Implementation of a consensus protocol for antibiotic use for bone and joint infection to reduce unnecessary outpatient parenteral antimicrobial therapy: A quality improvement initiative

Abstract

Objective: We aimed to decrease the use of outpatient parenteral antimicrobial therapy (OPAT) for patients admitted for bone and joint infections (BJIs) by applying a consensus protocol to suggest oral antibiotics for BJI. Design: A quasi-experimental before-and-after study. Setting: Inpatient setting at a single medical center. Patients: All inpatients admitted with a BJI. Methods: We developed a consensus table of oral antibiotics for BJI among infectious diseases (ID) specialists. Using the consensus table, we implemented a protocol consisting of a weekly reminder e-mail and case-based discussion with the consulting ID physician. Outcomes of patients during the implementation period (November 1, 2020, to May 31, 2021) were compared with those during the preimplementation period (January 1, 2019, to October 31, 2020). Our primary outcome was the proportion of patients treated with OPAT. Secondary outcomes included length of hospital stay (LOS) and recurrence or death within 6 months. Results: In total, 77 patients during the preimplementation period and 22 patients during the implementation period were identified to have a BJI. During the preimplementation period, 70.1% of patients received OPAT, whereas only 31.8% of patients had OPAT during the implementation period (P = .003). The median LOS after final ID recommendation was significantly shorter during the implementation period (median 3 days versus 1 day; P < .001). We detected no significant difference in the 6-month rate of recurrence (24.7% vs 31.8%; P = .46) or mortality (9.1% vs 9.1%; P = 1.00). Conclusions: More patients admitted with BJIs were treated with oral antibiotics during the implementation phase of our quality improvement initiative.

“Once more, with feeling”: no difference in outcomes between patients discharged on oral versus intravenous antibiotics for orthopedic infections in a propensity score matched cohort at a US medical center

“…6 The OVIVA trial provided clear data that PO antibiotics are as effective as IV antibiotics for the treatment of orthopedic infections, leading many centers (including ours) to start using oral antibiotic regimens more frequently. Several institutions have previously published their experience using oral antibiotics, either to treat orthopedic infections in general 13,14,23 or in specific situations. [24][25][26] Similar to the current study, many of these institutions made a concerted effort to consider oral antibiotics for the treatment of orthopedic infections and saw a subsequent increase in the proportion of patients discharged on oral antibiotics.…”

“…Oral antibiotics by default avoid all catheter-related complications, and are usually less expensive. [13][14][15] When institutions have applied the findings of OVIVA to their own practice, in general, they have found reduced costs with similar therapeutic outcomes. 13,16,17 However, despite the advantages of oral antibiotics and the findings of the OVIVA trial, many clinicians have been reluctant to switch to oral regimens for the treatment of bone and joint infections.…”

Switching from intravenous vancomycin to oral antibiotics reduces adverse events in a retrospective cohort of outpatients with orthopedic infections

“…As others have noted, changing the standard of care from IV to oral antibiotics will likely lead to fewer adverse outcomes and reduced cost of care 18 . Focused efforts by antimicrobial stewardship programs to reduce outpatient IV vancomycin use through protocolization, provider education, and other means should be encouraged 11 …”

“…[2][3][4][5] However, the drawbacks of intravenous (IV) antibiotics include cost, barriers to coordinating and managing outpatient IV therapy, risk of IV line complications, and the considerable risk of toxicity from commonly used IV antibiotics, in particular vancomycin. 6 Despite numerous studies indicating that oral (PO) antibiotics are as effective as IV antibiotics for the treatment of orthopedic infections, [7][8][9][10][11][12][13][14][15] including a large randomized clinical trial, 14 clinicians in the United States (US) remain reluctant to use PO antibiotics for the treatment of these serious infections. 16,17 One possible explanation for this reluctance is that the most robust evidence for the equivalence of PO and IV antibiotics comes from a randomized clinical trial in the United Kingdom (the OVIVA trial), which included only a small number of patients (N = 19) with methicillin-resistant Staphylococcus aureus (MRSA).…”

A Review of the Clinical Utilization of Oral Antibacterial Therapy in the Treatment of Bone Infections in Adults

“…Another study from the Veterans Administration Medical Center in Iowa City implemented a quality improvement protocol aimed at decreasing outpatient parenteral antimicrobial therapy (OPAT) and increasing oral antibiotic use. The outcomes demonstrated significantly lower lengths of stay and no difference in the 6-month recurrence rates or mortality [52]. However, aside from OVIVA, no other large randomized controlled trials to date have determined whether enteral antibiotic therapies are non-inferior to parenteral antibiotic therapies for the empiric treatment of osteomyelitis.…”