Assessing the switch from IV to oral in OPAT services

One of the major challenges of OPAT is to avoid the unnecessary prolongation of IV therapy because it is easy to do so.

It is therefore important that the timing of the IV to oral switch is regularly critically appraised whilst the patient is being treated and, ideally, that data are collected relating to this process.

The most obvious time to do this in real-time is at the weekly OPAT/COPAT MDT meeting. Additionally, if resources allow, data should be collated and presented in the yearly OPAT report and other report(s) (see resource in the downloads section below).

A suggested minimal data-set relating to the audit of IV to oral switch is provided below, although collecting all of this data may not be realistic for some services. Some of these data are likely to be collected for the clinical governance of OPAT and/or COPAT so limited additional data collection may be required:

• Age

• Sex

• Diagnosis

• Positive microbiology (including resistances)

• Allergies

• Comorbidities that impact oral antibiotic prescribing (e.g. epilepsy and fluoroquinolones)

• Medications that impact oral antibiotic prescribing (e.g. warfarin)

• Creatinine clearance (at the start of oral therapy to ensure dosing was correct and at the end to ensure deterioration because of therapy has not occurred)

• IV agent switched from

• Oral agent switched to (oral switch agent/regimen should be the narrowest-spectrum, safe and effective agent/regimen accounting for positive microbiology, the infection being treated, allergies, comorbidities and potential drug-drug interactions)

• Number of days of IV therapy, stratified by infection, versus guidance (i.e. one would expect most patients to receive no more than 2 weeks of IV therapy for native septic arthritis prior to switching to oral)

• Number of days of oral antibiotics prescribed versus guidance (i.e. is the length of oral therapy prescribed adherent with guidelines for the management of that infection (e.g. one would expect most patients with native septic arthritis to receive no more than 6 weeks of therapy in total of which up to 2 weeks (traditionally) would be IV and 4 weeks oral)

• Reasons for prolongation of IV/oral therapy if this has occurred

• Was an appropriate level of monitoring organised given the oral antibiotic(s) prescribed?

• Adverse effects that required cessation of oral therapy prior to the end of planned course

• Serious adverse effects that occurred after stopping oral therapy (e.g. Clostridium difficile infection)

• Clinical outcome at time of switch and at end of oral therapy (e.g. improved, no change, worse, died (and cause) compared to onset)

• Readmission to hospital within 90 days of switch (and was this related to the treated infection or an adverse effect of oral therapy)

• Recrudescence of the treated infection within 90 days of switch (longer follow-up may be required for infections such as chronic osteomyelitis and prosthetic joint infections that may recrudesce later than 90 days)