Pharmacist Coordinated Antimicrobial Therapy: OPAT and ... · ©2011 Franciscan St. Francis Health Pharmacist Coordinated Antimicrobial Therapy: OPAT and Transitions of Care Jennifer

©2011 Franciscan St. Francis Health

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:

• Estimated 25% of patients will develop adverse reactions

–Up to 10% of which will lead to early discontinuation of therapy

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

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

- Not drawn - Safety

- Wrong time - Unnecessary lab re-draws

- Suspension in therapy

- Patient sticks

- Costs

- NSAIDS

- Diuretics

- Antimicrobials



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

• 3rd 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



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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

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Frequency of Laboratory Monitoring

Antibiotic <1x/Week

N (%)

1x/Week

N (%)

2x/Week

N (%)

3x/Week

N (%)

>3x Week

N (%)

Total

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

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)

14.7% HCU within 30 days 6 month assessment

Mace AO, et al.

(n=242)

15% hospital readmission Pediatric patients

Chan M, et al.

(n=120)

10% readmitted for worsening

SSTI

SSTI only

Lai A, et al. (n=333) 24.4% HCU or complication from

IV antibiotic

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

• Reliance on the after visit summary (AVS) is error prone!

–Multiple changes

–Multiple people

–Multiple times

–Multiple systems

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


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



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

Documents

Pharmacist Coordinated Antimicrobial Therapy: OPAT and ... · ©2011 Franciscan St. Francis Health Pharmacist Coordinated Antimicrobial Therapy: OPAT and Transitions of Care Jennifer