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Outpatient Parenteral Antimicrobial Therapy in Vulnerable Populations—People Who Inject Drugs and the Homeless
Outpatient parenteral antimicrobial therapy (OPAT) programs allow patients to receive antibiotic therapy at home or in other settings.1-3 Bacterial infections among people who inject drugs (PWID) and the homeless are common, leading to complicated treatment strategies. Those with opioid dependence have frequent hospitalizations.4 Bacteremia and endocarditis frequently require intravenous (IV) antibiotics5-7 and may be difficult to treat. Creating outpatient treatment plans for PWID and the homeless is challenging, and there is a paucity of data on OPAT effectiveness in these groups as they are often excluded from OPAT services.1,2,8
We evaluated treatment outcomes in PWID and the homeless in our OPAT program.
METHODS
We conducted a retrospective cohort study of hospitalized adults discharged from Harborview Medical Center (HMC) with OPAT from January 1, 2015 to April 30, 2016. HMC is a county hospital in Seattle, Washington, affiliated with the University of Washington (UW). Infectious disease specialists supervise our OPAT program and provide follow-up care. We partner with a medical respite facility, a discharge option for homeless patients.9 Respite is staffed by HMC nurses, mental health specialists, and case managers.
Patients aged >18 years were enrolled in OPAT if they were discharged with >2 weeks of IV therapy or required laboratory monitoring while on oral antibiotics. Patients with multiple hospitalizations were included for their initial OPAT encounter only. PWID discharged to respite were instructed not to use their vascular access to inject drugs, but drug abstinence was not required. A tamper-evident sticker was placed over lines that nurses evaluated daily. Patients violating line-tampering restrictions were discharged from respite, and OPAT providers developed alternative antibiotic plans.
The two primary exposures evaluated were patient-reported injection drug use and housing status, and our primary exposure measure was the four-category combination: (1) housed non-PWID, (2) housed PWID, (3) homeless non-PWID, and (4) homeless PWID. Current drug use was defined as use within three months of hospitalization. Homelessness was defined as lack of stable housing. Patients receiving chemotherapy, prolonged steroids, biologic agents, or those with organ transplant were considered immunocompromised.
The primary outcome was clinical cure, defined as completion of antibiotic therapy and resolution of infection, determined by OPAT providers. Patients who were placed on oral suppressive antibiotics or died before treatment completion were considered not cured. Unknown status, including care transfer and lost to follow-up, were noted separately. Lost to follow-up was assumed if patients did not return for care, their care was not formally transferred, and no other medical information was available.
Secondary outcomes included hospital length of stay (LOS), secondary bacteremia, line-tampering, and 30-day readmissions. Secondary bacteremia was defined as bacteremia with a different pathogen from the index illness, which occurred during the initial treatment course. Readmission included readmissions related to OPAT (ie, recurrent or worsening infection, treatment-related toxicities, line-tampering, secondary bacteremia, and line-associated complications).
Data collection was performed using REDCap, a data-capturing software program linked to the electronic medical record (EMR).10 Hospitalization dates and demographics were electronically populated from the EMR. Details regarding drug use, homelessness, comorbidities, diagnosis, discharge complications, clinical cure, and lost to follow-up were manually entered.
Statistical Analysis
Statistical calculations were performed using SAS (v. 9.4). Chi-square testing and analysis of variance were conducted to assess group differences in demographics, infection types, and clinical outcomes.
Primary and secondary outcomes were further evaluated by univariable logistic regression and presented as odds ratios, with the non-PWID housed group serving as the reference. Given the large number of PWID and homeless patients lost to follow-up, sensitivity analyses were conducted using the assumption that patients with unknown clinical outcomes did not achieve cure (ie, chronic infection or death). Multivariable regression was performed on the outcomes of cure and 30-day readmission to OPAT using backward elimination to select a final model, initially including potential confounders of age, sex, and relevant comorbidities (DM and HIV). We assumed that those lost to follow-up were not cured (or readmitted). Other secondary outcomes were either rare events or those of uncertain relevance (eg, hospital LOS) to be evaluated in the multivariable analysis.
Our study did not meet the definition of research by the UW’s institutional review board. It was a quality improvement project funded by a UW Medicine Patient Safety Innovations Program Grant.
RESULTS
Overall, 596 patients received OPAT over 16 months. OPAT patients were categorized into groups as follows: homeless PWID (9%, n = 53), housed PWID (8%, n = 48), homeless non-PWID (8%, n = 45), and housed non-PWID (75%, n = 450).
PWID were younger than non-PWID, and the majority of patients in all groups were men (Table 1). PWID were more likely to have hepatitis C. Non-PWID appeared more likely to have diabetes and be immunosuppressed.
Patients had a total of 960 types of infection (Table 1). Bacteremia was the most common infection among PWID. Osteomyelitis was the most frequent infection in non-PWID.
Discharge location varied widely (P < .001; Table 1). The majority of patients with housing (housed PWID 60.4%, housed non-PWID 59.1%) were discharged to home, although 36.7% of housed non-PWID went to nursing facilities. Among homeless patients, 58.5% of PWID and 42.2% of non-PWID were discharged to respite; 10 patients were discharged to a shelter or street. Data specific to transition from IV to oral therapy were not recorded.
Cure rates among participants with known outcomes did not differ by group (Table 1; P = .85). In a sensitivity analysis of clinical cure, assuming those with unknown outcomes were not cured, housing status and drug use were significantly associated with cure (Table 1; P < .001, in the overall test), with rates lower among housed and homeless PWID groups (50.0% and 47.2%, respectively) compared with housed and homeless non-PWID groups (73.1% and 82.2%, respectively). In the multivariable analysis after backward elimination of noninfluential measures, only PWID and housing status were associated with cure; PWID, whether housed (OR = 0.37) or not (OR = 0.33), had lower odds of cure relative to housed non-PWID (Table 2).
Secondary outcomes, evaluated on all patients regardless of cure, differed by group (Table 1). Mean LOS appeared to be shortest for homeless PWID (15.5 days versus ≥18.0 for other groups; P < .001 for overall test). Homeless PWID patients appeared more likely to have secondary bacteremia (13.2% versus <4.2% in other groups; P < .001 for overall test), line tampering (35.9% versus <2.2% in other groups; P < .001), and 30-day readmission related to OPAT (26.4% versus <16.7% in other groups; P = .004). Compared with housed non-PWID using logistic regression, homeless PWID had a higher risk of secondary bacteremia (OR = 12.9; 95% CI 3.8-37.8; P < .001), line tampering (OR 88.4; 95% CI 24.5-318.3; P < .001), and readmission for OPAT (OR 2.4; 95% CI 1.2-4.6; P = .007). After adjusting for age, sex, and comorbidities, readmission for OPAT remained elevated in homeless PWID (OR = 2.4; 95% CI 1.2-4.6). No significant differences in secondary outcomes were found between housed non-PWID and also between housed PWID and homeless non-PWID.
Among homeless persons, discharge to respite care was not associated with improved outcomes, assuming those lost to follow-up did not achieve cure. Among non-PWID discharged to respite, the cure rate was 74% (14/19) compared with 88% (23/26) discharged elsewhere (P = .20). Among PWID, 48% (15/31) discharged to respite were cured compared with 45% (10/22) discharged elsewhere (P = .83).
DISCUSSION
Our study compares the outcomes of 596 OPAT patients, including PWID and the homeless. Among those retained in care, PWID achieved similar rates of cure compared with non-PWID groups. When assuming that all lost to follow-up had poor outcomes, the cure rates were markedly lower for PWID, with no difference noted by housing status.
Data on PWID and homeless enrolled in OPAT programs are limited.5,11,12 Few studies have reported the outcomes of infections in PWID and the homeless, as these populations often experience significant loss to follow-up due to transiency, lack of care continuity, and effective means of communication.
Cure was achieved in less than half of PWID, when lack of cure was assumed for unknown outcomes. This rate was substantially less than that for non-PWID groups. The assumption that those lost to follow-up did not achieve cure dramatically alters the inference; the truth may lie somewhere between the primary and sensitivity analyses. Homeless PWID remained at the highest risk for lost to follow-up, secondary bacteremia, line-tampering, and 30-day readmission related to OPAT.
PWID have traditionally been considered as a high-risk group for OPAT,1,2,8 but to completely restrict PWID from OPAT may not be appropriate. Ho et al. studied 29 PWID who were selectively enrolled to receive OPAT, and 28 completed IV therapy without any instances of line-tampering, death, or unknown clinical status.6 Recent literature suggests that some candidates can succeed with OPAT, despite drug use.13,14
Homelessness is also considered a barrier to OPAT.1,8 Medical respite is a harm-reduction model implemented for patients who require subacute care.9 In our study, among homeless patients, PWID status was the primary determinant of whether therapy was successful, rather than respite care.
Our study may have limited generalizability to other populations. We are a single-center facility in a large, urban city. PWID and housing status were self-reported but were verified before discharge. Most of our patients were men and white; thus, outcomes may differ for others. Due to the nature of the data, cost effectiveness could not be directly calculated. LOS and readmissions serve as proxy measures.
When patients remain engaged in care, PWID and the homeless achieved comparable clinical cure rates to those of housed non-PWID. Moving forward, OPAT can be more effective in PWID and the homeless with careful patient selection and close clinical support. Access to medication-assisted therapy, such as methadone or buprenorphine,15 may improve follow-up rates and linkage to outpatient care. Additional treatment strategies to improve retention in and adherence to care may promote successful outcomes in these vulnerable populations.
Disclosures
Presented at the Poster Abstract Session: Clinical Practice Issues at ID Week, October 26–30, 2016, New Orleans, LA. No conflicts of interested related to this work for all authors.
Funding
AW and AM received NIH NIAID grant K24 AI 071113-06 and UW Medicine Patient Safety Innovations Program Grant.
1. Tice, AD, Rehm SJ, Dalovisio JR, et al. Practice guidelines for outpatient parenteral antimicrobial therapy. IDSA guidelines. Clin Infect Dis. 2004; 38(12):1651-1672. doi: 10.1086/420939. PubMed
2. Williams DN, Baker CA, Kind AC, Sannes MR. The history and evolution of outpatient parenteral antibiotic therapy (OPAT). Int J Antimicrob Agents. 2015;46(3):307-312. doi: 10.1016/j.ijantimicag.2015.07.001. PubMed
3. Gilchrist M, Seaton RA. Outpatient parenteral antimicrobial therapy and antimicrobial stewardship: challenges and checklists. J Antimicrob Chemother. 2015;70(4);965-970. doi: 10.1093/jac/dku517. PubMed
4. Ronan MV, Herzig SJ. Hospitalizations related to opioid abuse/dependence and associated serious infections from 2002-2012. Health Aff (Milwood). 2016;35(5):832-837. doi: 10.1377/hlthaff.2015.1424. PubMed
5. Beieler AM, Dellit TH, Chan JD, et al. Successful implementation of outpatient parenteral antibiotic therapy at a medical respite facility for homeless patients. J Hosp Med. 2016;11(8):531-535. doi: 10.1002/jhm.2597. PubMed
6. Ho J, Archuleta S, Sulaiman Z, Fisher D. Safe and successful treatment of intravenous drug users with a peripherally inserted central catheter in an outpatient parenteral antibiotic treatment service. J Antimicrob Chemother. 2010;65:2641-2644. doi: 10.1093/jac/dkq355. PubMed
7. Suleyman G, Kenney R, Zervos MJ, Weinmann A. Safety and efficacy of outpatient parenteral antibiotic therapy in an academic infectious disease clinic. J Clin Pharm Ther. 2017;42(1):39-43. doi: 10.1111/jcpt.12465. PubMed
8. Bhavan KP, Brown LS, Haley RW. Self-administered outpatient antimicrobial infusion by uninsured patients discharged from a safety-net hospital: a propensity-score-balanced retrospective cohort study. PLoS Med. 2015;12(12):e1001922. doi: 10.1371/journal.pmed. PubMed
9. Seattle-King County Medical Respite. https://www.kingcounty.gov/depts/health/locations/homeless-health/healthcare-for-the-homeless/services/medical-respite.aspx. Accessed October 2, 2018.
10. Harris PA, Taylor R, Thielke R, et al. Research electronic data capture (REDCap) – a metadata-driven methodology and workflow process for providing translational research informatics support. J Biomed Inform. 2009;42:377-3781. doi: 10.1016/j.jbi.2008.08.010. PubMed
11. Buerhle DJ, Shields RK, Shah N, Shoff C, Sheridan K. Risk factors associated with outpatient parenteral antibiotic therapy program failure among intravenous drug users. Open Forum Infect Dis.2017;4(3):ofx102. doi: 10.1093/ofid/ofx102. PubMed
12. Hernandez W, Price C, Knepper B, McLees M, Young H. Outpatient parenteral antimicrobial therapy administration in a homeless population. J Infus Nurs. 2016;39(2):81-85. doi: 10.1097/NAN.0000000000000165. PubMed
13. Sukuki J, Johnson J, Montgomery M, Hayden M, Price C. Outpatient parenteral antimicrobial therapy among people who inject drugs: a review of the literature. Open Forum Infect Dis. 2018;5(9):ofy194. doi: 10.1093/ofid/ofy194. PubMed
14. D’Couto HT, Robbins GK, Ard KL, Wakeman SE, Alves J, Nelson SB. Outcomes according to discharge location for persons who inject drugs receiving outpatient parenteral antimicrobial therapy. Open Forum Infect Dis. 2018;5(5):ofy056. doi: 10.1093/ofid/ofy056. PubMed
15. Rosenthal ES, Karchmer AW, Theisen-Toupal J, Castillo RA, Rowley CF. Suboptimal addiction interventions for patients hospitalized with injection drug use-associated infective endocarditis. Am J Med. 2016;129(5):481-485. doi: 10.1016/j.amjmed.2015.09.024. PubMed
Outpatient parenteral antimicrobial therapy (OPAT) programs allow patients to receive antibiotic therapy at home or in other settings.1-3 Bacterial infections among people who inject drugs (PWID) and the homeless are common, leading to complicated treatment strategies. Those with opioid dependence have frequent hospitalizations.4 Bacteremia and endocarditis frequently require intravenous (IV) antibiotics5-7 and may be difficult to treat. Creating outpatient treatment plans for PWID and the homeless is challenging, and there is a paucity of data on OPAT effectiveness in these groups as they are often excluded from OPAT services.1,2,8
We evaluated treatment outcomes in PWID and the homeless in our OPAT program.
