{"paper_id":"104b485d-9b0b-4ef0-b5e7-2d5b39856277","body_text":"Current Status of Outpatient Parenteral Antimicrobial Therapy (OPAT) At a University-Affiliated Acute-Care Hospital in The Republic of Korea | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Current Status of Outpatient Parenteral Antimicrobial Therapy (OPAT) At a University-Affiliated Acute-Care Hospital in The Republic of Korea Eunjeong Heo, Yoonhee Choi, Hyung-sook Kim, Hyung Wook Namgung, and 7 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-960331/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Objectives The aim of this study was to describe current status of outpatient parenteral antimicrobial therapy (OPAT) at a tertiary care hospital in the Republic of Korea. Methods This retrospective study was conducted on outpatients and referral patients who had a prescription of parenteral antibiotics from July to December 2019. We reviewed the prescribed antimicrobials, the indication of antimicrobial therapy, where patients administered antimicrobial injection and management of pre- and post- prescriptions. Results Of the 577 episodes included in this study, 399 (69.2%) were delivered by referral model, 178 (30.8%) by outpatient model. About 70% of OPATs were prescribed in the pulmonology, infectious diseases, orthopedics, gastroenterology, and hematology departments. Five antibiotics (ertapenem (26.0%), ceftriaxone (12.8%), kanamycin (11.8%), amikacin (10.1%), and cefazolin (8.5%)) accounted for 69.2% of the total OPATs. Urinary tract infections (27.3%), respiratory infections (20.8%), and intra-abdominal infections (15.9%) are the most frequent indications of OPAT. After prescription, there were 295 (73.9%) follow-up visits in referral model and 150 (84.3%) in outpatient model ( p <0.05). Laboratory tests necessary for monitoring were totally performed in 274 (47.5%). Conclusions We found that significant number of OPAT was prescribed, follow-up visits were not performed in about a quarter of episodes, and laboratory monitoring was not fully conducted in more than half of the cases. Therefore, it is necessary to establish an appropriate management program for OPAT. Considering limited resources and the distribution of OPAT prescriptions, it may be effective to select frequently used antibiotics or frequently prescribed departments and start the program for them. General Microbiology Infectious Diseases OPAT Republic Hospital antibiotics Background When long-term parenteral antibiotics are required for outpatients or patients who are being discharged, patients are asked to visit outpatient injection centers or are referred to other hospitals. For such treatment, many countries have well-established outpatient parenteral antimicrobial therapy (OPAT) systems. Many studies have shown successful treatment outcome through OPAT and reported reduced costs through reduction of hospital stay. ( 1 – 5 ) According to the 2018 Infectious Diseases Society of America (IDSA) guideline for management of OPAT, it is important that patients are in the appropriate setting for OPAT and all patients should have infectious diseases (ID) expert review prior to initiation of OPAT. OPAT is defined as administration of intravenous antimicrobial therapy without hospital admission ( 6 ) and it is recommended that an OPAT management team monitors the treatment response, test results, and side effects throughout the treatment. ( 7 ) However, systematic procedures or protocols to manage OPAT, and even information on the current status of prescription of parenteral antibiotics for outpatients and referred patients are lacking in the Republic of Korea. Therefore, the present study aims to investigate the current status of OPAT at a tertiary hospital in Korea. This study also seeks to compare pre- and post-prescription management of patients according to the administration model and to investigate the occurrence of adverse reactions. Methods 1. Participants We searched all patients who were prescribed OPAT between July 1 and December 31, 2019 at Seoul National University Bundang Hospital (SNUBH) which is a 1,300 beds tertiary-care, university-affiliated hospital. Exclusion criteria included one-day prescription of parenteral antibiotics and prescriptions through routes other than intramuscular or intravenous injections. The study was conducted under the approval of the institutional review board (IRB) of SNUBH. Informed consent was waived by the IRB. (IRB No. B-2007/625-105) 2. Data collection and analysis 1) Data collection We reviewed the participants' 1 year of electronic medical records between January 1 and December 31, 2019 and collected the following clinical information: age, sex, department treated, diagnosis, indications, type of parenteral antibiotics, number of days, and place where the antibiotics were administered. In the referral model, the documentation of the selected facility was collected. In addition, in order to investigate the pre- and post-prescription management of OPAT, the following data were collected: outpatient visits for follow-up, lab tests, adverse reactions of OPAT, emergency room visits, and hospitalizations. 2) Definition and analysis of study variables Referral model included cases where the prescribed parenteral antibiotics were administered at a nursing hospital or primary care facility. Outpatient model included cases where the parenteral antibiotics were administered at our hospital's injection center or emergency room or through our hospital's visiting injection services. Mixed model included cases where the patients received the antibiotics partially at other medical facilities and partially at our injection center or emergency room. We compared the following variables according to the administration model: department that prescribed the parenteral antibiotics, antibiotics prescribed, indications for prescription, treatment duration, and treatment outcome. When a new parenteral antibiotic was prescribed less than 14 days from the end of the first prescription, this was counted as one case. Moreover, prescription of two or more antibiotics on the same day was also counted as one case. The department that prescribed the parenteral antibiotics and the antibiotics prescribed were counted in terms of the number of episodes, whereas the indications for prescription, treatment duration, and treatment outcome were counted in terms of the number of cases. In terms of the possibility of conversion to oral antibiotics, discharged patients whose clinical conditions could be assessed were evaluated based on our hospital's criteria for conversion of parenteral antibiotics to oral antibiotics. ( 8 ) The evaluation was reviewed by two pharmacists (a resident and an executive pharmacist) in the antibiotics management team. Conversion from parenteral antibiotics to oral antibiotics was considered to be possible in patients who satisfied all 5 criteria (Additional file 1). In order to investigate whether tests necessary for monitoring following the prescription of parenteral antibiotics were ordered and performed, the list of necessary tests for each antibiotic was established based on the OPAT guideline published by the IDSA. ( 6 ) For antibiotics that were not included in the guideline, relevant publications were reviewed. ( 9 , 10 ) Cases were divided into those where all necessary tests were ordered, those where only some necessary tests were ordered, and those where none was ordered. In order to investigate the presence of adverse reactions, cases of reactions documented in charts during follow-up outpatient visits after the prescription of parenteral antibiotics were collected. When patients had multiple adverse reactions to one prescription, these were counted as separate cases. The collected cases of adverse reactions were evaluated as definite and probable events using the Naranjo scale, and the results were reviewed by the two pharmacists. ( 11 ) Moreover, cases that visited the emergency room or were readmitted within 30 days of discharge were collected. The association with cases of emergency visits or hospitalizations and adverse drug reactions were assessed based on the medical records. 3. Statistical analysis In order to compare pre- and post-prescription management of OPAT according to the administration model, statistical analyses comparing the referral model and outpatient model were performed. Pearson's chi-square analyses were performed for follow-up visits and ordering and implementation of necessary tests. Fisher's exact test was used for prescriptions that could be switched from parenteral to oral antibiotics. Statistical analyses were conducted with IBM SPSS statistics ver. 25.0 (IBM Corp., Armonk, NY, USA). P values below 0.05 were interpreted as statistically significant. Results 1. Participants’ characteristics During the study period, a total of 321 patients were prescribed OPAT. The mean age of the patients was 71 years, and 164 (51.1%) were male. The Charlson comorbidity score had a median of 3 (inter-quartile range, IQR 2-4). There were 577 episodes of prescriptions and 383 patient cases. There were 399 (69.2%) episodes in the referral model and 178 (30.8%) episodes in the outpatient model (Table 1 ). Table 1 Basic characteristics of patients and antibiotics administration models. Characteristics N (%) Patients 321 Age, Median(IQR * ) (years) 71 (60, 79) Male 164 (51.1%) Charlson-comorbidity score, Median(IQR * ) 3 (2, 4) Antibiotics administration models Episodes (N=577) Cases (N=383) Referral model 399 (69.2%) 258 (67.4%) Outpatient model 178 (30.8%) 112 (29.2%) Mixed model - 13 (3.4%) * Inter quartile range † 3 episodes/3 cases administered by home-care nurse at home 2. Current status of OPAT prescription and treatment outcome Departments that prescribed antibiotics, selected antibiotics and site of infection in OPAT prescription are included on the Table 2. Ertapenem (26.0%), ceftriaxone (12.8%), kanamycin (11.8%), amikacin (10.1%), and cefazolin (8.5%) were frequently used antibiotics for OPAT. Five departments accounted for 71.4 % of total episodes; pulmonology, infectious diseases, orthopedics, gastroenterology, hematology. 