Outpatient parenteral antimicrobial therapy: updated recommendations from the UK.

Outpatient parenteral antimicrobial therapy (OPAT) offers safe, effective and patient-centred care for adults and children. The OPAT UK good practice recommendations for adults and children have recently been updated through a process of literature review, expert consensus and extensive stakeholder consultation. Here we discuss the key changes in the updated recommendations in the context of recent developments, including novel antimicrobial agents and delivery devices, the place of oral antimicrobials as an alternative to intravenous therapy, new OPAT service models and the broader antimicrobial stewardship agenda.

Incorporating medical leadership into undergraduate curricula: a proposal for a spiral curriculum.

PURPOSE: There is increasing recognition of the importance of incorporating medical leadership training into undergraduate medical curricula and this is now advocated by the General Medical Council (GMC) and supported through the development of the Undergraduate Medical Leadership Competency Framework (MLCF). However to date, few medical schools have done so in a systematic way and training/experience in medical leadership at undergraduate level is sporadic and often based on local enthusiasm. The purpose of this paper is to outline a theoretical curriculum to stimulate and support medical leadership development at undergraduate level. DESIGN/METHODOLOGY/APPROACH: This study describes a theoretical framework for incorporation of medical leadership training into undergraduate curricula using a spiral curriculum approach, linked to competences outlined in the Undergraduate Medical Leadership Competency Framework. The curriculum includes core training in medical leadership for all students within each year group with additional tiers of learning for students with a particular interest. FINDINGS: This curriculum includes theoretical and practical learning opportunities and it is designed to be deliverable within the existing teaching and National Health Service (NHS) structures. The engagement with local NHS organisations offers opportunities to broaden the university teaching faculty and also to streamline medical leadership development across undergraduate and postgraduate medical education. ORIGINALITY/VALUE: This theoretical curriculum is generic and therefore adaptable to a variety of undergraduate medical courses. The combination of theoretical and practical learning opportunities within a leadership spiral curriculum is a novel and systematic approach to undergraduate medical leadership development.

Updated good practice recommendations for outpatient parenteral antimicrobial therapy (OPAT) in adults and children in the UK.

UK good practice recommendations for outpatient parenteral antimicrobial therapy (OPAT) were published in 2012 and 2015 for adult and paediatric patients, respectively. Here we update the initial good practice recommendations in a combined document based on a further review of the OPAT literature and an extensive consultation process. As with the previous good practice recommendations, these updated recommendations are intended to provide pragmatic guidance for new and established OPAT services across a range of settings and to act as a set of quality indicators for service evaluation and quality improvement.

Assessment and management of active and latent TB.

More than 25% of the world population has been infected with tuberculosis (TB), however only 10% of those infected will ever develop active disease. Clinically significant disease occurs through progression of primary infection or through later reactivation of latent TB infection (LTBI); this is most likely to occur in the first few years following infection, although late reactivation can occur several decades later, particularly in individuals who become immunosuppressed. Risk of TB acquisition is increased in people who have come to the UK from high incidence countries or who are born in the UK but come from high-risk ethnic minority groups. In 2015, 73% of those diagnosed with active TB were born outside the UK. Other risk groups include those who are homeless, in prison or who misuse drugs or alcohol. Once infected people who are immunosuppressed are at greater risk of progression to active disease. Infants below the age of 12 months can develop rapidly progressive and potentially fatal infection. Initial clinical assessment with chest radiography and the collection of three deep respiratory samples for smear microscopy and culture remain the standard of care. The management of active TB has not changed significantly over many years. The most significant changes in the 2016 NICE guidance relate to screening for LTBI in individuals who are contacts of a patient with active TB, or who are recent entrants to the UK from a high incidence country. NICE recommends that only contacts of patients with active pulmonary or laryngeal TB be screened.

Spontaneous methicillin-sensitive Staphylococcus aureus spondylodiscitis-Short course antibiotic therapy may be adequate: Evidence from a single centre cohort.