METHODS
We conducted a retrospective cohort study of hospitalized adults discharged from Harborview Medical Center (HMC) with OPAT from January 1, 2015 to April 30, 2016. HMC is a county hospital in Seattle, Washington, affiliated with the University of Washington (UW). Infectious disease specialists supervise our OPAT program and provide follow-up care. We partner with a medical respite facility, a discharge option for homeless patients.9 Respite is staffed by HMC nurses, mental health specialists, and case managers.
Patients aged >18 years were enrolled in OPAT if they were discharged with >2 weeks of IV therapy or required laboratory monitoring while on oral antibiotics. Patients with multiple hospitalizations were included for their initial OPAT encounter only. PWID discharged to respite were instructed not to use their vascular access to inject drugs, but drug abstinence was not required. A tamper-evident sticker was placed over lines that nurses evaluated daily. Patients violating line-tampering restrictions were discharged from respite, and OPAT providers developed alternative antibiotic plans.
The two primary exposures evaluated were patient-reported injection drug use and housing status, and our primary exposure measure was the four-category combination: (1) housed non-PWID, (2) housed PWID, (3) homeless non-PWID, and (4) homeless PWID. Current drug use was defined as use within three months of hospitalization. Homelessness was defined as lack of stable housing. Patients receiving chemotherapy, prolonged steroids, biologic agents, or those with organ transplant were considered immunocompromised.
The primary outcome was clinical cure, defined as completion of antibiotic therapy and resolution of infection, determined by OPAT providers. Patients who were placed on oral suppressive antibiotics or died before treatment completion were considered not cured. Unknown status, including care transfer and lost to follow-up, were noted separately. Lost to follow-up was assumed if patients did not return for care, their care was not formally transferred, and no other medical information was available.
Secondary outcomes included hospital length of stay (LOS), secondary bacteremia, line-tampering, and 30-day readmissions. Secondary bacteremia was defined as bacteremia with a different pathogen from the index illness, which occurred during the initial treatment course. Readmission included readmissions related to OPAT (ie, recurrent or worsening infection, treatment-related toxicities, line-tampering, secondary bacteremia, and line-associated complications).
Data collection was performed using REDCap, a data-capturing software program linked to the electronic medical record (EMR).10 Hospitalization dates and demographics were electronically populated from the EMR. Details regarding drug use, homelessness, comorbidities, diagnosis, discharge complications, clinical cure, and lost to follow-up were manually entered.
Statistical Analysis
Statistical calculations were performed using SAS (v. 9.4). Chi-square testing and analysis of variance were conducted to assess group differences in demographics, infection types, and clinical outcomes.
Primary and secondary outcomes were further evaluated by univariable logistic regression and presented as odds ratios, with the non-PWID housed group serving as the reference. Given the large number of PWID and homeless patients lost to follow-up, sensitivity analyses were conducted using the assumption that patients with unknown clinical outcomes did not achieve cure (ie, chronic infection or death). Multivariable regression was performed on the outcomes of cure and 30-day readmission to OPAT using backward elimination to select a final model, initially including potential confounders of age, sex, and relevant comorbidities (DM and HIV). We assumed that those lost to follow-up were not cured (or readmitted). Other secondary outcomes were either rare events or those of uncertain relevance (eg, hospital LOS) to be evaluated in the multivariable analysis.
Our study did not meet the definition of research by the UW’s institutional review board. It was a quality improvement project funded by a UW Medicine Patient Safety Innovations Program Grant.
RESULTS
Overall, 596 patients received OPAT over 16 months. OPAT patients were categorized into groups as follows: homeless PWID (9%, n = 53), housed PWID (8%, n = 48), homeless non-PWID (8%, n = 45), and housed non-PWID (75%, n = 450).
PWID were younger than non-PWID, and the majority of patients in all groups were men (Table 1). PWID were more likely to have hepatitis C. Non-PWID appeared more likely to have diabetes and be immunosuppressed.
Patients had a total of 960 types of infection (Table 1). Bacteremia was the most common infection among PWID. Osteomyelitis was the most frequent infection in non-PWID.
Discharge location varied widely (P < .001; Table 1). The majority of patients with housing (housed PWID 60.4%, housed non-PWID 59.1%) were discharged to home, although 36.7% of housed non-PWID went to nursing facilities. Among homeless patients, 58.5% of PWID and 42.2% of non-PWID were discharged to respite; 10 patients were discharged to a shelter or street. Data specific to transition from IV to oral therapy were not recorded.
Cure rates among participants with known outcomes did not differ by group (Table 1; P = .85). In a sensitivity analysis of clinical cure, assuming those with unknown outcomes were not cured, housing status and drug use were significantly associated with cure (Table 1; P < .001, in the overall test), with rates lower among housed and homeless PWID groups (50.0% and 47.2%, respectively) compared with housed and homeless non-PWID groups (73.1% and 82.2%, respectively). In the multivariable analysis after backward elimination of noninfluential measures, only PWID and housing status were associated with cure; PWID, whether housed (OR = 0.37) or not (OR = 0.33), had lower odds of cure relative to housed non-PWID (Table 2).
Secondary outcomes, evaluated on all patients regardless of cure, differed by group (Table 1). Mean LOS appeared to be shortest for homeless PWID (15.5 days versus ≥18.0 for other groups; P < .001 for overall test). Homeless PWID patients appeared more likely to have secondary bacteremia (13.2% versus <4.2% in other groups; P < .001 for overall test), line tampering (35.9% versus <2.2% in other groups; P < .001), and 30-day readmission related to OPAT (26.4% versus <16.7% in other groups; P = .004). Compared with housed non-PWID using logistic regression, homeless PWID had a higher risk of secondary bacteremia (OR = 12.9; 95% CI 3.8-37.8; P < .001), line tampering (OR 88.4; 95% CI 24.5-318.3; P < .001), and readmission for OPAT (OR 2.4; 95% CI 1.2-4.6; P = .007). After adjusting for age, sex, and comorbidities, readmission for OPAT remained elevated in homeless PWID (OR = 2.4; 95% CI 1.2-4.6). No significant differences in secondary outcomes were found between housed non-PWID and also between housed PWID and homeless non-PWID.
Among homeless persons, discharge to respite care was not associated with improved outcomes, assuming those lost to follow-up did not achieve cure. Among non-PWID discharged to respite, the cure rate was 74% (14/19) compared with 88% (23/26) discharged elsewhere (P = .20). Among PWID, 48% (15/31) discharged to respite were cured compared with 45% (10/22) discharged elsewhere (P = .83).
DISCUSSION
Our study compares the outcomes of 596 OPAT patients, including PWID and the homeless. Among those retained in care, PWID achieved similar rates of cure compared with non-PWID groups. When assuming that all lost to follow-up had poor outcomes, the cure rates were markedly lower for PWID, with no difference noted by housing status.
Data on PWID and homeless enrolled in OPAT programs are limited.5,11,12 Few studies have reported the outcomes of infections in PWID and the homeless, as these populations often experience significant loss to follow-up due to transiency, lack of care continuity, and effective means of communication.
Cure was achieved in less than half of PWID, when lack of cure was assumed for unknown outcomes. This rate was substantially less than that for non-PWID groups. The assumption that those lost to follow-up did not achieve cure dramatically alters the inference; the truth may lie somewhere between the primary and sensitivity analyses. Homeless PWID remained at the highest risk for lost to follow-up, secondary bacteremia, line-tampering, and 30-day readmission related to OPAT.
PWID have traditionally been considered as a high-risk group for OPAT,1,2,8 but to completely restrict PWID from OPAT may not be appropriate. Ho et al. studied 29 PWID who were selectively enrolled to receive OPAT, and 28 completed IV therapy without any instances of line-tampering, death, or unknown clinical status.6 Recent literature suggests that some candidates can succeed with OPAT, despite drug use.13,14
Homelessness is also considered a barrier to OPAT.1,8 Medical respite is a harm-reduction model implemented for patients who require subacute care.9 In our study, among homeless patients, PWID status was the primary determinant of whether therapy was successful, rather than respite care.
Our study may have limited generalizability to other populations. We are a single-center facility in a large, urban city. PWID and housing status were self-reported but were verified before discharge. Most of our patients were men and white; thus, outcomes may differ for others. Due to the nature of the data, cost effectiveness could not be directly calculated. LOS and readmissions serve as proxy measures.
When patients remain engaged in care, PWID and the homeless achieved comparable clinical cure rates to those of housed non-PWID. Moving forward, OPAT can be more effective in PWID and the homeless with careful patient selection and close clinical support. Access to medication-assisted therapy, such as methadone or buprenorphine,15 may improve follow-up rates and linkage to outpatient care. Additional treatment strategies to improve retention in and adherence to care may promote successful outcomes in these vulnerable populations.
Disclosures
Presented at the Poster Abstract Session: Clinical Practice Issues at ID Week, October 26–30, 2016, New Orleans, LA. No conflicts of interested related to this work for all authors.
Funding
AW and AM received NIH NIAID grant K24 AI 071113-06 and UW Medicine Patient Safety Innovations Program Grant.
Outpatient parenteral antimicrobial therapy (OPAT) programs allow patients to receive antibiotic therapy at home or in other settings.1-3 Bacterial infections among people who inject drugs (PWID) and the homeless are common, leading to complicated treatment strategies. Those with opioid dependence have frequent hospitalizations.4 Bacteremia and endocarditis frequently require intravenous (IV) antibiotics5-7 and may be difficult to treat. Creating outpatient treatment plans for PWID and the homeless is challenging, and there is a paucity of data on OPAT effectiveness in these groups as they are often excluded from OPAT services.1,2,8
We evaluated treatment outcomes in PWID and the homeless in our OPAT program.
METHODS
We conducted a retrospective cohort study of hospitalized adults discharged from Harborview Medical Center (HMC) with OPAT from January 1, 2015 to April 30, 2016. HMC is a county hospital in Seattle, Washington, affiliated with the University of Washington (UW). Infectious disease specialists supervise our OPAT program and provide follow-up care. We partner with a medical respite facility, a discharge option for homeless patients.9 Respite is staffed by HMC nurses, mental health specialists, and case managers.
Patients aged >18 years were enrolled in OPAT if they were discharged with >2 weeks of IV therapy or required laboratory monitoring while on oral antibiotics. Patients with multiple hospitalizations were included for their initial OPAT encounter only. PWID discharged to respite were instructed not to use their vascular access to inject drugs, but drug abstinence was not required. A tamper-evident sticker was placed over lines that nurses evaluated daily. Patients violating line-tampering restrictions were discharged from respite, and OPAT providers developed alternative antibiotic plans.
The two primary exposures evaluated were patient-reported injection drug use and housing status, and our primary exposure measure was the four-category combination: (1) housed non-PWID, (2) housed PWID, (3) homeless non-PWID, and (4) homeless PWID. Current drug use was defined as use within three months of hospitalization. Homelessness was defined as lack of stable housing. Patients receiving chemotherapy, prolonged steroids, biologic agents, or those with organ transplant were considered immunocompromised.
The primary outcome was clinical cure, defined as completion of antibiotic therapy and resolution of infection, determined by OPAT providers. Patients who were placed on oral suppressive antibiotics or died before treatment completion were considered not cured. Unknown status, including care transfer and lost to follow-up, were noted separately. Lost to follow-up was assumed if patients did not return for care, their care was not formally transferred, and no other medical information was available.
Secondary outcomes included hospital length of stay (LOS), secondary bacteremia, line-tampering, and 30-day readmissions. Secondary bacteremia was defined as bacteremia with a different pathogen from the index illness, which occurred during the initial treatment course. Readmission included readmissions related to OPAT (ie, recurrent or worsening infection, treatment-related toxicities, line-tampering, secondary bacteremia, and line-associated complications).
Data collection was performed using REDCap, a data-capturing software program linked to the electronic medical record (EMR).10 Hospitalization dates and demographics were electronically populated from the EMR. Details regarding drug use, homelessness, comorbidities, diagnosis, discharge complications, clinical cure, and lost to follow-up were manually entered.
Statistical Analysis
Statistical calculations were performed using SAS (v. 9.4). Chi-square testing and analysis of variance were conducted to assess group differences in demographics, infection types, and clinical outcomes.
Primary and secondary outcomes were further evaluated by univariable logistic regression and presented as odds ratios, with the non-PWID housed group serving as the reference. Given the large number of PWID and homeless patients lost to follow-up, sensitivity analyses were conducted using the assumption that patients with unknown clinical outcomes did not achieve cure (ie, chronic infection or death). Multivariable regression was performed on the outcomes of cure and 30-day readmission to OPAT using backward elimination to select a final model, initially including potential confounders of age, sex, and relevant comorbidities (DM and HIV). We assumed that those lost to follow-up were not cured (or readmitted). Other secondary outcomes were either rare events or those of uncertain relevance (eg, hospital LOS) to be evaluated in the multivariable analysis.