274 (74.1%) cases were treated for 14 days or less (Table 3 ). In terms of treatment outcome, 296 (80.0%) cases had no continued prescription of antibiotics. Table 2 The departments that prescribed antibiotics, selected antibiotics and site of infections for outpatient parenteral antimicrobial therapy All, N (%) (N=577) Referral, N (%) (N=399) Outpatient, N (%) (N=178) Department Pulmonology 143 (24.8%) 101 (25.3%) 42 (23.6%) Infectious diseases 85 (14.7%) 40 (10.0%) 45 (25.3%) Orthopedics 65 (11.3%) 61 (15.3%) 4 (2.2%) Gastroenterology 60 (10.4%) 27 (6.8%) 33 (18.5%) Hematology 59 (10.2%) 57 (14.3%) 2 (1.1%) Nephrology 49 (8.5%) 31 (7.8%) 18 (10.1%) Others 116 (20.1%) 82 (20.6%) 34 (19.1%) Antibiotic Ertapenem 150 (26.0%) 77 (19.3%) 73 (41.0%) Ceftriaxone 74 (12.8%) 48 (12.0%) 26 (14.6%) Kanamycin 68 (11.8%) 45 (11.3%) 23 (12.9%) Amikacin 58 (10.1%) 40 (10.0%) 18 (10.1%) Cefazolin 49 (8.5%) 44 (11.0%) 5 (2.8%) Piperacillin/tazobactam 33 (5.7%) 33 (8.3%) 0 (0.0%) Vancomycin 30 (5.2%) 29 (7.3%) 1 (0.6%) Benzathine penicillin G 26 (4.5%) 1 (0.3%) 25 (14.0%) Others 89 (15.4%) 82 (20.6%) 7 (3.9%) Indications for prescriptions Urinary tract infections 101 (27.3%) 60 (23.3%) 41 (36.6%) Respiratory infections † 77 (20.8%) 67 (26.0%) 10 (8.9%) Intra-abdominal infections 59 (15.9%) 34 (13.2%) 25 (22.3%) Bone and joint infections 51 (13.8%) 49 (19.0%) 2 (1.8%) Others 82 (22.2%) 48 (18.6%) 34 (30.4%) * Based by all 370 cases; 258 cases in referral model, 112 cases in outpatient model † Respiratory infections include TB and NTM infections(30 cases, 8.1%). Table 3. Durations and outcomes of outpatient parenteral antimicrobial therapy. All, N (%) (N=370) Referral, N (%) (N=258) Outpatient, N (%) (N=112) Duration 2-14 days 274 (74.1%) 198 (76.7%) 76 (67.9%) 15-29 days 60 (16.2%) 33 (12.8%) 27 (24.1%) ≥ 30 days 36 (9.7%) 27 (10.5%) 9 (8.0%) Outcome Antibiotics treatment ended 296 (80.0%) 212 (82.2%) 84 (75.0%) Change to oral antibiotics 47 (12.7%) 29 (11.2%) 18 (16.1%) ER * visit or readmission 25 (6.8%) 15 (5.8%) 10 (8.9%) Change to other parenteral antibiotics 2 (0.5%) 2 (0.8%) - * Emergency room 3. Pre- and post-prescription management of OPAT Of the 241 episodes of OPAT prescription for discharged patients, conversion to oral antibiotics was considered possible in 9 (3.7%), and all these 9 episodes were in the referral model (Table 4 ). Of the 399 episodes of OPAT prescribed for administration at another facility (referral model), the facility's name was clearly documented in the prescription only in a small subset of episodes (n = 185, 46.4%). Table 4 Review of clinical monitoring for managing patients before/after infusion of parenteral antibiotics. All, N (%) (N=577) Referral, N (%) (N=399) Outpatient, N (%) (N=178) p value IV to PO conversion 9/241 (3.7%) 9/233 (3.9%) 0/8 (0.0%) 1.00 Record of infusion center 185 (46.4%) - Outpatient visit after administration 445 (77.1%) 295 (73.9%) 150 (84.3%) <0.05 Order rate of laboratory test 0.64 All 318 (55.1%) 215 (53.9%) 103 (57.9%) - Some 69 (12.0%) 48 (12.0%) 21 (11.8%) - None 190 (32.9%) 136 (34.1%) 54 (30.3%) - Implementation rate of laboratory test 0.07 All 274 (47.5%) 177 (44.4%) 97 (54.5%) - Some 64 (11.1%) 45 (11.3%) 19 (10.7%) - None 239 (41.4%) 177 (44.4%) 63 (34.8%) - 445 (77.1%) episodes had follow-up outpatient visits after the prescription; 295 (73.9%) episodes were in the referral model, whereas 150 (84.3%) episodes were in the outpatient model (Table 4 ). Follow-up visits were more frequently done in the outpatient model, with a statistically significant difference between the two models (p<0.05). All necessary tests for antibiotics were ordered by attending physician in 318 episodes (55.1%) and performed in 274 episodes (47.5%). 4. Adverse drug reactions The adverse reaction was developed were documented in 57 (12.8%) episodes. Of these episodes, 16 episodes had Naranjo scale scores corresponding to definite or probable (3.6%); of these, 13 were in the referral model (4.4%), and 3 were in the outpatient model (2.0%) (Table 5 ). A total of 70 episodes involved emergency room visits or hospitalizations within 30 days of prescription of OPAT (12.1%); of these, 3 (0.5%) were considered to be associated with the parenteral antibiotics prescribed (ertapenem and kanamycin). Table 5 Adverse drug reaction related with prescribed parenteral antibiotics. All, N (%) Referral, N (%) Outpatient, N (%) Adverse events associated episodes * 57/445 (12.8%) 44/295 (14.9%) 13/150(8.7%) ADR † associated episodes 16/445 (3.6%) 13/295 (4.4%) 3/150(2.0%) ER ‡ visit or admission 70/577(12.1%) 43/399(10.8%) 27/178(15.2%) Related with parenteral antibiotics 3/577(0.5%) 2/399(0.5%) 1/178(0.6%) * Adverse events instigated only for episodes that had outpatient visit after administration; All (445 episodes) † Adverse drug reaction ‡ Emergency room Discussion The present study assessed the current status and management of OPAT at a single hospital in the Republic of Korea, for the first time. In Korea, post-acute care patients refer to long term care facility to maintain parenteral antibiotics. But there are no fees or reimbursement for OPAT management and few institutions implement OPAT management team. This study may show the current status of OPAT in Korea. During the 6-month study period, significant number (577 episodes) of OPAT prescriptions were made through outpatient or referral models, and we investigated the administration model, follow-up outpatient visit rates after prescription, and monitoring test rates. We found that prescriptions from the top 5 departments that prescribe OPAT often accounted for approximately 70% of all prescriptions. This suggests that pre- and post-prescription management can be introduced preferentially to departments with high rates of prescription. Ertapenem, ceftriaxone, and kanamycin were often prescribed at our hospital, but studies of OPAT at other hospitals reported that ceftriaxone and teicoplanin were frequently prescribed. ( 12 – 14 ) The use of teicoplanin was low at our hospital as we use vancomycin as first line treatment for antibiotic-resistant gram-positive bacterial infection, such as methicillin-resistant Staphylococcus aureus . This difference is thought to be caused by each hospitals' had different patient groups and antibiotic prescribing behaviors. Thus, it is important that each hospital should develop its own strategy for antimicrobial stewardship based on the analysis of antibiotic use of the institution. Common indications for parenteral antibiotics in this study included urinary tract infection, respiratory infection, intra-abdominal infection, and bone and joint infection, consistent with other OPAT studies reporting that bone and joint infections are major indications for OPAT. ( 13 – 17 ) This finding might be due to the clinical characteristics of bone and joint infections requiring relatively long uses of parenteral antibiotics. In contrast, other studies have also reported that skin and soft tissue infections are major indications for OPAT. ( 12 , 14 , 16 , 17 ) In the referral model, 46.6 % of episodes had clear documentation of the facility selected to administer the antibiotics, and this indirectly suggests that management of administration of OPAT is inadequate. In the referral model in which the administration of OPAT is handed over to another facility, the transition can be made through hospitalization or outpatient visits to general hospitals, nursing hospital, clinics, and other various types of facilities. In Korea, there is no fee claims available for these referrals, and sharing of treatment information is also not systematic. As different facilities may be capable of different levels of tests and monitoring, it is important to confirm the facility to which the patient is being referred in advance to confirm whether the facility is capable of maintaining and managing OPAT. Moreover, systematic changes should be made to support continued treatment and management through exchange of information between facilities. More patients in the outpatient model had follow-up outpatient visits after the administration of OPAT than those in the referral model. This may be because patients who continued their care at another facility may have been followed up at that facility, thus not presenting to our hospital for follow-up. In addition, patients who received acute treatment at our hospital may have continued their treatment at a medical facility close to their home. In terms of the implementation of tests necessary for monitoring of parenteral antibiotics, the rate was higher in the outpatient model than in the referral model with a non-significant difference between the two models. Based on these findings, when follow-up at the same hospital is not carried out, the list of necessary tests for management of parenteral antibiotics and possible side effects should be offered at the time of referral. Subsequently, continued management should be offered through phone calls with patients. For management of OPAT, not only OPAT team but antimicrobial stewardship intervention can be helpful. When we evaluated the possibility of changes in the route of administration prior to antibiotics administration, conversion to oral antibiotics was considered to have been possible in 3.7% of prescriptions. Our hospital manages restricted antibiotics by regular ID consultations, and there is an electronic alert with automated consultations for positive blood culture test, so it seems to be well managed ( 18 ) . And Pharmacists in the antimicrobial stewardship team continue to offer the intervention (parenteral-to-oral conversion) to inpatients at our hospital. ( 19 , 20 ) And antimicrobial stewardship team can suggest appropriate duration of antimicrobial therapy. In the future, prescription of parenteral antibiotics for patients planned for discharge should be reviewed in advance to reduce inappropriate antibiotic use. In the present study, adverse drug reactions were confirmed in 3.6% of prescriptions of parenteral antibiotics in outpatient and referral models, and less than 1% of prescriptions led to emergency room visits or hospitalizations