Infectious diseases physician

Hello, my name is Andrew Seaton. I’m an infectious disease physician in Glasgow, and I am the clinical lead for our Outpatient Parental Antibiotic Therapy service. I was involved in setting the service up in about 2001. When we initially set up the service, there were two main patient groups that we focused on. The first was short term patients with skin and soft tissue infection in whom we would review on a daily basis to optimise IV to oral switch. And the second group of patients were patients with bone and joint infections. These were patients that tended to require longer courses of intravenous therapy.

Since that time, and once we had established our clinical practice in managing these two patient groups, we’ve expanded to deal with perhaps more complex patients with intra-abdominal infections with endocarditis and various other things including multi-drug resistant and gram negative infections. The key principle in all our patient interactions is really to identify patients who can be treated at home with intravenous therapy, but who otherwise would require inpatient management for their infection. The key thing is to reduce the length of stay or to avoid a hospital admission if at all possible. But they should never be done when there are alternative therapies such as oral antibiotic therapy available.

I’m going to speak about specific roles of the infection specialist and the management of patients in an OPAT service. First of all, it’s very important about assessing the patient, assessing their suitability. From a medical point of view, have they got an infection that’s amenable to intravenous therapy? Is it an infection that could potentially be treated with oral therapy? Or do the colleagues who have referred the patient– have they considered other diagnoses, which are not infectious, and no therapy at all is required? So that’s the first sort of gate keeping function of the infection specialist to ensure the services is properly used.

The second thing is to assess the other medical issues to see if there are any medical issues that would preclude the use of Outpatient Parental Antibiotic Therapy. So it might be uncontrolled diabetes, uncontrolled heart failure, or other things. We also think about other social issues or psychological issues that might preclude people coming onto the service. So this is all part of the assessment which we do very much in conjunction with our specialist nurse. Thereafter, the severity of the infection– it’s very important to know that this is an infection that is not so severe, that it would be dangerous to discharge them from hospital.

But we have to have a good understanding of the likely clinical progress with IV therapy and that there weren’t any other requirements related to the infection that would require hospitalisation. Once we’ve made that decision, it’s a dynamic process so patients will not necessarily stay on intravenous therapy for the entire duration. We’ll be assessing them regularly, daily if it’s a skin and soft tissue infection through our specialist nurses to see if we can optimise switch to oral therapy, or weekly with other deeper seated more complex infections. But all the time thinking about whether we can switch from IV to oral therapy. We’re very much part of the multi-disciplinary team with anti-microbial pharmacists and the specialist nurse practitioner.

And we meet once a week in a programmed way to discuss the progress and response to therapy of all our patients that are on the programme at the time. So this includes reviewing biochemical results to make sure there’s no acute kidney injury developing, liver function tests to ensure that they’re not developing any hepato- toxicity, and haematological monitoring. And all of these are very relevant and perhaps sometimes specific to individual antibiotics that we use. We’re also cognisant that there our patients who attend OPAT will also be seeing other specialists, and we have to keep abreast of other specialist views in their treatment. So there’s a constant dialogue and communication between the referring specialist and ourselves, and particularly with infection specialist.

And part of that review in the multi-discipline team meeting is to take that on board and also think about investigations, radiology, and other special tests– for instance, doing ECGs or echocardiograms– as required.