Our study did not meet the definition of research by the UW’s institutional review board. It was a quality improvement project funded by a UW Medicine Patient Safety Innovations Program Grant.
RESULTS
Overall, 596 patients received OPAT over 16 months. OPAT patients were categorized into groups as follows: homeless PWID (9%, n = 53), housed PWID (8%, n = 48), homeless non-PWID (8%, n = 45), and housed non-PWID (75%, n = 450).
PWID were younger than non-PWID, and the majority of patients in all groups were men (Table 1). PWID were more likely to have hepatitis C. Non-PWID appeared more likely to have diabetes and be immunosuppressed.
Patients had a total of 960 types of infection (Table 1). Bacteremia was the most common infection among PWID. Osteomyelitis was the most frequent infection in non-PWID.
Discharge location varied widely (P < .001; Table 1). The majority of patients with housing (housed PWID 60.4%, housed non-PWID 59.1%) were discharged to home, although 36.7% of housed non-PWID went to nursing facilities. Among homeless patients, 58.5% of PWID and 42.2% of non-PWID were discharged to respite; 10 patients were discharged to a shelter or street. Data specific to transition from IV to oral therapy were not recorded.
Cure rates among participants with known outcomes did not differ by group (Table 1; P = .85). In a sensitivity analysis of clinical cure, assuming those with unknown outcomes were not cured, housing status and drug use were significantly associated with cure (Table 1; P < .001, in the overall test), with rates lower among housed and homeless PWID groups (50.0% and 47.2%, respectively) compared with housed and homeless non-PWID groups (73.1% and 82.2%, respectively). In the multivariable analysis after backward elimination of noninfluential measures, only PWID and housing status were associated with cure; PWID, whether housed (OR = 0.37) or not (OR = 0.33), had lower odds of cure relative to housed non-PWID (Table 2).
Secondary outcomes, evaluated on all patients regardless of cure, differed by group (Table 1). Mean LOS appeared to be shortest for homeless PWID (15.5 days versus ≥18.0 for other groups; P < .001 for overall test). Homeless PWID patients appeared more likely to have secondary bacteremia (13.2% versus <4.2% in other groups; P < .001 for overall test), line tampering (35.9% versus <2.2% in other groups; P < .001), and 30-day readmission related to OPAT (26.4% versus <16.7% in other groups; P = .004). Compared with housed non-PWID using logistic regression, homeless PWID had a higher risk of secondary bacteremia (OR = 12.9; 95% CI 3.8-37.8; P < .001), line tampering (OR 88.4; 95% CI 24.5-318.3; P < .001), and readmission for OPAT (OR 2.4; 95% CI 1.2-4.6; P = .007). After adjusting for age, sex, and comorbidities, readmission for OPAT remained elevated in homeless PWID (OR = 2.4; 95% CI 1.2-4.6). No significant differences in secondary outcomes were found between housed non-PWID and also between housed PWID and homeless non-PWID.
Among homeless persons, discharge to respite care was not associated with improved outcomes, assuming those lost to follow-up did not achieve cure. Among non-PWID discharged to respite, the cure rate was 74% (14/19) compared with 88% (23/26) discharged elsewhere (P = .20). Among PWID, 48% (15/31) discharged to respite were cured compared with 45% (10/22) discharged elsewhere (P = .83).
DISCUSSION
Our study compares the outcomes of 596 OPAT patients, including PWID and the homeless. Among those retained in care, PWID achieved similar rates of cure compared with non-PWID groups. When assuming that all lost to follow-up had poor outcomes, the cure rates were markedly lower for PWID, with no difference noted by housing status.
Data on PWID and homeless enrolled in OPAT programs are limited.5,11,12 Few studies have reported the outcomes of infections in PWID and the homeless, as these populations often experience significant loss to follow-up due to transiency, lack of care continuity, and effective means of communication.
Cure was achieved in less than half of PWID, when lack of cure was assumed for unknown outcomes. This rate was substantially less than that for non-PWID groups. The assumption that those lost to follow-up did not achieve cure dramatically alters the inference; the truth may lie somewhere between the primary and sensitivity analyses. Homeless PWID remained at the highest risk for lost to follow-up, secondary bacteremia, line-tampering, and 30-day readmission related to OPAT.
PWID have traditionally been considered as a high-risk group for OPAT,1,2,8 but to completely restrict PWID from OPAT may not be appropriate. Ho et al. studied 29 PWID who were selectively enrolled to receive OPAT, and 28 completed IV therapy without any instances of line-tampering, death, or unknown clinical status.6 Recent literature suggests that some candidates can succeed with OPAT, despite drug use.13,14
Homelessness is also considered a barrier to OPAT.1,8 Medical respite is a harm-reduction model implemented for patients who require subacute care.9 In our study, among homeless patients, PWID status was the primary determinant of whether therapy was successful, rather than respite care.
Our study may have limited generalizability to other populations. We are a single-center facility in a large, urban city. PWID and housing status were self-reported but were verified before discharge. Most of our patients were men and white; thus, outcomes may differ for others. Due to the nature of the data, cost effectiveness could not be directly calculated. LOS and readmissions serve as proxy measures.
When patients remain engaged in care, PWID and the homeless achieved comparable clinical cure rates to those of housed non-PWID. Moving forward, OPAT can be more effective in PWID and the homeless with careful patient selection and close clinical support. Access to medication-assisted therapy, such as methadone or buprenorphine,15 may improve follow-up rates and linkage to outpatient care. Additional treatment strategies to improve retention in and adherence to care may promote successful outcomes in these vulnerable populations.
Disclosures
Presented at the Poster Abstract Session: Clinical Practice Issues at ID Week, October 26–30, 2016, New Orleans, LA. No conflicts of interested related to this work for all authors.
Funding
AW and AM received NIH NIAID grant K24 AI 071113-06 and UW Medicine Patient Safety Innovations Program Grant.
1. Tice, AD, Rehm SJ, Dalovisio JR, et al. Practice guidelines for outpatient parenteral antimicrobial therapy. IDSA guidelines. Clin Infect Dis. 2004; 38(12):1651-1672. doi: 10.1086/420939. PubMed
2. Williams DN, Baker CA, Kind AC, Sannes MR. The history and evolution of outpatient parenteral antibiotic therapy (OPAT). Int J Antimicrob Agents. 2015;46(3):307-312. doi: 10.1016/j.ijantimicag.2015.07.001. PubMed
3. Gilchrist M, Seaton RA. Outpatient parenteral antimicrobial therapy and antimicrobial stewardship: challenges and checklists. J Antimicrob Chemother. 2015;70(4);965-970. doi: 10.1093/jac/dku517. PubMed
4. Ronan MV, Herzig SJ. Hospitalizations related to opioid abuse/dependence and associated serious infections from 2002-2012. Health Aff (Milwood). 2016;35(5):832-837. doi: 10.1377/hlthaff.2015.1424. PubMed
5. Beieler AM, Dellit TH, Chan JD, et al. Successful implementation of outpatient parenteral antibiotic therapy at a medical respite facility for homeless patients. J Hosp Med. 2016;11(8):531-535. doi: 10.1002/jhm.2597. PubMed
6. Ho J, Archuleta S, Sulaiman Z, Fisher D. Safe and successful treatment of intravenous drug users with a peripherally inserted central catheter in an outpatient parenteral antibiotic treatment service. J Antimicrob Chemother. 2010;65:2641-2644. doi: 10.1093/jac/dkq355. PubMed
7. Suleyman G, Kenney R, Zervos MJ, Weinmann A. Safety and efficacy of outpatient parenteral antibiotic therapy in an academic infectious disease clinic. J Clin Pharm Ther. 2017;42(1):39-43. doi: 10.1111/jcpt.12465. PubMed
8. Bhavan KP, Brown LS, Haley RW. Self-administered outpatient antimicrobial infusion by uninsured patients discharged from a safety-net hospital: a propensity-score-balanced retrospective cohort study. PLoS Med. 2015;12(12):e1001922. doi: 10.1371/journal.pmed. PubMed
9. Seattle-King County Medical Respite. https://www.kingcounty.gov/depts/health/locations/homeless-health/healthcare-for-the-homeless/services/medical-respite.aspx. Accessed October 2, 2018.
10. Harris PA, Taylor R, Thielke R, et al. Research electronic data capture (REDCap) – a metadata-driven methodology and workflow process for providing translational research informatics support. J Biomed Inform. 2009;42:377-3781. doi: 10.1016/j.jbi.2008.08.010. PubMed
11. Buerhle DJ, Shields RK, Shah N, Shoff C, Sheridan K. Risk factors associated with outpatient parenteral antibiotic therapy program failure among intravenous drug users. Open Forum Infect Dis.2017;4(3):ofx102. doi: 10.1093/ofid/ofx102. PubMed
12. Hernandez W, Price C, Knepper B, McLees M, Young H. Outpatient parenteral antimicrobial therapy administration in a homeless population. J Infus Nurs. 2016;39(2):81-85. doi: 10.1097/NAN.0000000000000165. PubMed
13. Sukuki J, Johnson J, Montgomery M, Hayden M, Price C. Outpatient parenteral antimicrobial therapy among people who inject drugs: a review of the literature. Open Forum Infect Dis. 2018;5(9):ofy194. doi: 10.1093/ofid/ofy194. PubMed
14. D’Couto HT, Robbins GK, Ard KL, Wakeman SE, Alves J, Nelson SB. Outcomes according to discharge location for persons who inject drugs receiving outpatient parenteral antimicrobial therapy. Open Forum Infect Dis. 2018;5(5):ofy056. doi: 10.1093/ofid/ofy056. PubMed
15. Rosenthal ES, Karchmer AW, Theisen-Toupal J, Castillo RA, Rowley CF. Suboptimal addiction interventions for patients hospitalized with injection drug use-associated infective endocarditis. Am J Med. 2016;129(5):481-485. doi: 10.1016/j.amjmed.2015.09.024. PubMed
1. Tice, AD, Rehm SJ, Dalovisio JR, et al. Practice guidelines for outpatient parenteral antimicrobial therapy. IDSA guidelines. Clin Infect Dis. 2004; 38(12):1651-1672. doi: 10.1086/420939. PubMed
2. Williams DN, Baker CA, Kind AC, Sannes MR. The history and evolution of outpatient parenteral antibiotic therapy (OPAT). Int J Antimicrob Agents. 2015;46(3):307-312. doi: 10.1016/j.ijantimicag.2015.07.001. PubMed
3. Gilchrist M, Seaton RA. Outpatient parenteral antimicrobial therapy and antimicrobial stewardship: challenges and checklists. J Antimicrob Chemother. 2015;70(4);965-970. doi: 10.1093/jac/dku517. PubMed
4. Ronan MV, Herzig SJ. Hospitalizations related to opioid abuse/dependence and associated serious infections from 2002-2012. Health Aff (Milwood). 2016;35(5):832-837. doi: 10.1377/hlthaff.2015.1424. PubMed
5. Beieler AM, Dellit TH, Chan JD, et al. Successful implementation of outpatient parenteral antibiotic therapy at a medical respite facility for homeless patients. J Hosp Med. 2016;11(8):531-535. doi: 10.1002/jhm.2597. PubMed
6. Ho J, Archuleta S, Sulaiman Z, Fisher D. Safe and successful treatment of intravenous drug users with a peripherally inserted central catheter in an outpatient parenteral antibiotic treatment service. J Antimicrob Chemother. 2010;65:2641-2644. doi: 10.1093/jac/dkq355. PubMed
7. Suleyman G, Kenney R, Zervos MJ, Weinmann A. Safety and efficacy of outpatient parenteral antibiotic therapy in an academic infectious disease clinic. J Clin Pharm Ther. 2017;42(1):39-43. doi: 10.1111/jcpt.12465. PubMed
8. Bhavan KP, Brown LS, Haley RW. Self-administered outpatient antimicrobial infusion by uninsured patients discharged from a safety-net hospital: a propensity-score-balanced retrospective cohort study. PLoS Med. 2015;12(12):e1001922. doi: 10.1371/journal.pmed. PubMed
9. Seattle-King County Medical Respite. https://www.kingcounty.gov/depts/health/locations/homeless-health/healthcare-for-the-homeless/services/medical-respite.aspx. Accessed October 2, 2018.
10. Harris PA, Taylor R, Thielke R, et al. Research electronic data capture (REDCap) – a metadata-driven methodology and workflow process for providing translational research informatics support. J Biomed Inform. 2009;42:377-3781. doi: 10.1016/j.jbi.2008.08.010. PubMed
11. Buerhle DJ, Shields RK, Shah N, Shoff C, Sheridan K. Risk factors associated with outpatient parenteral antibiotic therapy program failure among intravenous drug users. Open Forum Infect Dis.2017;4(3):ofx102. doi: 10.1093/ofid/ofx102. PubMed
12. Hernandez W, Price C, Knepper B, McLees M, Young H. Outpatient parenteral antimicrobial therapy administration in a homeless population. J Infus Nurs. 2016;39(2):81-85. doi: 10.1097/NAN.0000000000000165. PubMed
13. Sukuki J, Johnson J, Montgomery M, Hayden M, Price C. Outpatient parenteral antimicrobial therapy among people who inject drugs: a review of the literature. Open Forum Infect Dis. 2018;5(9):ofy194. doi: 10.1093/ofid/ofy194. PubMed
14. D’Couto HT, Robbins GK, Ard KL, Wakeman SE, Alves J, Nelson SB. Outcomes according to discharge location for persons who inject drugs receiving outpatient parenteral antimicrobial therapy. Open Forum Infect Dis. 2018;5(5):ofy056. doi: 10.1093/ofid/ofy056. PubMed
15. Rosenthal ES, Karchmer AW, Theisen-Toupal J, Castillo RA, Rowley CF. Suboptimal addiction interventions for patients hospitalized with injection drug use-associated infective endocarditis. Am J Med. 2016;129(5):481-485. doi: 10.1016/j.amjmed.2015.09.024. PubMed
© 2019 Society of Hospital Medicine
Outpatient parenteral antimicrobial therapy for homeless patients saves lives, cuts costs
Prolonged hospitalizations for complicated patients with severe infections who need long courses of intravenous antibiotics, are common in many institutions.
