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Perspectives of Patients on Outpatient Parenteral Antimicrobial Therapy: Experiences and Adherence

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Introduction Non-adherence to medication is a burden to the US healthcare system and is associated with poor clinical outcomes. Data on outpatient parenteral antimicrobial therapy (OPAT) treatment plan adherence are lacking. The purpose of this study is to determine the rate of non-adherence and factors associated with it. Methods We surveyed patients discharged from a tertiary hospital on OPAT between February and August 2019 about their baseline characteristics, OPAT regimen, adherence, and experience with OPAT. Results Sixty-five patients responded to the survey. Median age was 62 years, and 56% were male. The rate of reported non-adherence to intravenous (IV) antibiotics was 10%. Factors associated with non-adherence to IV antibiotics included younger age, household income of <$20,000, and lack of time for administering IV antibiotics (30 vs. 64 years, P<0.01; 83% vs. 20%, P<0.01; and 33% vs. 4%, P=0.04; in non-adherent vs. adherent groups, respectively). While less frequent administration (once or twice daily) and having friend or family support during IV antibiotic administration were associated with better adherence (17% vs. 76%, P<0.01; and 17% vs. 66%, P=0.03; in non-adherent vs. adherent groups, respectively). Most patients attended their infectious diseases clinic visits (n=44, 71%), and the most commonly cited reasons for missing an appointment were lacking transportation (n=12, 60%), not feeling well (n=8, 40%), and being unaware of the appointment (n=6, 30%). Conclusion Less frequent antibiotic dosing and better social support were associated with improved adherence to OPAT. In contrast, younger age, lower income, and lack of time were associated with non-adherence.
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Perspectives of Patients on Outpatient Parenteral Antimicrobial Therapy: Experiences and
Adherence
Yasir Hamad1, Sai Dodda2, Allison Frank3, Joe Beggs4, Christopher Sleckman4, Glen
Kleinschmidt4, Michael A Lane1,5, Yvonne Burnett1,2.
1 Department of Internal Medicine, Washington University in St. Louis School of Medicine, St.
Louis, MO
2 St. Louis College of Pharmacy, St. Louis, MO
3 Department of Occupational Therapy, Washington University in St Louis School of Medicine,
St. Louis, MO
4 Department of Biomedical Engineering, Washington University in St. Louis, St. Louis, MO
5 Center for Clinical Excellence, BJC HealthCare, St. Louis, MO
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Corresponding Author & Requests for Reprints:
Yasir Hamad, MD
yhamad@wustl.edu
Campus Box 8051, 4523 Clayton Ave. St. Louis, MO 63110
Division of Infectious Diseases
Washington University School of Medicine
Tel: 314-237-1453
Fax: 314-454-8687
Keywords: OPAT, Adherence, no-show, Compliance, social support
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Abstract
Introduction: Non-adherence to medication is a burden to the US healthcare system and is
associated with poor clinical outcomes. Data on outpatient parenteral antimicrobial therapy
(OPAT) treatment plan adherence are lacking. The purpose of this study is to determine the
rate of non-adherence and factors associated with it.
Methods: We surveyed patients discharged from a tertiary hospital on OPAT between February
and August 2019 about their baseline characteristics, OPAT regimen, adherence, and
experience with OPAT.
Results: Sixty-five patients responded to the survey. Median age was 62 years, and 56% were
male. The rate of reported non-adherence to intravenous (IV) antibiotics was 10%. Factors
associated with non-adherence to IV antibiotics included younger age, household income of
<$20,000, and lack of time for administering IV antibiotics (30 vs. 64 years, P<0.01; 83% vs. 20%,
P<0.01; and 33% vs. 4%, P=0.04; in non-adherent vs. adherent groups, respectively). While less
frequent administration (once or twice daily) and having friend or family support during IV
antibiotic administration were associated with better adherence (17% vs. 76%, P<0.01; and 17%
vs. 66%, P=0.03; in non-adherent vs. adherent groups, respectively). Most patients attended
their infectious diseases clinic visits (n=44, 71%), and the most commonly cited reasons for
missing an appointment were lacking transportation (n=12, 60%), not feeling well (n=8, 40%),
and being unaware of the appointment (n=6, 30%).
Conclusion: Less frequent antibiotic dosing and better social support were associated with
improved adherence to OPAT. In contrast, younger age, lower income, and lack of time were
associated with non-adherence.
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INTRODUCTION
Outpatient parenteral antimicrobial therapy (OPAT) is an effective modality for treating
patients with serious infectious diseases (ID) outside of a hospital setting [1, 2]. By allowing
patients to receive treatment at home, OPAT avoids expenses associated with prolonged
hospital stays, reduces exposure to nosocomial pathogens, and allows patients to maintain a
normal lifestyle [3]. OPAT is generally considered safe, but requires close monitoring for
therapy-related complications and treatment failure [4]. Past studies have shown readmission
rates for OPAT patients range from 6-26% [5-7]. These readmissions can result from worsening
infection, line complications, or comorbidities [5-7].