associated with adverse drug reactions. However, a previous study reported that adverse reactions were seen in 18% of cases within 2 weeks of discharge, ( 12 ) and another study reported that re-hospitalization was seen in up to 27% of patients. ( 21 ) Referring to the other studies, since only medical records were analyzed retrospectively, mild side effects might not be recorded by physicians and it cannot be recognized in our study. Moreover, although we did not confirm any catheter-associated bloodstream infections in this study, these infections were frequently reported in studies conducted in other countries. ( 13 , 22 ) In Korea, self-administration of intravenous agents by patients is not allowed, and patients are often discharged without central venous catheters. These differences in practice may have led to the differences seen in the results. A few limitations should be considered when interpreting the results of this study. First, because of retrospective nature of this study, we could not assess the treatment outcome, adverse reaction of antibiotics, whether antibiotics had changed or added etc. in patients without follow-up visit. Second, when no follow-up visits were done, more adverse reactions than those documented could have happened. However, as these were not documented, the number of adverse reactions could have been underestimated given the retrospective design of the present study. Last, since this study was conducted at a single hospital, the results may be different from other hospitals in South Korea. This study investigated the departments that frequently prescribe parenteral antibiotics for outpatients and referred patients, as well as frequently prescribed antibiotics and the indications for them. The study also found that appropriate candidates for monitoring should be selected prior to administration of parenteral antibiotics and that monitoring should be implemented. This study is significant in that it was able to confirm the participants who require monitoring of parenteral antibiotics, the scope of monitoring, and the necessity of a monitoring system through its findings. Conclusion According to the present study findings, approximately 70% of OPAT were prescribed in 5 departments, and 5 antibiotics accounted for 70% of all prescriptions. We also confirmed that follow-up after prescription is lacking. Therefore, a comprehensive monitoring system and antimicrobial stewardship for safe and effective OPAT is necessary, and the findings of this study will serve as useful basic data for the system. Declarations Ethics approval and consent to participate This retrospective study was approved by the institutional review board (IRB) of Seoul National University Bundang Hospital (B-2007/625-105), and a waiver for written consent was obtained from the IRB. Consent for publication All authors agree publication of this paper. Availability of data and materials All data generated or analyzed during this study are included in this published article and its supplementary information files. Competing interests All authors declare that there are no conflicts of interest. Funding This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. Authors' contributions YC, EH, JYL, KHS designed study and drafted paper. YC, EH collected and analyzed the patient data. JYL, HWN, EL1, EL2 analyzed and interpreted the patient data regarding antibiotic therapy and antibiotic adverse reaction. EH, JTJ, ESK, HBK, KHS analyzed and interpreted the patient data regarding infectious disease and outpatient parenteral antibiotic therapy(OPAT). All authors read and approved the final manuscript. Acknowledgements The authors thank the Medical Informatics team at the Seoul National University Bundang Hospital for data supply. We are particularly grateful to all the pharmacists colleagues. References Chapman AL, Dixon S, Andrews D, Lillie PJ, Bazaz R, Patchett JD. Clinical efficacy and cost-effectiveness of outpatient parenteral antibiotic therapy (OPAT): a UK perspective. J Antimicrob Chemother. 2009;64(6):1316–24. Durojaiye OC, Bell H, Andrews D, Ntziora F, Cartwright K. 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University Bundang Hospital\",\"correspondingAuthor\":false,\"prefix\":\"\",\"firstName\":\"Hyung\",\"middleName\":\"Wook\",\"lastName\":\"Namgung\",\"suffix\":\"\"},{\"id\":59245892,\"identity\":\"59bda8c4-6b39-47e8-b1c2-5f75e1b735c7\",\"order_by\":4,\"name\":\"Eunsook Lee\",\"email\":\"\",\"orcid\":\"\",\"institution\":\"Seoul National University Bundang Hospital\",\"correspondingAuthor\":false,\"prefix\":\"\",\"firstName\":\"Eunsook\",\"middleName\":\"\",\"lastName\":\"Lee\",\"suffix\":\"\"},{\"id\":59245893,\"identity\":\"d44f1480-7931-4659-9597-baa3641a9966\",\"order_by\":5,\"name\":\"Euni Lee\",\"email\":\"\",\"orcid\":\"\",\"institution\":\"Seoul National University\",\"correspondingAuthor\":false,\"prefix\":\"\",\"firstName\":\"Euni\",\"middleName\":\"\",\"lastName\":\"Lee\",\"suffix\":\"\"},{\"id\":59245894,\"identity\":\"c7ec24ff-6bfa-437c-a065-a2f8791e5001\",\"order_by\":6,\"name\":\"Ju-Yeun Lee\",\"email\":\"\",\"orcid\":\"\",\"institution\":\"Seoul National Univeristy\",\"correspondingAuthor\":false,\"prefix\":\"\",\"firstName\":\"Ju-Yeun\",\"middleName\":\"\",\"lastName\":\"Lee\",\"suffix\":\"\"},{\"id\":59245895,\"identity\":\"d270ff09-3d6f-433a-ba1a-b47f578c6737\",\"order_by\":7,\"name\":\"Jong Tak Jung\",\"email\":\"\",\"orcid\":\"\",\"institution\":\"Seoul National University Bundang Hospital\",\"correspondingAuthor\":false,\"prefix\":\"\",\"firstName\":\"Jong\",\"middleName\":\"Tak\",\"lastName\":\"Jung\",\"suffix\":\"\"},{\"id\":59245896,\"identity\":\"dcf60c4f-d14a-4622-80c7-57310f172d9b\",\"order_by\":8,\"name\":\"Eu Suk Kim\",\"email\":\"\",\"orcid\":\"\",\"institution\":\"Seoul National University Bundang Hospital\",\"correspondingAuthor\":false,\"prefix\":\"\",\"firstName\":\"Eu\",\"middleName\":\"Suk\",\"lastName\":\"Kim\",\"suffix\":\"\"},{\"id\":59245897,\"identity\":\"57f024c0-fc86-4d77-8b03-42859437c3c4\",\"order_by\":9,\"name\":\"Hong Bin Kim\",\"email\":\"\",\"orcid\":\"\",\"institution\":\"Seoul National University Bundang Hospital\",\"correspondingAuthor\":false,\"prefix\":\"\",\"firstName\":\"Hong\",\"middleName\":\"Bin\",\"lastName\":\"Kim\",\"suffix\":\"\"},{\"id\":59245898,\"identity\":\"d7f5962c-6fb6-4766-9af7-e6115194b5fb\",\"order_by\":10,\"name\":\"Kyoung-Ho Song\",\"email\":\"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA0klEQVRIiWNgGAWjYBACCQkIzdgPIhMKSNEyswGkxYAULRsOgChitEjObn/4uODXNtnN51cnfnhgwCDPL3YAvxZpmTPGxjP7bhtvu/F2swTQYYYzZyfg1yInkcMmzdtzO3HbjbMbQFoSDG4T1JL+DKxl84yzm38QpUVaIsFMmufH7cQN/L3biLNFckaOsTFvw23jGTd4t1kkGEgQ9ovEjfSHj3n+3Jbt7z+7+eaPCht5fmkCWsCAsQ2kGaxSggjlYPAHiPkPEKt6FIyCUTAKRhoAABAHSEL3Cnx3AAAAAElFTkSuQmCC\",\"orcid\":\"https://orcid.org/0000-0002-4517-3840\",\"institution\":\"Seoul National University Bundang Hospital\",\"correspondingAuthor\":true,\"prefix\":\"\",\"firstName\":\"Kyoung-Ho\",\"middleName\":\"\",\"lastName\":\"Song\",\"suffix\":\"\"}],\"badges\":[],\"createdAt\":\"2021-10-08 10:47:13\",\"currentVersionCode\":1,\"declarations\":\"\",\"doi\":\"10.21203/rs.3.rs-960331/v1\",\"doiUrl\":\"https://doi.org/10.21203/rs.3.rs-960331/v1\",\"draftVersion\":[],\"editorialEvents\":[],\"editorialNote\":\"\",\"failedWorkflow\":false,\"files\":[{\"id\":15465376,\"identity\":\"046fe656-659b-4104-9b54-4fdbcddfb55b\",\"added_by\":\"auto\",\"created_at\":\"2021-11-12 05:24:40\",\"extension\":\"pdf\",\"order_by\":0,\"title\":\"\",\"display\":\"\",\"copyAsset\":false,\"role\":\"manuscript-pdf\",\"size\":401543,\"visible\":true,\"origin\":\"\",\"legend\":\"\",\"description\":\"\",\"filename\":\"manuscript.pdf\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-960331/v1/9fbe1ad6-f54e-419d-8f78-f0c85fd5a106.pdf\"},{\"id\":14993530,\"identity\":\"85cbabf8-de60-4415-bc3d-ab3e1990a2e9\",\"added_by\":\"auto\",\"created_at\":\"2021-10-28 15:29:46\",\"extension\":\"docx\",\"order_by\":5,\"title\":\"\",\"display\":\"\",\"copyAsset\":false,\"role\":\"supplement\",\"size\":21337,\"visible\":true,\"origin\":\"\",\"legend\":\"\",\"description\":\"\",\"filename\":\"Additionalfile1.docx\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-960331/v1/1357ad98cbc367fbd1308604.docx\"}],\"financialInterests\":\"\",\"formattedTitle\":\"\\u003cp\\u003eCurrent Status of Outpatient Parenteral Antimicrobial Therapy (OPAT) At a University-Affiliated Acute-Care Hospital in The Republic of Korea\\u003c/p\\u003e\",\"fulltext\":[{\"header\":\"Background\",\"content\":\"\\u003cp\\u003eWhen long-term parenteral antibiotics are required for outpatients or patients who are being discharged, patients are asked to visit outpatient injection centers or are referred to other hospitals. For such treatment, many countries have well-established outpatient parenteral antimicrobial therapy (OPAT) systems. Many studies have shown successful treatment outcome through OPAT and reported reduced costs through reduction of hospital stay. \\u003csup\\u003e(\\u003cspan additionalcitationids=\\\"CR2 CR3 CR4\\\" citationid=\\\"CR1\\\" class=\\\"CitationRef\\\"\\u003e1\\u003c/span\\u003e\\u0026ndash;\\u003cspan citationid=\\\"CR5\\\" class=\\\"CitationRef\\\"\\u003e5\\u003c/span\\u003e)\\u003c/sup\\u003e According to the 2018 Infectious Diseases Society of America (IDSA) guideline for management of OPAT, it is important that patients are in the appropriate setting for OPAT and all patients should have infectious diseases (ID) expert review prior to initiation of OPAT. OPAT is defined as administration of intravenous antimicrobial therapy without hospital admission\\u003csup\\u003e(\\u003cspan citationid=\\\"CR6\\\" class=\\\"CitationRef\\\"\\u003e6\\u003c/span\\u003e)\\u003c/sup\\u003e and it is recommended that an OPAT management team monitors the treatment response, test results, and side effects throughout the treatment.