IV / Oral Switch and
Early Discharge Strategies
Matthew Dryden MD
Royal Hampshire Hospital
Winchester, UK
Southampton University
matthew.dryden@wehct.nhs.uk
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)
ECCMID Delegates (n = 343)
Expert Panel (n = 13)
No temperature for 24 h
No evidence of hypotension,
shock, clinical improvement
Site of Infection
Normal WBC
Falling inflammatory
markers (eg, CRP)
0
10
20
30
Dryden M et al. Clin Microbiol Infect 2010; 16(Suppl 1): 3-31
40
50
%
60
70
80
90
100
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
EU, 8.3 days, 2000
7.2 days, 2008
Source: OECD Health Data 2010; Eurostat Statistics Database.
Planned Care Provision
Building 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
• Home
•
•
•
•
•
•
•
•
•
Expertise
Close observation
Monitoring
Expensive
HC complications
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 Recovery
Patient 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
Advantages
• Home environment
• Continued attendance at
work/school
• Reduced risk of HCAI
• Better use of hospital
beds
• Patient empowerment
• Reduced HC costs
Nathwani D et al, JAC. 2009; 64(3):447-53.
Disadvantages
•
•
•
•
•
•
Disruption to home life
Stressful for family
Compliance
Misuse of IV access
Decreased supervision
Access to emergency
care
• Non-adherence to
medical advice
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
14
Mean duration of IV therapy, days
Linezolid 600m g IV/PO q12h
12
P<0.001
10.4
Vancom ycin 15 m g/kg IV q12h*
P<0.001
9.8
10
8
6
5.6
5.3
4
2
0
PP
* Vancomycin dose adjusted for creatinine clearance and trough levels
Itani K et al. Am J Surgery 2010;199(6):804-16.
mITT
Length of Stay
The mean length of hospital stay at EOS was significantly shorter in the
linezolid group than in the vancomycin group1
14
Linezolid 600mg IV/PO q12h
Vancomycin 15 mg/kg IV q12h*
Mean length of stay, days
12
10
8
P=0.022
P=0.016
8.9
8.9
7.7
7.6
6
4
2
0
PP
* Vancomycin dose adjusted for creatinine clearance and trough levels
1 Itani K et al. Am J Surgery 2010; 199(6):804-16.
mITT
GOing Home Study
Glycopeptides to Oral treatment at
HOME study
Hammersmith and
Charing Cross
Hospitals, London
Wendy Lawson, Lead Pharmacist
Infectious Diseases, Hammersmith Hospital
Results
52% patients
had intervention made
Bamford K et al. Clin Microbiol Infect 2008; 14: Suppl 7:S362.
Savings
££????
 0.5 FTE Antibiotic Pharmacist
Bamford K et al. Clin Microbiol Infect 2008; 14: Suppl 7:S362.
Post Discharge Follow Up
 Patient’s GP informed about study
recruitment
 All patients reviewed by telephone by SP at
end of antibiotic treatment
 Patients switched to linezolid monitored
weekly at clinic appointment
 Routine 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?
Need for IV route?
Switch IV to Oral?
Does the patient need to be in hospital?
Reasons preventing Discharge?
Suitable for OPAT (IV or oral)?
Stop?
Discharge?
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
IV
Route
Oral
Total
%
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%
6
1.08%
6
1.08%
6
1.08%
Cefalexin
Cefuroxime
Linezolid
6
6
6
Discharge recommendation and site of infection
180
160
140
120
100
80
No
Yes
60
40
20
0
sp
e
R
T
SS
I
I
UT
I
IA
E
e
tis
i
d
ar
c
o
nd
n
o
B
S
N
C
Reason(s) preventing discharge: 340/429
Awaiting nursing
home
1%
Team choice
1%
Other reason
7%
Co-morbidity
18%
Requires rehab
10%
Requires surgical /
medical input
50%
Requires social
input
13%
Potential Bed Days Saved
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)
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 2011
1. 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