Spontaneous methicillin-sensitive Staphylococcus aureus spondylodiscitis is increasing in prevalence and there appears to be little consensus on the optimum management of this condition. This paper analyses antimicrobial therapy and associated outcomes over a seven-year period at a large UK hospital trust. A retrospective search strategy identified 55 patients; notes were available for 39. Patients were treated with a median 12 weeks of antibiotics (IQR 7), with 6 weeks intravenous (IQR 3) and 9 weeks oral therapy (IQR 6). 23 different treatment regimens were utilised. 33/36 (92%) patients for whom outcomes were available were cured or improved at latest follow-up. This study reports a wide variation in antibiotic prescribing at a single centre. Outcomes were generally positive regardless of total duration of therapy and proportion of intravenous therapy. These findings highlight the need for multi-centre prospective randomised controlled trials to determine the most clinically effective and low-risk treatment strategy.

Patient retention of training in self-administration of intravenous antibiotic therapy in an outpatient parenteral antibiotic therapy service.

AIMS AND OBJECTIVES: To assess patient retention of initial training on completion of self-administration of a prolonged course of intravenous therapy. BACKGROUND: Outpatient parenteral antibiotic therapy is being used increasingly in the UK, and patients requiring prolonged antibiotic courses may be trained to self-administer therapy. DESIGN: Prospective clinical evaluation. METHODS: Patients self-administering parenteral antibiotic therapy through the Sheffield outpatient parenteral antibiotic therapy service were assessed when nearing completion of therapy for correct technique in five key areas of proficiency using a scoring system. RESULTS: Twenty-nine patients and nine carers were reassessed, at a median interval of 35 days after completion of the initial training package. Of these, 35 of 38 were fully competent in all areas. Three patients showed incomplete retention of their initial training. All made errors relating to use of sterile technique. CONCLUSIONS: Overall retention of training was excellent, and this supports earlier reports that patient-administered outpatient parenteral antibiotic therapy is as safe as nurse-administered therapy. However, this study highlighted a small number of patients or carers who were not fully competent at maintaining sterile technique, and as a result, the protocol for training patients has been altered. RELEVANCE TO CLINICAL PRACTICE: In this study, we assess patients' ability to maintain safe self-administration of therapy over a period of time. Patients are increasingly involved and engaged in their own health care, and this study provides a novel approach to assessing their competence in practical procedures.

Outpatient parenteral antimicrobial therapy in a changing NHS: challenges and opportunities.

Up to 4% of inpatients are in hospital solely to receive intravenous antimicrobial therapy. Outpatient parenteral antimicrobial therapy (OPAT) offers the opportunity for improved efficiency and patient choice through early discharge from hospital or admission avoidance, while maintaining quality of care. OPAT aligns well with key priorities in the new NHS and in this article I explore how new developments in the national healthcare context might be exploited to promote the ongoing evolution of OPAT in the UK.

Outpatient parenteral antibiotic therapy for infective endocarditis: a review of 4 years' experience at a UK centre.

OBJECTIVES: To review the role of outpatient parenteral antibiotic therapy (OPAT) in the management of infective endocarditis (IE) with the aim to guide further development of the service modality both locally and at other centres, in light of the evolving recommendations on patient suitability in international guidelines. METHODS: A retrospective case review of all patients receiving OPAT for IE in Sheffield between January 2006 and October 2010 was conducted. Data were collected on site and microbiology of infection, antibiotic regimens, adverse events during OPAT therapy and outcomes were studied. RESULTS: A total of 36 episodes of IE were treated in 34 patients. All patients received initial treatment as inpatients. Treatment was successful in 34/36 episodes (94.4%) with no evidence of recurrence at a median of 30 months follow-up. One patient had a relapse 2 months after completion of OPAT for enterococcal endocarditis and was found to have concurrent chronic prostatitis. One patient died of a ruptured pulmonary root abscess while receiving OPAT. Adverse events occurred in 12 episodes (33.3%), of which seven were line associated. In four cases adverse events resulted in re-hospitalisation. A successful outcome was achieved in 22/24 episodes (91.7%) deemed to be less suitable for OPAT due to higher risk of complications by Infectious Diseases Society of America guidelines. CONCLUSIONS: OPAT is a safe and effective means of completing therapy for IE, including prosthetic valve endocarditis and other cases at a higher risk of complicated disease. However, the relatively high rate of adverse events highlights the need for well-developed protocols and policies for patient selection and follow-up within the context of a formal OPAT service.