\\u003csup\\u003e(\\u003cspan citationid=\\\"CR7\\\" class=\\\"CitationRef\\\"\\u003e7\\u003c/span\\u003e)\\u003c/sup\\u003e\\u003c/p\\u003e \\u003cp\\u003eHowever, systematic procedures or protocols to manage OPAT, and even information on the current status of prescription of parenteral antibiotics for outpatients and referred patients are lacking in the Republic of Korea. Therefore, the present study aims to investigate the current status of OPAT at a tertiary hospital in Korea. This study also seeks to compare pre- and post-prescription management of patients according to the administration model and to investigate the occurrence of adverse reactions.\\u003c/p\\u003e\"},{\"header\":\"Methods\",\"content\":\" \\u003cdiv id=\\\"Sec2\\\" class=\\\"Section2\\\"\\u003e \\u003ch2\\u003e1. Participants\\u003c/h2\\u003e \\u003cp\\u003e We searched all patients who were prescribed OPAT between July 1 and December 31, 2019 at Seoul National University Bundang Hospital (SNUBH) which is a 1,300 beds tertiary-care, university-affiliated hospital. Exclusion criteria included one-day prescription of parenteral antibiotics and prescriptions through routes other than intramuscular or intravenous injections. The study was conducted under the approval of the institutional review board (IRB) of SNUBH. Informed consent was waived by the IRB. (IRB No. B-2007/625-105)\\u003c/p\\u003e \\u003ch2\\u003e2. Data collection and analysis\\u003c/h2\\u003e \\u003c/div\\u003e \\u003cdiv id=\\\"Sec3\\\" class=\\\"Section2\\\"\\u003e \\u003ch2\\u003e1) Data collection\\u003c/h2\\u003e \\u003cp\\u003eWe reviewed the participants' 1 year of electronic medical records between January 1 and December 31, 2019 and collected the following clinical information: age, sex, department treated, diagnosis, indications, type of parenteral antibiotics, number of days, and place where the antibiotics were administered. In the referral model, the documentation of the selected facility was collected. In addition, in order to investigate the pre- and post-prescription management of OPAT, the following data were collected: outpatient visits for follow-up, lab tests, adverse reactions of OPAT, emergency room visits, and hospitalizations.\\u003c/p\\u003e \\u003c/div\\u003e \\u003cdiv id=\\\"Sec4\\\" class=\\\"Section2\\\"\\u003e \\u003ch2\\u003e2) Definition and analysis of study variables\\u003c/h2\\u003e \\u003cp\\u003eReferral model included cases where the prescribed parenteral antibiotics were administered at a nursing hospital or primary care facility. Outpatient model included cases where the parenteral antibiotics were administered at our hospital's injection center or emergency room or through our hospital's visiting injection services. Mixed model included cases where the patients received the antibiotics partially at other medical facilities and partially at our injection center or emergency room.\\u003c/p\\u003e \\u003cp\\u003eWe compared the following variables according to the administration model: department that prescribed the parenteral antibiotics, antibiotics prescribed, indications for prescription, treatment duration, and treatment outcome. When a new parenteral antibiotic was prescribed less than 14 days from the end of the first prescription, this was counted as one case. Moreover, prescription of two or more antibiotics on the same day was also counted as one case. The department that prescribed the parenteral antibiotics and the antibiotics prescribed were counted in terms of the number of episodes, whereas the indications for prescription, treatment duration, and treatment outcome were counted in terms of the number of cases.\\u003c/p\\u003e \\u003cp\\u003eIn terms of the possibility of conversion to oral antibiotics, discharged patients whose clinical conditions could be assessed were evaluated based on our hospital's criteria for conversion of parenteral antibiotics to oral antibiotics.\\u003csup\\u003e(\\u003cspan citationid=\\\"CR8\\\" class=\\\"CitationRef\\\"\\u003e8\\u003c/span\\u003e)\\u003c/sup\\u003e The evaluation was reviewed by two pharmacists (a resident and an executive pharmacist) in the antibiotics management team. Conversion from parenteral antibiotics to oral antibiotics was considered to be possible in patients who satisfied all 5 criteria (Additional file 1).\\u003c/p\\u003e \\u003cp\\u003e In order to investigate whether tests necessary for monitoring following the prescription of parenteral antibiotics were ordered and performed, the list of necessary tests for each antibiotic was established based on the OPAT guideline published by the IDSA.\\u003csup\\u003e(\\u003cspan citationid=\\\"CR6\\\" class=\\\"CitationRef\\\"\\u003e6\\u003c/span\\u003e)\\u003c/sup\\u003e For antibiotics that were not included in the guideline, relevant publications were reviewed.\\u003csup\\u003e(\\u003cspan citationid=\\\"CR9\\\" class=\\\"CitationRef\\\"\\u003e9\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR10\\\" class=\\\"CitationRef\\\"\\u003e10\\u003c/span\\u003e)\\u003c/sup\\u003e Cases were divided into those where all necessary tests were ordered, those where only some necessary tests were ordered, and those where none was ordered.\\u003c/p\\u003e \\u003cp\\u003eIn order to investigate the presence of adverse reactions, cases of reactions documented in charts during follow-up outpatient visits after the prescription of parenteral antibiotics were collected. When patients had multiple adverse reactions to one prescription, these were counted as separate cases. The collected cases of adverse reactions were evaluated as definite and probable events using the Naranjo scale, and the results were reviewed by the two pharmacists.\\u003csup\\u003e(\\u003cspan citationid=\\\"CR11\\\" class=\\\"CitationRef\\\"\\u003e11\\u003c/span\\u003e)\\u003c/sup\\u003e Moreover, cases that visited the emergency room or were readmitted within 30 days of discharge were collected. The association with cases of emergency visits or hospitalizations and adverse drug reactions were assessed based on the medical records.\\u003c/p\\u003e \\u003c/div\\u003e \\u003cdiv id=\\\"Sec5\\\" class=\\\"Section2\\\"\\u003e \\u003ch2\\u003e3. Statistical analysis\\u003c/h2\\u003e \\u003cp\\u003e In order to compare pre- and post-prescription management of OPAT according to the administration model, statistical analyses comparing the referral model and outpatient model were performed. Pearson's chi-square analyses were performed for follow-up visits and ordering and implementation of necessary tests. Fisher's exact test was used for prescriptions that could be switched from parenteral to oral antibiotics. Statistical analyses were conducted with IBM SPSS statistics ver. 25.0 (IBM Corp., Armonk, NY, USA). P values below 0.05 were interpreted as statistically significant.\\u003c/p\\u003e \\u003c/div\\u003e\"},{\"header\":\"Results\",\"content\":\"\\u003cdiv class=\\\"Section2\\\" id=\\\"Sec7\\\"\\u003e\\n \\u003ch2\\u003e1. Participants\\u0026rsquo; characteristics\\u003c/h2\\u003e\\n \\u003cp\\u003eDuring the study period, a total of 321 patients were prescribed OPAT. The mean age of the patients was 71 years, and 164 (51.1%) were male. The Charlson comorbidity score had a median of 3 (inter-quartile range, IQR 2-4). There were 577 episodes of prescriptions and 383 patient cases. There were 399 (69.2%) episodes in the referral model and 178 (30.8%) episodes in the outpatient model (Table \\u003cspan class=\\\"InternalRef\\\"\\u003e1\\u003c/span\\u003e).\\u0026nbsp;\\u003c/p\\u003e\\n \\u003ctable border=\\\"1\\\" id=\\\"Tab1\\\"\\u003e\\n \\u003ccaption language=\\\"En\\\"\\u003e\\n \\u003cdiv class=\\\"CaptionNumber\\\"\\u003eTable 1\\u003c/div\\u003e\\n \\u003cdiv class=\\\"CaptionContent\\\"\\u003e\\n \\u003cp\\u003eBasic characteristics of patients and antibiotics administration models.\\u003c/p\\u003e\\n \\u003c/div\\u003e\\n \\u003c/caption\\u003e\\n \\u003cthead\\u003e\\n \\u003ctr\\u003e\\n \\u003cth align=\\\"left\\\"\\u003e\\n \\u003cp\\u003eCharacteristics\\u003c/p\\u003e\\n \\u003c/th\\u003e\\n \\u003cth align=\\\"left\\\" colspan=\\\"3\\\"\\u003e\\n \\u003cp\\u003eN (%)\\u003c/p\\u003e\\n \\u003c/th\\u003e\\n \\u003c/tr\\u003e\\n \\u003c/thead\\u003e\\n \\u003ctbody\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003ePatients\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\" colspan=\\\"3\\\"\\u003e\\n \\u003cp\\u003e321\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003eAge, Median(IQR\\u003csup\\u003e*\\u003c/sup\\u003e) (years)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\" colspan=\\\"3\\\"\\u003e\\n \\u003cp\\u003e71 (60, 79)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003eMale\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\" colspan=\\\"3\\\"\\u003e\\n \\u003cp\\u003e164 (51.1%)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003eCharlson-comorbidity score, Median(IQR\\u003csup\\u003e*\\u003c/sup\\u003e)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\" colspan=\\\"3\\\"\\u003e\\n \\u003cp\\u003e3 (2, 4)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003eAntibiotics administration models\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\" colspan=\\\"2\\\"\\u003e\\n \\u003cp\\u003eEpisodes (N=577)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003eCases (N=383)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003eReferral model\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e399 (69.2%)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\" colspan=\\\"2\\\"\\u003e\\n \\u003cp\\u003e258 (67.4%)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003eOutpatient model\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e178 (30.8%)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\" colspan=\\\"2\\\"\\u003e\\n \\u003cp\\u003e112 (29.2%)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003eMixed model\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e-\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\" colspan=\\\"2\\\"\\u003e\\n \\u003cp\\u003e13 (3.4%)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd align=\\\"left\\\" colspan=\\\"4\\\"\\u003e\\n \\u003cp\\u003e\\u003csup\\u003e*\\u003c/sup\\u003e Inter quartile range\\u003c/p\\u003e\\n \\u003cp\\u003e\\u003csup\\u003e\\u0026dagger;\\u003c/sup\\u003e 3 episodes/3 cases administered by home-care nurse at home\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003c/tbody\\u003e\\n \\u003c/table\\u003e\\n \\u003cp\\u003e\\u003c/p\\u003e\\n \\u003cp\\u003e\\u003cbr\\u003e\\u003c/p\\u003e\\n\\u003c/div\\u003e\\n\\u003cdiv class=\\\"Section2\\\" id=\\\"Sec8\\\"\\u003e\\n \\u003ch2\\u003e2. Current status of OPAT prescription and treatment outcome\\u003c/h2\\u003e\\n \\u003cp\\u003eDepartments that prescribed antibiotics, selected antibiotics and site of infection in OPAT prescription are included on the Table 2. Ertapenem (26.0%), ceftriaxone (12.8%), kanamycin (11.8%), amikacin (10.1%), and cefazolin (8.5%) were frequently used antibiotics for OPAT. Five departments accounted for 71.4 % of total episodes; pulmonology, infectious diseases, orthopedics, gastroenterology, hematology. 