management of skin and soft tissue infections via opat€¦ · daily skin & soft tissue...
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MANAGEMENT OF SKIN AND SOFT TISSUE INFECTIONS VIA OPAT
Claire VallanceSpecialist OPAT Nurse Practitioner
Queen Elizabeth University Hospital, Glasgow
The OPAT Team4 Clinical nurse specialistsRun nurse led clinics Mon – FriAssess patients for suitabilityTrain patients to self-administer IVABxInsert and care for Vascular Access Devices (VAD)Nurse led SSTI pathway
Infectious Disease ConsultantsVet referrals Make OPAT appropriate Abx plans
Antimicrobial PharmacistsReview patient medication for interactionsReview blood results for dose adjustments
REFERRED AND ACCEPTED TO OPAT
NON SKIN & SOFT TISSUE INFECTIONS
ASSESSED BY CNS FOR SUITABILITYTRAIN FOR SELF-ADMINISTRATION OR ATTEND DAILY
SKIN & SOFT TISSUE INFECTION
ASSESSED DAILY IN CLINIC BY CNSPGD FOLLOWEDIVOST BY CNS
PATIENTS
REFERRALSAVOIDED ADMISSION
• DIRECT FROM GPs• DIRECT FROM IAU• DIRECT FROM ED
• FIRST DOSE IS GIVEN AND DISCHARGED
SUPPORTED DISCHARGE
• 3 TIMES WEEKLY WARD ROUND ARU– Antimicrobial stewardship– Direct admission to ID unit
• FACILITATE DISCHARGE FROM WARDS
PATIENT GROUP DIRECTION (PGD)• Written instructions to help supply and
administer medicines to patients
• Strict legal requirements, including condition to be treated, medicine to be used and exclusion criteria
• Medicines should be supplied in pre-packs which are made up by a pharmacist
• Staff in training observe assessment and treatment of patients then carry out own assessment under supervision
• Complete competency framework with the help of a fully trained mentor.
PATIENT SELECTION• Diagnosed with SSTI, been reviewed by
a medical practitioner and require IVABx
• Must be able to attend clinic daily for assessment
• NEWS score ≤ 2• No concerns regarding local
complications• No drug/alcohol misuse• No other reason for hospital admission• Animal/human bites need hospital
medical review
PATIENT ASSESSMENT
• Patients are assessed daily by CNS• Observations and routine bloods• First visit glucose and blood cultures• Assess skin heat, erythema, pain and
swelling• If lower limb SSTI check for tinea pedis
(both feet).• Continue IVABx until significant reduction
in heat, erythema and pain.
Created by Dr Beth White, Fiona Robb. Approved by AUC March 2017. Review date March 2019
Referral Pathway for Management of Skin and Soft Tissue Infection via QEUH Outpatient Parenteral Antibiotic Therapy (OPAT) Service
Man
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ent
Seve
rity
Asse
ssm
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Category 1 • NEWS 0 -1
• No signs of systemic toxicity
• No uncontrolled co-morbidities
• Not yet tried oral antibiotics
Category 2 • NEWS 0-1
• Systemically ill, or well but with a co-morbidity such as peripheral vascular disease, chronic venous insufficiency or morbid obesity which may complicate or delay resolution of their infection.
• Well but cellulitis worsening despite appropriate oral antibiotics
Category 3 • NEWS 2-4
• Significant systemic upset such as acute confusion, tachycardia, tachypnoea, hypotension
• Unstable co-morbidities (eg AKI, cardiac decompensation or uncontrolled BMs)
Category 4 • NEWS ≥ 5
• Septic shock
• Severe life / limb threatening infection such as necrotising fasciitis.
Can usually be managed with oral antimicrobials as an outpatient
Skin or soft tissue infection affecting upper or lower limb(s) or face (erysipelas)
Requires IV Rx Consider OPAT
Inclusion Criteria • Ambulatory and self-
caring (or have carer to look after them)
• Post-surgical site infection only by appropriate surgical speciality after their review
• Hand trauma or possible bone/joint infection or bursitis only by orthopaedics after their review
• Recent hospital admission, diabetic ulcer, prev MRSA or CDI only after discussion with Infectious Diseases specialist
OPAT Exclusion Criteria
• Alcohol dependency
• IV Drug misuse • Significant mental health
morbidity/ deliberate self harm
• Orbital cellulitis
• Renal function ≤ CKD 4 (<eGFR 30 ml/min/1.73 m2)
• Immunosuppression
• Other medical problems requiring inpatient management
• Pregnancy / breast feeding
• <18 yr old
Requires inpatient IV Rx See GGC inpatient infection management
guidelines
If NO life-threatening Penicillin /beta-lactam allergy • Give 2g Ceftriaxone IV • Observe for 30 mins If previous anaphylaxis or other life-threatening penicillin /beta-lactam allergy • give Daptomycin 6mg/kg IV (using
actual body weight, dose rounded to nearest vial-350 mg or 500 mg vials)
• Refer to OPAT via Trakcare • Phone OPAT nurse specialist
(83107) for appt time Mon-Fri • Sat-Sun phone Medical Day Unit
(83105) between 0830-0900
*OPAT is based in the Medical Day Unit, 1st Floor, QEUH*
Created by Dr Beth White, Fiona Robb. Approved by AUC March 2017. Review date March 2019
Referral Pathway for Management of Skin and Soft Tissue Infection via QEUH Outpatient Parenteral Antibiotic Therapy (OPAT) Service
Man
agem
ent
Seve
rity
Asse
ssm
ent
Category 1 • NEWS 0 -1
• No signs of systemic toxicity
• No uncontrolled co-morbidities
• Not yet tried oral antibiotics
Category 2 • NEWS 0-1
• Systemically ill, or well but with a co-morbidity such as peripheral vascular disease, chronic venous insufficiency or morbid obesity which may complicate or delay resolution of their infection.