Good practice recommendations for outpatient parenteral antimicrobial therapy (OPAT) in adults in the UK: a consensus statement.

These good practice recommendations for outpatient parenteral antimicrobial therapy (OPAT) are an update to a previous consensus statement on OPAT in the UK published in 1998. They are based on previous national and international guidelines, but have been further developed through an extensive consultation process, and are underpinned by evidence from published literature on OPAT. They provide pragmatic guidance on the development and delivery of OPAT services, looking at all aspects of service design, care delivery, outcome monitoring and quality assurance, with the aim of ensuring that OPAT services provide high-quality, low-risk care, whatever the healthcare setting. They will provide a useful resource for teams developing new services, as well as a practical set of quality indicators for existing services.

Tuberculosis in UK cities: workload and effectiveness of tuberculosis control programmes.

BACKGROUND: Tuberculosis (TB) has increased within the UK and, in response, targets for TB control have been set and interventions recommended. The question was whether these had been implemented and, if so, had they been effective in reducing TB cases. METHODS: Epidemiological data were obtained from enhanced surveillance and clinics. Primary care trusts or TB clinics with an average of > 100 TB cases per year were identified and provided reflections on the reasons for any change in their local incidence, which was compared to an audit against the national TB plan. RESULTS: Access to data for planning varied (0-22 months). Sputum smear status was usually well recorded within the clinics. All cities had TB networks, a key worker for each case, free treatment and arrangements to treat HIV co-infection. Achievement of targets in the national plan correlated well with change in workload figures for the commissioning organizations (Spearman's rank correlation R = 0.8, P < 0.01) but not with clinic numbers. Four cities had not achieved the target of one nurse per 40 notifications (Birmingham, Bradford, Manchester and Sheffield). Compared to other cities, their loss to follow-up during treatment was usually > 6% (χ2 = 4.2, P < 0.05), there was less TB detected by screening and less outreach. Manchester was most poorly resourced and showed the highest rate of increase of TB. Direct referral from radiology, sputum from primary care and outreach workers were cited as important in TB control. CONCLUSION: TB control programmes depend on adequate numbers of specialist TB nurses for early detection and case-holding.Please see related article: http://www.biomedcentral.com/1741-7015/9/127.

New tests will improve detection of latent TB.

In the UK cases of active TB have risen substantially over the past 20 years. This increase has occurred almost exclusively in individuals born outside the UK, who now constitute more than two-thirds of cases. Only around one in ten people who are infected will develop active disease. The remaining 90% are presumed to have latent TB infection (LTBI) where viable mycobacteria are thought to persist for decades, and may reactivate if the host's immune system is weakened. In a country such as the UK with a low incidence of TB, a high proportion of cases result from reactivation of latent TB, rather than transmission by infectious cases. In the past 10 years a novel type of diagnostic test for LTBI has been developed: the interferon-gamma release assays (IGRA). Their major advantage over the tuberculin skin test is that they are not affected by prior BCG vaccination and they have a specificity of well over 90%. These tests are unable to distinguish between active and latent TB infection: this distinction must be performed purely on clinical grounds. Patients with a positive test should be assessed by a clinician with expertise in TB to ensure an appropriate management plan for each patient. The role of IGRAs in diagnosis of active TB is limited since in a patient with suspected active TB a positive result may indicate LTBI in combination with an alternative diagnosis. At a population level screening and chemoprophylaxis contributes usefully to TB control. However, only those under 35 with LTBI should receive prophylaxis. After this age the increasing risks of hepatotoxicity begin to outweigh the diminishing benefits of prophylaxis. The exceptions are healthcare workers, where the benefits are not just to the individual but also extend to their patients, and immunocompromised patients. The IGRAs represent a major development in the diagnosis of LTBI. While currently most of their use is through established TB screening services, it is likely in future that they will also be used routinely in general practice to screen individuals at high risk of LTBI.

Outpatient parenteral antimicrobial therapy: Recent developments and future prospects.