Medication non-adherence is a burden to the US healthcare system, leading to higher
healthcare costs and worse patient outcomes. The annual cost of medication non-adherence in
the US is estimated to be $300 billion [8, 9]. Non-adherence to oral antibiotics has been linked
to poor clinical outcomes such as infection relapses, need for new antibiotics, and additional
medical procedures [10]. Factors that are associated with non-adherence to oral antibiotics
include prescription of multiple antibiotics and changing healthcare providers for outpatient
care [10]. In another study, increased dosing frequency negatively impacted oral antibiotic
adherence rates [11]. Antibiotics taken once, twice, or three times daily had adherence rates of
80%, 69%, and 38%, respectively [11]. Reasons for missing scheduled oral doses include being
away from home, asleep, or simply forgetting [10]. However, there is a lack of literature on the
rates and predictors of non-adherence in OPAT.
Infectious Diseases Society of America recommends close clinical follow-up for OPAT
patients [12]. Thus, patients’ adherence to office visits is a vital component of OPAT care. A
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recent study showed that attendance at follow-up OPAT clinic visits was associated with a
lower readmission rate compared to those who had no follow-up visit [13]. Adherence to OPAT
follow-up appointments has been reported as high, but factors such as transportation, illness,
and work commitments impede some patients from attending their scheduled appointments
[14].
This study aims to quantify the rate of non-adherence among OPAT users and
understand the reasons leading to “no-show” appointments. We conducted a survey to gather
detailed information about patient identified factors related to non-adherence.
METHODS
Instrument
The survey was developed in collaboration with an ID physician and ID pharmacist. This
survey contained 21 multiple choice or Likert-style items and two free-text items allowing
respondents to provide additional comments. The survey was piloted with a group of content
experts, and questions were modified based on their feedback. The survey recorded the
respondents’ demographic, experience and adherence with OPAT, communication with
healthcare providers, and barriers to receiving optimal OPAT care (Appendix).
Study Population and Distribution
The Infectious Diseases Clinic at Washington University in St. Louis School of Medicine
monitors patients who are discharged from Barnes-Jewish Hospital on OPAT following inpatient
care. The OPAT program follows 1,500 patients annually. About one third of the patients are
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discharged to post-acute care facilities while the rest are discharged home with home health
and outpatient infusion centers. The majority of the patients (50%) discharged home on OPAT
are cared for by BJC home care services, while the rest are covered by multiple different home
health care agencies such as Coram and Option Care. Only patients who were discharged home
were asked to participate in the survey. Patients discharged on OPAT are scheduled to follow
up with an infectious diseases provider in 2 weeks. The appointment is usually scheduled prior
to hospital discharge and the instructions are printed and handed to the patient upon hospital
discharge. For the small number of patients who are discharged prior to appointment
scheduling, the clinic staff contact the patient to make the appointment for the visit. Patients
receive an automated call from the clinic to remind them about the appointment 3 days prior
to the visit and a text message 2 days prior to the visit. The most common infection category in
our OPAT program is bone and joint infections (40%), followed by blood stream infections
(21%), intra-abdominal infections (11%), and skin and soft tissue infections (8%). The clinic
distributed our surveys to patients returning for their follow-up appointments between
February and August 2019. Patients then placed the confidential, anonymous surveys in a
locked survey box. The survey was also sent via mail to patients’ home addresses on April 29,
2019 and July 22, 2019 to patients who had completed their course within the last 30 days.
Patients were asked to mail the completed survey back to the investigators in an anonymous,
pre-stamped return envelope. The study was approved by the Washington University School of
Medicine Human Research Protection Office and St. Louis College of Pharmacy’s Institutional
Review Board.
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Data Analysis
Categorical data was presented using frequencies. To analyze risk factors associated
with non-adherence we used the Fisher Exact test for categorical variables, and Mann-Whitney
U test for continuous variables. For multiple choice questions we analyzed the responses based
on the percentage of patients who answered “Agree” or “Strongly Agree” as opposed to other
answers. Differences were considered statistically significant if P<0.05. All quantitative analyses
were performed using SAS 9.4 software (Cary, NC).
We also analyzed qualitative data. Participants were asked to answer the free-test
responses: “Explain the barriers you encounter to taking your IV antibiotics as prescribed” and
“Please use the space below to share any additional information about your experience taking
IV antibiotics or to elaborate on a question listed above.Three authors (S.D., C.S., and Y.H.)
systematically read responses and independently categorized them. Disagreements were
resolved by discussion between the team members. Percentages of respondents that answered
each item and illustrative quotes are presented.
RESULTS
A total of 174 surveys were mailed to adult OPAT patients. Twenty-seven (16%)
participants responded and completed the survey. Additionally, 38 participants completed
surveys in the clinic during the study period, resulting in a total of 65 survey responses.
Respondents’ median age was 62 years (IQR 53-69), and 56% were male. Sixteen respondents
(27%) had an annual income below $20,000, and 19 (33%) were unemployed. Almost half of the
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respondents had to pay a copayment or coinsurance in order to receive IV antibiotics n=30
(49%). Thirty-five (55%) respondents received only one IV antibiotic, 17 (27%) received two, and
12 (19%) received at least three. Most respondents received intravenous antibiotics either once
or two times per day (24 [38%], or 19 [30%], respectively). Thirty-four respondents (55%) spent
at least an hour administering their antibiotics, including 14 (23%) who spent two hours per day
(Table 1).
Most respondents (90%) reported strict adherence to IV antibiotics, while 6 (10%)
reported missing 1-2 doses per week. Thirty-seven respondents (60%) reported having no
reminder system in place, while 28 (45%) reported using an alarm, chart, or reminder from
someone. Thirty-nine respondents (62%) had a family member or friend help them administer
IV antibiotics, and 18 (29%) reported administering IV antibiotics independently (Table 1).
