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Self-Administered Outpatient Parenteral Antimicrobial Therapy for Urinary Tract Infection from the Emergency Department: A Safe and Effective Strategy to Avoid Hospital Admission.

Introduction

Urinary tract infection (UTI) is one of the most commonly treated pathologies in hospital emergency departments (EDs). UTIs comprise approximately 22% of all infectious processes and are a common reason for hospital admission (1). The growing prevalence of multidrug resistant microorganisms (MRM) as a cause of UTI and other infections currently entails a severe public health problem (2). The consumption of resources arising from the treatment of UTI is very high, and in the United States alone, it is responsible for approximately 100,00 hospital admissions out of more than 1 million visits to EDs and a cost of more than US$1 billion (3). All these circumstances make UTI a complex clinical entity and a challenge for health care professionals.

However, alternative care systems that avoid the patient admission into a conventional hospital ward should mean improved efficiency. In this sense, some models denominated the outpatient parenteral antimicrobial therapy (OPAT), which is based on the administration of parenteral antibiotics at home, have obtained excellent results in terms of safety and efficacy in the context of clinically stable infectious processes (4). Among them, there is a variant known as self-administered OPAT (S-OPAT) in which health care staff trains carers or the patient to administer parenteral medication, which raises the efficiency even more, given that the costs arising from nursing visits are vastly reduced (5).

Moreover, in Spain, there are hospitalization-at-home (HaH) units, a more complex alternative care resource than OPAT, which offer a diagnostic and therapeutic support at home similar to the one provided on the ward and can treat any clinical process with hospital admission criteria. In these units, not only antimicrobials are administered parenterally but also other drugs are administered intravenously. Serum therapy, prior oxygen therapy, analgesics, antipyretics, and nebulized medications can be administered, blood derivatives are transfused, and all kinds of biological samples can be collected at home (6).

The primary objective of our study is to determine the safety and efficacy of UTI treatment by means of an S-OPAT regimen supported within the scope of a HaH program in patients referred directly from ED.

Materials and Methods

Study design

This was a retrospective, observational study of a series of patients. The study was approved by the Ethics Committee of the Autonomous Community of Cantabria (2017.249).

Study context and population

In Marques de Valdecilla University Hospital, a third level hospital with an approximate capacity of 900 beds, all episodes of patients diagnosed with UTI with hospital admission criteria according to the European Association of Urology, (7) who received S-OPAT in the HaH unit immediately after being treated in the ED during a two-year period (2015-2016) were analyzed.

Data collection

Epidemiological (sex, age), clinical (comorbidity, nephrourological history, the type of UTI, the type of antibiotic, S-OPAT duration), and microbiological study variables were obtained from the clinical history records (on paper and/or electronic) of the hospital and were included in a Microsoft Excel-like database.

Objectives

The objectives were to determine safety (domiciliary mortality, complications that obliged an unexpected return to hospital, and subsequent intra-hospital death) and efficacy (healing rate, recurrence of the UTI) of this care modality.

Statistical analysis

Variables were analyzed with the statistical software package Statistical Package for Social Sciences version 11.5 (SPSS Inc.; Chicago, IL, USA). A descriptive analysis was performed; quantitative and qualitative variables were expressed as the mean [+ or -] standard deviation and percentage and proportions, respectively.

Results

Characteristics of the population studied

During the study period, emergency doctors admitted 1,394 episodes of UTI, of which 268 (19.2%) were in compliance with the HaH admission criteria, whereby they were transferred home to complete the stipulated therapeutic plan (Table 1). The description of the basal characteristics of patients and the most important microbiological characteristics of UTI episodes are summarized in Table 2.

Safety and effectiveness

The results concerning safety and efficacy are summarized in Table 3. Regarding safety, during S-OPAT, only one death occurred at home because of broncho-aspiration in an extremely elderly patient with a highly deteriorated basal functional situation. In 16.1% of patients, a clinical complication appeared mostly unrelated to infection. Most of these (79.1%) could be resolved at home. A total of 20 patients had to return to hospital, nine because of major medical complications. Four of these complications may have been related to the infectious process (two episodes of exacerbation of chronic renal failure, one epileptic crisis probably following the administration of ertapenem, and one case of therapeutic failure despite theoretically correct initial treatment). Another eight patients returned because of socio familial problems that made it impossible to continue the S-OPAT, and a further three returned because of having scheduled surgery unrelated to the UTI. One of the patients who returned died for reasons unrelated to UTI.