274 (74.1%) cases were treated for 14 days or less (Table \\u003cspan class=\\\"InternalRef\\\"\\u003e3\\u003c/span\\u003e). In terms of treatment outcome, 296 (80.0%) cases had no continued prescription of antibiotics.\\u003c/p\\u003e\\n \\u003ctable border=\\\"1\\\" id=\\\"Tab2\\\"\\u003e\\n \\u003ccaption language=\\\"En\\\"\\u003e\\n \\u003cdiv class=\\\"CaptionNumber\\\"\\u003eTable 2\\u003c/div\\u003e\\n \\u003cdiv class=\\\"CaptionContent\\\"\\u003e\\n \\u003cp\\u003eThe departments that prescribed antibiotics, selected antibiotics and site of infections for outpatient parenteral antimicrobial therapy\\u003c/p\\u003e\\n \\u003c/div\\u003e\\n \\u003c/caption\\u003e\\n \\u003ctbody\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003eAll, N (%)\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003e(N=577)\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003eReferral, N (%) (N=399)\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003eOutpatient, N (%)\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003e(N=178)\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003eDepartment\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003ePulmonology\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e143 (24.8%)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e101 (25.3%)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e42 (23.6%)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003eInfectious diseases\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e85 (14.7%)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e40 (10.0%)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e45 (25.3%)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003eOrthopedics\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e65 (11.3%)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e61 (15.3%)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e4 (2.2%)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003eGastroenterology\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e60 (10.4%)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e27 (6.8%)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e33 (18.5%)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003eHematology\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e59 (10.2%)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e57 (14.3%)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e2 (1.1%)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003eNephrology\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e49 (8.5%)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e31 (7.8%)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e18 (10.1%)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003eOthers\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e116 (20.1%)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e82 (20.6%)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e34 (19.1%)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003eAntibiotic\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003eErtapenem\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e150 (26.0%)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e77 (19.3%)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e73 (41.0%)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003eCeftriaxone\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e74 (12.8%)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e48 (12.0%)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e26 (14.6%)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003eKanamycin\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e68 (11.8%)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e45 (11.3%)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e23 (12.9%)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003eAmikacin\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e58 (10.1%)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e40 (10.0%)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e18 (10.1%)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003eCefazolin\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e49 (8.5%)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e44 (11.0%)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e5 (2.8%)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003ePiperacillin/tazobactam\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e33 (5.7%)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e33 (8.3%)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e0 (0.0%)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003eVancomycin\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e30 (5.2%)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e29 (7.3%)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e1 (0.6%)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003eBenzathine penicillin G\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e26 (4.5%)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e1 (0.3%)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e25 (14.0%)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003eOthers\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e89 (15.4%)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e82 (20.6%)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e7 (3.9%)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003eIndications for prescriptions\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003eUrinary tract infections\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e101 (27.3%)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e60 (23.3%)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e41 (36.6%)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003eRespiratory infections\\u003csup\\u003e\\u0026dagger;\\u003c/sup\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e77 (20.8%)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e67 (26.0%)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e10 (8.9%)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003eIntra-abdominal infections\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e59 (15.9%)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e34 (13.2%)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e25 (22.3%)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003eBone and joint infections\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e51 (13.8%)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e49 (19.0%)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e2 (1.8%)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003eOthers\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e82 (22.2%)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e48 (18.6%)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e34 (30.4%)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd align=\\\"left\\\" colspan=\\\"4\\\"\\u003e\\n \\u003cp\\u003e\\u003csup\\u003e*\\u003c/sup\\u003e Based by all 370 cases; 258 cases in referral model, 112 cases in outpatient model\\u003c/p\\u003e\\n \\u003cp\\u003e\\u003csup\\u003e\\u0026dagger;\\u003c/sup\\u003e Respiratory infections include TB and NTM infections(30 cases, 8.1%).\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003c/tbody\\u003e\\n \\u003c/table\\u003e\\n \\u003cp\\u003e\\u003c/p\\u003e\\n \\u003cp\\u003e\\u003cbr\\u003e\\u003c/p\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003eTable 3. Durations and outcomes of outpatient parenteral antimicrobial therapy.\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003ctable border=\\\"1\\\" id=\\\"Taba\\\"\\u003e\\n \\u003cthead\\u003e\\n \\u003ctr\\u003e\\n \\u003cth align=\\\"left\\\"\\u003e\\u0026nbsp;\\u003c/th\\u003e\\n \\u003cth align=\\\"left\\\"\\u003e\\n \\u003cp\\u003eAll, N (%)\\u003c/p\\u003e\\n \\u003cp\\u003e(N=370)\\u003c/p\\u003e\\n \\u003c/th\\u003e\\n \\u003cth align=\\\"left\\\"\\u003e\\n \\u003cp\\u003eReferral, N (%) (N=258)\\u003c/p\\u003e\\n \\u003c/th\\u003e\\n \\u003cth align=\\\"left\\\"\\u003e\\n \\u003cp\\u003eOutpatient, N (%)\\u003c/p\\u003e\\n \\u003cp\\u003e(N=112)\\u003c/p\\u003e\\n \\u003c/th\\u003e\\n \\u003c/tr\\u003e\\n \\u003c/thead\\u003e\\n \\u003ctbody\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003eDuration\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e2-14 days\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e274 (74.1%)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e198 (76.7%)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e76 (67.9%)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e15-29 days\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e60 (16.2%)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e33 (12.8%)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e27 (24.1%)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e\\u0026ge; 30 days\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e36 (9.7%)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e27 (10.5%)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e9 (8.0%)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003eOutcome\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003eAntibiotics treatment ended\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e296 (80.0%)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e212 (82.2%)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e84 (75.0%)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003eChange to oral