Respondents contacted a variety of healthcare resources when they had questions about their
IV antibiotic therapy including home health service (n=47, 75%), pharmacist (n=22, 35%) or
primary physician (n=21, 33%). Most respondents (n=44, 71%) were compliant with ID doctor
appointments. Reasons for missed clinic appointments were mostly due to lack of
transportation in 12 (60%), not feeling well in 8 (40%), and being unaware of the appointment
in 6 (30%) responses. In the subset of respondents who answered the survey by mail, 18 (62%)
reported adherence to clinic visits. Among the 11 mail-in respondents who reported missing a
clinic visit, the most common reasons were not feeling well in 7 (63%) and lack of
transportation in 4 (36%) responses.
Seventeen respondents (27%) felt they spent too much time administering antibiotics.
Only 4 (6%) said they did not have enough time to administer the prescribed antibiotics.
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Twenty-one respondents (34%) reported not knowing the side effects of their medication, while
6 respondents (10%) reported having a serious side effect from the antibiotics (Tables 1-2).
Factors that were associated with medication non-adherence included younger age,
household income of <$20,000, and not having enough time for IV antibiotics administration
(30 vs. 64 years, P<0.01; 83% vs. 20%, P<0.01; and 33% vs. 4%, P=0.04, in non-adherent vs.
adherent groups, respectively). While less frequent administration and having friend or family
support during IV antibiotics administration were associated with lower risk of non-adherence
(17% vs. 76%, P<0.01 and 17% vs. 66%, P=0.03, in non-adherent vs. adherent groups,
respectively). Lack of knowledge about side effects and medication reminders were not found
to be associated with non-adherence (Table 3).
A total of 24 patients provided free text responses about barriers to receipt of IV
antibiotics (Table 4). Common barriers included difficulties in the administration of antibiotics
by the patient (n=5, 20.8%), central line related issues (n=5, 20.8%), extensive time needed to
administer IV antibiotics (n=4, 16.7%), challenges with going to doctor’s appointments while on
IV antibiotics (n=3, 12.5%), medication side effects (n=2, 8.3%), and limitations in social
activities (n=1, 4.2%).
Furthermore, 24 respondents provided additional free text responses about their overall
experience on OPAT. The most common themes included were about experiencing side effects
(n=7, 29.2%) and having a great experience with OPAT (n=5, 20.8%), whereas 2 patients (8.3%)
commented about the financial cost of OPAT. As one respondent explained, “Out of pocket
costs [were] too high. [I am] Still paying on the $4,000 bill.” One respondent discussed being
frustrated about not receiving the results of the weekly lab draws. Despite the reported
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challenges with OPAT, 20.8% of participants providing free text responses felt the use of OPAT
was easy and satisfying. As one respondent stated, “Very easy. Anyone can do it.” (Table 5).
DISCUSSION
This study examines patient-reported rates of non-adherence with OPAT and identified
factors associated with non-adherence. Overall, patients self-reported relatively high rates of
adherence to therapy with 90% of respondents reporting no missed doses in an average week.
OPAT medication non-adherence was found to be disproportionately associated among people
who are young, low-income, self-reportedly busy, and without social support. Non-adherence
to clinical follow-ups was more common as 29% reported missing an ID appointment. The most
common reason leading to “no-show” appointments at the ID clinic was lack of transportation.
This study supports a strong positive correlation between medication adherence and
age. The median ages of non-adherent and adherent groups were 30 and 64, respectively. This
may be surprising since the geriatric population is more prone to chronic and recurrent illness
which may require chronic medication with multiple drugs. However, others have also found
that younger adults are more likely to be non-adherent to therapy in various other populations
[15-18]. Therefore, other risk factors such as knowledge of the drug’s purpose, complexity of
the drug regimen, and type of prescriber should be considered when planning OPAT treatment
regimens [19].
Multiple socio-economic factors have been found to affect adherence. Higher rates of
medication non-adherence have been reported in a study assessing low-income, uninsured
patients [20]. Individuals with lower income tend to be younger, which is a known risk factor for
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non-adherence [21]. Social support networks also have an impact on adherence to OPAT. This
study showed that having a friend or family member assist with IV antibiotic administration was
associated with better rates of OPAT adherence. This is consistent with prior studies that have
shown the association between medication adherence and practical social support, which can
be defined as having a family member who helps with medications or transportation [22].
Previous studies have found mixed results for using reminders as an aid to assist with
medication adherence [23, 24]. In our study we did not find an association between reminders
and adherence. This adds to a mixed collection of results in the literature on the efficacy of
reminders across multiple modalities to improve medication adherence. Vervloet et al. found
that text message reminders improve medication adherence to oral medication in Type 2
Diabetes patients who are electronically monitored in real-time [23]. Liu et al. showed that
reminders from medication monitors improved adherence in tuberculosis patients, but text
message reminders did not. In general, many types of interventions have attempted to improve
adherence in diverse treatment regimens, but most have failed. [24].
Our study showed that simpler regimens with once or twice daily dosing were
associated with improved adherence to IV antibiotics. This is consistent with literature that
reports lower rates of adherence with multiple administrations per day [11]. Unlike oral
antibiotics, IV antibiotics require significantly more time to administer. In this survey, 55% of
patients reported spending more than an hour per day to administer the antibiotics, with nearly
a quarter of all patients spending at least two hours per day. Clinicians should keep this in mind
when recommending an OPAT regimen and use simpler regimens when feasible.
