from patient pressure to return home and to work as ... infusion centre (Poretz, 1991) which may either be in a .... liaison nurses on-call for problems and patients.
Journal of Antimicrobial Chemotherapy (1996) 38, 557-559
Leading article
increasing experience with OPIVAT for patients with neutropenia and fever, if careJ Anumicrob Chemoiher 1996, 38: 557-559 fully selected (Rubenstein et al., 1993; Talcott et al., 1994). There are several models of OPIVAT Medical care in hospitals is increasingly complex and expensive Hospitalization is delivery that may be appropriate in differing required for a variety of reasons including the health care settings or for different patients. A need for surgery, nursing care, and diagnosis common mode of delivery in the USA is the and stabilization of senous diseases. Many infusion centre (Poretz, 1991) which may hospitalized patients require parenteral therapy either be in a hospital or may be an and it is not uncommon for patients to remain independent, commercial service. In this in hospital solely to receive intravenous model, patients discharged on iv antibiotics antibiotics because no suitable oral alternative attend the infusion centre to receive part exists. Since the late 1970s, in the USA, such or all of their treatment, continuing under patients have increasingly been treated on an the supervision of their referring physician in outpatient basis (Kind et at, 1979, Poretz et the outpatient clinic. Another model is the al., 1982). What are the reasons for providing office-based OPIVAT programme where outpatient intravenous (IV) antibiotic therapy the patient attends the physician's office for (OP1VAT), what conditions are suitable for treatment and supervision (Tice, 1991). In the such an approach and how can such treatment UK these two might be amalgamated so that patients are treated in the hospital outpatient be delivered? In the USA, much of the pressure to develop department. With other models the patient is OPIVAT has arisen from a desire to decrease treated in their own home The patient, or costs associated with hospital stay as well as carer, may be trained to administer the from patient pressure to return home and to antibiotics themselves or, as we do in Oxford, work as early as possible. In other settings the patient is treated by a visiting nurse where OPIVAT is beginning to be developed, specialist (Kayley et al., 1996). In practice, such as the UK and the Netherlands, while cost any of the above models can be combined to is an important concern, there are also issues to suit individual requirements but, whichever do with reduced number of acute hospital beds, model is used, it is necessary to have a more complicated infections requiring pro- well-trained multidisciplinary team to oversee longed iv antibiotics and increased patient the treatment programmes (Rehm & Weinexpectations of early discharge and community stein, 1983). Such a team should include a physician with an interest in infection, a nurse care. A variety of infections are amenable to specialist in iv therapy and a pharmacist. Whatever the indication for OPIVAT or OPIVAT, the most common ones being soft tissue infections and orthopaedic infections the mode of its delivery, there are several (Williams, 1995). With careful selection, issues to be considered before the patient is patients with endocarditis (Stamboulian et al., discharged home. The most important involve 1991; Francioli el al., 1992), pneumonia the patient and their disease It is essential (Morales & Snead, 1994) and pyelonephritis reliably to diagnose the infection and to be (Millar et al., 1995) can be treated outside sure that no suitable alternative oral antihospital. In addition, the increasing number biotic exists. The patient must be fully of AIDS patients with cytomegalovirus retini- informed and willing to be discharged with tis often receive outpatient iv antiviral agents OPIVAT. In addition, the patient must be and sometimes antibiotics (Drew, 1988; medically and mentally stable for discharge. Morales & von Behren, 1994). There is also The home environment should be clean and Outpatient intravenous antibiotic therapy
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have running water and, ideally, the patient should have a telephone for accessing help Intravenous access must be maintained and there are a variety of ways of ensuring this. Patients attending infusion centres may only require short peripheral cannulae, with hepann locks, which can be re-sited at the infusion centre every few days as required. Patients receiving OPIVAT at home or requiring prolonged treatment are usually better off with indwelling central venous catheters These may be traditional Hickman or Broviac catheters or the newer peripherally inserted central catheters (PICC). PICC lines are now commonly used for OPIVAT and reduce the costs associated with traditional subclavian lines (Graham et al. 1991; Lam et al., 1994). Two other important considerations are which antibiotics are suitable and how should they be infused? Although in practice any antibiotic can be used, those with pharmacokinetic profiles that allow once or twice daily dosing, such as ceftriaxone, vancomycin, teicoplanin and aminoglycosides are more suited to OPIVAT (Craig, 1995). Minimising the number of daily doses saves time, is cheaper, in terms of labour and disposables, and leads to less handling of the infusion line, thus reducing the risk of line-related sepsis For home therapy it is important to know the shelf life of the diluted antibiotic preparation. Some, such as benzylpenicillin, may become inactivated relatively quickly at room temperature and others, such as vancomycin, may be stable for many days, particularly if refrigerated (Craig, 1995). Infusion of antibiotics outside hospital is relatively easy now that there are a variety of pumps and infusion devices available. These range from simple, disposable, pressurized plastic elastomeric devices which infuse the antibiotic against gravity at a constant rate through a filter (Rich. 1992). to sophisticated programmable electronic pumps capable of either continuous infusion or intermittent bolus dosing (New et al . 1991). There are considerable advantages to OPIVAT. Studies in the USA have consistently shown that there are cost savings associated with OPIVAT (Balinsky & Nesbitt. 1989). In addition, patient satisfaction is increased because they can return home, increasing their autonomy, and often return to work while still on treatment. There can also be indirect advantages. Early discharge of one patient can lead to earlier admission of another, reducing waiting lists Earlier discharge may also reduce
the risk of nosocomial infections, an increasing problem in many hospitals OPIVAT is not without risks. Patients may feel insecure or unsupported at home. Line problems, such as thrombosis or infection, can occur. Anaphylaxis may be a worry but the risk should be very small if the patient receives their initial treatment in hospital Also, there is the danger that treatment failure or complications may be recognised late, outside hospital. Nevertheless, most of these problems can be overcome with a motivated multidisciplinary team, proper training of all concerned and good communication between the hospital team, the patient and the community carers. Regular clinic supervision of patients on therapy is essential. General practitioners may feel they are being asked to do the hospital's work without adequate recompense. A written shared care protocol to facilitate communication between the hospital and general practitioner is helpful and it is important that the general practitioner is contacted prior to discharge of the patient and is in agreement with the plans. In Oxford we have our home iv liaison nurses on-call for problems and patients have direct access to the infectious diseases ward, so the general practitioner is not troubled by any technical or clinical problems related to OPIVAT. Some general practitioners may want more active involvement in these cases and that is always welcomed. CHRISTOPHER P. CONLON Infections Discuses Unit. Nuflielil Depurtmenl of Medicine. John Rudclijfe Hospital. Oxford OX} 9DU. UK
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