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IV / Oral Switch and Early Discharge Strategies Matthew Dryden MD Royal Hampshire Hospital Winchester, UK Southampton University

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Presentation on theme: "IV / Oral Switch and Early Discharge Strategies Matthew Dryden MD Royal Hampshire Hospital Winchester, UK Southampton University"— Presentation transcript:

1 IV / Oral Switch and Early Discharge Strategies Matthew Dryden MD Royal Hampshire Hospital Winchester, UK Southampton University

2 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 NameLocation Phil HowardLeeds Rob TownsendSheffield Brian Jones / John CoiaGlasgow Kathy Bamford / Wendy LawsonImperial, London Rhidian Morgan-JonesCardiff Paul WadeSt Thomas’, London Das Pillay / Peter HawkeyBirmingham

3 IV or Oral?

4 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) % Dryden M et al. Clin Microbiol Infect 2010; 16(Suppl 1): 3-31

5 IV oral switch

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7 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

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9 Early discharge – a better approach for managing infection?

10 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 , total of 1,899 MRSA bacteraemias  25,605 C. difficile infections.

11 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, days, 2008

12 Planned Care Provision Building a Healthcare Fit for the Future – UK DoH Accessed April 2011;

13 Florence Nightingale, Scutari, 1850 Men’s emergency ward. East London 1860’s

14 Women’s ward, Scotland 1955 Crowded maternity ward Philippines

15 Perhaps care at home would be an improvement

16 Hospital or Home Care Hospital Expertise Close observation Monitoring Expensive HC complications Home Patient preference More comfortable Improved recovery Less monitoring or observation

17 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

18 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 AdvantagesDisadvantages Nathwani D et al, JAC. 2009; 64(3):

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21 Outpatient Antibiotic Use in DDD in 20 European Countries Coenen et al JAC (2009) 64, 200–205.

22 Parenteral antibiotic use as a proportion of total outpatient antibiotic use Coenen et al JAC (2009) 64, 200–205.

23 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 P<0.001 Mean duration of IV therapy, days * Vancomycin dose adjusted for creatinine clearance and trough levels Itani K et al. Am J Surgery 2010;199(6):

24 Length of Stay The mean length of hospital stay at EOS was significantly shorter in the linezolid group than in the vancomycin group 1 P=0.022P= Itani K et al. Am J Surgery 2010; 199(6): Mean length of stay, days * Vancomycin dose adjusted for creatinine clearance and trough levels

25 GOing Home Study Hammersmith and Charing Cross Hospitals, London Wendy Lawson, Lead Pharmacist Infectious Diseases, Hammersmith Hospital Glycopeptides to Oral treatment at HOME study

26 Results Bamford K et al. Clin Microbiol Infect 2008; 14: Suppl 7:S % patients had intervention made

27 Savings ££????  0.5 FTE Antibiotic Pharmacist Bamford K et al. Clin Microbiol Infect 2008; 14: Suppl 7:S362.

28 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.

29 Antibiotic Early Discharge Service Evaluation

30 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

31 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

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34 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

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37 Discharge recommendation and site of infection

38 Reason(s) preventing discharge: 340/429

39 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

40 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

41 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

42 Centre Acknowledgement NameLocation Matthew Dryden / Kordo Saeed / Natalie Parker Winchester Phil HowardLeeds Rob TownsendSheffield Brian Jones / John CoiaGlasgow Kathy Bamford / Wendy LawsonImperial, London Paul WadeSt Thomas’, London

43 Antibiotic Management and Early Discharge from Hospital: An Economic Analysis. Alastair Gray 1, Matthew Dryden 2, ECCMID poster 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

44 The End


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