Outpatient parenteral antimicrobial therapy (OPAT) is a safe and cost-effective way to administer intravenous (IV) antimicrobial therapy to patients with the potential to decrease hospital length of stay (LOS). OPAT programs train motivated patients in self-administration of IV medications at home, in a stable environment. Ideally, infectious disease (ID) consultation should be involved to determine appropriate candidates for OPAT as well as a suitable drug regimen and duration of therapy.
A potential barrier to successful utilization of OPAT programs is the need for stable housing at discharge for home infusion services.
Challenge facing homeless patients
There is very little published data regarding the use of OPAT at a medical respite facility for homeless patients. This may be due to perceived concerns of difficulty in administering OPAT to these disadvantaged patients for multiple reasons such as unstable or no housing, inability to stay engaged in medical care, and underlying mental illness and substance abuse problems. In particular, active substance abuse, specifically injection drug use (IDU), is a significant problem.
Traditionally, homeless patients requiring ongoing parenteral therapy have remained inpatient for the duration of their course, which can cause significant inpatient discharge delays and increased LOS. Recommending long-term parenteral therapy as an inpatient for all patients who are homeless or have a history of IDU can lead to prolonged hospitalizations, increased health care costs and contribute to conflicts between patients and staff.
Our study, recently published in the Journal of Hospital Medicine (J Hosp Med. 2016 Apr 27. doi: 10.1002/jhm.2597), aimed to evaluate our experience with administering OPAT to homeless patients at a medical respite facility and to determine if patients could complete a successful treatment course of antibiotics for a variety of illnesses.
We demonstrated that 87% of homeless patients were able to complete a defined course of antibiotic therapy, and 64% were successfully treated with OPAT at medical respite. To our knowledge this is the first study evaluating this specific population (including those with homelessness, mental illness, substance abuse) in which OPAT was received at medical respite.
Our rate of adverse events was 7%, similar to other OPAT studies in the published literature. Our total readmission rate of 30% was similar to what current literature suggests. Our data suggest that providing OPAT to homeless patients is feasible at a medical respite facility with care coordination between members of a multidisciplinary team, including nursing, home infusion pharmacist, and ID clinic.
Partnering with medical respite programs is important, as home infusion services are not available otherwise to homeless patients. The recommendation for ID consultation is beneficial to determine candidacy for OPAT, including close scrutiny of social behaviors in the OPAT patient selection process, and can assist with transitions in care from inpatient to outpatient setting.
Homeless IDU patients remain a challenging population to treat with long term IV antibiotics. However, in certain circumstances, IDU alone may not be a reason to fully exclude someone from OPAT candidacy. Careful review of substance abuse history and evaluation of psychosocial factors are needed. Furthermore, an evaluation of the patient’s willingness to comply with care agreements while inpatient and at medical respite, and ensuring appropriate resources for chemical dependency treatment are needed. Early consideration of oral antimicrobial options if the patient is readmitted for complications/non-adherence should be encouraged.
Medical respite programs
Treating homeless IDU patients with OPAT is possible under close supervision at medical respite. Our patients sign an agreement to refrain from using their IV access for drug use. Security seals are used on all connections and tubing to prevent tampering. The IV access sites are inspected daily, and ID providers are contacted to discuss any patients suspicious of tampering with their IV to determine plan of care – either readmission or transition to oral antibiotics.
Medical respite programs are gaining in popularity in the United States. Medical respite can help engage patients in follow-up care and provide linkage to housing, mental health, and chemical dependency services. Many programs support harm reduction IDU practices and offer referrals for substance abuse treatment programs, which are not typically offered during inpatient admission in most hospitals.
Medical respite may continue to be a site of OPAT expansion, as there is continued pressure to discharge nonacute patients from the hospital. Moving forward, it may be beneficial for hospitals, public health departments, and communities to support these programs, which can assist with close monitoring of homeless patients receiving OPAT.
There are ongoing challenges for housed IDU patients who require OPAT, as medical respite placement and home infusion are generally not options, and skilled nursing facility placement can be difficult. Careful review of substance abuse history; evaluation of psychosocial factors, such as housing status; mental health history; and outpatient support systems are needed.
Again, ID consultation is highly recommended to determine appropriate IV therapy, and if possible, early transition to oral antimicrobial therapy, as well as duration of treatment for specific illnesses on a case-by-case basis. Close follow-up is needed to ensure patient compliance with prescribed antimicrobial regimen, sometimes requiring weekly visits.
OPAT is effective for many patients, and it is optimal to utilize ID consultation to determine appropriate candidates – particularly among homeless and IDU patients. OPAT can be successful in a closely monitored medical respite setting for homeless patients with multiple comorbidities, with the help of a multidisciplinary team. Medical respite OPAT can decrease LOS in patients who would otherwise require long hospitalizations, resulting in overall cost savings.
Shireesha Dhanireddy, MD, is medical director of the infectious disease clinic at Harborview Medical Center, Seattle. Alison Beieler, PA-C, MPAS, runs the OPAT program in the infectious disease clinic at Harborview Medical Center.
Prolonged hospitalizations for complicated patients with severe infections who need long courses of intravenous antibiotics, are common in many institutions.
Outpatient parenteral antimicrobial therapy (OPAT) is a safe and cost-effective way to administer intravenous (IV) antimicrobial therapy to patients with the potential to decrease hospital length of stay (LOS). OPAT programs train motivated patients in self-administration of IV medications at home, in a stable environment. Ideally, infectious disease (ID) consultation should be involved to determine appropriate candidates for OPAT as well as a suitable drug regimen and duration of therapy.
A potential barrier to successful utilization of OPAT programs is the need for stable housing at discharge for home infusion services.
Challenge facing homeless patients
There is very little published data regarding the use of OPAT at a medical respite facility for homeless patients. This may be due to perceived concerns of difficulty in administering OPAT to these disadvantaged patients for multiple reasons such as unstable or no housing, inability to stay engaged in medical care, and underlying mental illness and substance abuse problems. In particular, active substance abuse, specifically injection drug use (IDU), is a significant problem.
Traditionally, homeless patients requiring ongoing parenteral therapy have remained inpatient for the duration of their course, which can cause significant inpatient discharge delays and increased LOS. Recommending long-term parenteral therapy as an inpatient for all patients who are homeless or have a history of IDU can lead to prolonged hospitalizations, increased health care costs and contribute to conflicts between patients and staff.
Our study, recently published in the Journal of Hospital Medicine (J Hosp Med. 2016 Apr 27. doi: 10.1002/jhm.2597), aimed to evaluate our experience with administering OPAT to homeless patients at a medical respite facility and to determine if patients could complete a successful treatment course of antibiotics for a variety of illnesses.
We demonstrated that 87% of homeless patients were able to complete a defined course of antibiotic therapy, and 64% were successfully treated with OPAT at medical respite. To our knowledge this is the first study evaluating this specific population (including those with homelessness, mental illness, substance abuse) in which OPAT was received at medical respite.
Our rate of adverse events was 7%, similar to other OPAT studies in the published literature. Our total readmission rate of 30% was similar to what current literature suggests. Our data suggest that providing OPAT to homeless patients is feasible at a medical respite facility with care coordination between members of a multidisciplinary team, including nursing, home infusion pharmacist, and ID clinic.
Partnering with medical respite programs is important, as home infusion services are not available otherwise to homeless patients. The recommendation for ID consultation is beneficial to determine candidacy for OPAT, including close scrutiny of social behaviors in the OPAT patient selection process, and can assist with transitions in care from inpatient to outpatient setting.
Homeless IDU patients remain a challenging population to treat with long term IV antibiotics. However, in certain circumstances, IDU alone may not be a reason to fully exclude someone from OPAT candidacy. Careful review of substance abuse history and evaluation of psychosocial factors are needed. Furthermore, an evaluation of the patient’s willingness to comply with care agreements while inpatient and at medical respite, and ensuring appropriate resources for chemical dependency treatment are needed. Early consideration of oral antimicrobial options if the patient is readmitted for complications/non-adherence should be encouraged.
Medical respite programs
Treating homeless IDU patients with OPAT is possible under close supervision at medical respite. Our patients sign an agreement to refrain from using their IV access for drug use. Security seals are used on all connections and tubing to prevent tampering. The IV access sites are inspected daily, and ID providers are contacted to discuss any patients suspicious of tampering with their IV to determine plan of care – either readmission or transition to oral antibiotics.
Medical respite programs are gaining in popularity in the United States. Medical respite can help engage patients in follow-up care and provide linkage to housing, mental health, and chemical dependency services. Many programs support harm reduction IDU practices and offer referrals for substance abuse treatment programs, which are not typically offered during inpatient admission in most hospitals.
Medical respite may continue to be a site of OPAT expansion, as there is continued pressure to discharge nonacute patients from the hospital. Moving forward, it may be beneficial for hospitals, public health departments, and communities to support these programs, which can assist with close monitoring of homeless patients receiving OPAT.
There are ongoing challenges for housed IDU patients who require OPAT, as medical respite placement and home infusion are generally not options, and skilled nursing facility placement can be difficult. Careful review of substance abuse history; evaluation of psychosocial factors, such as housing status; mental health history; and outpatient support systems are needed.
Again, ID consultation is highly recommended to determine appropriate IV therapy, and if possible, early transition to oral antimicrobial therapy, as well as duration of treatment for specific illnesses on a case-by-case basis. Close follow-up is needed to ensure patient compliance with prescribed antimicrobial regimen, sometimes requiring weekly visits.
OPAT is effective for many patients, and it is optimal to utilize ID consultation to determine appropriate candidates – particularly among homeless and IDU patients. OPAT can be successful in a closely monitored medical respite setting for homeless patients with multiple comorbidities, with the help of a multidisciplinary team. Medical respite OPAT can decrease LOS in patients who would otherwise require long hospitalizations, resulting in overall cost savings.
Shireesha Dhanireddy, MD, is medical director of the infectious disease clinic at Harborview Medical Center, Seattle. Alison Beieler, PA-C, MPAS, runs the OPAT program in the infectious disease clinic at Harborview Medical Center.
Prolonged hospitalizations for complicated patients with severe infections who need long courses of intravenous antibiotics, are common in many institutions.
Outpatient parenteral antimicrobial therapy (OPAT) is a safe and cost-effective way to administer intravenous (IV) antimicrobial therapy to patients with the potential to decrease hospital length of stay (LOS). OPAT programs train motivated patients in self-administration of IV medications at home, in a stable environment. Ideally, infectious disease (ID) consultation should be involved to determine appropriate candidates for OPAT as well as a suitable drug regimen and duration of therapy.
A potential barrier to successful utilization of OPAT programs is the need for stable housing at discharge for home infusion services.
Challenge facing homeless patients
There is very little published data regarding the use of OPAT at a medical respite facility for homeless patients. This may be due to perceived concerns of difficulty in administering OPAT to these disadvantaged patients for multiple reasons such as unstable or no housing, inability to stay engaged in medical care, and underlying mental illness and substance abuse problems. In particular, active substance abuse, specifically injection drug use (IDU), is a significant problem.
Traditionally, homeless patients requiring ongoing parenteral therapy have remained inpatient for the duration of their course, which can cause significant inpatient discharge delays and increased LOS. Recommending long-term parenteral therapy as an inpatient for all patients who are homeless or have a history of IDU can lead to prolonged hospitalizations, increased health care costs and contribute to conflicts between patients and staff.
Our study, recently published in the Journal of Hospital Medicine (J Hosp Med. 2016 Apr 27. doi: 10.1002/jhm.2597), aimed to evaluate our experience with administering OPAT to homeless patients at a medical respite facility and to determine if patients could complete a successful treatment course of antibiotics for a variety of illnesses.
We demonstrated that 87% of homeless patients were able to complete a defined course of antibiotic therapy, and 64% were successfully treated with OPAT at medical respite. To our knowledge this is the first study evaluating this specific population (including those with homelessness, mental illness, substance abuse) in which OPAT was received at medical respite.
Our rate of adverse events was 7%, similar to other OPAT studies in the published literature. Our total readmission rate of 30% was similar to what current literature suggests. Our data suggest that providing OPAT to homeless patients is feasible at a medical respite facility with care coordination between members of a multidisciplinary team, including nursing, home infusion pharmacist, and ID clinic.
Partnering with medical respite programs is important, as home infusion services are not available otherwise to homeless patients. The recommendation for ID consultation is beneficial to determine candidacy for OPAT, including close scrutiny of social behaviors in the OPAT patient selection process, and can assist with transitions in care from inpatient to outpatient setting.
