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IV / Oral Switch andEarly Discharge Strategies
Matthew Dryden MDRoyal Hampshire Hospital
Winchester, UKSouthampton University
Disclosures and Acknowledgements
• Research and educational grants, honoraria and Advisory board member: Pfizer, Bayer HealthCare, AstraZeneca, Janssen-Cilag and Basilea
• I am grateful to colleagues who collaborated with collecting antibiotic management and early discharge data
Name Location
Phil Howard Leeds
Rob Townsend Sheffield
Brian Jones / John Coia Glasgow
Kathy Bamford / Wendy Lawson Imperial, London
Rhidian Morgan-Jones Cardiff
Paul Wade St Thomas’, London
Das Pillay / Peter Hawkey Birmingham
IV or Oral?
Which of the Following Criteria are Important for an Early Switch From IV to Oral in a Patient With MRSA Infection Able to Take Oral
Medication? (choose all that apply)
0 10 20 30 40 50 60 70 80 90 100
Falling inflammatorymarkers (eg, CRP)
Normal WBC
Site of Infection
No evidence of hypotension,shock, clinical improvement
No temperature for 24 h
ECCMID Delegates (n = 343)
Expert Panel (n = 13)
%Dryden M et al. Clin Microbiol Infect 2010; 16(Suppl 1): 3-31
IV oral switch
Conditions that might require more prolonged IV antibiotics
• S. aureus bacteraemia• Necrotising cSSTI• Severe infections in
chemotherapy and neutropenia
• Infected implants / prostheses
• Meningitis/encephalitis• Intracranial abscesses• Mediastinitis• Empyema
• Endocarditis• Exacerbation of CF /
bronchiectasis• Inadequately drained
abscess• Liver abscess• Cavitating pneumonia• Osteomyelitis• Septic arthritis
Early discharge – a better approach for managing infection?
UK NHS (England) Health statistics
14 million people are admitted to hospital each year and the
NHS treats a million people every 36 hours.
In 2009-10, total of 1,899 MRSA bacteraemias
25,605 C. difficile infections.
Average Length of Stay in Hospital for All Causes, Europe 2000 and 2008
Source: OECD Health Data 2010; Eurostat Statistics Database.
EU, 8.3 days, 2000 7.2 days, 2008
Planned Care ProvisionBuilding a Healthcare Fit for the Future
– UK DoH 2011
http://www.dh.gov.uk/prod_consum_dh/groups/ . http://www.scotland.gov.uk/Publications/2005/05/23141307/13171. Accessed April 2011;
Florence Nightingale, Scutari, 1850
Men’s emergency ward. East London 1860’s
Women’s ward, Scotland 1955
Crowded maternity ward Philippines
Perhaps care at home would be an improvement
Hospital or Home Care
• Hospital• Expertise• Close observation• Monitoring• Expensive• HC complications
• Home• Patient preference• More comfortable• Improved recovery• Less monitoring or
observation
The Patient Perspective Chair National Concern for Healthcare Infections - Graham Tanner
OPAT – An Aid to RecoveryPatient Benefit Compared with Hospitalisation
• Patients/carers can have greater control over their condition and therapy
• Improved patient dignity• Freedom from social isolation• Less risk of developing psychological problems due to
boredom• Improved nutrition/hydration• Less sleep deprivation• Less risk of developing pressure sores• Less risk of contracting or transmitting infection• Once discharged can allow the patient to lead as an as
near “normal” life as possible
IV OPAT
• Home environment• Continued attendance at
work/school• Reduced risk of HCAI• Better use of hospital
beds• Patient empowerment• Reduced HC costs
• Disruption to home life• Stressful for family• Compliance• Misuse of IV access• Decreased supervision• Access to emergency
care• Non-adherence to
medical advice
Advantages Disadvantages
Nathwani D et al, JAC. 2009; 64(3):447-53.
Outpatient Antibiotic Use in DDD in 20 European Countries
Coenen et al JAC (2009) 64, 200–205.
Parenteral antibiotic use as a proportion of total outpatient antibiotic
use
Coenen et al JAC (2009) 64, 200–205.
Duration of IV Therapy in a study of MRSA soft tissue infection
The mean duration of IV therapy at EOS was significantly shorter in the linezolid group than in the vancomycin group
5.6 5.3
10.49.8
0
2
4
6
8
10
12
14
PP mITT
Linezolid 600mg IV/PO q12h Vancomycin 15 mg/kg IV q12h*
P<0.001 P<0.001
Me
an
du
rati
on
of
IV t
he
rap
y,
da
ys
* Vancomycin dose adjusted for creatinine clearance and trough levels
Itani K et al. Am J Surgery 2010;199(6):804-16.
Length of StayThe mean length of hospital stay at EOS was significantly shorter in the linezolid group than in the vancomycin group1
7.6 7.7
8.9 8.9
0
2
4
6
8
10
12
14
PP mITT
Linezolid 600mg IV/PO q12h Vancomycin 15 mg/kg IV q12h*
P=0.022 P=0.016
1 Itani K et al. Am J Surgery 2010; 199(6):804-16.
Me
an
le
ng
th o
f s
tay
, d
ay
s
* Vancomycin dose adjusted for creatinine clearance and trough levels
GOing Home Study
Hammersmith and Charing Cross
Hospitals, London
Wendy Lawson, Lead PharmacistInfectious Diseases, Hammersmith Hospital
Glycopeptides to Oral treatment atHOME study
Results
Bamford K et al. Clin Microbiol Infect 2008; 14: Suppl 7:S362.