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The strengths of this study includes novelty in examining adherence in the OPAT
population, of which data is scarce. The participants spanned different ages and socio-economic
backgrounds allowing us to examine the effects of these factors on adherence. This study
identified OPAT-specific factors that are associated with non-adherence so that clinicians can
identify those at high-risk and address preventable factors to improve adherence.
Despite a small sample size, this is the largest study addressing non-adherence in OPAT.
Response rate to the mail survey was low; however, this could in part be due to the lack of
reminders. Since the responses were anonymized we were not able to compare the
respondents to the non-respondents to see if the two groups were different. However, the fact
that responses came from patients across different age groups and socioeconomic backgrounds
improves the generalizability of the survey results. Additionally, like other studies, the main
limitation of the results presented here is a dependency on subjective self-reporting. These
descriptions may be unreliable for three different reasons: (1) subjects may have forgotten
when and how they took their medication, (2) they may not have been truthful out of the
perceived fear that their answers would affect their continued treatment, or (3) patients who
were unconcerned with their care may not have answered survey questions, whereas patients
concerned about their health did respond (non-responder bias). We addressed each of these
concerns as follows. First, to decrease the likelihood of forgetfulness, surveys were
administered to current patients in the clinic or mailed to patients who recently completed
their OPAT treatment. Second, patients were notified that surveys were anonymous, and
identifying information was removed. Third, while the non-responder bias might have resulted
in a lower response rate from non-adherent patients, we collected enough responses from
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patients who reported non-adherence and were able to identify some risk factors associated
with medication adherence. The outcomes of this study can lead to a more efficient workflow
that improves patient care, medication adherence, and clinic attendance.
CONCLUSION:
While younger age, lower income, and lack of time for IV antibiotic administration were
factors associated with non-adherence, less frequent dosing regimens and having friend or
family support during IV antibiotic administration were protective. Lack of transportation was
also the main risk factor for missing follow-up infectious diseases clinic visits. With information
collected in this survey, we garnered a better understanding of this patient population that will
lead to targeted efforts to improve care for OPAT patients.
TRANSPARENCY DECLARATIONS:
S.D., A.F., J.B., C.S., and G.K. are cofounders of HIVE Medical, a student-run start-up that is
trying to improve medication adherence for OPAT. Y.H., M.A.L, and Y.B. have nothing to
declare.
ACKNOWLEDGEMENT:
This work was supported by a grant from the Sling Health Incubator program, St. Louis MO.
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Table 1: Characteristics and responses of 65 patients who responded to the survey
Characteristics
N (%)
Age Median (IQR)
62 (53-69)
Sex (Female) (58 responses)
26 (44.8%)
Annual Household Income: (59 responses)
<$20,000
16 (27.1%)
$20,000-$50,000
21 (35.6%)
$50,000-$100,000
17 (28.8%)
$100,000+
5 (8.5%)
Employment: (57 responses)
Employed
20 (35.1%)
Unemployed
19 (33.3%)
On disability
18 (31.6%)
Does insurance cover antibiotics cost (61 responses)
All of the cost
30 (49.2%)
Part of the cost
30 (49.2%)
None
1 (1.6%)
How many IV antibiotics prescribed (64 responses)
1
35 (54.7%)
2
17 (26.6%)
3
2 (3.1%)
4 or more
10 (15.9%)
How often do you take IV antibiotics (63 responses)
Once daily
24 (38.1%)
Twice daily
19 (30.2%)
Three times daily
16 (25.4%)
Other
4 (6.3%)
How much time do you spend per day taking IV antibiotics (62 responses)
<30 minutes
12 (19.4%)
30-60 minutes
16 (25.8%)
1-2 hours
20 (32.3%)
2+ hours
14 (22.6%)
How many other medications do you take (63 responses) Median (IQR)
6 (3-10)
Who do you ask if you have questions about IV antibiotics (63 responses)
Home health service
47 (74.6%)
Pharmacy
22 (34.9%)
Primary doctor
21 (33.3%)
Nurse
3 (4.8%)
I wait until next doctor visit
2 (3.2%)
If I miss my doctor’s appointment, it is because: (62 responses)
I have never missed an appointment
44 (71%)
Reasons for missed clinic appointment (20 of 61 responses) responder can
choose more than one choice
I don’t have a ride
12 (60%)
I don’t feel well
8 (40%)
I was unaware of the appointment
6 (30%)
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I don’t have time off work
2 (10%)
I was hospitalized
1 (5%)
How do you remember to take your IV antibiotics (62 responses)
responder can choose more than one choice
I just remember
37 (59.7%)
I have an alarm set up
14 (22.6%)
Someone reminds me
14 (22.6%)
How many doses of IV antibiotics have you missed per week (62 responses)
1-2
6 (9.7%)
3-4
0
>4
0
None
56 (90.3%)
Who administers your IV antibiotics (63 responses)
A family member/ Friend
39 (61.9%)
Self only
18 (28.6%)
A nurse
6 (9.5%)
Abbreviations: IQR: inter-quartile range, IV: Intravenous.
*Respondents were able to select all responses that applied; numbers add to more than 100%
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Table 2: Responses of survey participants to the multiple choice questions
Likert scale questions responses
Agree/Strongly
agree
Neutral
Disagree/Strongly
Disagree
I don’t have enough time to administer my
antibiotics
4 (6.3%)
5 (7.8%)
55 (85.9%)
I don’t know the side effects of my medications
21 (33.9%)
10 (16.1%)
31 (50%)
I spend too much time administering antibiotics
17 (27.4%)
13 (21%)
32 (51.6%)
I do NOT have a consistent way to get my IV
antibiotics.