As for efficacy, once the 11 patients that returned to hospital for socio-familial reasons and scheduled surgery were excluded, the healing rate attained in those in whom it was possible to complete the S-OPAT program was 96.5%. During the first month following discharge from HaH, 11 (4.4%) patients who completed S-OPAT were readmitted because of the recurrence of the UTI. A further six did so for reasons outside the scope of the UTI (two because of broncho-aspiration, one because of superinfected pressure ulcers, and three because of scheduled surgery).

Discussion

This work reveals that despite the UTI complexity because of its various symptoms (fever, pain, dehydration, etc.) at the time of diagnosis, it is possible to safely and effectively perform S-OPAT within a HaH unit. To the best of our knowledge, our work is novel as there are no precedents in the literature that dealt with this issue.

Thanks to the HaH unit, the ED avoided the admission of almost one in every five patients diagnosed with UTI with hospital admission criteria and obtained from the outset, which had a positive impact on the management of hospital resources (relief of the ED congestion, improved availability of beds in the traditional hospital ward, etc.). In this context, in accordance with recent publications that advocate the need to set out new care strategies that would help to homogenize hospital admission decisions, the HaH could reduce the costs significantly (8). Therefore, Stuck et al. recently concluded that emergency physicians are highly receptive to referring patients to HaH units, but they demand that referral processes be quick (9).

Data obtained in our series share the epidemiological similarities with those observed in recent literature, and they revealed the increasingly more common onset of the MRM strains as causal UTI factors (9). From the microbiological point of view, our series is notable because of its extremely high index of collection of urine cultures with more than 60% coming back as positive; these figures are higher than those found in the literature (approximately 41%) (10). E. coli turned out to be the most commonly isolated microorganism, both in urine and blood cultures. The high presence of MRM strains in our series (more than 15% of isolates), well above the 5% from other studies, (11) highlights the important work of our HaH unit with the aim of limiting their dissemination within the hospital setting.

Our S-OPAT program was extremely safe because only a little more than 3% of patients returned to hospital because of major medical complications. The low mortality rate turned out to be more than assumable, given the baseline characteristics of the deceased patient. The results obtained in terms of efficacy were satisfactory, and a healing rate similar to the one published recently by a Spanish group that applied traditional OPAT (12) was attained.

The success of our S-OPAT model in this context is most likely due to several reasons. First, the close collaboration with the ED staff fosters an effective process of patients' home referral (9). However, early administration of antimicrobials and collection of microbiological samples favored a better clinical course in patients, something corroborated by the abundant literature that revealed that both actions improve the prognosis of infectious processes seen in ED (13). Finally, appropriate selection of patients and the efficacy of our HaH unit when responding to any complication at home were essential for the program's success.

Study limitations

We believe the internal validity of our work is high because there was no loss of information. Moreover, the S-OPAT model has been supported in a HaH unit with more than 30 years of experience. However, this study has some limitations, derived specifically from the concrete features of our HaH unit, which can hinder its practical application in other contexts. Such specificities would be their dependence on a tertiary hospital, their close daily collaboration with the ED for referral of any kind of HaH subsidiary process, and finally, their major capacity to provide with their own health care personnel and 24 hours a day, a fast response to any clinical complication of the patient in their own home. All of this can hinder the extrapolation of our conclusions to other medical care contexts.

Conclusion

To conclude, the S-OPAT model supported within a HaH unit is safe and effective in the treatment of complex UTI cases, referred directly from the ED. This also constitutes a doubly useful care tool for the hospital by improving the overall bed management and avoiding the intra-hospital dissemination of MRM strains.