Homeless IDU patients remain a challenging population to treat with long term IV antibiotics. However, in certain circumstances, IDU alone may not be a reason to fully exclude someone from OPAT candidacy. Careful review of substance abuse history and evaluation of psychosocial factors are needed. Furthermore, an evaluation of the patient’s willingness to comply with care agreements while inpatient and at medical respite, and ensuring appropriate resources for chemical dependency treatment are needed. Early consideration of oral antimicrobial options if the patient is readmitted for complications/non-adherence should be encouraged.
Medical respite programs
Treating homeless IDU patients with OPAT is possible under close supervision at medical respite. Our patients sign an agreement to refrain from using their IV access for drug use. Security seals are used on all connections and tubing to prevent tampering. The IV access sites are inspected daily, and ID providers are contacted to discuss any patients suspicious of tampering with their IV to determine plan of care – either readmission or transition to oral antibiotics.
Medical respite programs are gaining in popularity in the United States. Medical respite can help engage patients in follow-up care and provide linkage to housing, mental health, and chemical dependency services. Many programs support harm reduction IDU practices and offer referrals for substance abuse treatment programs, which are not typically offered during inpatient admission in most hospitals.
Medical respite may continue to be a site of OPAT expansion, as there is continued pressure to discharge nonacute patients from the hospital. Moving forward, it may be beneficial for hospitals, public health departments, and communities to support these programs, which can assist with close monitoring of homeless patients receiving OPAT.
There are ongoing challenges for housed IDU patients who require OPAT, as medical respite placement and home infusion are generally not options, and skilled nursing facility placement can be difficult. Careful review of substance abuse history; evaluation of psychosocial factors, such as housing status; mental health history; and outpatient support systems are needed.
Again, ID consultation is highly recommended to determine appropriate IV therapy, and if possible, early transition to oral antimicrobial therapy, as well as duration of treatment for specific illnesses on a case-by-case basis. Close follow-up is needed to ensure patient compliance with prescribed antimicrobial regimen, sometimes requiring weekly visits.
OPAT is effective for many patients, and it is optimal to utilize ID consultation to determine appropriate candidates – particularly among homeless and IDU patients. OPAT can be successful in a closely monitored medical respite setting for homeless patients with multiple comorbidities, with the help of a multidisciplinary team. Medical respite OPAT can decrease LOS in patients who would otherwise require long hospitalizations, resulting in overall cost savings.
Shireesha Dhanireddy, MD, is medical director of the infectious disease clinic at Harborview Medical Center, Seattle. Alison Beieler, PA-C, MPAS, runs the OPAT program in the infectious disease clinic at Harborview Medical Center.
OPAT at a Medical Respite Facility
Prolonged hospitalizations for complex patients with severe infections and difficult social situations are becoming very common in many institutions. Outpatient parenteral antimicrobial therapy (OPAT) is widely used[1] and has been found to be a safe, efficient, and cost‐effective way to administer intravenous (IV) antimicrobial therapy to patients, with the potential to decrease hospital length of stay (LOS) and to improve patient satisfaction.[2] Infectious disease (ID) consultation should be involved to determine appropriate candidates for OPAT as well as a suitable drug regimen and duration of therapy,[3] or if oral alternatives can be utilized.[4] OPAT patients require close laboratory monitoring and provider follow‐up for the duration of their care. The combination of ID consultation, patient selection, laboratory monitoring, and follow‐up care have been described as part of a proposed OPAT bundle in recent medical literature.[5] Appropriate patient selection is a key component as to whether or not a patient will be successful with OPAT once discharged from the hospital. Current Infectious Diseases Society of America (IDSA) guidelines recommend that patients be evaluated for stable housing and ability to perform OPAT‐specific duties prior to discharge.[3]
To our knowledge there are no published data regarding the use of OPAT at a medical respite facility for homeless patients with co‐morbid substance abuse and mental illness issues. This may be due to perceived concerns of difficulty in administering OPAT to these disadvantaged patients for multiple reasons such as unstable or no housing, inability to stay engaged in medical care, and underlying mental illness and substance abuse problems. In particular, the concern for substance abuse, specifically injection drug use (IDU), is a significant problem. The current IDSA guidelines for OPAT recommend patients who are likely to abuse a vascular access system are poor candidates for OPAT.[3]
A major barrier to successful utilization of OPAT programs is the need for stable housing so that antibiotics can be administered in a safe setting. Recommending long‐term parenteral therapy as an inpatient for all patients who are homeless or have a history of IDU can lead to prolonged hospitalizations, increased healthcare costs, and contribute to conflicts between patients and staff. Chemical dependence treatment is not available in most inpatient settings, leaving patients with addiction issues without options. Most patients would prefer, when given the choice, to be treated with OPAT outside of the inpatient setting.[6]
This study aimed to evaluate our experience with administering OPAT to homeless patients at a medical respite facility and to determine if patients could complete a successful treatment course of antibiotics for a variety of illnesses.
METHODS
Harborview Medical Center (HMC) is a 413‐bed county hospital, and serves as a major teaching hospital for the University of Washington. It is a level 1 trauma/burn center for Washington, Wyoming, Alaska, Montana, and Idaho. The hospital has 61 psychiatric beds, 29 rehabilitation beds, and 89 intensive care unit beds, with over 60,000 emergency department visits per year. Harborview also serves as a public safety‐net hospital for King County, providing $219 million in charity care in 2013.
Housed in a building adjacent to HMC is a 34‐bed medical respite program,[7] which was established in 2011 through collaboration with King County and 6 other hospitals to serve the homeless population needing medical care, similar to programs in Boston[8] and San Francisco.[9] It is staffed by a multidisciplinary team from HMC including a physician, nurse practitioners, registered nurses, medical assistants, mental health specialists, case managers, and security guards, and accepts patients from all hospitals and clinics within King County. To qualify for medical respite, patient must be homeless and require ongoing nursing needs (ie, wound care, parenteral therapy). Referred patients are screened by a nurse prior to admission. The projected daily cost at medical respite is $350 per patient.
Medical respite is a harm‐reduction model, which includes information on needle exchange programs, narcan kits and education on safer injection practices. Resources are available for patients wishing to start a rehabilitation program, including opiate replacement therapy. Patients may leave the premises during the day, but a curfew is enforced at 9 pm nightly. Patients sign a contract on admission to refrain from using their IV line for IDU and peripherally‐inserted central catheter (PICC) port is secured and monitored for manipulation. Patients who exhibit threatening behavior or who use alcohol/drugs on site are discharged from the program. Patients in need of OPAT must keep nurse visits once or twice daily depending on medication and wound care. Medications needing more frequent dosing were placed on a battery‐operated pump and changed once every 24 hours by nursing.
After obtaining approval from the University of Washington Institutional Review Board, we performed a retrospective chart review of homeless patients over 18 years old discharged from HMC who received OPAT at medical respite from January 1, 2012 to January 1, 2014. There were no exclusions for race, gender, or insurance status. Patients included in the study were respite candidates, and required prolonged parenteral antibiotic therapy. Data collection was performed using a REDCap data collection tool and REDCap grant support.[10] Demographics, diagnosis, and comorbidities, including mental illness, current IDU at time of admission, and remote IDU (last use >3 months ago) were obtained from the electronic medical record. Surgical, microbiologic, and antimicrobial therapy, including route (IV or oral), duration of therapy, and adverse events were abstracted. Primary outcome was defined as successful completion of OPAT at medical respite without nonadherence to therapy or readmission (for presumed OPAT failure). A secondary outcome was antimicrobial course completion for a specific diagnosis defined by achieving goal duration of parenteral and/or oral antibiotic therapy as deemed appropriate by an ID provider. Nonadherence is defined as missing greater than 2 doses of scheduled antibiotic, absence from respite for greater than 24 hours, evidence of line tampering, or expulsion from respite for violation of care agreement. Recurrence of infection was defined as subsequent infection at the same site, following completion of a prior antimicrobial course, at the most recent follow‐up visit.
Continuous variables are expressed as the mean standard deviation, and categorical variables are expressed as the proportion of the entire population. Categorical variables are compared using the 2 test. A 2‐sided P value of <0.05 was considered statistically significant.
RESULTS
Fifty‐one homeless patients were identified with 53 episodes of OPAT between January 1, 2012 and January 1, 2014. For ease of reporting, the number of episodes of OPAT (n = 53) was used as the denominator instead of number of patients (n = 51) for descriptive statistics. The average age was 45 10.4 years (range, 2262 years), 38 (72%) patients were male, and 39 (74%) were Caucasian. Comorbidities included 28 (53%) patients with current IDU and 9 (17%) with a remote history of IDU, 32 (60%) with hepatitis C infection, and 14 (26%) with mental illness (Table 1).
| Comorbidities | No. per Patient Episode, n = 53 (%) |
|---|---|
| |
| Hepatitis C infection | 32 (60%) |
| Current IDU | 28 (53%) |
| Psychiatric/mental illness | 14 (26%) |
| Remote IDU | 9 (17%) |
| Hypertension | 7 (13%) |
| Diabetes type 1 or type 2 | 5 (9%) |
| Rheumatologic diagnosis | 3 (6%) |
| Obesity | 2 (4%) |
| Cardiovascular disease | 2 (4%) |
| Peripheral vascular disease | 2 (4%) |
| Congestive heart failure | 2 (4%) |
| Chronic kidney disease (any stage) | 1 (2%) |
| HIV | 1 (2%) |
Forty‐six (87%) patients were evaluated by an ID physician during their admission. Diagnosis (some patients had multiple) requiring OPAT included: bacteremia in 28, osteomyelitis in 22, skin and soft tissue infection in 19, endocarditis in 15, and epidural abscess in 7 patients. Twenty‐nine patients underwent surgical intervention. The pathogens recovered were primarily gram‐positive organisms. Multidrug resistant organisms were isolated in 11 patients. The IV medications used included vancomycin, nafcillin, cefazolin, ertapenem, and daptomycin.
Forty‐six (87%) patients completed a defined course of antibiotic therapy (deemed appropriate therapy by an ID physician) for their specific infection. Thirty‐four (64%) patients were successfully treated with OPAT at medical respite. There were 19 (36%) failures, which included nonadherent patients, some of whom required urgent readmission (Table 2). There were a total of 16 readmissions, and 10 of those were considered OPAT failures, whereas the other 6 were not (patients admitted for other reasons including, surgery, and IV malfunction). Of the total readmissions, 12 of those were current or remote IDU patients. There is a trend toward a higher prevalence of current/remote IDU among those with clinical failure (15/19, 79%) compared to those with clinical success (22/34, 65%) (P = 0.2788). Overall, 27 (51%) patients were switched to oral therapy after completing an initial IV course. Oral agents used were: trimethoprim‐sulfamethoxazole, rifampin, doxycycline, fluconazole, linezolid, fluoroquinolones, and amoxicillin/clavulanic acid. The average length of OPAT was 22 days. The average daily cost of an acute‐care bed day in 2015 was $1500 at our institution. The cost savings to our institution (using $1500/day inpatient cost compared to $350 per day at medical respite) was $25,000 per episode of OPAT.
| No. of Episodes of Care, n = 53 (%) | |
|---|---|
| |
| Successfully treated at medical respite | 34 (64%) |
| Nonadherent to therapy | 19 (36%) |
| Left respite with IV line in place | 6 [2 admitted, 3 orals, 1 lost] |
| Missed IV doses and switched to orals | 5 |
| Missed IV doses and admitted | 8 admitted |
| Any hospital readmission | 16 (30%) |
| Readmissions, assumed failures | 10 (19%) |
| PICC‐lineassociated infection/bacteremia | 2 |
| SIRS with suspected line infection | 2 |
| Ongoing IDU /discharge from respite | 2 |
| Nonadherent with OPAT/altercations | 3 |
| Acute kidney injury | 1 |
| Readmissions, not counted as failures | 6 (11%) |
| PICC malfunction (leaking) | 2 [1 had further OPAT] |
| Surgery | 4 [3 had further OPAT] |
During the course of OPAT, 7 (13%) patients experienced an adverse event. Of those, we had 1 patient with drug rash, 1 with nausea, and 1 with diarrhea (not infectious). One patient developed leukopenia (white blood cells <4.0), and 2 patients developed neutropenia (absolute neutrophils <750). One patient developed significant elevation of creatinine(>1.9 upper limit of normal) and required inpatient admission. An additional 5 patients had a small elevation of creatinine that did not meet the criteria listed above and were not counted as adverse events by definition. At the study conclusion, 36 (68%) patients had no recurrence of infection at the most recent follow‐up visit at HMC; length of follow‐up ranged from 2 months to 2.5 years. One patient later died of nonOPAT‐related complications. In total, 11 (21%) patients were lost to follow‐up, 1 with a peripherally inserted central catheter line in place.
DISCUSSION
We demonstrated that 87% of homeless patients were able to complete a defined course of antibiotic therapy, and 64% were successfully treated with OPAT at medical respite. To our knowledge this is the first study evaluating this specific population in which OPAT was received at medical respite. Our rate of adverse events (some that required change in drug therapy) was similar to other OPAT studies in the published literature, ranging from 3% to 10% in 1 study,[3] and up to 11% in another.[11] Our total readmission rate of 30% was similar to what current literature suggests, ranging from 9%[11] up to 26%[12] for OPAT patients. Notably, 11% of the readmissions were not related to OPAT failure. This supports the recommendation for close scrutiny of social behaviors in the OPAT patient‐selection process; however, in certain circumstances, IDU alone may not be a reason to fully exclude someone from OPAT candidacy. Careful review of substance abuse history and evaluation of psychosocial factors, such as housing status, mental health history, and outpatient support system are needed. Furthermore, an evaluation of the patient's willingness to comply with care agreements while an inpatient and at respite, and ensuring appropriate resources for chemical dependency treatment are needed. Early consideration of oral antimicrobial options if the patient is readmitted for complications/nonadherence should be encouraged.