antibiotics\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e47 (12.7%)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e29 (11.2%)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e18 (16.1%)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003eER\\u003csup\\u003e*\\u003c/sup\\u003e visit or readmission\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e25 (6.8%)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e15 (5.8%)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e10 (8.9%)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003eChange to other parenteral antibiotics\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e2 (0.5%)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e2 (0.8%)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e-\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003c/tbody\\u003e\\n \\u003ctfoot\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd colspan=\\\"4\\\"\\u003e\\u003csup\\u003e*\\u003c/sup\\u003e Emergency room\\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003c/tfoot\\u003e\\n \\u003c/table\\u003e\\n \\u003cp\\u003e\\u003c/p\\u003e\\n \\u003cp\\u003e\\u003cbr\\u003e\\u003c/p\\u003e\\n\\u003c/div\\u003e\\n\\u003cdiv class=\\\"Section2\\\" id=\\\"Sec9\\\"\\u003e\\n \\u003ch2\\u003e3. Pre- and post-prescription management of OPAT\\u003c/h2\\u003e\\n \\u003cp\\u003eOf the 241 episodes of OPAT prescription for discharged patients, conversion to oral antibiotics was considered possible in 9 (3.7%), and all these 9 episodes were in the referral model (Table \\u003cspan class=\\\"InternalRef\\\"\\u003e4\\u003c/span\\u003e). Of the 399 episodes of OPAT prescribed for administration at another facility (referral model), the facility\\u0026apos;s name was clearly documented in the prescription only in a small subset of episodes (n = 185, 46.4%).\\u0026nbsp;\\u003c/p\\u003e\\n \\u003ctable border=\\\"1\\\" id=\\\"Tab3\\\"\\u003e\\n \\u003ccaption language=\\\"En\\\"\\u003e\\n \\u003cdiv class=\\\"CaptionNumber\\\"\\u003eTable 4\\u003c/div\\u003e\\n \\u003cdiv class=\\\"CaptionContent\\\"\\u003e\\n \\u003cp\\u003eReview of clinical monitoring for managing patients before/after infusion of parenteral antibiotics.\\u003c/p\\u003e\\n \\u003c/div\\u003e\\n \\u003c/caption\\u003e\\n \\u003cthead\\u003e\\n \\u003ctr\\u003e\\n \\u003cth align=\\\"left\\\"\\u003e\\u0026nbsp;\\u003c/th\\u003e\\n \\u003cth align=\\\"left\\\"\\u003e\\n \\u003cp\\u003eAll, N (%)\\u003c/p\\u003e\\n \\u003cp\\u003e(N=577)\\u003c/p\\u003e\\n \\u003c/th\\u003e\\n \\u003cth align=\\\"left\\\" colspan=\\\"3\\\"\\u003e\\n \\u003cp\\u003eReferral, N (%) (N=399)\\u003c/p\\u003e\\n \\u003c/th\\u003e\\n \\u003cth align=\\\"left\\\"\\u003e\\n \\u003cp\\u003eOutpatient, N (%)\\u003c/p\\u003e\\n \\u003cp\\u003e(N=178)\\u003c/p\\u003e\\n \\u003c/th\\u003e\\n \\u003cth align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e\\u003cem\\u003ep\\u003c/em\\u003e value\\u003c/p\\u003e\\n \\u003c/th\\u003e\\n \\u003c/tr\\u003e\\n \\u003c/thead\\u003e\\n \\u003ctbody\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003eIV to PO conversion\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\" colspan=\\\"2\\\"\\u003e\\n \\u003cp\\u003e9/241 (3.7%)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e9/233 (3.9%)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\" colspan=\\\"2\\\"\\u003e\\n \\u003cp\\u003e0/8 (0.0%)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e1.00\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003eRecord of infusion center\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\" colspan=\\\"2\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e185 (46.4%)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\" colspan=\\\"2\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e-\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003eOutpatient visit\\u003c/p\\u003e\\n \\u003cp\\u003eafter administration\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\" colspan=\\\"2\\\"\\u003e\\n \\u003cp\\u003e445 (77.1%)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e295 (73.9%)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\" colspan=\\\"2\\\"\\u003e\\n \\u003cp\\u003e150 (84.3%)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e\\u0026lt;0.05\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003eOrder rate of\\u003c/p\\u003e\\n \\u003cp\\u003elaboratory test\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\" colspan=\\\"2\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\" colspan=\\\"2\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e0.64\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003eAll\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\" colspan=\\\"2\\\"\\u003e\\n \\u003cp\\u003e318 (55.1%)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e215 (53.9%)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\" colspan=\\\"2\\\"\\u003e\\n \\u003cp\\u003e103 (57.9%)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e-\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003eSome\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\" colspan=\\\"2\\\"\\u003e\\n \\u003cp\\u003e69 (12.0%)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e48 (12.0%)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\" colspan=\\\"2\\\"\\u003e\\n \\u003cp\\u003e21 (11.8%)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e-\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003eNone\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\" colspan=\\\"2\\\"\\u003e\\n \\u003cp\\u003e190 (32.9%)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e136 (34.1%)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\" colspan=\\\"2\\\"\\u003e\\n \\u003cp\\u003e54 (30.3%)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e-\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003eImplementation rate of\\u003c/p\\u003e\\n \\u003cp\\u003elaboratory test\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\" colspan=\\\"2\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\" colspan=\\\"2\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e0.07\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003eAll\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\" colspan=\\\"2\\\"\\u003e\\n \\u003cp\\u003e274 (47.5%)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e177 (44.4%)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\" colspan=\\\"2\\\"\\u003e\\n \\u003cp\\u003e97 (54.5%)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e-\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003eSome\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\" colspan=\\\"2\\\"\\u003e\\n \\u003cp\\u003e64 (11.1%)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e45 (11.3%)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\" colspan=\\\"2\\\"\\u003e\\n \\u003cp\\u003e19 (10.7%)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e-\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003eNone\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\" colspan=\\\"2\\\"\\u003e\\n \\u003cp\\u003e239 (41.4%)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e177 (44.4%)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\" colspan=\\\"2\\\"\\u003e\\n \\u003cp\\u003e63 (34.8%)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e-\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003c/tbody\\u003e\\n \\u003c/table\\u003e\\n \\u003cp\\u003e\\u003c/p\\u003e\\n \\u003cp\\u003e\\u003cbr\\u003e\\u003c/p\\u003e\\n \\u003cp\\u003e445 (77.1%) episodes had follow-up outpatient visits after the prescription; 295 (73.9%) episodes were in the referral model, whereas 150 (84.3%) episodes were in the outpatient model (Table \\u003cspan class=\\\"InternalRef\\\"\\u003e4\\u003c/span\\u003e). Follow-up visits were more frequently done in the outpatient model, with a statistically significant difference between the two models (p\\u0026lt;0.05). All necessary tests for antibiotics were ordered by attending physician in 318 episodes (55.1%) and performed in 274 episodes (47.5%).\\u003c/p\\u003e\\n\\u003c/div\\u003e\\n\\u003cdiv class=\\\"Section2\\\" id=\\\"Sec10\\\"\\u003e\\n \\u003ch2\\u003e4. Adverse drug reactions\\u003c/h2\\u003e\\n \\u003cp\\u003eThe adverse reaction was developed were documented in 57 (12.8%) episodes. Of these episodes, 16 episodes had Naranjo scale scores corresponding to definite or probable (3.6%); of these, 13 were in the referral model (4.4%), and 3 were in the outpatient model (2.0%) (Table \\u003cspan class=\\\"InternalRef\\\"\\u003e5\\u003c/span\\u003e). A total of 70 episodes involved emergency room visits or hospitalizations within 30 days of prescription of OPAT (12.1%); of these, 3 (0.5%) were considered to be associated with the parenteral antibiotics prescribed (ertapenem and kanamycin).\\u0026nbsp;\\u003c/p\\u003e\\n \\u003ctable border=\\\"1\\\" id=\\\"Tab4\\\"\\u003e\\n \\u003ccaption language=\\\"En\\\"\\u003e\\n \\u003cdiv class=\\\"CaptionNumber\\\"\\u003eTable 5\\u003c/div\\u003e\\n \\u003cdiv class=\\\"CaptionContent\\\"\\u003e\\n \\u003cp\\u003eAdverse drug reaction related with prescribed parenteral antibiotics.