ORCID IDs of the authors: M.P.G. 0000-0003-2617-1644; A.G. 0000-0003-4864-1475; M.L.G.0000-0002-5814-4352; E.C.G. 0000- 0003-02535781; A.M.A.G. 0000-0001-6380-4717; A.G.S. 0000-0002-1164-8617; M.F.F.M. 0000-0001-5531-3416; I.A.M. 0000-0003-0664-2883; P.S.M. 0000-0003-2029-2816; E.G. 0000-0001-5871-5920; M.L.T. 0000-0001-7782-1796.

Corresponding Author: Aureliu Grasun e-mail: dr.aureliu@gmail.com

Received: 04.06.2018 * Accepted: 23.07.2018

DOI: 10.5152/eajem.2018.52724

Ethics Committee Approval: Ethics committee approval was received for this study from the Ethics Committee of the Autonomous Community of Cantabria (2017.249)

Informed Consent: Informed consent was not taken from patients due to the retrospective nature of the study.

Peer-review: Externally peer-reviewed.

Author Contributions: Concept--M.P.G., A.G., A.M.A.G.; Design--A.M.A.G.; Supervision--M.P.G., A.G., M.L.G., E.C.G., A.M.A.G., A.G.S., M.F.F.M., I.A.M., P.S.M., E.G., M.L.T.; Resources--M.P.G., A.G., M.L.G., E.C.G., A.M.A.G., A.G.S., M.F.F.M., I.A.M., P.S.M., E.G., M.L.T.; Materials--A.M.A.; Data Collection and/or Processing --M.P.G., A.G., M.L.G., E.C.G., A.M.A.G., A.G.S., M.F.F.M., I.A.M. P.S.M., E.G., M.L.T.; Literature Search--M.P.G., A.G., M.L.G., E.C.G., A.M.A.G., A.G.S., M.F.F.M., I.A.M. , P.S.M., E.G., M.L.T.; Writing Manuscript--A.G.; Critical Review--M.P.G., A.G., M.L.G., E.C.G., A.M.A.G., A.G.S., M.F.F.M., I.A.M., P.S.M., E.G., M.L.T.

Conflict of Interest: The authors have no conflict of interest to declare.

Financial Disclosure: The authors declared that this study has received no financial support.

References

(1.) Stamm WE, Hooton TM. Management of urinary tract infections in adults. N Engl J Med. 1993; 329: 1328-34. [CrossRef]

(2.) Chen YH1, Ko WC, Hsueh PR. Emerging resistance problems and future perspectives in pharmacotherapy for complicated urinary tract infections. Expert Opin Pharmacother. 2013; 14: 587-96. [CrossRef]

(3.) Cardwell SM, Crandon JL, Nicolau DP, McClure MH, Nailor MD. Epidemiology and economics of adult patients hospitalized with urinary tract infections. Hosp Prac. 2016; 44: 33-40. [CrossRef]

(4.) Williams DN, Baker CA, Kind AC, Sannes MR. The history and evolution of outpatient parenteral antibiotic therapy (OPAT). Int J Antimicrob Agents. 2015; 46: 307-12. [CrossRef]

(5.) Matthews PC, Conlon CP, Berendt AR, Kayley J, Jefferies L, Atkins BL, et al. Outpatient parenteral antimicrobial therapy (OPAT): is it safe for selected patients to self-administer at home? A retrospective analysis of a large cohort over 13 years. J Antimicrob Chemother. 2007; 60: 356-62. [CrossRef]

(6.) Gonzalez Ramallo VJ, Segado-Soriano A. Twenty-five years of hospital at home in Spain. Med Clin. 2006; 126: 332-3.

(7.) Johansen TEB, Botto H, Cek M, Grabe M, Tenke P, Wagenlehner FM, et al. Critical review of current definitions of urinary tract infections and proposal of an EAU/ESIU classification system. Int J Antimicrob Agents. 2011; 38(Suppl): 64-70. [CrossRef]

(8.) Researchers: new resources, tools needed to reduce variation in the admissions decisions. ED Manag. 2014; 26: 128-31.