Patients with serious infections requiring parenteral antimicrobial therapy are usually hospitalized for treatment. For certain conditions, however, administration of parenteral antibiotics outside the hospital setting may be safe, efficacious, convenient for patients and cost-beneficial. Outpatient parenteral antimicrobial therapy (OPAT) was developed in the US initially and its use has expanded globally during the past three decades. A wide variety of infections are amenable to treatment by OPAT. Once-daily agents such as ceftriaxone or teicoplanin and, more recently, antimicrobials such as ertapenem or daptomycin have been used for OPAT. The use of higher doses and less-frequent dosing of existing agents is being explored, and exciting new developments include the emergence of agents with broader-spectrum activity against drug-resistant organisms and the use of antifungal agents in the OPAT setting. Future prospects in OPAT include the use of more recently launched drugs such as telavancin, as well as drugs in development, including dalbavancin (Durata Therapeutics Inc) and omadacycline (PTK-0796; Novartis AG/PARATEK Pharmaceuticals Inc). This review outlines recent developments in, and future prospects for, the antimicrobial agents used in OPAT.

Ertapenem administered as outpatient parenteral antibiotic therapy for urinary tract infections caused by extended-spectrum-beta-lactamase-producing Gram-negative organisms.

OBJECTIVES: Infections with extended-spectrum-beta-lactamase-producing organisms are an increasing public health concern. We reviewed the use of an outpatient parenteral antibiotic therapy (OPAT) programme to facilitate the early discharge from hospital of patients with ESBL-associated urinary tract infections. METHODS: A retrospective review of patients treated for urinary tract infections caused by ESBL-producing organisms through the OPAT programme at the Royal Hallamshire Hospital, Sheffield, UK over a 4 year period to January 2010 was conducted. Data on patient demographics, clinical presentation and laboratory results were collected. RESULTS: Twenty-four OPAT episodes involving 11 patients were identified. Six patients (54.5%) had an underlying urological abnormality on presentation to OPAT. All patients were treated with parenteral ertapenem. Two patients had multiple infections treated by OPAT. The mean duration of the OPAT episodes was 9.9 days (range 3-42). A total of 238 inpatient bed days were avoided, with resultant cost savings. CONCLUSIONS: Ertapenem administration through OPAT may help to decrease the costs associated with ESBL infections by reducing the number of inpatient bed days required for their successful treatment.

Spontaneous abscess of the lumbar spine presenting as subacute back pain.

A 52-year-old lady was admitted with back pain, fever and reduced sensation in her left leg. Soon after admission she developed acute urinary retention. She underwent urgent MRI of the spine which showed an epidural abscess compressing the thecal sac which was treated with neurosurgical decompression and intravenous/oral antibiotics. Cultures from theatre grew Staphylococcus aureus sensitive to flucloxacillin. After 12 weeks of intravenous/oral antibiotics, she was discharged without any neurological disability.

Clinical efficacy and cost-effectiveness of outpatient parenteral antibiotic therapy (OPAT): a UK perspective.

OBJECTIVES: Outpatient parenteral antibiotic therapy (OPAT) is an effective treatment strategy for a wide variety of infections as long as clinical risk is minimized by conforming to practice guidelines. However, its cost-effectiveness has not been established in the setting of the UK National Health Service. We examined the clinical efficacy and cost-effectiveness of an OPAT service based in a large UK teaching hospital, predominantly using the outpatient 'infusion centre' and patient/carer administration models of service delivery. PATIENTS AND METHODS: Data on clinical activity and outcomes were collected prospectively on 334 episodes of treatment administered by the Sheffield OPAT service between January 2006 and January 2008. Cost-effectiveness was calculated by comparing real costs of OPAT with estimated inpatient costs for these patient episodes incorporating two additional sensitivity analyses. RESULTS: Of the OPAT episodes, 87% resulted in cure or improvement on completion of intravenous therapy. The readmission rate was 6.3%, and patient satisfaction was high. OPAT cost 41% of equivalent inpatient costs for an Infectious Diseases Unit, 47% of equivalent inpatient costs using national average costs and 61% of inpatient costs using minimum inpatient costs for each diagnosis. CONCLUSIONS: Using this service model, OPAT is safe and clinically effective, with low rates of complications/readmissions and high levels of patient satisfaction. OPAT is cost-effective when compared with equivalent inpatient care in the UK healthcare setting.