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

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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: OPAT@ggc.scot.nhs.uk