0
4 (6.5%)
58 (93.5%)
I would like to be able to take my IV antibiotics
outside home
6 (9.8%)
13 (21.3%)
42 (68.9%)
I would be interested in a device that makes it
easier to move around during IV antibiotic
administration
20 (31.7%)
23 (36.5%)
20 (31.7%)
I would be interested in a device that monitors
how I take my IV antibiotics and shares this
information with my doctor
27 (42.9%)
25 (39.7%)
11 (17.5%)
I experience serious side effects from my IV
antibiotics
6 (9.7%)
9 (14.5%)
47 (75.8%)
Abbreviations: IV: Intravenous.
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Table 3: Factors associated with non-adherence with IV antibiotics
Variable
Adherent Patients
(N=56) N(%) or
Median (IQR)
Non-adherent
patients (N=6) N(%)or
Median (IQR)
P value
Age Median
64 (57-69)
30 (19-39)
<0.01
Sex (Female)
23 (46%)
1 (20%)
0.37
Low income (<$20,000)
10 (19.6%)
5 (83.3%)
<0.01
Less frequent administration
(Daily or Twice Daily) for IV
antibiotics
41 (75.9%)
1 (16.7%)
<0.01
Family support in administration
of IV antibiotics
37 (66.1%)
1 (16.7%)
0.03
I spend too much time
administering antibiotics
15 (27.3%)
2 (33.3%)
>0.99
I don’t have enough time to
administer my antibiotics
2 (3.6%)
2 (33.3%)
0.04
I would like to be able to take my
IV antibiotics outside home
5 (9.4%)
1 (16.7%)
0.49
I don’t know the side effects of
my medications
20 (37%)
1 (16.7%)
0.41
Patient having a reminder set up
21 (38.2%)
3 (50%)
0.67
I missed an Infectious Diseases
clinic appointment
16 (29.1%)
4 (66.7%)
0.08
Abbreviations: IV: Intravenous; IQR: Interquartile range
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Table 4: Concerns raised about barriers in OPAT
Complaint
Frequency
(Percentage of 24
who Responded to
Item)
Illustrative quote
Difficulty in administering
IV antibiotics by the
patient
5 (20.8%)
“[I had difficulty in] Making sure everything stays sterile while
using the medicine”
“Cannot push plunger slow enough - too difficult to push in all
the ml's over such a long time doing it manually”
“[I had difficulty] learning how to switch bags. making sure
every 8 hours to take the oral antibiotic”
“My girlfriend had to go in the hospital for 2 days and it was
hard to do but I did them. She called to remind me”
Peripherally inserted
central catheter (PICC)
issues
5 (20.8%)
“PICC line isn't waterproof”
“[I had a] clog in my IV port
“[Had difficulty] changing clothing [while having PICC line in
place]”
Time needed to
administer IV antibiotics
4 (16.7%)
“That it was three times a day and 1.5 hrs each time. Very easily
snagged”
“It takes too long”
Challenges with doctor’s
appointments
3 (12.5%)
“Making appointments around the IV meds”
“The only time I may have an issue is the time of day. I normally
take antibiotic around lunch time everyday unless I'm at Dr.
Appointment which may delay the time of day its administered”
Medications side effects
2 (8.3%)
“I had severe side effects to all the medications I was
prescribed”
Limitation in social
activities
1 (4.2%)
“Not being able to go and socialize while taking them”
Abbreviations: OPAT: Outpatient parenteral antimicrobial therapy; IV: Intravenous
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Table 5: summary of additional comments provided by patients about their experience
Comment
Frequency
(Percentage of 24
who Responded to
Item)
Illustrative quote
Experienced side effects
7 (29.2%)
“Had allergic reaction and had to stop treatment”
“The antibiotic I was taking caused constipation and lowered my
white blood cell count”
“The side effects were terrible! Especially after 2 weeks! I was
happy when it was over. Thanks.”
Did have a good
experience
5 (20.8%)
“I was happy with the ability to us[e] the device provided and I
didn't need an IV pole like in the hospital”
“I like taking at home instead of an outpatient location.
Especially since its daily. Very convenient
“Very easy. Anyone can do it”
Financial cost
2 (8.3%)
“Out of pocket costs [was] too high. [I am] Still paying on the
$4,000 bill”
“I called billing 3x with no return call. I have supplies left that I
did not need. Would like to get credit for those supplies! I did
not”
Abbreviations: IV: Intravenous
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... The management of bone and joint infections has traditionally required possible surgical debridement and long-term IV and oral antibiotics [12,[52][53][54]. Even with prolonged durations of antimicrobial therapy extending 6-8 weeks and surgical debridement, the recurrence rate of chronic osteomyelitis in adults is 30% at 12 months [53]. ...
... Another study looking at adherence to outpatient intravenous antimicrobial therapy sought to determine adherence rates and factors affecting them. The authors found the rate of reported nonadherence was 10% and the factors associated with nonadherence were younger age (30 vs 64 years, P < 0.01), household income of < $20,000, and lack of time for administering IV antibiotics [54]. They also report that less frequent administration, defined as once or twice daily, and family or friend support were associated with better adherence. ...
