An ongoing dialogue on HIV/AIDS, infectious diseases,
February 19th, 2018
Can We Solve the Morass of Outpatient Intravenous Antibiotic Therapy?
If you want to get an ID doctor riled up, here are a few reliable strategies:
- Get an ID consult on a complex patient just to summarize the chart for your discharge summary.
- Endorse the view that procedural doctors deserve their vastly higher salaries than MDs in cognitive specialties.
- Prescribe azithromycin for patients with bad colds.
- Discharge a patient from the hospital on intravenous antibiotics when an oral antibiotic would work just as well.
I’ve not hidden my distaste for unnecessary “outpatient parenteral antimicrobial therapy,” or OPAT on this blog, once devoting a whole post to oral antibiotics with excellent absorption.
It’s not just the inconvenience and potential dangers (blood clots, secondary infections from the IV catheters) of OPAT that I dislike. It’s also that there is essentially no support (read: money) for the clinicians charged with monitoring these complex patients, or for coordinating the many people who may be involved in their care.
Payers certainly don’t pay doctors or nurses for the substantial phone time, emails, and faxes that each OPAT patient generates. This may motivate some doctors to schedule unnecessary outpatient visits for these cases — otherwise they’d get nothing.
And since nobody is paying anyone to oversee the care of OPAT patients, there’s often a “Who me?” approach to their follow-up that is neither good for patient care or the morale of their providers.
Or just as bad, there are too many cooks in the kitchen, and no one is quite clear who’s responsible for what.
A recent post on the IDSA website by ID doctor Parker Hudson detailed this thorny issue perfectly:
Our OPAT program spends a disproportionate amount of time trying to track down labs/levels from patients on IV antibiotics who were discharged to SNFs [skilled nursing facilities]. Despite our orders and requests, most of these values are interpreted and managed by medical directors and not sent back to us — the ID docs writing the orders and following up the patients.
What followed were literally dozens of comments from other ID doctors with similar problems, problems we certainly experience on a daily basis with our OPAT program as well.
To illustrate the complexity, here’s a case — and then a very simple poll.
A 57-year-old man with diabetes and chronic renal disease is referred for admission by his primary care provider (PCP) with 2 weeks of progressive back pain, and found to have spinal osteomyelitis secondary to MRSA. A peripherally inserted central catheter (PICC) line is placed, and because of severe ongoing pain, he is discharged on hospital day 5 to a skilled nursing facility to complete 6 weeks of parenteral vancomycin and to receive physical therapy. At the time of discharge, his ID consultant (who does not do outpatient ID care) recommends that safety labs be done twice weekly, and vancomycin levels once weekly. An outpatient appointment with a different ID doctor is scheduled for 4 weeks later, as well as with his PCP.
Now, take the poll — and if you have a moment, provide the rationale for your answer in the comments section. Bonus points for any practical solutions to the OPAT morass — they would be most welcome!