Pharmacist Coordinated Antimicrobial Therapy: OPAT and Transitions of Care Jennifer McCann, PharmD, BCCCP State Director of Clinical Pharmacy Services St. Vincent Health Indiana
Conflicts of Interest No actual conflicts of interest.
Objectives Describe the growing pace of IV antimicrobials in transitions of care Evaluate a patient for safety and efficacy IV antimicrobials List complications associated with IV antimicrobials Generate changes at a practice site that will improve the success of OPAT treatment courses
OPAT Background Definition: provision of parenteral antimicrobial therapy of at least 2 doses on different days without intervening hospitalization Outpatient refers to any of the following: Home Physician office Hospital based ambulatory care clinic Emergency departments Hemodialysis centers Free standing infusion centers Long term care facilities Skilled nursing care facilities Rehabilitation centers Estimated 25% of patients will develop adverse reactions Up to 10% of which will lead to early discontinuation of therapy Tice AD, et al. Practice Guidelines for OPAT; CID 2004:38 (15 June) Chapman ALN, et al. Journal of Antimicrobial Chemotherapy May 2012
OPAT Prescribing Common Indications Prosthetic joint infections Osteomyelitis Endocarditis Complicated SSKI Bacteremia Common Antimicrobials Vancomycin Daptomycin Cefazolin Ceftriaxone Antipseudomonal or broad spectrum antimicrobials: Carbapenems Piperacillin/Tazobactam Cefepime
Think, Pair and Share What are the most common reasons IV antimicrobials are is discontinued early or changed to alternative drugs?
Provider Reports Lane, MA, et al. Infect Control Hosp Epidemiol. 2014 Jul
Example Vancomycin - NSAIDS - Diuretics - Antimicrobials - Not drawn - Safety - Wrong time - Unnecessary lab re-draws - Suspension in therapy - Patient sticks - Costs
Think, Pair and Share List the most significant adverse effects associated with the gram negative or broad spectrum antimicrobials.
Clostridium difficile infection (CDI) Estimated costs 1 billion dollars/year in the US Exposure to healthcare facility is associated with 70% 80% of cases Clinical signs: Acute onset watery diarrhea Unexplained leukocytosis of 15,000 Elevation in serum Cr >1.5 Most commonly associated with: Antimicrobial selections 3 rd generation cephalosporins: Ceftriaxone Clindamycin Broad spectrum antimicrobial agents Prolonged courses of antimicrobials Lambert PJ, et al. Infect Control Hosp Epidemiol 2009; McGlone SM,et al. Clin Microbiol Infect 2012; Slimings C, Riley TV. J Antimicrob Chemother 2014
Think, Pair and Share amazon List the components of a complete OPAT antimicrobial order.
Order completeness The Basics Medication Dose Route Frequency The Safeguards Routine laboratory monitoring Line care & removal plan Duration of therapy (end date) Appropriate provider follow up Communication plan with team amazon
Frequency of Laboratory Monitoring Antibiotic <1x/Week N (%) 1x/Week N (%) 2x/Week N (%) 3x/Week N (%) >3x Week N (%) Daptomycin 33 (8) 385 (88) 20 (5) 1 (0) 0 (0) 439 Vancomycin 16 (4) 343 (77) 84 (19) 2 (0) 0 (0) 445 Oxacillin/Nafcillin 38 (9) 385 (87) 17 (4) 2 (0) 0 (0) 442 Total Cephalosporins 44 (10) 384 (87) 11 (2) 1 (0) 1 (0) 441 Carbapenems 44 (10) 388 (87) 12 (3) 0 (0) 0 (0) 444 Amphotericin 22 (5) 98 (24) 194 (47) 91 (22) 10 (2) 415 Aminoglycosides 23 (5) 130 (30) 247 (57) 31 (7) 4 (1) 435 Lane, MA, et al. Infect Control Hosp Epidemiol. 2014 Jul
Franciscan Health Indianapolis PCAT Program Founded in 2015 Pharmacist dedicated to program since Nov 2016 Patient criteria for inclusion in program: Inpatient hospitalization Consult received during index hospital stay ID provider consulted Discharged on IV antimicrobials
Program Overview Support of discharge planning process Antimicrobial stewardship Dose optimization conducive for home administration Post discharge weekly monitoring
Overview of Demographics Consult Volume Disposition at Discharge Antimicrobial Prescribing Trends Readmission or ED use
Consult Volume Total patient consults: 546 pts Discharged on IV therapy: 421 patients 125 patients excluded post discharge: 48 switched to PO 13 completed in house 6 no ID consult 7 hospice 51 other reasons Missing data Left AMA
Disposition at Discharge
Antimicrobial Prescribing Patterns Vancomycin SAR: 52.6% Home: 27% IVIC: 9.8% HD: 10.6% Anti-pseudomonal SAR: 51.7% Home: 37.8% IVIC: 10.5% Ceftriaxone Home or IVIC: 71%
Hospital Readmission or ED Utilization Sample of 95 patients over 6 month period 14 patient with hospital readmission or ED use within 30 days 60% patients returned to home Franciscan Health Indianapolis (n=95) Mace AO, et al. (n=242) 14.7% HCU within 30 days 6 month assessment 15% hospital readmission Pediatric patients Chan M, et al. (n=120) Lai A, et al. (n=333) 10% readmitted for worsening SSTI 24.4% HCU or complication from IV antibiotic SSTI only Included hospital readmission, ADR, line complication Huck D, et al. (n=400) 20.5% hospital readmission Cleveland clinic, 2 month ECF 36%
Program Goals 1. All patients are discharged with complete OPAT orders 2. Routine communication with pharmacist, ID and other providers 3. Routine documention in the patient medical record 4. Patients are informed and involved in their antimicrobial care decisions 5. Establish benchmarks for clinical and financial success of program
Transition to Home
Transition to Healthcare Facilities All patients are discharged with clear, complete, and accurate IV antibiotic and monitoring orders GAP Analysis Questions Answer YES if Recommendation Is Performed in the Majority of patients No Action Required Answer NO if GAP Has Been Identified (Currently NOT in practice) Answer SORT OF if Recommendation is Performed some of the time BUT not consistently OR Is Not Applicable OR is in Progress Reliance on the after visit summary (AVS) is error prone! Multiple changes Multiple people Multiple times Multiple systems
Our Stories Inadvertent continuation of IV antimicrobials for an additional 4 wks IV line remained in place for 4 weeks after completion Hospital readmissions with CLABSI Extended stay out of pocket Missed PO transition Wrong interpretation of serum concentrations Prolonged disruptions in therapy, disease relapse, hospital readmission Lack of routine laboratory monitoring Hospital readmissions with AKI
Think, Pair and Share Share your stories What suggestions do you have for your site to improve the safety and effectiveness of IV antimicrobials?
Take Home Points IV antimicrobial prescribing at hospital discharge is complex Opportunities for safer, simplified prescribing exists Complete treatment plans are necessary Treatment success relies on monitoring for safe and effective care Renal failure Line care CDI Share ways to improve the care of your IV antimicrobial treated patient
Pharmacist Coordinated Antimicrobial Therapy: OPAT and Transitions of Care Jennifer McCann, PharmD, BCCCP State Director of Clinical Pharmacy Services St. Vincent Health Indiana