a Infection and Immunodeficiency Unit, Ninewells Hospital, Tayside University Hospitals, Dundee DD1 9SY, UK; b Infections Limited, PS, Stadium Way Consulting, 401 Broadway, Tacoma, WA 98402, USA
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Abstract |
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Introduction |
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The area of infectious diseases lends itself well to the study of outcomes, with well-defined diseases and usually curative therapies. There are, however, growing concerns about the overuse of antimicrobials and resulting resistance in microbes. In response, the United Kingdom Antimicrobial Resistance Strategy and Action Plan has set a goal to improve the correlation of data on patterns of antimicrobial use, antimicrobial resistant organisms, and the illness due to them.2 The new European health strategy3,4 echoes this concern and calls for networks and data collection systems to analyse information for best practices and guidelines to disseminate to providers.
The current evidence-based approach to understanding the treatment of infectious diseases has been helpful, but is limited in that the evidence is often based on outdated, industry-sponsored articles and the personal perspectives of the authors. The consequences are obvious with the proliferation of practice guidelines that rarely have the same recommendations.
The use of outpatient parenteral antimicrobial therapy (OPAT) was first described in 1974,5 yet it is new for many healthcare systems. Its use has grown rapidly in the USA because of cost savings. It is estimated that >250 000 Americans receive OPAT each year.6 It is common in China, and is evolving in South America and Europe7 as well.
OPAT has become a part of routine recommendations and practice guidelines for many infections, including community-acquired pneumonia and meningitis.812 It is likely to increase further because of its potential to save the cost of hospital care and improve the allocation of limited healthcare resources.
Many comparative studies of inpatient versus outpatient care have been carried out with regard to economic issues,1315 with a consistent cost saving from outpatient care found when the services provided are similar. The article by Board et al.16 is particularly revealing, with cost comparisons of randomized patients. The studies of patient care outcomes that have been carried out have demonstrated good outcomes. In the USA it would no longer be acceptable to randomize patients to inpatient versus outpatient therapy, as the insurance companies would not pay for hospital care, which is estimated to be three or four times more expensive. Randomized comparisons of hospitalized patients with outpatients are also difficult because of different levels of acuity and complexity of care as well as the social or economic issues that often dictate admissions.
From a microbiology perspective, there are also increasing concerns about the percentage of patients with hospital-acquired infection. This is estimated to be 5% of admissions in the USA and to have a prevalence of 9% of hospitalized patients in the UK.1719 Each infection is estimated to add more than $2500 to the cost of care in the USA. The rate of infection in outpatient care seems considerably lower.20 In addition to the risk of nosocomial infections, there is a growing concern about organisms that are increasingly resistant to antibiotics, which seems to be a particular issue in hospitals where the most potent antibiotics are used.2123
With the theoretical advantages and increasing use of OPAT, it is critical that its safety and effectiveness be evaluated and that standards are established to measure outcomes and discover its limitations.14,24 Practice guidelines have been written for OPAT in several countries, but need to be updated continually to meet the changing needs and advances.2527 There need to be methods of measuring the risks and benefits of outpatient therapies as people look outside the box of the hospital for solutions to many of today's healthcare problems.
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The OPAT Outcomes Registry |
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The OPAT Outcomes Registry provides information about the infections being treated commonly (Figure), the pathogens found and the primary antibiotics used. Additional information is available on the OPAT website (http://www.opat.com). It also provides information for sites to compare their own programme over time and to benchmark themselves and their experience with the aggregate of the other sites.
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Studies of OPAT risks and benefits are particularly important from a safety standpoint as serious infections are being treated in a new environment without the safeguards and supervision of the hospital environment. They may also involve new technology and social issues that are not well understood. Using the outcome indicators of Table 1, outcomes can be assessed with findings as indicated in Table 2
. This information can also be used to compare centres with the aggregate and to track changes over time.
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The International OPAT Outcomes Registry |
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Some interesting comparisons include the diagnoses treated, antibiotics used for OPAT, sites of care and administration routes (Table 3). As is demonstrated, osteomyelitis and soft tissue infections are the commonly treated infections in the UK and North America. Ceftriaxone is the most frequently used antibiotic in the UK, Italy and the USA, whereas cefazolin is the primary antibiotic used in the OPAT sites in Canada. The significance of these differences is unclear, but the variations in antibiotic use should provide useful insight into which regimens are most effective and best tolerated. The variations between countries also provide insight into the opportunities to treat new infections and the mechanisms involved in developing treatment regimens.
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The Dundee OPAT Outcomes Registry |
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Future applications of the Registry |
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The information gathered by the OPAT Outcomes Registry can be used for a variety of other purposes as well. The indicators of clinical, bacterial and programme outcomes can be used to evaluate different treatment regimens, and gain insight into the most effective antibiotic dosing, and duration of therapy. This information can be presented in an interactive format on the Internet or through pocket PC devices. It will allow an added perspective in antibiotic decision-making with continual updating and a critical mass of data that will provide statistically significant values for analysis with many disease states. This will provide a system that incorporates a true learning process with a real-time, live database.
The Registry data can also be used to monitor antibiotic resistance by collecting microbiology findings at the start and end of therapy. This can provide reflections of the levels of antibiotic resistance in serious infections in the community and identify organisms that develop resistance during therapy.
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Conclusion |
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The number of contributing centres and the volume of patient data entered are obviously critical in increasing the value and relevance of the data to patient care. New sites (for further information consult http://www.opat.com) and research funding are welcome.
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Notes |
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References |
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2 . Department of Health. (2000). UK Antimicrobial Resistance Strategy and Action Plan. Department of Health, London.
3 . European Commission. (2000). Communication from the Commission to the Council, the European Parliament, the Economic and Social Committee and the Committee of the Regions on the health strategy of the European Community. EC, Brussels [COM(2000)285 final].
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Received 28 March 2001; returned 11 July 2001; revised 3 September 2001; accepted 8 October 2001