\\u003c/p\\u003e\\n \\u003c/div\\u003e\\n \\u003c/caption\\u003e\\n \\u003cthead\\u003e\\n \\u003ctr\\u003e\\n \\u003cth align=\\\"left\\\"\\u003e\\u0026nbsp;\\u003c/th\\u003e\\n \\u003cth align=\\\"left\\\"\\u003e\\n \\u003cp\\u003eAll, N (%)\\u003c/p\\u003e\\n \\u003c/th\\u003e\\n \\u003cth align=\\\"left\\\" colspan=\\\"2\\\"\\u003e\\n \\u003cp\\u003eReferral, N (%)\\u003c/p\\u003e\\n \\u003c/th\\u003e\\n \\u003cth align=\\\"left\\\"\\u003e\\n \\u003cp\\u003eOutpatient, N (%)\\u003c/p\\u003e\\n \\u003c/th\\u003e\\n \\u003c/tr\\u003e\\n \\u003c/thead\\u003e\\n \\u003ctbody\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003eAdverse events associated\\u003c/p\\u003e\\n \\u003cp\\u003eepisodes\\u003csup\\u003e*\\u003c/sup\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\" colspan=\\\"2\\\"\\u003e\\n \\u003cp\\u003e57/445 (12.8%)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e44/295 (14.9%)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e13/150(8.7%)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003eADR\\u003csup\\u003e\\u0026dagger;\\u003c/sup\\u003e associated episodes\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\" colspan=\\\"2\\\"\\u003e\\n \\u003cp\\u003e16/445 (3.6%)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e13/295 (4.4%)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e3/150(2.0%)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003eER\\u003csup\\u003e\\u0026Dagger;\\u003c/sup\\u003e visit or admission\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\" colspan=\\\"2\\\"\\u003e\\n \\u003cp\\u003e70/577(12.1%)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e43/399(10.8%)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e27/178(15.2%)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003eRelated with parenteral antibiotics\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\" colspan=\\\"2\\\"\\u003e\\n \\u003cp\\u003e3/577(0.5%)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e2/399(0.5%)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003e1/178(0.6%)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003c/tbody\\u003e\\n \\u003ctfoot\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd colspan=\\\"5\\\"\\u003e\\u003csup\\u003e*\\u003c/sup\\u003e Adverse events instigated only for episodes that had outpatient visit after administration; All (445 episodes)\\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd colspan=\\\"5\\\"\\u003e\\u003csup\\u003e\\u0026dagger;\\u003c/sup\\u003e Adverse drug reaction\\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd colspan=\\\"5\\\"\\u003e\\u003csup\\u003e\\u0026Dagger;\\u003c/sup\\u003e Emergency room\\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003c/tfoot\\u003e\\n \\u003c/table\\u003e\\n \\u003cp\\u003e\\u003c/p\\u003e\\n\\u003c/div\\u003e\"},{\"header\":\"Discussion\",\"content\":\"\\u003cp\\u003eThe present study assessed the current status and management of OPAT at a single hospital in the Republic of Korea, for the first time. In Korea, post-acute care patients refer to long term care facility to maintain parenteral antibiotics. But there are no fees or reimbursement for OPAT management and few institutions implement OPAT management team. This study may show the current status of OPAT in Korea. During the 6-month study period, significant number (577 episodes) of OPAT prescriptions were made through outpatient or referral models, and we investigated the administration model, follow-up outpatient visit rates after prescription, and monitoring test rates.\\u003c/p\\u003e \\u003cp\\u003eWe found that prescriptions from the top 5 departments that prescribe OPAT often accounted for approximately 70% of all prescriptions. This suggests that pre- and post-prescription management can be introduced preferentially to departments with high rates of prescription. Ertapenem, ceftriaxone, and kanamycin were often prescribed at our hospital, but studies of OPAT at other hospitals reported that ceftriaxone and teicoplanin were frequently prescribed.\\u003csup\\u003e(\\u003cspan additionalcitationids=\\\"CR13\\\" citationid=\\\"CR12\\\" class=\\\"CitationRef\\\"\\u003e12\\u003c/span\\u003e\\u0026ndash;\\u003cspan citationid=\\\"CR14\\\" class=\\\"CitationRef\\\"\\u003e14\\u003c/span\\u003e)\\u003c/sup\\u003e The use of teicoplanin was low at our hospital as we use vancomycin as first line treatment for antibiotic-resistant gram-positive bacterial infection, such as methicillin-resistant \\u003cem\\u003eStaphylococcus aureus\\u003c/em\\u003e. This difference is thought to be caused by each hospitals' had different patient groups and antibiotic prescribing behaviors. Thus, it is important that each hospital should develop its own strategy for antimicrobial stewardship based on the analysis of antibiotic use of the institution.\\u003c/p\\u003e \\u003cp\\u003eCommon indications for parenteral antibiotics in this study included urinary tract infection, respiratory infection, intra-abdominal infection, and bone and joint infection, consistent with other OPAT studies reporting that bone and joint infections are major indications for OPAT.\\u003csup\\u003e(\\u003cspan additionalcitationids=\\\"CR14 CR15 CR16\\\" citationid=\\\"CR13\\\" class=\\\"CitationRef\\\"\\u003e13\\u003c/span\\u003e\\u0026ndash;\\u003cspan citationid=\\\"CR17\\\" class=\\\"CitationRef\\\"\\u003e17\\u003c/span\\u003e)\\u003c/sup\\u003e This finding might be due to the clinical characteristics of bone and joint infections requiring relatively long uses of parenteral antibiotics. In contrast, other studies have also reported that skin and soft tissue infections are major indications for OPAT.\\u003csup\\u003e(\\u003cspan citationid=\\\"CR12\\\" class=\\\"CitationRef\\\"\\u003e12\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR14\\\" class=\\\"CitationRef\\\"\\u003e14\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR16\\\" class=\\\"CitationRef\\\"\\u003e16\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR17\\\" class=\\\"CitationRef\\\"\\u003e17\\u003c/span\\u003e)\\u003c/sup\\u003e\\u003c/p\\u003e \\u003cp\\u003eIn the referral model, 46.6 % of episodes had clear documentation of the facility selected to administer the antibiotics, and this indirectly suggests that management of administration of OPAT is inadequate. In the referral model in which the administration of OPAT is handed over to another facility, the transition can be made through hospitalization or outpatient visits to general hospitals, nursing hospital, clinics, and other various types of facilities. In Korea, there is no fee claims available for these referrals, and sharing of treatment information is also not systematic. As different facilities may be capable of different levels of tests and monitoring, it is important to confirm the facility to which the patient is being referred in advance to confirm whether the facility is capable of maintaining and managing OPAT. Moreover, systematic changes should be made to support continued treatment and management through exchange of information between facilities.\\u003c/p\\u003e \\u003cp\\u003eMore patients in the outpatient model had follow-up outpatient visits after the administration of OPAT than those in the referral model. This may be because patients who continued their care at another facility may have been followed up at that facility, thus not presenting to our hospital for follow-up. In addition, patients who received acute treatment at our hospital may have continued their treatment at a medical facility close to their home. In terms of the implementation of tests necessary for monitoring of parenteral antibiotics, the rate was higher in the outpatient model than in the referral model with a non-significant difference between the two models. Based on these findings, when follow-up at the same hospital is not carried out, the list of necessary tests for management of parenteral antibiotics and possible side effects should be offered at the time of referral. Subsequently, continued management should be offered through phone calls with patients.\\u003c/p\\u003e \\u003cp\\u003eFor management of OPAT, not only OPAT team but antimicrobial stewardship intervention can be helpful. When we evaluated the possibility of changes in the route of administration prior to antibiotics administration, conversion to oral antibiotics was considered to have been possible in 3.7% of prescriptions. Our hospital manages restricted antibiotics by regular ID consultations, and there is an electronic alert with automated consultations for positive blood culture test, so it seems to be well managed\\u003csup\\u003e(\\u003cspan citationid=\\\"CR18\\\" class=\\\"CitationRef\\\"\\u003e18\\u003c/span\\u003e)\\u003c/sup\\u003e. And Pharmacists in the antimicrobial stewardship team continue to offer the intervention (parenteral-to-oral conversion) to inpatients at our hospital.\\u003csup\\u003e(\\u003cspan citationid=\\\"CR19\\\" class=\\\"CitationRef\\\"\\u003e19\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR20\\\" class=\\\"CitationRef\\\"\\u003e20\\u003c/span\\u003e)\\u003c/sup\\u003e And antimicrobial stewardship team can suggest appropriate duration of antimicrobial therapy. In the future, prescription of parenteral antibiotics for patients planned for discharge should be reviewed in advance to reduce inappropriate antibiotic use.\\u003c/p\\u003e \\u003cp\\u003eIn the present study, adverse drug reactions were confirmed in 3.6% of prescriptions of parenteral antibiotics in outpatient and referral models, and less than 1% of prescriptions led to emergency room visits or hospitalizations associated with adverse drug reactions. However, a previous study reported that adverse reactions were seen in 18% of cases within 2 weeks of discharge,\\u003csup\\u003e(\\u003cspan citationid=\\\"CR12\\\" class=\\\"CitationRef\\\"\\u003e12\\u003c/span\\u003e)\\u003c/sup\\u003e and another study reported that re-hospitalization was seen in up to 27% of patients.\\u003csup\\u003e(\\u003cspan citationid=\\\"CR21\\\" class=\\\"CitationRef\\\"\\u003e21\\u003c/span\\u003e)\\u003c/sup\\u003e Referring to the other studies, since only medical records were analyzed retrospectively, mild side effects might not be recorded by physicians and it cannot be recognized in our study. Moreover, although we did not confirm any catheter-associated bloodstream infections in this study, these infections were frequently reported in studies conducted in other countries.\\u003csup\\u003e(\\u003cspan citationid=\\\"CR13\\\" class=\\\"CitationRef\\\"\\u003e13\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR22\\\" class=\\\"CitationRef\\\"\\u003e22\\u003c/span\\u003e)\\u003c/sup\\u003e In Korea, self-administration of intravenous agents by patients is not allowed, and patients are often discharged without central venous catheters. These differences in practice may have led to the differences seen in the results.