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Creating a plan

Creating care plans.
Hello. My name is Andrew Seaton. I’m an Infectious Disease Physician in Glasgow, and I am the clinical lead for outpatient parenteral 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 were short-term patients with skin and soft tissue infection and 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 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 hospital admission if at all possible. But this should never be done when there are alternative therapies, such as oral antibiotic therapy, available.
But going on to speak about the specific roles of the infection specialist and the management of patients of 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 non-infectious and no therapy at all is required? So that’s the first gatekeeping function of the infection specialist, to ensure the service 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 parenteral 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 aren’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 multidisciplinary team with antimicrobial 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 hepatotoxicity, 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 our patients who attend OPAT will also be seeing other specialists, and we have to keep abreast of other specialists’ views in their treatment.
So there’s a constant dialogue and communication between the referring specialists and ourselves, and particularly with the 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. The other aspect of an infection specialist’s role in the OPAT service, of course, is organisational, and that’s about designing pathways of care, designing treatment guidelines, and working within the team, again particularly anti-microbial pharmacists and microbiology colleagues, to ensure that we’re selecting the right kind of antibiotics for the right condition. So there’s all that going on.
We’ve developed specific pathways of care, like a patient group direction, which enables us to allow our specialist nurses to go through the clinical decision making in certain infections, like cellulitis. But this is also applicable to other conditions. Also, we’re very much involved as the infection specialists in monitoring outcomes. It’s critical that you have good governance around your service and, again, working in the team to assess risks of line-related infections and other antibiotic-related effects, as well as looking at patient outcomes and those factors that are associated with poor outcomes and that will lead us to modify our service design. And then finally, really, an OPAT service– I mentioned the treatment in our patients is dynamic. Service development is also dynamic.
And we’re always looking at new opportunities and new clinical areas where there are patients who previously may have been neglected and have not been given the opportunity to come onto the programme, but who might benefit. So looking for future patient populations that could benefit from the service.

What things might you consider when devising an OPAT plan?

The stewardship principle of the right drug, for the right condition, for the right duration and right route should always be considered when creating an OPAT plan.

Factors which will influence this plan include:

  • The patient’s clinical and social picture.

  • Previous and current microbiology including antibiograms: a list of antibiotics that have been tested in the laboratory against the organism that is causing the infection. A pathogen is either ‘sensitive/susceptible’ or ‘resistant’. Antibiograms are used as a guide by clinicians to decide which antibiotics to administer to a patient.

  • Radiological imaging as appropriate.

  • Need for surgical intervention / source control as appropriate.

  • Laboratory markers and antimicrobial therapeutic monitoring.

  • Tolerability and effectiveness of the patient’s antimicrobial regimen.

  • Opportunities for intravenous to oral switching.

  • Specialist review and plan (outside of the OPAT team).

Review the video with Dr Andrew Seaton who outlines his role in the OPAT team and share your thoughts with others by posting in the comments below.

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OPAT: Outpatient Parenteral Antimicrobial Therapy

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