Our findings are consistent with results reported by Ho and colleagues, which demonstrated a success rate of 97% of IDU OPAT patients.[13] They carefully chose 29 study patients from 906 in their OPAT program over several years, giving them daily infusions under close supervision. Patients signed an agreement to refrain from accessing their IV lines for drug use. Special security seals were used on all connections and tubing to prevent line tampering. Medical respite in King County uses a similar technique, using a Tegaderm dressing to cover all valves and tubing junction sites to prevent tampering. The IV lines are inspected daily, and ID providers were contacted to discuss any patients suspicious of tampering with their lines to discuss next appropriate steps, either readmission or transition to oral antibiotics. Half of our patients were switched to oral therapy during their course, consistent with current literature.[12, 14]
Traditionally, homeless patients requiring ongoing parenteral therapy have remained inpatients for the duration of their course. Feigal and colleagues evaluated the connection between homelessness and inpatient discharge delays for placement over a 6‐month period in 2009 at an urban hospital.[15] They found homeless patients awaiting placement had an increased median LOS of 26 days, compared to housed individuals with 14 days. Homeless patients without a psychiatric disorder had a delay in discharge 60% longer compared to those with housing, with data adjusted for multiple variables. The cause for delay in discharge in homeless patients was found in those awaiting group home or nursing facility placement, in 50% of cases, whereas delay for chemical dependency program was in 17% of cases, and other local treatment center in 12% of cases.
Medical respite programs are gaining in popularity in the United States since they began in the mid‐1980s.[16] A review by Doran and colleagues found medical respite can result in cost avoidance for hospitals by limiting inpatient days and readmissions.[17] Medical respite can also help engage patients in follow‐up care and assist with housing placement. Many programs promote safe IDU practices and offer referrals for rehabilitation programs, both of which are programs that are not available in most hospitals. Medical respite may continue to be a site of OPAT expansion, as there is continued pressure to discharge nonacute patients from the hospital. Moving forward, it may be beneficial for hospitals, public health departments, and communities to support these programs, which can assist with close monitoring of homeless patients receiving OPAT.
There were several limitations in our study. This was a retrospective observational study with a small patient population comprised of a high prevalence of current and remote IDU. The single center study makes it difficult to generalize to other settings. In addition, there were no comparative data with historical controls, making it difficult to perform comparative analysis.
OPAT is effective for many patients, and it is optimal to utilize ID consultation to determine appropriate candidacy,[3, 4, 5] particularly among IDU. OPAT can be successful in a closely monitored medical respite setting for homeless patients with the help of a multidisciplinary team. Medical respite OPAT can decrease inpatient stays in patients who would otherwise require long hospitalizations, resulting in overall cost savings, and may lead to improved patient satisfaction. Future research linking other outcomes of medical respite OPAT, including substance‐dependence treatment and transition to housing, is warranted.
Acknowledgements
The authors thank the staff at the Harborview Medical Center Infectious Disease Clinic and at Edward Thomas House Medical Respite for their help in this study.
Disclosures: Presented at the oral abstract session Clinical Practice IssuesOPAT in Diverse Populations, IDWeek, October 812, 2014, Philadelphia, Pennsylvania. The authors report no conflicts of interest.
- , , , et al. Experience of infectious diseases consultants with outpatient parenteral antimicrobial therapy: results of an emerging infections network survey. Clin Infect Dis. 2006;43:1290–1295.
- , , , et al. Randomized controlled trial of intravenous antibiotic therapy for cellulitis at home compared with hospital. BMJ. 2005;330:129.
- , , , et al. Practice guidelines for outpatient parenteral antimicrobial therapy. IDSA guidelines. Clin Infect Dis. 2004;38:1651–1672.
- , , . Mandatory infectious diseases approval of outpatient parenteral antimicrobial therapy (OPAT): clinical and economic outcomes of averted cases. J Antimicrob Chemother. 2014;10:1093–1099.
- , , , . Are we ready for an outpatient parenteral antimicrobial therapy bundle? A critical appraisal of the evidence. Clin Infect Dis. 2013;57:419–424.
- , , , et al. Willingness to pay to access patient preferences for therapy in a Canadian setting. BMC Health Serv Res. 2005;5:43.
- UW Medicine. Respite program at Jefferson Terrace (Edward Thomas House). University of Washington website. Available at: http://www.uwmedicine.org/locations/respite‐program‐jefferson‐terrace. Accessed October 1, 2015.
- Boston Healthcare for the Homeless Program. Medical respite care at the Barbara McInnis House. Available at: http://www.bhchp.org/medical‐respite‐care. Accessed October 1, 2015.
- San Francisco Department of Public Health. Medical Respite and Sobering Center. Available at: https://www.sfdph.org/dph/comupg/oprograms/HUH/medrespite.asp. Accessed October 1, 2015.
- , , , , , . Research electronic data capture (REDCap)—a metadata‐driven methodology and workflow process for providing translational research informatics support. J Biomed Inform. 2009;42:377–381.
- , , . Outpatient parenteral antimicrobial therapy (OPAT) in a teaching hospital‐based practice: a retrospective cohort study describing experience and evolution over 10 years. Int J Antimicro Agents. 2012;39:407–413.
- , , , et al. Prediction model for 30‐day hospital readmissions among patients discharged receiving outpatient parenteral antibiotic therapy. Clin Infect Dis. 2014;58:812–819.
- , , , . Safe and successful treatment of intravenous drug users with a peripherally inserted central catheter in an outpatient parenteral antibiotic treatment service. J Antimicrob Chemother. 2010;65:2641–2644.
- , . Outpatient parenteral antimicrobial therapy and antimicrobial stewardship: challenges and checklists. J Antimicrob Chemother. 2015;70:965–970.
- , , , , , . Homelessness and discharge delays from an urban safety net hospital. Public Health. 2014;128:1033–1035.
- , , . Medical respite care for homeless people: a growing national phenomenon. J Health Care Poor Underserved. 2009;20:36–41.
- , , , . Medical respite programs for homeless patients: a systematic review. J Health Care Poor Underserved. 2013;24:499–524.
Prolonged hospitalizations for complex patients with severe infections and difficult social situations are becoming very common in many institutions. Outpatient parenteral antimicrobial therapy (OPAT) is widely used[1] and has been found to be a safe, efficient, and cost‐effective way to administer intravenous (IV) antimicrobial therapy to patients, with the potential to decrease hospital length of stay (LOS) and to improve patient satisfaction.[2] Infectious disease (ID) consultation should be involved to determine appropriate candidates for OPAT as well as a suitable drug regimen and duration of therapy,[3] or if oral alternatives can be utilized.[4] OPAT patients require close laboratory monitoring and provider follow‐up for the duration of their care. The combination of ID consultation, patient selection, laboratory monitoring, and follow‐up care have been described as part of a proposed OPAT bundle in recent medical literature.[5] Appropriate patient selection is a key component as to whether or not a patient will be successful with OPAT once discharged from the hospital. Current Infectious Diseases Society of America (IDSA) guidelines recommend that patients be evaluated for stable housing and ability to perform OPAT‐specific duties prior to discharge.[3]
To our knowledge there are no published data regarding the use of OPAT at a medical respite facility for homeless patients with co‐morbid substance abuse and mental illness issues. This may be due to perceived concerns of difficulty in administering OPAT to these disadvantaged patients for multiple reasons such as unstable or no housing, inability to stay engaged in medical care, and underlying mental illness and substance abuse problems. In particular, the concern for substance abuse, specifically injection drug use (IDU), is a significant problem. The current IDSA guidelines for OPAT recommend patients who are likely to abuse a vascular access system are poor candidates for OPAT.[3]
A major barrier to successful utilization of OPAT programs is the need for stable housing so that antibiotics can be administered in a safe setting. Recommending long‐term parenteral therapy as an inpatient for all patients who are homeless or have a history of IDU can lead to prolonged hospitalizations, increased healthcare costs, and contribute to conflicts between patients and staff. Chemical dependence treatment is not available in most inpatient settings, leaving patients with addiction issues without options. Most patients would prefer, when given the choice, to be treated with OPAT outside of the inpatient setting.[6]
This study aimed to evaluate our experience with administering OPAT to homeless patients at a medical respite facility and to determine if patients could complete a successful treatment course of antibiotics for a variety of illnesses.
METHODS
Harborview Medical Center (HMC) is a 413‐bed county hospital, and serves as a major teaching hospital for the University of Washington. It is a level 1 trauma/burn center for Washington, Wyoming, Alaska, Montana, and Idaho. The hospital has 61 psychiatric beds, 29 rehabilitation beds, and 89 intensive care unit beds, with over 60,000 emergency department visits per year. Harborview also serves as a public safety‐net hospital for King County, providing $219 million in charity care in 2013.
Housed in a building adjacent to HMC is a 34‐bed medical respite program,[7] which was established in 2011 through collaboration with King County and 6 other hospitals to serve the homeless population needing medical care, similar to programs in Boston[8] and San Francisco.[9] It is staffed by a multidisciplinary team from HMC including a physician, nurse practitioners, registered nurses, medical assistants, mental health specialists, case managers, and security guards, and accepts patients from all hospitals and clinics within King County. To qualify for medical respite, patient must be homeless and require ongoing nursing needs (ie, wound care, parenteral therapy). Referred patients are screened by a nurse prior to admission. The projected daily cost at medical respite is $350 per patient.
Medical respite is a harm‐reduction model, which includes information on needle exchange programs, narcan kits and education on safer injection practices. Resources are available for patients wishing to start a rehabilitation program, including opiate replacement therapy. Patients may leave the premises during the day, but a curfew is enforced at 9 pm nightly. Patients sign a contract on admission to refrain from using their IV line for IDU and peripherally‐inserted central catheter (PICC) port is secured and monitored for manipulation. Patients who exhibit threatening behavior or who use alcohol/drugs on site are discharged from the program. Patients in need of OPAT must keep nurse visits once or twice daily depending on medication and wound care. Medications needing more frequent dosing were placed on a battery‐operated pump and changed once every 24 hours by nursing.
After obtaining approval from the University of Washington Institutional Review Board, we performed a retrospective chart review of homeless patients over 18 years old discharged from HMC who received OPAT at medical respite from January 1, 2012 to January 1, 2014. There were no exclusions for race, gender, or insurance status. Patients included in the study were respite candidates, and required prolonged parenteral antibiotic therapy. Data collection was performed using a REDCap data collection tool and REDCap grant support.[10] Demographics, diagnosis, and comorbidities, including mental illness, current IDU at time of admission, and remote IDU (last use >3 months ago) were obtained from the electronic medical record. Surgical, microbiologic, and antimicrobial therapy, including route (IV or oral), duration of therapy, and adverse events were abstracted. Primary outcome was defined as successful completion of OPAT at medical respite without nonadherence to therapy or readmission (for presumed OPAT failure). A secondary outcome was antimicrobial course completion for a specific diagnosis defined by achieving goal duration of parenteral and/or oral antibiotic therapy as deemed appropriate by an ID provider. Nonadherence is defined as missing greater than 2 doses of scheduled antibiotic, absence from respite for greater than 24 hours, evidence of line tampering, or expulsion from respite for violation of care agreement. Recurrence of infection was defined as subsequent infection at the same site, following completion of a prior antimicrobial course, at the most recent follow‐up visit.
Continuous variables are expressed as the mean standard deviation, and categorical variables are expressed as the proportion of the entire population. Categorical variables are compared using the 2 test. A 2‐sided P value of <0.05 was considered statistically significant.
RESULTS
Fifty‐one homeless patients were identified with 53 episodes of OPAT between January 1, 2012 and January 1, 2014. For ease of reporting, the number of episodes of OPAT (n = 53) was used as the denominator instead of number of patients (n = 51) for descriptive statistics. The average age was 45 10.4 years (range, 2262 years), 38 (72%) patients were male, and 39 (74%) were Caucasian. Comorbidities included 28 (53%) patients with current IDU and 9 (17%) with a remote history of IDU, 32 (60%) with hepatitis C infection, and 14 (26%) with mental illness (Table 1).
| Comorbidities | No. per Patient Episode, n = 53 (%) |
|---|---|
| |
| Hepatitis C infection | 32 (60%) |
| Current IDU | 28 (53%) |
| Psychiatric/mental illness | 14 (26%) |
| Remote IDU | 9 (17%) |
| Hypertension | 7 (13%) |
| Diabetes type 1 or type 2 | 5 (9%) |
| Rheumatologic diagnosis | 3 (6%) |
| Obesity | 2 (4%) |
| Cardiovascular disease | 2 (4%) |
| Peripheral vascular disease | 2 (4%) |
| Congestive heart failure | 2 (4%) |
| Chronic kidney disease (any stage) | 1 (2%) |
| HIV | 1 (2%) |
Forty‐six (87%) patients were evaluated by an ID physician during their admission. Diagnosis (some patients had multiple) requiring OPAT included: bacteremia in 28, osteomyelitis in 22, skin and soft tissue infection in 19, endocarditis in 15, and epidural abscess in 7 patients. Twenty‐nine patients underwent surgical intervention. The pathogens recovered were primarily gram‐positive organisms. Multidrug resistant organisms were isolated in 11 patients. The IV medications used included vancomycin, nafcillin, cefazolin, ertapenem, and daptomycin.