Article
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Purpose of Review The standard of care for serious Gram-positive bacterial infections, such as osteomyelitis and infective endocarditis, has traditionally required prolonged durations of intravenous antibiotics. Recent literature has suggested that oral antibiotics are non-inferior in certain patient populations. Despite these advancements, there are still patients with practical implications that render oral antimicrobial therapy unappealing, including history of medication non-adherence or lack of a suitable oral option given organism isolation. As a result, long acting lipoglycopeptides (dalbavancin and oritavancin) are an attractive alternative therapy to mitigate these concerns. The purpose of this focused review is to summarize the use of these antibiotic therapies for off-label indications and their associated clinical outcomes. Recent Findings Here, we discuss the pharmacokinetics and pharmacodynamics, published literature evaluating the treatment of bone and joint infections and infective endocarditis, and clinical utility of dalbavancin and oritavancin. Summary Long-acting lipoglycopeptides have been evaluated as primary and secondary treatments of serious Gram-positive infections. Providers may be motivated to prescribe these agents more often based on unfavorable patient-specific characteristics and to facilitate early hospital discharge. Careful clinical consideration is warranted to optimize treatment success and limit inappropriate use of these novel medications.
... These programs enable clinically stable patients to receive optimal antimicrobial treatment after hospital discharge [1]. There are two modalities of OPAT programs, one of which involves the administration of the antimicrobial in the patient's home and the other at an infectious disease outpatient center [2]. OPAT programs provide several advantages, such as the improvement of the quality of life of patients, allowing them to continue with their daily routine at home despite receiving intravenous antibiotics. ...
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Outpatient parenteral antimicrobial therapy (OPAThttp) programs have become an important healthcare tool around the world. Portable elastomeric infusion pumps are functional devices for ambulatory delivery of antimicrobial drugs, and their stability is an essential point to guarantee an appropriate infusion administration. We conducted a systematic review to provide a synthesis and a critical evaluation of the current evidence regarding antimicrobial stability in elastomeric pumps. Data sources were PubMed, EMBASE, and Web of Sciences. The review protocol was registered on the Center for Open Science, and it was carried out following the PRISMA guidelines. Studies were eligible if the aim was the evaluation of the physicochemical stability of an antimicrobial agent stored in an elastomeric device. Of the 613 papers identified, 33 met the inclusion criteria. The most studied group of antimicrobials was penicillins, followed by cephalosporins and carbapenems. In general, the stability results of the antimicrobials that have been studied in more than one article agree with each other, with the exception of ampicillin, flucloxacillin, and ceftazidime. The antibiotics that displayed a longer stability were glycopeptides and clindamycin. Regarding the stability of antifungals and antivirals, only caspofungin, voriconazole, and ganciclovir have been investigated. The information provided in this article should be considered in patient treatments within the OPAT setting. Further stability studies are needed to confirm the appropriate use of the antimicrobials included in this program to ensure optimal patient outcomes.
... Infectious Disease physicians saw all included patients and hence there is some degree of homogeneity in work up, management and treatment duration of these patients. In a recent survey of OPAT patients at our institution, receiving a simpler regimen once or twice daily was significantly associated with A c c e p t e d M a n u s c r i p t 15 better adherence when compared with more frequent dosing regimens (76% vs 17% of adherent and non-adherent groups respectively, P 0.01) [24]. Thus, patients are more likely to adhere to ceftriaxone as compared to more frequent dosing regimens of oxacillin or cefazolin. ...
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Introduction Staphylococcus aureus blood stream infections (BSI) are associated with significant morbidity and mortality. Ceftriaxone is convenient for outpatient parenteral antimicrobial therapy (OPAT), but data for this indication are limited. Methods Adult patients with MSSA BSI discharged on OPAT with cefazolin, oxacillin, or ceftriaxone for at least 7 days were included. We compared outcomes of ceftriaxone vs either oxacillin or cefazolin. Ninety-day all-cause mortality, readmission due to MSSA infection, and microbiological failure were examined as a composite outcome and compared among groups. Rates of antibiotic switches due to intolerance were assessed. Results Of 243 patients included, 148 (61%) were discharged on ceftriaxone and 95 (39%) were discharged on either oxacillin or cefazolin. The ceftriaxone group had lower rates of ICU care, endocarditis, and shorter duration of bacteremia, but higher rates of cancer diagnoses. There was no significant difference in the composite adverse outcome in the oxacillin or cefazolin group vs the ceftriaxone group [18 (19%) vs 31 (21%), P 0.70] comprising microbiological failure [6 (6.3%) vs 9 (6.1%), P 0.94], 90-day all-cause mortality [7 (7.4%) vs 15 (10.1%), P 0.46] or readmission due to MSSA infection [10 (10.5%) vs 13 (8.8 %), P 0.65]. Antibiotic intolerance necessitating a change was similar between the two groups [4 (4.2%) vs 6 (4.1%), P 0.95]. Conclusion For patients with MSSA BSI discharged on OPAT, within the limitations of the small numbers and retrospective design we did not find a significant difference in outcomes for ceftriaxone therapy when compared to oxacillin or cefazolin therapy
