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Some OPAT courses unnecessary, modifiable
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The use of outpatient parenteral antimicrobial therapy in the Veterans Affairs System may be modifiable or avoidable in a substantial percentage of cases, highlighting the need for improved oversight in these settings, according to recent data.
In the retrospective review, researchers evaluated all courses of outpatient parenteral antimicrobial therapy (OPAT) at the Salt Lake City VA Medical Center for patients referred for home infusion therapy, between Jan. 1 and Dec. 31, 2012. Through a medical chart review, researchers examined data including antimicrobials used, indication, duration of therapy, culture results and whether infectious disease consultation occurred.
Two infectious disease specialists evaluated all courses of OPAT to identify possible modifications, such as changing a drug, dosage or duration of treatment, switching from IV to oral drugs, reducing the number of drugs. For each potential modification, the two reviewers determined whether this change would have definitely, possibly or not been recommended, and used descriptive statistics to compare OPAT courses with and without ID consultation.
The researchers identified 192 courses of OPAT given to 148 patients. Of these, 68% occurred after hospital discharge and comprised 2% of the hospital’s discharges during the course of the study. An ID consult occurred with 58% of OPAT courses. The most prevalent indications for OPAT were bone and joint infections (31%), urinary tract infections (23%) and skin and soft-tissue infections (SSTIs, 17%). The most commonly prescribed antimicrobial agents included vancomycin (34%) carbapenems (26%) third-generation cephalosporins (16%) and antipseudomonal penicillins (14%). A pathogen was detected for 120 courses, and of the remaining 72 courses, 39 had negative culture results and no culture was performed in 33. The therapy was administered for a median duration of 15 days.
Modifications were recommended in 60% of the courses, with the most prevalent modifications being a switch from IV to oral treatment (30%), change in treatment duration (22%) and drug substitution (22%).
OPAT was potentially avoidable in 41% of the courses (11% discontinue therapy, 30% IV to oral conversion), and cases in which the OPAT course included ID consultation had a lower prevalence of modification recommendations compared to cases without ID consultation (46% ID consultation vs. 80% no ID consultation; P < 001).
“A significant proportion of OPAT use at our institution is likely modifiable or avoidable, even when ID physicians are involved,” the researchers wrote. “An [antimicrobial stewardship program] intervention has the potential to reduce OPAT overuse while lowering costs and improving patient safety. Expansion of such an intervention could have a significant impact on the VA Health Care System.” – by Jennifer Byrne
Disclosure: The researchers report no relevant disclosures.
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