Forty‐six (87%) patients completed a defined course of antibiotic therapy (deemed appropriate therapy by an ID physician) for their specific infection. Thirty‐four (64%) patients were successfully treated with OPAT at medical respite. There were 19 (36%) failures, which included nonadherent patients, some of whom required urgent readmission (Table 2). There were a total of 16 readmissions, and 10 of those were considered OPAT failures, whereas the other 6 were not (patients admitted for other reasons including, surgery, and IV malfunction). Of the total readmissions, 12 of those were current or remote IDU patients. There is a trend toward a higher prevalence of current/remote IDU among those with clinical failure (15/19, 79%) compared to those with clinical success (22/34, 65%) (P = 0.2788). Overall, 27 (51%) patients were switched to oral therapy after completing an initial IV course. Oral agents used were: trimethoprim‐sulfamethoxazole, rifampin, doxycycline, fluconazole, linezolid, fluoroquinolones, and amoxicillin/clavulanic acid. The average length of OPAT was 22 days. The average daily cost of an acute‐care bed day in 2015 was $1500 at our institution. The cost savings to our institution (using $1500/day inpatient cost compared to $350 per day at medical respite) was $25,000 per episode of OPAT.
| No. of Episodes of Care, n = 53 (%) | |
|---|---|
| |
| Successfully treated at medical respite | 34 (64%) |
| Nonadherent to therapy | 19 (36%) |
| Left respite with IV line in place | 6 [2 admitted, 3 orals, 1 lost] |
| Missed IV doses and switched to orals | 5 |
| Missed IV doses and admitted | 8 admitted |
| Any hospital readmission | 16 (30%) |
| Readmissions, assumed failures | 10 (19%) |
| PICC‐lineassociated infection/bacteremia | 2 |
| SIRS with suspected line infection | 2 |
| Ongoing IDU /discharge from respite | 2 |
| Nonadherent with OPAT/altercations | 3 |
| Acute kidney injury | 1 |
| Readmissions, not counted as failures | 6 (11%) |
| PICC malfunction (leaking) | 2 [1 had further OPAT] |
| Surgery | 4 [3 had further OPAT] |
During the course of OPAT, 7 (13%) patients experienced an adverse event. Of those, we had 1 patient with drug rash, 1 with nausea, and 1 with diarrhea (not infectious). One patient developed leukopenia (white blood cells <4.0), and 2 patients developed neutropenia (absolute neutrophils <750). One patient developed significant elevation of creatinine(>1.9 upper limit of normal) and required inpatient admission. An additional 5 patients had a small elevation of creatinine that did not meet the criteria listed above and were not counted as adverse events by definition. At the study conclusion, 36 (68%) patients had no recurrence of infection at the most recent follow‐up visit at HMC; length of follow‐up ranged from 2 months to 2.5 years. One patient later died of nonOPAT‐related complications. In total, 11 (21%) patients were lost to follow‐up, 1 with a peripherally inserted central catheter line in place.
DISCUSSION
We demonstrated that 87% of homeless patients were able to complete a defined course of antibiotic therapy, and 64% were successfully treated with OPAT at medical respite. To our knowledge this is the first study evaluating this specific population in which OPAT was received at medical respite. Our rate of adverse events (some that required change in drug therapy) was similar to other OPAT studies in the published literature, ranging from 3% to 10% in 1 study,[3] and up to 11% in another.[11] Our total readmission rate of 30% was similar to what current literature suggests, ranging from 9%[11] up to 26%[12] for OPAT patients. Notably, 11% of the readmissions were not related to OPAT failure. This supports the recommendation for close scrutiny of social behaviors in the OPAT patient‐selection process; however, in certain circumstances, IDU alone may not be a reason to fully exclude someone from OPAT candidacy. Careful review of substance abuse history and evaluation of psychosocial factors, such as housing status, mental health history, and outpatient support system are needed. Furthermore, an evaluation of the patient's willingness to comply with care agreements while an inpatient and at respite, and ensuring appropriate resources for chemical dependency treatment are needed. Early consideration of oral antimicrobial options if the patient is readmitted for complications/nonadherence should be encouraged.
Our findings are consistent with results reported by Ho and colleagues, which demonstrated a success rate of 97% of IDU OPAT patients.[13] They carefully chose 29 study patients from 906 in their OPAT program over several years, giving them daily infusions under close supervision. Patients signed an agreement to refrain from accessing their IV lines for drug use. Special security seals were used on all connections and tubing to prevent line tampering. Medical respite in King County uses a similar technique, using a Tegaderm dressing to cover all valves and tubing junction sites to prevent tampering. The IV lines are inspected daily, and ID providers were contacted to discuss any patients suspicious of tampering with their lines to discuss next appropriate steps, either readmission or transition to oral antibiotics. Half of our patients were switched to oral therapy during their course, consistent with current literature.[12, 14]
Traditionally, homeless patients requiring ongoing parenteral therapy have remained inpatients for the duration of their course. Feigal and colleagues evaluated the connection between homelessness and inpatient discharge delays for placement over a 6‐month period in 2009 at an urban hospital.[15] They found homeless patients awaiting placement had an increased median LOS of 26 days, compared to housed individuals with 14 days. Homeless patients without a psychiatric disorder had a delay in discharge 60% longer compared to those with housing, with data adjusted for multiple variables. The cause for delay in discharge in homeless patients was found in those awaiting group home or nursing facility placement, in 50% of cases, whereas delay for chemical dependency program was in 17% of cases, and other local treatment center in 12% of cases.
Medical respite programs are gaining in popularity in the United States since they began in the mid‐1980s.[16] A review by Doran and colleagues found medical respite can result in cost avoidance for hospitals by limiting inpatient days and readmissions.[17] Medical respite can also help engage patients in follow‐up care and assist with housing placement. Many programs promote safe IDU practices and offer referrals for rehabilitation programs, both of which are programs that are not available in most hospitals. Medical respite may continue to be a site of OPAT expansion, as there is continued pressure to discharge nonacute patients from the hospital. Moving forward, it may be beneficial for hospitals, public health departments, and communities to support these programs, which can assist with close monitoring of homeless patients receiving OPAT.
There were several limitations in our study. This was a retrospective observational study with a small patient population comprised of a high prevalence of current and remote IDU. The single center study makes it difficult to generalize to other settings. In addition, there were no comparative data with historical controls, making it difficult to perform comparative analysis.
OPAT is effective for many patients, and it is optimal to utilize ID consultation to determine appropriate candidacy,[3, 4, 5] particularly among IDU. OPAT can be successful in a closely monitored medical respite setting for homeless patients with the help of a multidisciplinary team. Medical respite OPAT can decrease inpatient stays in patients who would otherwise require long hospitalizations, resulting in overall cost savings, and may lead to improved patient satisfaction. Future research linking other outcomes of medical respite OPAT, including substance‐dependence treatment and transition to housing, is warranted.
Acknowledgements
The authors thank the staff at the Harborview Medical Center Infectious Disease Clinic and at Edward Thomas House Medical Respite for their help in this study.
Disclosures: Presented at the oral abstract session Clinical Practice IssuesOPAT in Diverse Populations, IDWeek, October 812, 2014, Philadelphia, Pennsylvania. The authors report no conflicts of interest.
Prolonged hospitalizations for complex patients with severe infections and difficult social situations are becoming very common in many institutions. Outpatient parenteral antimicrobial therapy (OPAT) is widely used[1] and has been found to be a safe, efficient, and cost‐effective way to administer intravenous (IV) antimicrobial therapy to patients, with the potential to decrease hospital length of stay (LOS) and to improve patient satisfaction.[2] Infectious disease (ID) consultation should be involved to determine appropriate candidates for OPAT as well as a suitable drug regimen and duration of therapy,[3] or if oral alternatives can be utilized.[4] OPAT patients require close laboratory monitoring and provider follow‐up for the duration of their care. The combination of ID consultation, patient selection, laboratory monitoring, and follow‐up care have been described as part of a proposed OPAT bundle in recent medical literature.[5] Appropriate patient selection is a key component as to whether or not a patient will be successful with OPAT once discharged from the hospital. Current Infectious Diseases Society of America (IDSA) guidelines recommend that patients be evaluated for stable housing and ability to perform OPAT‐specific duties prior to discharge.[3]
To our knowledge there are no published data regarding the use of OPAT at a medical respite facility for homeless patients with co‐morbid substance abuse and mental illness issues. This may be due to perceived concerns of difficulty in administering OPAT to these disadvantaged patients for multiple reasons such as unstable or no housing, inability to stay engaged in medical care, and underlying mental illness and substance abuse problems. In particular, the concern for substance abuse, specifically injection drug use (IDU), is a significant problem. The current IDSA guidelines for OPAT recommend patients who are likely to abuse a vascular access system are poor candidates for OPAT.[3]
A major barrier to successful utilization of OPAT programs is the need for stable housing so that antibiotics can be administered in a safe setting. Recommending long‐term parenteral therapy as an inpatient for all patients who are homeless or have a history of IDU can lead to prolonged hospitalizations, increased healthcare costs, and contribute to conflicts between patients and staff. Chemical dependence treatment is not available in most inpatient settings, leaving patients with addiction issues without options. Most patients would prefer, when given the choice, to be treated with OPAT outside of the inpatient setting.[6]
This study aimed to evaluate our experience with administering OPAT to homeless patients at a medical respite facility and to determine if patients could complete a successful treatment course of antibiotics for a variety of illnesses.
METHODS
Harborview Medical Center (HMC) is a 413‐bed county hospital, and serves as a major teaching hospital for the University of Washington. It is a level 1 trauma/burn center for Washington, Wyoming, Alaska, Montana, and Idaho. The hospital has 61 psychiatric beds, 29 rehabilitation beds, and 89 intensive care unit beds, with over 60,000 emergency department visits per year. Harborview also serves as a public safety‐net hospital for King County, providing $219 million in charity care in 2013.
Housed in a building adjacent to HMC is a 34‐bed medical respite program,[7] which was established in 2011 through collaboration with King County and 6 other hospitals to serve the homeless population needing medical care, similar to programs in Boston[8] and San Francisco.[9] It is staffed by a multidisciplinary team from HMC including a physician, nurse practitioners, registered nurses, medical assistants, mental health specialists, case managers, and security guards, and accepts patients from all hospitals and clinics within King County. To qualify for medical respite, patient must be homeless and require ongoing nursing needs (ie, wound care, parenteral therapy). Referred patients are screened by a nurse prior to admission. The projected daily cost at medical respite is $350 per patient.
Medical respite is a harm‐reduction model, which includes information on needle exchange programs, narcan kits and education on safer injection practices. Resources are available for patients wishing to start a rehabilitation program, including opiate replacement therapy. Patients may leave the premises during the day, but a curfew is enforced at 9 pm nightly. Patients sign a contract on admission to refrain from using their IV line for IDU and peripherally‐inserted central catheter (PICC) port is secured and monitored for manipulation. Patients who exhibit threatening behavior or who use alcohol/drugs on site are discharged from the program. Patients in need of OPAT must keep nurse visits once or twice daily depending on medication and wound care. Medications needing more frequent dosing were placed on a battery‐operated pump and changed once every 24 hours by nursing.
After obtaining approval from the University of Washington Institutional Review Board, we performed a retrospective chart review of homeless patients over 18 years old discharged from HMC who received OPAT at medical respite from January 1, 2012 to January 1, 2014. There were no exclusions for race, gender, or insurance status. Patients included in the study were respite candidates, and required prolonged parenteral antibiotic therapy. Data collection was performed using a REDCap data collection tool and REDCap grant support.[10] Demographics, diagnosis, and comorbidities, including mental illness, current IDU at time of admission, and remote IDU (last use >3 months ago) were obtained from the electronic medical record. Surgical, microbiologic, and antimicrobial therapy, including route (IV or oral), duration of therapy, and adverse events were abstracted. Primary outcome was defined as successful completion of OPAT at medical respite without nonadherence to therapy or readmission (for presumed OPAT failure). A secondary outcome was antimicrobial course completion for a specific diagnosis defined by achieving goal duration of parenteral and/or oral antibiotic therapy as deemed appropriate by an ID provider. Nonadherence is defined as missing greater than 2 doses of scheduled antibiotic, absence from respite for greater than 24 hours, evidence of line tampering, or expulsion from respite for violation of care agreement. Recurrence of infection was defined as subsequent infection at the same site, following completion of a prior antimicrobial course, at the most recent follow‐up visit.
Continuous variables are expressed as the mean standard deviation, and categorical variables are expressed as the proportion of the entire population. Categorical variables are compared using the 2 test. A 2‐sided P value of <0.05 was considered statistically significant.
RESULTS
Fifty‐one homeless patients were identified with 53 episodes of OPAT between January 1, 2012 and January 1, 2014. For ease of reporting, the number of episodes of OPAT (n = 53) was used as the denominator instead of number of patients (n = 51) for descriptive statistics. The average age was 45 10.4 years (range, 2262 years), 38 (72%) patients were male, and 39 (74%) were Caucasian. Comorbidities included 28 (53%) patients with current IDU and 9 (17%) with a remote history of IDU, 32 (60%) with hepatitis C infection, and 14 (26%) with mental illness (Table 1).
| Comorbidities | No. per Patient Episode, n = 53 (%) |
|---|---|
| |
| Hepatitis C infection | 32 (60%) |
| Current IDU | 28 (53%) |
| Psychiatric/mental illness | 14 (26%) |
| Remote IDU | 9 (17%) |
| Hypertension | 7 (13%) |
| Diabetes type 1 or type 2 | 5 (9%) |
| Rheumatologic diagnosis | 3 (6%) |
| Obesity | 2 (4%) |
| Cardiovascular disease | 2 (4%) |
| Peripheral vascular disease | 2 (4%) |
| Congestive heart failure | 2 (4%) |
| Chronic kidney disease (any stage) | 1 (2%) |
| HIV | 1 (2%) |
Forty‐six (87%) patients were evaluated by an ID physician during their admission. Diagnosis (some patients had multiple) requiring OPAT included: bacteremia in 28, osteomyelitis in 22, skin and soft tissue infection in 19, endocarditis in 15, and epidural abscess in 7 patients. Twenty‐nine patients underwent surgical intervention. The pathogens recovered were primarily gram‐positive organisms. Multidrug resistant organisms were isolated in 11 patients. The IV medications used included vancomycin, nafcillin, cefazolin, ertapenem, and daptomycin.