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Background Outpatient parenteral antibiotic therapy (OPAT) is a safe and effective care delivery system that allows patients to receive intravenous (IV) antibiotic therapy outside of the hospital. OPAT patients require frequent follow-up appointments for clinical and laboratory monitoring of common adverse outcomes of any IV antibiotic administration such as line infections, adverse drug events, and reinfection. Despite the known importance of clinical monitoring, patient factors that influence adherence to OPAT appointments are unknown. The objective of this study was to identify factors that influence adherence to OPAT appointments, in order to improve the OPAT program and make adherence easier for patients if possible. Methods 80 patients undergoing OPAT between December 2014 and January 2016 were interviewed via telephone regarding the following: reasons for not showing up to appointments, when the first follow up appointment was scheduled, whether they received appointment reminders, transit time, and whether they had to make special arrangements to attend their appointments. Results Adherence to follow-up appointments was high (83.8%). 52.5% of initial follow-up appointments were made while patients were still in the hospital. 92% of patients received at least one reminder in the form of a letter (32%), call to cell phone (21%), call to landline (22%), email (17%), or other (1%). Participants mostly cited either transportation (23.4%) or other (30.4%), specifically not feeling well, and work as the reason for missing an appointment. Conclusion The majority of patients attended all appointments, and of those, almost all received an appointment reminder, suggesting this is an important factor contributing to appointment adherence. These data reveal some of the barriers some patients face. Future studies can examine whether decreased appointment adherence leads to worse clinical outcomes. Figure 1 View large Download slide Transportation and other were the most cited reasons for missing appointments. Figure 1 View large Download slide Transportation and other were the most cited reasons for missing appointments. Figure 2 View large Download slide The majority of participants received a reminder for an upcoming appointment in the form of a letter. Figure 2 View large Download slide The majority of participants received a reminder for an upcoming appointment in the form of a letter. Figure 3 View large Download slide The majority of initial follow-up appointments were scheduled while patients were in the hospital. Figure 3 View large Download slide The majority of initial follow-up appointments were scheduled while patients were in the hospital. Disclosures G. Allison, Merck: Grant Investigator and Speaker’s Bureau, Grant recipient and Salary
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Background Outpatient parenteral antibiotic therapy (OPAT) is a safe and effective modality for treating serious infections. This study was undertaken to define the value of OPAT in a multicentered infectious disease (ID) private practice setting. Methods Over a period of 32 months, 6120 patients were treated using 19 outpatient ID offices in 6 states. Analysis included patient demographics, indications of OPAT, diagnoses, therapeutic agent, duration of therapy, and site of therapy initiation. Outcomes were stratified by therapeutic success, clinical relapse, therapeutic complications, and hospitalizations after initiating therapy. Statistical analysis included an ordinal logistic regression analysis. Results Forty-three percent of patients initiated therapy in an outpatient office, and 57% began therapy in a hospital. Most common diagnoses treated were bone and joint (32.2%), abscesses (18.8%), cellulitis (18.5%), and urinary tract infection (10.8%). Ninety-four percent of patients were successfully treated, and only 3% were hospitalized after beginning therapy. Most common cause of treatment failure was a relapse of primary infection (60%), progression of primary infection (21%), and therapeutic complication (19%). Conclusions An ID-supervised OPAT program is safe, efficient, and clinically effective. By maximizing the delivery of outpatient care, OPAT provides a tangible value to hospitals, payers, and patients. This program is a distinctive competency available to ID physicians who offer this service to patients.
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β-Lactam antibiotics are commonly used in outpatient parenteral antimicrobial therapy (OPAT), but data regarding outcomes of long-term therapy are limited. The purpose of this study was to compare treatment success, readmission and antibiotic switch rates in patients treated with β-lactam antibiotics as OPAT. We carried out a retrospective review of all patients, discharged from Tufts Medical Center with cefazolin, ceftriaxone, ertapenem or oxacillin, between January 2009 and June 2013. A competing risks analysis was used to compare the cumulative incidence of first occurrence of treatment success, antibiotic switch and 30 day readmission for each drug. Four hundred patients were identified (cefazolin n = 38, ceftriaxone n = 104, ertapenem n = 128 and oxacillin n = 130). Baseline demographics were similar. Treatment success rates were higher for ceftriaxone and ertapenem (cefazolin 61%, ceftriaxone 81%, ertapenem 73% and oxacillin 58%; P < 0.001). Thirty-day all-cause readmissions were similar (cefazolin 21%, ceftriaxone 14%, ertapenem 20% and oxacillin 15%; P = 0.46). In 400 OPAT courses, 37 out of 50 antibiotic switches were accomplished without readmission. Adverse drug events (ADEs) were the most common reason for outpatient antibiotic switches (31/37, 84%). The ADE rate was higher for the oxacillin group (cefazolin 2.0 versus ceftriaxone 1.5 versus ertapenem 2.9 versus oxacillin 8.4 per 1000 OPAT days; P < 0.001). OPAT with β-lactam antibiotics is effective, but antibiotic switches for adverse events were more frequent with oxacillin use. Clinicians should be cognizant of the risk of readmissions and ADEs in OPAT patients, as the value of OPAT lies in reducing patient morbidity and readmissions by managing ADEs and preventing clinical failures. © The Author 2015. Published by Oxford University Press on behalf of the British Society for Antimicrobial Chemotherapy. All rights reserved. For Permissions, please e-mail: journals.permissions@oup.com.
