Home versus hospital intravenous antibiotic therapy in the treatment of young adults with cystic fibrosis

Abstract

H Ho om me e v ve er rs su us s h ho os sp pi it ta al l i in nt tr ra av ve en no ou us s a an nt ti ib bi io ot ti ic c t th he er ra ap py y i in n t th he e t tr re ea at tm me en nt t o of f y yo ou un ng g a ad du ul lt ts s w wi it th h c cy ys st ti ic c f fi ib br ro os si is s The case records of all patients attending the Leeds adult cystic fibrosis clinic were reviewed to identify those who had received home intravenous antibiotic treatment. All home treatments undertaken were included. For each home treatment, the temporally closest hospital treatment for that patient was then selected for comparison and the changes with treatment in peak expiratory flow rate (PEFR), forced vital capacity (FVC), forced expiratory volume in one second (FEV 1 ), Creactive protein (CRP), plasma viscosity, total white cell count, absolute neutrophil count, total immunoglobulin G (IgG) concentration, chest X-ray score (Northern), clinical score, Shwachman-Kulczyki score and weight were analysed for differences between home treatment and hospital treatment. Fifty one paired home/hospital treatments in 25 patients were compared.The improvement in total white cell count was found to be significantly greater in the hospital group, but the difference was very small. The improvements in absolute neutrophil count, and all the other measured variables, were the same in the two groups.Treatment of exacerbations of cystic fibrosis at home or in hospital is, thus, equally effective given proper patient selection and adequate monitoring of the response to treatment.

Location and Duration of Treatment of Cystic Fibrosis Respiratory Exacerbations Do Not Affect Outcomes

“…Currently, there is little evidence to direct physicians' therapies of exacerbations. Prior studies have provided conflicting results as to the efficacy of intravenous antibiotic therapy administered at home compared with that administered in the hospital (4)(5)(6)(7)(8)(9)(10)(11)(12)(13)(14)(15)(16)(17). The only prospective randomized study of the venue of antibiotic administration for respiratory exacerbations in patients with CF published to date found that there was no difference in lung function by therapy venue (7).…”

“…On the other hand, longterm costs may not be reduced in the outpatient setting because of the need for longer and more frequent courses of antibiotics (9), and quality of life may not be better across all domains (7,10). Additionally, several studies have documented no difference between inpatient and outpatient therapy in terms of compliance with antibiotic therapy (5) or improvement in FEV 1 (4)(5)(6)(7)(10)(11)(12)(13). Conversely, other studies have shown a significantly greater improvement in FEV 1 after inpatient treatment compared with outpatient treatment (9,(14)(15)(16)(17).…”

The Community IntraVenous Antibiotic Study (CIVAS): a mixed-methods evaluation of patient preferences for and cost-effectiveness of different service models for delivering outpatient parenteral antimicrobial therapy

“…12,41 Results from those studies assessing the impact of treatment via OPAT specifically on lung function in patients with cystic fibrosis were either inconclusive or found no impact. 42,43,58,60 In the remaining studies, which looked at aspects of clinical effectiveness for OPAT only, rates of cure and/or improvement ranged from 61.1% to 100% (mean 89.6%; median 92.4%). When the various OPAT models are considered individually, the highest average cure/improvement rate was seen for the SN model (90.6%), followed by SA (91.3%), the GN model (90.0%) and HO treatment (85.9%).…”

“…Five studies did not specify the OPAT model that was being used, 48,52,55,61,62 and three others reported combined results for multiple models. 29,49,63 Synthesis of the findings from these studies indicates that, regardless of the model used, there is little evidence of impact on either drug-related side effects or number of deaths in OPAT patients in comparison to patients receiving treatment in hospital 10,22,25,[41][42][43][56][57][58][59]64 (see Appendix 1, Tables 32 and 34). One study looking at outpatient attendance 22 did find a higher death rate (1 patient vs. 0 patients), but this was a small study and the overall rate of side effects was lower in OPAT patients (15% vs. 18%).…”

“…48,[52][53][54][55] Synthesis of the findings from these studies indicates that, regardless of the OPAT model used, there is little impact on the duration of i.v. antibiotic treatment in comparison with inpatient treatment 12,22,25,[41][42][43][56][57][58] (see Appendix 1, Table 32). The effect of OPAT on cure rate, however, is less conclusive.…”