Forty‐six (87%) patients completed a defined course of antibiotic therapy (deemed appropriate therapy by an ID physician) for their specific infection. Thirty‐four (64%) patients were successfully treated with OPAT at medical respite. There were 19 (36%) failures, which included nonadherent patients, some of whom required urgent readmission (Table 2). There were a total of 16 readmissions, and 10 of those were considered OPAT failures, whereas the other 6 were not (patients admitted for other reasons including, surgery, and IV malfunction). Of the total readmissions, 12 of those were current or remote IDU patients. There is a trend toward a higher prevalence of current/remote IDU among those with clinical failure (15/19, 79%) compared to those with clinical success (22/34, 65%) (P = 0.2788). Overall, 27 (51%) patients were switched to oral therapy after completing an initial IV course. Oral agents used were: trimethoprim‐sulfamethoxazole, rifampin, doxycycline, fluconazole, linezolid, fluoroquinolones, and amoxicillin/clavulanic acid. The average length of OPAT was 22 days. The average daily cost of an acute‐care bed day in 2015 was $1500 at our institution. The cost savings to our institution (using $1500/day inpatient cost compared to $350 per day at medical respite) was $25,000 per episode of OPAT.
| No. of Episodes of Care, n = 53 (%) | |
|---|---|
| |
| Successfully treated at medical respite | 34 (64%) |
| Nonadherent to therapy | 19 (36%) |
| Left respite with IV line in place | 6 [2 admitted, 3 orals, 1 lost] |
| Missed IV doses and switched to orals | 5 |
| Missed IV doses and admitted | 8 admitted |
| Any hospital readmission | 16 (30%) |
| Readmissions, assumed failures | 10 (19%) |
| PICC‐lineassociated infection/bacteremia | 2 |
| SIRS with suspected line infection | 2 |
| Ongoing IDU /discharge from respite | 2 |
| Nonadherent with OPAT/altercations | 3 |
| Acute kidney injury | 1 |
| Readmissions, not counted as failures | 6 (11%) |
| PICC malfunction (leaking) | 2 [1 had further OPAT] |
| Surgery | 4 [3 had further OPAT] |
During the course of OPAT, 7 (13%) patients experienced an adverse event. Of those, we had 1 patient with drug rash, 1 with nausea, and 1 with diarrhea (not infectious). One patient developed leukopenia (white blood cells <4.0), and 2 patients developed neutropenia (absolute neutrophils <750). One patient developed significant elevation of creatinine(>1.9 upper limit of normal) and required inpatient admission. An additional 5 patients had a small elevation of creatinine that did not meet the criteria listed above and were not counted as adverse events by definition. At the study conclusion, 36 (68%) patients had no recurrence of infection at the most recent follow‐up visit at HMC; length of follow‐up ranged from 2 months to 2.5 years. One patient later died of nonOPAT‐related complications. In total, 11 (21%) patients were lost to follow‐up, 1 with a peripherally inserted central catheter line in place.
DISCUSSION
We demonstrated that 87% of homeless patients were able to complete a defined course of antibiotic therapy, and 64% were successfully treated with OPAT at medical respite. To our knowledge this is the first study evaluating this specific population in which OPAT was received at medical respite. Our rate of adverse events (some that required change in drug therapy) was similar to other OPAT studies in the published literature, ranging from 3% to 10% in 1 study,[3] and up to 11% in another.[11] Our total readmission rate of 30% was similar to what current literature suggests, ranging from 9%[11] up to 26%[12] for OPAT patients. Notably, 11% of the readmissions were not related to OPAT failure. This supports the recommendation for close scrutiny of social behaviors in the OPAT patient‐selection process; however, in certain circumstances, IDU alone may not be a reason to fully exclude someone from OPAT candidacy. Careful review of substance abuse history and evaluation of psychosocial factors, such as housing status, mental health history, and outpatient support system are needed. Furthermore, an evaluation of the patient's willingness to comply with care agreements while an inpatient and at respite, and ensuring appropriate resources for chemical dependency treatment are needed. Early consideration of oral antimicrobial options if the patient is readmitted for complications/nonadherence should be encouraged.
Our findings are consistent with results reported by Ho and colleagues, which demonstrated a success rate of 97% of IDU OPAT patients.[13] They carefully chose 29 study patients from 906 in their OPAT program over several years, giving them daily infusions under close supervision. Patients signed an agreement to refrain from accessing their IV lines for drug use. Special security seals were used on all connections and tubing to prevent line tampering. Medical respite in King County uses a similar technique, using a Tegaderm dressing to cover all valves and tubing junction sites to prevent tampering. The IV lines are inspected daily, and ID providers were contacted to discuss any patients suspicious of tampering with their lines to discuss next appropriate steps, either readmission or transition to oral antibiotics. Half of our patients were switched to oral therapy during their course, consistent with current literature.[12, 14]
Traditionally, homeless patients requiring ongoing parenteral therapy have remained inpatients for the duration of their course. Feigal and colleagues evaluated the connection between homelessness and inpatient discharge delays for placement over a 6‐month period in 2009 at an urban hospital.[15] They found homeless patients awaiting placement had an increased median LOS of 26 days, compared to housed individuals with 14 days. Homeless patients without a psychiatric disorder had a delay in discharge 60% longer compared to those with housing, with data adjusted for multiple variables. The cause for delay in discharge in homeless patients was found in those awaiting group home or nursing facility placement, in 50% of cases, whereas delay for chemical dependency program was in 17% of cases, and other local treatment center in 12% of cases.
Medical respite programs are gaining in popularity in the United States since they began in the mid‐1980s.[16] A review by Doran and colleagues found medical respite can result in cost avoidance for hospitals by limiting inpatient days and readmissions.[17] Medical respite can also help engage patients in follow‐up care and assist with housing placement. Many programs promote safe IDU practices and offer referrals for rehabilitation programs, both of which are programs that are not available in most hospitals. Medical respite may continue to be a site of OPAT expansion, as there is continued pressure to discharge nonacute patients from the hospital. Moving forward, it may be beneficial for hospitals, public health departments, and communities to support these programs, which can assist with close monitoring of homeless patients receiving OPAT.
There were several limitations in our study. This was a retrospective observational study with a small patient population comprised of a high prevalence of current and remote IDU. The single center study makes it difficult to generalize to other settings. In addition, there were no comparative data with historical controls, making it difficult to perform comparative analysis.
OPAT is effective for many patients, and it is optimal to utilize ID consultation to determine appropriate candidacy,[3, 4, 5] particularly among IDU. OPAT can be successful in a closely monitored medical respite setting for homeless patients with the help of a multidisciplinary team. Medical respite OPAT can decrease inpatient stays in patients who would otherwise require long hospitalizations, resulting in overall cost savings, and may lead to improved patient satisfaction. Future research linking other outcomes of medical respite OPAT, including substance‐dependence treatment and transition to housing, is warranted.
Acknowledgements
The authors thank the staff at the Harborview Medical Center Infectious Disease Clinic and at Edward Thomas House Medical Respite for their help in this study.
Disclosures: Presented at the oral abstract session Clinical Practice IssuesOPAT in Diverse Populations, IDWeek, October 812, 2014, Philadelphia, Pennsylvania. The authors report no conflicts of interest.
- , , , et al. Experience of infectious diseases consultants with outpatient parenteral antimicrobial therapy: results of an emerging infections network survey. Clin Infect Dis. 2006;43:1290–1295.
- , , , et al. Randomized controlled trial of intravenous antibiotic therapy for cellulitis at home compared with hospital. BMJ. 2005;330:129.
- , , , et al. Practice guidelines for outpatient parenteral antimicrobial therapy. IDSA guidelines. Clin Infect Dis. 2004;38:1651–1672.
- , , . Mandatory infectious diseases approval of outpatient parenteral antimicrobial therapy (OPAT): clinical and economic outcomes of averted cases. J Antimicrob Chemother. 2014;10:1093–1099.
- , , , . Are we ready for an outpatient parenteral antimicrobial therapy bundle? A critical appraisal of the evidence. Clin Infect Dis. 2013;57:419–424.
- , , , et al. Willingness to pay to access patient preferences for therapy in a Canadian setting. BMC Health Serv Res. 2005;5:43.
- UW Medicine. Respite program at Jefferson Terrace (Edward Thomas House). University of Washington website. Available at: http://www.uwmedicine.org/locations/respite‐program‐jefferson‐terrace. Accessed October 1, 2015.
- Boston Healthcare for the Homeless Program. Medical respite care at the Barbara McInnis House. Available at: http://www.bhchp.org/medical‐respite‐care. Accessed October 1, 2015.
- San Francisco Department of Public Health. Medical Respite and Sobering Center. Available at: https://www.sfdph.org/dph/comupg/oprograms/HUH/medrespite.asp. Accessed October 1, 2015.
- , , , , , . Research electronic data capture (REDCap)—a metadata‐driven methodology and workflow process for providing translational research informatics support. J Biomed Inform. 2009;42:377–381.
- , , . Outpatient parenteral antimicrobial therapy (OPAT) in a teaching hospital‐based practice: a retrospective cohort study describing experience and evolution over 10 years. Int J Antimicro Agents. 2012;39:407–413.
- , , , et al. Prediction model for 30‐day hospital readmissions among patients discharged receiving outpatient parenteral antibiotic therapy. Clin Infect Dis. 2014;58:812–819.
- , , , . Safe and successful treatment of intravenous drug users with a peripherally inserted central catheter in an outpatient parenteral antibiotic treatment service. J Antimicrob Chemother. 2010;65:2641–2644.
- , . Outpatient parenteral antimicrobial therapy and antimicrobial stewardship: challenges and checklists. J Antimicrob Chemother. 2015;70:965–970.
- , , , , , . Homelessness and discharge delays from an urban safety net hospital. Public Health. 2014;128:1033–1035.
- , , . Medical respite care for homeless people: a growing national phenomenon. J Health Care Poor Underserved. 2009;20:36–41.
- , , , . Medical respite programs for homeless patients: a systematic review. J Health Care Poor Underserved. 2013;24:499–524.
- , , , et al. Experience of infectious diseases consultants with outpatient parenteral antimicrobial therapy: results of an emerging infections network survey. Clin Infect Dis. 2006;43:1290–1295.
- , , , et al. Randomized controlled trial of intravenous antibiotic therapy for cellulitis at home compared with hospital. BMJ. 2005;330:129.
- , , , et al. Practice guidelines for outpatient parenteral antimicrobial therapy. IDSA guidelines. Clin Infect Dis. 2004;38:1651–1672.
- , , . Mandatory infectious diseases approval of outpatient parenteral antimicrobial therapy (OPAT): clinical and economic outcomes of averted cases. J Antimicrob Chemother. 2014;10:1093–1099.
- , , , . Are we ready for an outpatient parenteral antimicrobial therapy bundle? A critical appraisal of the evidence. Clin Infect Dis. 2013;57:419–424.
- , , , et al. Willingness to pay to access patient preferences for therapy in a Canadian setting. BMC Health Serv Res. 2005;5:43.
- UW Medicine. Respite program at Jefferson Terrace (Edward Thomas House). University of Washington website. Available at: http://www.uwmedicine.org/locations/respite‐program‐jefferson‐terrace. Accessed October 1, 2015.
- Boston Healthcare for the Homeless Program. Medical respite care at the Barbara McInnis House. Available at: http://www.bhchp.org/medical‐respite‐care. Accessed October 1, 2015.
- San Francisco Department of Public Health. Medical Respite and Sobering Center. Available at: https://www.sfdph.org/dph/comupg/oprograms/HUH/medrespite.asp. Accessed October 1, 2015.
- , , , , , . Research electronic data capture (REDCap)—a metadata‐driven methodology and workflow process for providing translational research informatics support. J Biomed Inform. 2009;42:377–381.
- , , . Outpatient parenteral antimicrobial therapy (OPAT) in a teaching hospital‐based practice: a retrospective cohort study describing experience and evolution over 10 years. Int J Antimicro Agents. 2012;39:407–413.
- , , , et al. Prediction model for 30‐day hospital readmissions among patients discharged receiving outpatient parenteral antibiotic therapy. Clin Infect Dis. 2014;58:812–819.
- , , , . Safe and successful treatment of intravenous drug users with a peripherally inserted central catheter in an outpatient parenteral antibiotic treatment service. J Antimicrob Chemother. 2010;65:2641–2644.
- , . Outpatient parenteral antimicrobial therapy and antimicrobial stewardship: challenges and checklists. J Antimicrob Chemother. 2015;70:965–970.
- , , , , , . Homelessness and discharge delays from an urban safety net hospital. Public Health. 2014;128:1033–1035.
- , , . Medical respite care for homeless people: a growing national phenomenon. J Health Care Poor Underserved. 2009;20:36–41.
- , , , . Medical respite programs for homeless patients: a systematic review. J Health Care Poor Underserved. 2013;24:499–524.