Article
Background: Outpatient parenteral antimicrobial therapy (OPAT) programs allow patients to receive intravenous treatment in the outpatient setting. We developed a predictive model of thirty-day readmission among hospitalized patients discharged on OPAT from two academic medical centers with a dedicated OPAT clinic for management. Methods: A retrospective chart review was performed and logistic regression was used to assess OPAT and other outpatient clinic follow-up in conjunction with age, sex, pathogen, diagnosis, discharge medication, planned length of therapy, and Charlson comorbidity score. We hypothesized that at least one follow-up visit at the Emory OPAT clinic would reduce the risk for hospital readmission within 30 days. Results: Among 755 patients, 137 (18%) were readmitted within 30 days. Most patients (73%) received outpatient follow-up care at Emory Healthcare within 30 days of discharge or prior to readmission, including 52% of patients visiting the OPAT clinic. The multivariate logistic regression model indicated that a follow-up OPAT clinic visit was associated with lower readmission compared to those who had no follow-up visit (OR 0.10, 95% CI 0.06-0.17) after adjusting for infection with enterococci, Charlson score, discharge location, and county of residence. Conclusion: These results can inform potential interventions to prevent readmissions through OPAT clinic follow-up and to further assess factors associated with successful care transitions from the inpatient to outpatient setting.
Article
Background: Poor adherence to long-term therapies is a public health concern that affects all populations. Little is known about the context of adherence in chronic diseases for the uninsured population in the United States. Objective: To evaluate medication adherence and barriers among low-income, uninsured adults recently initiating new therapy for a chronic disease. Methods: A cross-sectional study in two Community Health Centers located in Chatham County, Georgia, was performed between September and December 2015. Patients, randomly selected for inclusion in the study, were eligible if they had been prescribed medication for 2 or more chronic conditions and had recently started a new medication regimen. The Morisky-Green-Levine questionnaire was used to assess adherence. Potential barriers were analyzed using the Multidimensional Model proposed by the World Health Organization-social and economic, healthcare team and system-related, condition-related, therapy-related, and patient-related factors. Multivariate logistic regression models were used to analyze factors associated with non-adherence. Results: A total of 150 participants were interviewed at 6 months after treatment initiation. Non-adherence was reported by 52% of the participants. Higher adjusted odds of non-adherence were observed in participants who did not receive information about their medications (adjusted odds ratio [AOR] = 2.40, 95% confidence interval [CI] = 1.01-5.74), did not regularly visit a primary health-care provider (AOR = 2.74, 95% CI = 1.09-6.88), and had changes in their treatment (AOR = 3.75, 95% CI = 1.62-8.70). Alternatively, adjusted odds of non-adherence were lower for patients who reported using pillboxes (AOR = 0.31, 95% CI = 0.10-0.95), having help from a caregiver (AOR = 0.15, 95% CI = 0.04-0.60), and integrating medication dosing into daily routines (AOR = 0.18, 95% CI = 0.06-0.59). Conclusions: Medication non-adherence was common among low-income, uninsured patients initiating therapy for chronic conditions. Several modifiable barriers highlight opportunities to address medication non-adherence through multidisciplinary interventions.
Article
Study objective: Outpatient parenteral antimicrobial therapy (OPAT) is increasingly used and unfortunately, readmissions during OPAT are common. The purpose of this study was to identify predictors of hospital readmission among patients receiving OPAT. Design: Retrospective cohort study. Setting: Large, academic, tertiary-care hospital. Patients: A total of 216 adults who were discharged and received OPAT through a peripherally inserted central catheter for at least 2 days for treatment of an active infection, excluding patients with cystic fibrosis, between January 2012 and August 2013; of these patients, 43 had hospital readmissions and 173 did not. Measurements and main results: The median age of all study patients was 56 years. Common infections included bone and joint (32%), genital/urinary tract (16%), endocarditis (14%), central nervous system (9.7%), and pneumonia (9.7%). For the 43 patients (20%) who had readmissions, reasons for readmission were infection recurrence or progression (33%), adverse drug reactions (24%), central catheter-associated issues (16%), or non-OPAT-related reasons (27%). In the multivariate analysis, patients assigned to a primary care physician were less likely to be readmitted (odds ratio [OR] 0.286, 95% confidence interval [CI] 0.115-0.711), whereas factors independently associated with an increased readmission rate included previous hospital admission in the past 12 months (OR 2.588, 95% CI 1.159-5.778), medical history of malignant lymphoma (OR 25.172, 95% CI 2.311-272.209), and increased planned OPAT duration (OR 1.058, 95% CI 1.034-1.082). Conclusion: Readmissions while patients received OPAT were common. Therefore, proactive interventions including primary care physician assignment to facilitate follow-up and communication should be implemented to decrease the risk of readmission, particularly in the identified high-risk populations. This article is protected by copyright. All rights reserved.
Article
Skin and soft tissue infections (SSTIs) are common and frequently recur. Poor adherence to antibiotic therapy may lead to suboptimal clinical outcomes. However, adherence to oral antibiotic therapy for SSTIs and its relationship to clinical outcomes have not been examined. We enrolled adult patients hospitalized with uncomplicated SSTIs caused by S. aureus being discharged with oral antibiotics to complete therapy. We fit participants' pill bottle with an electronic bottle cap that recorded each pill bottle opening, administered an in-person standardized questionnaire at enrollment, 14 days, and 30 days, and reviewed participants' medical records to determine outcomes. Our primary outcomes was poor clinical response, defined as change in antibiotic therapy, new incision and drainage procedure, or a new skin infection within 30 days of hospital discharge. Of our 188 participants, 87 had complete data available for analysis. Among these participants, 40 (46%) had a poor clinical response to at 30 days. Mean electronically-measured adherence to antibiotic therapy was significantly different than self-reported adherence (57% vs. 96%, p