(9.) Stuck A, Crowley C, Martinez T, Wittgrove A, Brennan JJ, Chan TC, et al. Perspectives on Home-based Healthcare as an Alternative to Hospital Admission After Emergency Treatment. West J Emerg Med. 2017; 18: 761-9. [CrossRef]

(10.) Martinez Ortiz de Zarate M, Gonzalez Del Castillo J, Julian Jimenez A, Piera Salmeron P, Llopis Roca F, et al. Estudio INFURG-SEMES: epidemiologia de las infecciones atendidas en los servicios de urgencias hospitalarios y evolucion durante la ultima decada. Emergencias 2013; 25: 368-378

(11.) Jorgensen S, Zurayk M, Yeung, S. Terry J, Dunn M, Nieberg, P Wong-Beringer A. Risk factors for early return visits to the emergency department in patients with urinary tract infection. Am J Emerg Med. 2018; 36: 12-7. [CrossRef]

(12.) Soledad Gallardo M, Anton A, Pulido Herrero E, Itziar Larruscain M, Guinea Suarez R, Garcia Gutierrez S, et al. Effectiveness of a home hospitalization program for patients with urinary tract infection after discharge from an emergency department. Emergencias. 2017 29: 313-9.

(13.) Liu VX, Fielding-Singh V, Greene JD, Baker JM, Iwashyna TJ, Bhattacharya J, et al. The Timing of Early Antibiotics and Hospital Mortality in Sepsis. Am J Respir Crit Care Med. 2017; 196: 856-63. [CrossRef]

Marcos Pajaron Guerrero [1] (iD), Aureliu Grasun [2] (iD), Marta Lisa Gracia [3] (iD), Estela Cobo Garcia [2] (iD), Ana Maria Arnaiz Garcia [5] (iD), Ana Gonzalez Sanemeterio [2] (iD), Manuel Francisco Fernandez Miera [1] (iD), Iciar Allende Mancisidor [4] (iD), Pedro Sanroma Mendizabal [1] (iD), Elena Grasun [6] (iD), Maria Lara Torre [2] (iD)

[1] Hospital At Home Unit, Marques De Valdecilla University Hospital, Santander, Spain

[2] Emergency Department, Marques De Valdecilla University Hospital, Santander, Spain

[3] Hospital At Home Unit, Hospital Sierrallana, Torrelavega, Spain

[4] Primary Care and Community Medicine, Santa Cruz De Bezana, Spain

[5] Infectious Disease Unit, Marques De Valdecilla University Hospital, Santander, Spain

[6] Primary Care And Community Medicine, El Astillero, Spain
Table 1. Inclusion Criteria for an Episode of UTI in the HaH, Avoiding
the Hospital Admission Program of the HUMV

General:

Voluntary participation of the patient and carer(s) after
being informed on the functioning of the HaH

Requirement for a 24 h/day carer in the home of the patient

HaH operating within the catchment area of 15 km from the hospital

Specific:

Commitment on the part of the patients and carer(s) to the S-OPAT
scheme

Clinical stability (hemodynamic stability)

Laboratory criteria (suitable stable renal function)

Absence of obstructive acute renal failure using urological ultrasound

HaH: hospitalization at home; HUMV: Hospital Universitario Marques de
Valdecilla; UTI: urinary tract infection; S-OPAT: self-administered
outpatient parenteral antimicrobial therapy

Table 2. Basal characteristics, specific features, and microbiological
finding of the UTI episodes in HaH

