Antimicrobial Stewardship in an Outpatient Parenteral Antibiotic Therapy Program

Antimicrobial stewardship activities have been in place at the Edward Hines, Jr. VA Hospital in Hines, Illinois, since 1988. Initial activities, including antimicrobial restriction and the start of an outpatient-infusion program justified and led to dedicated funding for hiring the first infectious diseases (ID) clinical pharmacist. This position was initiated in 1992 and has been maintained since then. The committed multidisciplinary team, including ID physicians, ID clinical pharmacists, venous access nurses (VAN), microbiologists, infection control practitioners, and an outpatient-infusion coordinator have led stewardship activities at this VA.

One of the first efforts of the team was the development of the outpatient parenteral antibiotic therapy (OPAT) program.¹ The program began in 1989 and has served more than 1,200 veterans. Outpatient parenteral antibiotic therapy is only one component of the stewardship program, which provides safe, effective, and cost-minimizing care for veterans, and is the focus of this article.

Background

Complex medical care and escalating costs have pushed all but the most seriously ill patients out of the hospital setting for care delivery. The reality is that patients who might have received care for non–life-threatening problems in a hospital bed are now relegated to an outpatient status. Beginning in the 1970s, OPAT has been used to facilitate the cost-effective, safe administration of antibiotics as an alternative to an extensive, expensive hospital stay.² Initially developed for use in a nonhospital health care setting, the administration of antibiotics under the guidance of a health care provider (HCP) has now been extended to a self-administered infusion program.^3,4 Under the latter, patients and caregivers are educated to safely administer IV antibiotics for extended periods at home.

This program uses elements of both health care–associated OPAT and self-administered OPAT (S-OPAT) to accomplish its goals: (1) safe, effective administration of antibiotic therapy to a variety of patients; (2) reduction in bed days of care (BDOC); (3) reduction of the economic burden to the hospitals’ global budgets; and (4) reduction in the incidence of common nosocomially-acquired infections, including those caused by Clostridium difficile (C difficile), methicillin-resistant Staphylococcus aureus, and vancomycin-resistant enterococcus.³

The advantages of S-OPAT have been fully realized in a variety of countries, enabling patients to receive necessary therapy in the comfort of their homes and providing them with the ability to lead normal lives without the confinement of a protracted hospital stay.^5-7

Description of OPAT

The outpatient-infusion team provides specialized care for patients in accordance with the OPAT national guidelines from patient screening to program discharge.⁸ The dedicated staff include the OPAT nurse coordinator, VAN, pharmacists, and ID consultants. The VAN places the venous access device (VAD), educates the patient and caregiver in the care and safety of the catheter, aseptic technique, and infusion of the selected antimicrobial agent, and monitors the laboratory work. The VA may contract an outside nursing agency to provide support and reinforcement of IV administration for the patient and caregiver.

The pharmacists oversee the pharmacokinetics and pharmacodynamics of the antimicrobials as well as monitor for any toxicities that could potentially arise during and after therapy. The ID consultants identify the infection, collaborate with the pharmacists to select the most appropriate antimicrobial regimen, and determine the duration of required therapy. The team then regularly monitors the patient in the ID clinic until there is evidence of infection resolution.

Primary care providers who want to enroll patients in the OPAT program place a formal electronic consult to the ID team for antibiotic recommendation, to the outpatient infusion team for assessment of potential outpatient therapy, and to the venous access team for insertion of the VAD. The consults are completed after receiving consent from the patient, developing a patient-centered treatment plan, and determining the patient’s ability to comprehend and adhere to the program requirements. The patient or caregiver must be able to competently demonstrate aseptic technique for IV administration prior to discharge. The pharmacist educates the patient or caregiver about the stability, storage requirements, and potential adverse drug reactions of the antimicrobial.

Eligible patients must have resolved their acute medical problems and require > 1 week of therapy to treat their infection. Patients chosen for OPAT or S-OPAT must have a suitable living environment with access to a refrigerator, a telephone, and transportation to return to the hospital for follow-up. Most patients and caregivers are eager to learn and recognize the advantages of home-based care.

The VANs are a central component of the program. They maintain open communication with the patient during the entire treatment course and help triage issues to the appropriate HCP. In addition, they are responsible for submitting catheter-related bloodstream infection (CRBSI) information to the hospital administration, which then gets reported to the National Healthcare Safety Network (NHSN).