Outpatient parenteral antimicrobial therapy for orthopedic infections – a successful public healthcare experience in Brazil

Abstract

Treatment of orthopedic infections usually requires prolonged antimicrobial therapy, ranging from 14 days up to 6 months. Nowadays, rising levels of antimicrobial resistance demands parenteral therapy for many patients. Outpatient parenteral antimicrobial therapy (OPAT) is a modality that allows treatment out of hospital in these situations. In Brazil, where a public universal healthcare system allows full coverage for all citizens, implantation and dissemination of OPAT programs would be beneficial for patients and for the system, because it would allow a better allocation of health resources. The Instituto de Ortopedia e Traumatologia do Hospital das Clínicas da Faculdade de Medicina da USP (IOT) started, in July 2013, a partnership with municipal health authorities in Sao Paulo, Brazil, in order to initiate an OPAT program in which patients discharged from that hospital would be able to continue antimicrobial therapy at primary care facilities. When necessary, patients could also receive their therapy at the day-hospital located at IOT. Primary care nursing and physician staff were trained about antimicrobial infusion and peripherally inserted central catheter manipulation. An OPAT specific antimicrobial protocol was designed and a special reference and counter-reference organized. As a result, 450 primary healthcare professionals were trained. In the first year of this program, 116 patients were discharged for OPAT. Chronic and acute osteomyelitis were most frequent diagnosis. Teicoplanin, ertapenem and tigecycline were the most used drugs. Duration of treatment varied from 10 to 180 days (average 101, median 42). Total sum of days in OPAT regimen was 11,698. Only 3 patients presented adverse effects. Partnership between services of different levels of complexity allowed implantation of a safe and effective public healthcare OPAT program for treatment of orthopedic infections. This program can serve as a model for developing similar strategies in other regions of Brazil and Latin America.

Care transition strategies in Latin American countries: an integrative review

“…Five studies were found related to discharge planning (17)(18)(19)(24)(25) . Planning was centered on the health conditions of patients (19) , cognitive capacity (17,19) , social support, and the needs of patients (19) .…”

“…Five studies were found related to discharge planning (17)(18)(19)(24)(25) . Planning was centered on the health conditions of patients (19) , cognitive capacity (17,19) , social support, and the needs of patients (19) . Care plans included drug lists and instructions (18,(24)(25) , social support to access health care services (19) , underlying illnesses, warning signs and symptoms, nutritional care, instructions regarding continued use of medications, and clinical follow-ups (18,25) .…”

“…Planning was centered on the health conditions of patients (19) , cognitive capacity (17,19) , social support, and the needs of patients (19) . Care plans included drug lists and instructions (18,(24)(25) , social support to access health care services (19) , underlying illnesses, warning signs and symptoms, nutritional care, instructions regarding continued use of medications, and clinical follow-ups (18,25) . One study developed a discharge planning guide around safe medication usage for pediatric patients and their caregivers due to their complex health needs (24) .…”

“…Patient education and promotion of self-management activities were identified in ten studies of this review (15)(16)(17)(18)(19)(20)(21)(22)(24)(25) . Instructions related to self-care and the treatment prescribed at discharge were provided most of the time by nurses (15)(16)20) , multi-professional teams (18)(19)(21)(22)24) , pharmacists for drug use (17,25) .…”

“…Patient education and promotion of self-management activities were identified in ten studies of this review (15)(16)(17)(18)(19)(20)(21)(22)(24)(25) . Instructions related to self-care and the treatment prescribed at discharge were provided most of the time by nurses (15)(16)20) , multi-professional teams (18)(19)(21)(22)24) , pharmacists for drug use (17,25) . Educational actions were focused on the use of central venous catheters (19) , potential adverse effects of drugs (16)(17)25) , use of medications (17)(18)20,22,(24)(25) , selfcare and proper diet (18) , individual needs (15,(20)(21)24) and educational materials (22,25) .…”