• Well but cellulitis worsening despite appropriate oral antibiotics
Category 3 • NEWS 2-4
• Significant systemic upset such as acute confusion, tachycardia, tachypnoea, hypotension
• Unstable co-morbidities (eg AKI, cardiac decompensation or uncontrolled BMs)
Category 4 • NEWS ≥ 5
• Septic shock
• Severe life / limb threatening infection such as necrotising fasciitis.
Can usually be managed with oral antimicrobials as an outpatient
Skin or soft tissue infection affecting upper or lower limb(s) or face (erysipelas)
Requires IV Rx Consider OPAT
Inclusion Criteria • Ambulatory and self-
caring (or have carer to look after them)
• Post-surgical site infection only by appropriate surgical speciality after their review
• Hand trauma or possible bone/joint infection or bursitis only by orthopaedics after their review
• Recent hospital admission, diabetic ulcer, prev MRSA or CDI only after discussion with Infectious Diseases specialist
OPAT Exclusion Criteria
• Alcohol dependency
• IV Drug misuse • Significant mental health
morbidity/ deliberate self harm
• Orbital cellulitis
• Renal function ≤ CKD 4 (<eGFR 30 ml/min/1.73 m2)
• Immunosuppression
• Other medical problems requiring inpatient management
• Pregnancy / breast feeding
• <18 yr old
Requires inpatient IV Rx See GGC inpatient infection management
guidelines
If NO life-threatening Penicillin /beta-lactam allergy • Give 2g Ceftriaxone IV • Observe for 30 mins If previous anaphylaxis or other life-threatening penicillin /beta-lactam allergy • give Daptomycin 6mg/kg IV (using
actual body weight, dose rounded to nearest vial-350 mg or 500 mg vials)
• Refer to OPAT via Trakcare • Phone OPAT nurse specialist
(83107) for appt time Mon-Fri • Sat-Sun phone Medical Day Unit
(83105) between 0830-0900
*OPAT is based in the Medical Day Unit, 1st Floor, QEUH*
TREATMENT OPTIONS
TREATMENT• Oral Clindamycin if younger than 70 • Oral Flucloxacillin for over 70• Oral course of 5 day• Tinea Pedis treated with topical Miconazole for 10 days
after lesions have healed.• IV Dalbavancin if logistical difficulties for daily attendence
– Once weekly– ID physician must be consulted
FOLLOW-UP• Patients return to clinic on completion of oral antibiotics• May be given a further oral course• Repeat bloods taken• Further follow-up may be given dependent on
improvement.• Patients have to be re-referred for any further infections.
CASE STUDY 1• 54 year old female seen on SSTI ward
round• Had 24 hours IV Fluclox, still heat in legs,
NEWS 1• Given dose of IV Ceftriaxone, discharged,
attends OPAT clinic the following day.• Further 2 days of IV Ceftriaxone,
switched to oral clinda for 5 days• Review at day 5 – no heat, swelling and
erythema improving. Discharged from OPAT.
CASE STUDY 2• 64 year old man referred from GP
• 3 courses of oral Abx over the last 3 weeks, leg not improving
• On assessment: dry, itchy skin, slight swelling and erythema, no heat, NEWS 0, CRP 7
• Advised to stop all Abx, no active cellulitis - ?Varicose eczema
• Advice on signs of recurrence and skin care given -?Dermatology review
• Discharged from OPAT.
Outcome following OPAT Nurse review (n= 372)
86, 23%
91, 24%
32, 9%
163, 44%
Supported dischargeAvoided admissionAMSAdmission
511 Bed Days Saved (177 patients)
Outcomes177 patients
172 cured3 improvement2 readmitted
Drug Event5 rash1 neuropathy (linezolid)1 “out of body experience” (daptomycin)
• No vascular device infections• No SABs• No CDI
Patient Satisfaction100 questionnaires sent17 returned:
would all attend service again
Summary• Nurse-led SSTI pathway using a PGD• Accept patients from GP, IAU, ARU & IP wards• Average 3-5 days IV therapy followed by 5 days oral
therapy• Assessed daily by CNS• Reviewed by CNS at end of oral treatment• 177 patients accepted , 172 were cured of infection at
end of treatment.
https://www.futurelearn.com/courses/outpatient-patenteral-antimicrobial-therapy
Acknowledgements• OPAT CNS
Liz CollisonLynn O’ReillyClaire Summerhill
• AMPsLee StewartFiona Robb
• MEDICAL TEAMDr Andrew SeatonDr Neil RitchieDr Beth White OPAT are based in Queen Elizabeth
University Hospital GlasgowTelephone: 0141 452 3107Email: [email protected]