OPAT-Antimicrobial Stewardship Team Coordination Ideal For Improving Patient Outcomes Upon Readmission

Improved indication documentation and antimicrobial stewardship involvement may improve patient outcomes in some patients who are on outpatient parenteral antimicrobial therapy (OPAT) for ease of administration (EOA) that are readmitted to the hospital, according to research presented by Rachel S. Britt, PharmD, Beth Israel Deaconess Medical Center, Boston, Massachusetts, at ID Week 2018 held this year in San Francisco, California.

Patients who require longer-term courses of antimicrobials, such as individuals with osteomyelitis or endocarditis, may be ideal candidates for OPAT, which allows for the administration of longer courses of intravenous (IV) medications in an outpatient clinic or the patient’s home, without requiring a hospital stay. To allow for EOA, oftentimes the patient’s therapy regimen includes a switch to a broader spectrum antibiotic such as ertapenem or daptomycin that requires less frequent dosing, which is easier to manage outside of the hospital.

If a patient requires readmission, however, it may be beneficial for them to be tailored to a pre-OPAT regimen of a narrow-spectrum antibiotic to minimize any “collateral damage,” such as the development of antimicrobial resistance and Clostridium difficile infections, and reduce cost, according to Dr. Britt.

“With OPAT, it’s unknown what happens with these patients after they are enrolled upon discharge,” explained Dr. Britt. “[They may be] put on one of these broad-spectrum therapies for EOA; but, if they come back into the hospital, where we have the resources to put them on narrower, less-expensive therapies that require more frequent dosing, we wanted to know, are they being put back on those agents.”

Dr. Britt stressed that there are some caveats to this, of course, as some readmissions are preplanned by medicine and surgery, and patients are only in the hospital for 1 or 2 days. Therefore, clinicians have to work closely with their inpatient and OPAT stewardship teams to identify for which patients the switch would make sense.

For their single-center, retrospective study, Dr. Britt and her team reviewed the charts of adult patients who had been enrolled in OPAT and discharged from the hospital between January 1, 2014, and September 30, 2017, on either daptomycin or ertapenem for EOA. Those patients who had been receiving directed carbapenem or daptomycin before being enrolled in OPAT were excluded from the study.

The primary outcome was the percentage of patients who were readmitted to the hospital during or within 90 days of the OPAT course of therapy and maintained on an EOA regimen. Inpatient therapy cost, rates of C difficile, and adverse drug reactions were secondary outcomes (see video).

EOA regimens were continued in 27% of the readmissions. The results indicated that 71 of the 188 patients identified as receiving an OPAT EOA regimen were readmitted to the hospital (n = 113 unique readmissions). Eighty-one percent of the patients were male, and the median age was 57 years. About 8.6% of the patients on daptomycin ended up with C difficile infections versus 6.1% in the ertapenem arm (see video). According to the study abstract, the median drug acquisition cost of inpatient EOA was $112 per readmission.

According to Dr. Britt, these results indicate that with better coordination between the OPAT and antimicrobial stewardship teams, patients may be given more appropriate antimicrobial regimens to improve patient outcomes and reduce costs (see video).

Better provider order entry indication documentation and coordination between OPAT and stewardship teams may facilitate appropriate regimen tailoring in certain patients upon hospital readmission during OPAT.

Since the completion of the study, Dr. Britt and her team have presented these results to their OPAT team and they look forward to discussing and determining any changes that need to be made to create the best regimens for these patients, which may include remaining on the broad-spectrum therapy (see video).

Some limitations of the study include that it was a retrospective, observational, single-center study and that data collection was limited to the documentation bias and information that was contained within the medical records. Furthermore, as this was a single-center study, the investigators were unable to see whether or not patients had been admitted to another medical center in between discharge and readmission, and if they were continued on their OPAT therapy.

Session: Poster Abstract Session: Clinical Practice Issues: HIV, Sepsis, QI, Diagnosis

Poster 1923: OPAT or no-PAT? Evaluation of Outpatient Parenteral Antimicrobial Therapy (OPAT) Patients Receiving Daptomycin or Ertapenem for “Ease of Administration”

Disclosures:

R. S. Britt, None

M. T. Lasalvia, None

S. Padival, None

P. V. Patel, None

C. McCoy, Merck Inc: Scientific Advisor , Consulting fee . Allergan: Scientific Advisor , Consulting fee .

M. V. Mahoney, Melinta Therapeutics: Consultant , Consulting fee . Cutis Pharma: Consultant , Consulting fee . Tetraphase Pharmaceuticals, Inc.: Consultant , Consulting fee . Roche Diagnostics USA: Consultant , Consulting fee .