52% patientshad intervention made
Savings
££????
0.5 FTE Antibiotic PharmacistBamford K et al. Clin Microbiol Infect 2008; 14: Suppl 7:S362.
Post Discharge Follow UpPatient’s GP informed about study recruitmentAll patients reviewed by telephone by SP at
end of antibiotic treatmentPatients switched to linezolid monitored weekly
at clinic appointmentRoutine follow up by teams
Only 1 patient readmitted within 28 days for unrelated reason
Bamford K et al. Clin Microbiol Infect 2008; 14: Suppl 7:S362.
Antibiotic Early Discharge Service Evaluation
Hypothesis and Methods
• ? Significant numbers of patients who remain in hospital solely for antibiotic treatment
• Develop Audit tool to assess patients on Abx and whether they could be discharged from hospital safely on antibiotics (IV or oral)
• 6 hospitals collecting data on Abx use and discharge from hospital
• Acute medical and surgical wards
• All patients on Abx on a given day, assessment of continuing requirement for Abx and whether the infection can be managed in the community.
• Data collected by a team of antibiotic pharmacist, physician, nurse
Antibiotic Management and Early Discharge
Patient + Antibiotic
Continue? Stop?Need for IV route? Discharge?Switch IV to Oral?Does the patient need to be in hospital?Reasons preventing Discharge?Suitable for OPAT (IV or oral)?
Compare potential Discharge Date with Actual Discharge Date - bed days saved
Collect Data, multiple sites across UK- Clinical and health economic outcomes
Develop Standards of Care for early discharge in infection and care in the community
Results• 1356 patients reviewed in acute medical and surgical wards in 6 Hospitals; • 429 (32%) were on antibiotics
• 165/429 (38%) on IV; 264/429 (62%) on oral
Stop 99 (23%) could stop antibiotic immediately, 26 patients on IV
Continue 330 (77%) patients needed to continue antibiotics
Switch• 139 patients remaining on IV Abx, 47 (34%) could be switched to oral
Discharge• 89/429 (20%) patients were recommended for discharge
OPAT• 10 required IV OPAT; 55 required oral OPAT; 24 had antibiotics stopped
Distribution of antibiotics prescribed:
Antibiotic Route Total % IV Oral
Co-amoxiclav 34 65 99 17.84%
Amoxicillin 9 46 55 9.91%
Flucloxacillin 20 34 54 9.73%
Piperacillin/Tazobactam 54 54 9.73%
Metronidazole 21 22 43 7.75%
Doxycycline 42 42 7.57%
Trimethoprim 36 36 6.49%
Clarithromycin 2 26 28 5.05%
Vancomycin 16 2 18 3.24%
Benzylpenicillin 16 16 2.88%
Meropenem 16 16 2.88%
Ciprofloxacin 2 11 13 2.34%
Clindamycin 3 5 8 1.44%
Gentamicin 8 8 1.44%
Cefalexin 6 6 1.08%
Cefuroxime 6 6 1.08%
Linezolid 6 6 1.08%
Discharge recommendation and site of infection
0
20
40
60
80
100
120
140
160
180
RespSSTI
UTIIA
IBone
Endocarditi
sCNS
No
Yes
Reason(s) preventing discharge: 340/429
Co-morbidity18%
Requires rehab10%
Requires social input13%
Requires surgical / medical input
50%
Team choice1%
Awaiting nursing home
1%
Other reason7%
Using date of actual discharge of patient, calculated
• 89 patients could have left on day of review• 481 bed days saved• £120,450 potential ‘saving’ (£250/bed /day)
Potential Bed Days Saved
Conclusion
• An effective way of identifying patients who could be managed at home on IV or oral antibiotics
• Significant financial and clinical benefits • Improved antibiotic management
• Improved clinical care
• Reduce unnecessary bed occupancy and ease pressure on beds
• Reduce length of stay
• Prevent HCAI
• Reduces socio-economic burden of HCAIs
• Reduction in costs – antibiotics, IVs, bed days saved
• Improved ward efficiency and productivity
Recommendations
• All hospitals use a systematic review of antibiotics and infection management to identify patients for early discharge
• Improve resourcing of Infection teams
• Develop standards of care for early discharge • Put into practice
Centre Acknowledgement
Name Location
Matthew Dryden / Kordo Saeed / Natalie Parker
Winchester
Phil Howard Leeds
Rob Townsend Sheffield
Brian Jones / John Coia Glasgow
Kathy Bamford / Wendy Lawson Imperial, London
Paul Wade St Thomas’, London
Antibiotic Management and Early Discharge from Hospital: An Economic Analysis. Alastair Gray1, Matthew Dryden2, ECCMID poster 20111. Health Economics Research Centre, University of Oxford. 2. Royal Hampshire Hosp, Winchester, United Kingdom
• Patients: 291 total on ABx; 161 (55%) on oral. 130 (45%) on IV
• 82/ 291 (28%) could be discharged
• Saving on in-patient days of £186,731
• Saving on adjusted antibiotic regimens of £1,689
• Cost for AMT and medical review – £2468
• Cost of Community support - £6227
• Cost of OPAT £10,728
• NET saving of £170,198 or £2076 (95% c.i. £1196, £2955) per patient
The End
