-up. Patients in this study were intended to be assessed weekly, which was not achieved in many cases. Delays in care seemingly increased risk of hospital readmission. OPAT programs can use these findings to identify potentially high-risk patients, such as those on 3 or more agents or with immune compromise, to prioritize them for early ID follow-up to help prevent readmission. However, patients on well-tolerated antibiotics, like ceftriaxone, may not require early follow-up. Additional research on risk factors associated with readmission in patients on OPAT is necessary to further stratify which individuals would most benefit from early ID follow-up. Furthermore, programs with an interdisciplinary approach (eg, inclusion of nurses, pharmacists) may be able to optimize safe OPAT based on the reasons for readmission in this study.

Adamsick and Bidell are clinical pharmacists in infectious diseases and internal medicine at Massachusetts General Hospital.

* indicates active members of the Society of Infectious Diseases Pharmacists.

References

1. Tice AD, Rehm SJ, Dalovisio JR, et al; Infectious Diseases Society of America. Practice guidelines for outpatient parenteral antimicrobial therapy. IDSA guidelines. Clin Infect Dis. 2004;38(12):1651-1672. doi: 10.1086/420939.
2. Chary A, Tice AD, Martinelli LP, Liedtke LA, Plantenga MS, Strausbaugh LJ; Infectious Diseases Society of America Emerging Infections Network. Experience of infectious diseases consultants with outpatient parenteral antimicrobial therapy: results of an emerging infections network survey. Clin Infect Dis. 2006;43(10):1290-1295. doi: 10.1086/508456.
3. Huck D, Ginsberg JP, Gordon SM, Nowacki AS, Rehm SJ, Shrestha NK. Association of laboratory test result availability and rehospitalizations in an outpatient parenteral antimicrobial therapy programme. J Antimicrob Chemother. 2014;69(1):228-233. doi: 10.1093/jac/dkt303.
4. Lee B, Tam I, Weigel B 4th, et al. Comparative outcomes of β-lactam antibiotics in outpatient parenteral antibiotic therapy: treatment success, readmissions and antibiotic switches. J Antimicrob Chemother. 2015;70(8):2389-2396. doi: 10.1093/jac/dkv130.
5. Saini E, Ali M, Du P, Crook T, Zurlo J. Early infectious disease outpatient follow-up of outpatient parenteral antimicrobial therapy patients reduces 30-day readmission. Clin Infect Dis. 2019;69(5):865-868. doi: 10.1093/cid/ciz073.

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