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ABSTRACT
Introduction
Outpatient parenteral antimicrobial therapy (OPAT) is safe and effective for selected patients managed within an organized clinical service. Service configurations however are evolving, patient populations are changing and new evidence is emerging which challenges traditional OPAT practice.
Areas covered
This review will discuss evolving OPAT service delivery from the traditional model of infusion center toward nonspecialist, community and remotely delivered OPAT and the challenges this represents. We consider new patient populations including those with incurable infection or infections at the end of life and difficult to reach populations including people who inject drugs. The evidence base that underpins the multi-disciplinary approach to OPAT delivery will be examined and particularly the role of the antimicrobial pharmacist and specialist nurse. Evidence for new treatment options which challenge established OPAT practice including complex oral antibiotic regimens, long acting parenteral agents and drug stability in continuous infusion antibiotics will be considered. Finally we emphasize the central importance of antimicrobial stewardship and good clinical governance which should underpin OPAT practice.
Expert opinion
Changing patient populations, service structures and team roles coupled with a growing infection management evidence base means that OPAT services and practice must evolve. Challenging traditional practice is essential to ensure best patient outcomes and cost-efficiency.
Article highlights
• OPAT service delivery is evolving from a traditional infusion center model run by infection specialists to more diverse service models including those delivered by nonspecialists in community-based settings and integrated within broader ambulatory care and ‘hospital in the home’ services.
• Clinical pharmacy and specialist nurses are core members of the OPAT team with key evolving roles in service delivery.
• Growing evidence supports the use of highly bio-available oral antibiotics in bone and joint infection and endocarditis where prolonged intravenous (IV) therapy previously would have been standard practice.
• Evidence is emerging that supports ambulatory treatment of serious Gram-positive infections utilizing new, long acting parenteral agents (e.g. dalbavancin) without the need for an indwelling vascular device, in difficult to reach groups, including in people who inject drugs.
• Antimicrobial stewardship principles and considerations (IV to oral switch, use of narrower spectrum antibiotics and shorter duration therapy) should be at the center of good OPAT practice
• New data is emerging to either support (flucloxacillin) or refute (meropenem) the use of key antibiotics via continuous IV infusion in the OPAT setting.
• Palliative OPAT is an emergent OPAT population encompassing management of incurable and life-limiting infection and infection complicating end of life care. It is an important and growing patient group where a careful, personalized approach to care is required.
Declaration of interest
RA Seaton is a former BSAC council member and is co-lead of BSAC OPAT initiative. The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed.
Reviewer disclosures
Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.