Basal Characteristics
  Age (mean, SD)                               59.3 (22.0)
  Women (n, %)                                 142 (53.0)
  Existence of comorbidity (n, %)              161 (60.1)
  Charlson index (mean, SD)                    1.7 (1.9)
  Urinary catheter carrier (n, %)              30 (11.2)
  Neoplasia of the urinary tract (n, %)        21 (7.8)
  Neurogenic bladder dysfunction (n, %)        11 (4.1)
  Renal lithiasis (n, %)                       7 (2.6)
Specific Type of UTI (n, %)
  Pyelonephritis                               84 (31.3)
  Urosepsis                                    63 (23.5)
  Complicated cystitis                         57 (21.3)
  Prostatitis                                  43 (16.0)
  Infection associated with urinary catheter   18 (6.7)
  Orchiepididymitis                            3 (1.1)
Antibiotics most commonly used (n, %) *
  Ceftriaxone                                  175 (46.6)
  Gentamycin                                   88 (23.4)
  Ertapenem                                    53 (14.1)
  Piperacillin-tazobactam                      13 (3.4)
  Meropenem                                    12 (3.2)
  Duration of S-OPAT (days, SD)                10.7 (7.1)
Microbiological finding
  Documented microorganisms in urine cultures (n, %) ***
  Total positive urine cultures (n, %) **      156 (61.4)
  Escherichia coli                             92 (59.0)
  Klebsiella pneumoniae                        18 (11.5)
  Pseudomonas aeruginosa                       14 (9.0)
  Proteus mirabilis                            8 (5.1)
  Morganella morganii                          6(3.8)
Documented microorganisms on blood cultures (n, %)
  Total positive blood cultures (n, %) ****    19 (14.7)
  Escherichia coli                             13 (68.4)
  Proteus mirabilis                            2 (10.5)
  Klebsiella pneumoniae                        2 (10.5)
  Coagulase-negative Staphylococcus            1 (5.3)
  Morganella morganii                          1 (5.2)
Documented MDR microorganisms (n, %)
  Total positive MDR microorganisms in         27 (15.4)
  the 175 isolates (n, %)
  Escherichia coli ESBL                        10 (37.0)
  Klebsiella pneumoniae ESBL                   5 (18.5)
  Morganella morganii ESBL                     4 (14.8)
  Pseudomonas aeruginosa MDR                   4 (14.8)
  Proteus mirabilis ESBL                       2 (7.4)
  Providencia stuartii ESBL                    2 (7.4)

ESBL: extended spectrum beta-lactamase; HaH: hospitalization at home;
MDR: multidrug resistant; SD: standard deviation; UTI: urinary tract
infection

* The total number of antibiotics administered was 375. Other
antibiotics used were; Ceftazidime, cefepime, amikacin, tobramycin,
ciprofloxacin, levofloxacin, amoxicillin-clavulanic acid, aztreonam

** Total number of patients in whom a urine culture was processed: 254
(94.8%). Most (56.1%) patients with a negative urine culture had
received antibiotic treatment before the sample was collected.

*** Other documented microorganisms: Enterococcus faecalis,
Coagulase-neg- ative Staphylococcus, Candida albicans, Ureaplasma
urealyticum, Methicillin-resistant Staphylococcus aureus, Providencia
stuartii.

**** Total number of patients in whom blood cultures were processed:
129 (48.1%).

Table 3. Safety and efficacy of the HaH program based on S-OPAT
during the UTI episodes

Safety
Mortality (n, %)                                         1 (0.4)
Total number of patients who returned to the hospital    20 (7.5)
(n, %)
Complications that required unexpected return (n, %)     9 (3.4)
  2 heart failure
  2 severe exacerbated chronic renal failure
  1 ischemic stroke
  1 therapeutic failure of the UTI
  1 supraventricular tachycardia
  1 hematuria
  1 convulsive crisis
Complications resolved at home (n, %)                    34 (12.7)
  5 episodes of diarrhea after antibiotics
  5 episodes of acute urine retention
  5 episodes of exacerbated chronic renal failure
  3 episodes of confusional syndrome
  3 episodes of hematuria
  3 episodes of thrush
  3 episodes of LFT abnormality induced by antibiotics
  2 episodes of unbalanced diabetes
  2 episodes of drug fever
  2 episodes of pseudomembranous colitis
  1 episode of supraventricular tachycardia
Effectiveness
Healing rate (n, %)                                      248 (96.4)
Recurrence of the UTI (n, %)                             11 (4.4)

HaH: hospitalization at home; S-OPAT: self-administered outpatient
parenteral antimicrobial therapy; UTI: urinary tract infection; LFT:
liver functional tests
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Article Details
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Title Annotation:Original Article
Author:Guerrero, Marcos Pajaron; Grasun, Aureliu; Gracia, Marta Lisa; Garcia, Estela Cobo; Garcia, Ana Mari
Publication:Eurasian Journal of Emergency Medicine
Article Type:Report
Date:Dec 1, 2018
Words:3083
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