Complex oral antibiotic therapy within OPAT – An introduction

The complex outpatient oral and parenteral antibiotic therapy (COPAT) service was established in Hull and East Yorkshire Hospitals NHS Trust (HEYHT), in 2010.

The service was established to oversee the outpatient monitoring of Linezolid according to guidelines following a few episodes of sub-optimal monitoring that lead to patient harm.

The service has subsequently evolved considerably and now cares for approximately 140 patients each year prescribed a wide range of what we describe as “complex oral antibiotic regimens”.

This model of care is increasingly being incorporated into the service specification of OPAT services across the UK which predominantly aims to:

• reduce the risk of serious antibiotic related adverse effects (AEs)

• respond to AEs quickly if they do occur

• oversee therapeutic drug monitoring (TDM) for clinical situations requiring it

• improve patient adherence and experience

• optimise clinical efficacy

• minimise antibiotic exposure and the emergence of resistance

• facilitate patient discharge from hospital, or admission avoidance, if clinically appropriate

At HEYHT, Linezolid is a restricted (ALERT) antibiotic, governed by local guidelines (see resources below), and can only be prescribed following approval by a Dept. of Infection consultant.

It cannot be prescribed by primary care physicians.

All patients being discharged from hospital with a planned outpatient course of Linezolid (more than 7 days) are referred to this service. They must have a robust a priori treatment plan from the infection consultant involved in the care of that patient. Our pharmacy colleagues refuse to dispense prescriptions without such approval and will highlight unapproved prescriptions to the Dept. of Infection.

Referrals to COPAT include patients with various infections from:

• primary care
• emergency and ambulatory care departments
• medical and surgical sub-speciality wards following an inpatient admission
• our own service (i.e. being switched from OPAT to COPAT)
• our combined OPAT-Podiatry clinic
• local general and sub-speciality infection clinics

Patients are reviewed weekly (if prescribed Linezolid) or as often as is clinically indicated when prescribed other complex oral antibiotic regimens.

Complex oral antibiotic regimens that require regular monitoring are sometimes prescribed for patients with serious infections who would have otherwise received IV therapy, but who, for example, do not want to be admitted to hospital or want to be discharged from hospital and for whom outpatient-based OPAT is unsuitable.

Alternative models of care for the monitoring of complex oral antibiotic regimens can be undertaken within a specialist infection outpatient clinic or primary care. Novel models of care such as advanced clinical practitioner (ACP) or physician associate led services are also evolving in the UK.

Whilst the exact approach deployed should not be prescriptive, and will depend on various local factors including the availability of human resources and infection expertise, the principles of complex oral antibiotic monitoring remains the same regardless of the healthcare professionals leading it.

Please note that the monitoring of some complex antimicrobial regimens, such those used in the management of HIV, hepatitis and tuberculosis, remains within the respective sub-speciality outpatient clinics and is not referred to in this module.