\\u003c/p\\u003e \\u003cp\\u003eA few limitations should be considered when interpreting the results of this study. First, because of retrospective nature of this study, we could not assess the treatment outcome, adverse reaction of antibiotics, whether antibiotics had changed or added etc. in patients without follow-up visit. Second, when no follow-up visits were done, more adverse reactions than those documented could have happened. However, as these were not documented, the number of adverse reactions could have been underestimated given the retrospective design of the present study. Last, since this study was conducted at a single hospital, the results may be different from other hospitals in South Korea.\\u003c/p\\u003e \\u003cp\\u003eThis study investigated the departments that frequently prescribe parenteral antibiotics for outpatients and referred patients, as well as frequently prescribed antibiotics and the indications for them. The study also found that appropriate candidates for monitoring should be selected prior to administration of parenteral antibiotics and that monitoring should be implemented. This study is significant in that it was able to confirm the participants who require monitoring of parenteral antibiotics, the scope of monitoring, and the necessity of a monitoring system through its findings.\\u003c/p\\u003e\"},{\"header\":\"Conclusion\",\"content\":\"\\u003cp\\u003eAccording to the present study findings, approximately 70% of OPAT were prescribed in 5 departments, and 5 antibiotics accounted for 70% of all prescriptions. We also confirmed that follow-up after prescription is lacking. Therefore, a comprehensive monitoring system and antimicrobial stewardship for safe and effective OPAT is necessary, and the findings of this study will serve as useful basic data for the system.\\u003c/p\\u003e\"},{\"header\":\"Declarations\",\"content\":\"\\u003cp\\u003e\\u003cstrong\\u003eEthics approval and consent to participate\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eThis retrospective study was approved by the institutional review board (IRB) of Seoul National University Bundang Hospital (B-2007/625-105), and a waiver for written consent was obtained from the IRB.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eConsent for publication\\u0026nbsp;\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eAll authors agree publication of this paper.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eAvailability of data and materials\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eAll data generated or analyzed during this study are included in this published article and its supplementary information files.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eCompeting interests\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eAll authors declare that there are no conflicts of interest.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eFunding\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eThis research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eAuthors\\u0026apos; contributions\\u0026nbsp;\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eYC, EH, JYL, KHS designed study and drafted paper. YC, EH collected and analyzed the patient data. JYL, HWN, EL1, EL2 analyzed and interpreted the patient data regarding antibiotic therapy and antibiotic adverse reaction. EH, JTJ, ESK, HBK, KHS analyzed and interpreted the patient data regarding infectious disease and outpatient parenteral antibiotic therapy(OPAT). All authors read and approved the final manuscript.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eAcknowledgements\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eThe authors thank the Medical Informatics team at the Seoul National University Bundang Hospital for data supply. We are particularly grateful to all the pharmacists colleagues.\\u003c/p\\u003e\"},{\"header\":\"References\",\"content\":\"\\u003col\\u003e\\u003cli\\u003e\\u003cspan\\u003eChapman AL, Dixon S, Andrews D, Lillie PJ, Bazaz R, Patchett JD. Clinical efficacy and cost-effectiveness of outpatient parenteral antibiotic therapy (OPAT): a UK perspective. J Antimicrob Chemother. 2009;64(6):1316\\u0026ndash;24.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eDurojaiye OC, Bell H, Andrews D, Ntziora F, Cartwright K. Clinical efficacy, cost analysis and patient acceptability of outpatient parenteral antibiotic therapy (OPAT): a decade of Sheffield (UK) OPAT service. Int J Antimicrob Agents. 2018;51(1):26\\u0026ndash;32.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eWai AO, Frighetto L, Marra CA, Chan E, Jewesson PJ. Cost Analysis of an Adult Outpatient Parenteral Antibiotic Therapy (OPAT) Programme. PharmacoEconomics. 2000;18(5):451\\u0026ndash;7.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eSeetoh T, Lye DC, Cook AR, Archuleta S, Chan M, Sulaiman Z, et al. An outcomes analysis of outpatient parenteral antibiotic therapy (OPAT) in a large Asian cohort. Int J Antimicrob Agents. 2013;41(6):569\\u0026ndash;73.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eBarr DA, Semple L, Seaton RA. Outpatient parenteral antimicrobial therapy (OPAT) in a teaching hospital-based practice: a retrospective cohort study describing experience and evolution over 10 years. Int J Antimicrob Agents. 2012;39(5):407\\u0026ndash;13.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eTice AD, Rehm SJ, Dalovisio JR, Bradley JS, Martinelli LP, Graham DR, et al. Practice guidelines for outpatient parenteral antimicrobial therapy. IDSA guidelines. Clin Infect Dis. 2004;38(12):1651\\u0026ndash;72.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eHalilovic J, Christensen CL, Nguyen HH. Managing an outpatient parenteral antibiotic therapy team: challenges and solutions. Ther Clin Risk Manag. 2014;10:459\\u0026ndash;65.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eAkhloufi H, Hulscher M, Melles DC, Prins JM, van der Sijs H, Verbon A. Development of operationalized intravenous to oral antibiotic switch criteria. J Antimicrob Chemother. 2017;72(2):543\\u0026ndash;6.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eTsuji BT, Pogue JM, Zavascki AP, Paul M, Daikos GL, Forrest A, et al. International consensus guidelines for the optimal use of the polymyxins: endorsed by the American College of Clinical Pharmacy (ACCP), European Society of Clinical Microbiology and Infectious Diseases (ESCMID), Infectious Diseases Society of America (IDSA), International Society for Anti-infective Pharmacology (ISAP), Society of Critical Care Medicine (SCCM), and Society of Infectious Diseases Pharmacists (SIDP). Pharmacotherapy. 2019;39(1):10\\u0026ndash;39.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eWeir CB, Le JK. Metronidazole. 2020. In: StatPearls [Internet]. Treasure Island (FL): StatPearls. Available from: \\u003cspan class=\\\"ExternalRef\\\"\\u003e\\u003cspan class=\\\"RefSource\\\"\\u003ehttps://www.ncbi.nlm.nih.gov/pubmed/30969550\\u003c/span\\u003e\\u003c/span\\u003e.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eNaranjo CA, Busto U, Sellers EM, Sandor P, Ruiz I, Roberts EA, et al. A method for estimating the probability of adverse drug reactions. Clin Pharmacol Ther. 1981;30(2):239\\u0026ndash;45.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eKeller SC, Williams D, Gavgani M, Hirsch D, Adamovich J, Hohl D, et al. Rates of and risk factors for adverse drug events in outpatient parenteral antimicrobial therapy. Clin Infect Dis. 2018;66(1):11\\u0026ndash;9.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eMatthews PC, Conlon CP, Berendt AR, Kayley J, Jefferies L, Atkins BL, et al. Outpatient parenteral antimicrobial therapy (OPAT): is it safe for selected patients to self-administer at home? A retrospective analysis of a large cohort over 13 years. J Antimicrob Chemother. 2007;60(2):356\\u0026ndash;62.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eHatcher J, Costelloe C, Cele R, Viljanen A, Samarasinghe D, Satta G, et al. Factors associated with successful completion of outpatient parenteral antibiotic therapy (OPAT): A 10-year review from a large West London service. Int J Antimicrob Agents. 2019;54(2):207\\u0026ndash;14.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eHase R, Yokoyama Y, Suzuki H, Uno S, Mikawa T, Suzuki D, et al. Review of the first comprehensive outpatient parenteral antimicrobial therapy program in a tertiary care hospital in Japan. Int J Infect Dis. 2020;95:210\\u0026ndash;5.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eMuldoon EG, Switkowski K, Tice A, Snydman DR, Allison GM. A national survey of infectious disease practitioners on their use of outpatient parenteral antimicrobial therapy (OPAT). Infect Dis (Lond). 2015;47(1):39\\u0026ndash;45.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eUpton A, Ellis-Pegler RB, Woodhouse A. Outpatient parenteral antimicrobial therapy (OPAT): a review of experience at auckland hospital. N Z Med J. 2004;117(1200):U1020.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eKim M, Song KH, Kim CJ, Song M, Choe PG, Park WB, et al. Electronic Alerts with Automated Consultations Promote Appropriate Antimicrobial Prescriptions. PLoS One. 2016;11(8):e0160551.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003ePark SM, Kim HS, Jeong YM, Lee JH, Lee E, Lee E, et al. Impact of Intervention by an Antimicrobial Stewardship Team on Conversion from Intravenous to Oral Fluoroquinolones. Infect Chemother. 2017;49(1):31\\u0026ndash;7.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eKim SH, Heo EJ. HB K. Impact of expanded intervention by pharmacist-involved antimicrobial stewardship program on IV-to-PO conversion. J Kor Soc Health-syst Pharm. 2019.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eMeans L, Bleasdale S, Sikka M, Gross AE. Predictors of hospital readmission in patients receiving outpatient parenteral antimicrobial therapy. Pharmacotherapy. 2016;36(8):934\\u0026ndash;9.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eUnderwood J, Marks M, Collins S, Logan S, Pollara G. Intravenous catheter-related adverse events exceed drug-related adverse events in outpatient parenteral antimicrobial therapy. J Antimicrob Chemother. 2019;74(3):787\\u0026ndash;90.\\u003c/span\\u003e\\u003c/li\\u003e\\u003c/ol\\u003e\"}],\"fulltextSource\":\"\",\"fullText\":\"\",\"funders\":[],\"hasAdminPriorityOnWorkflow\":false,\"hasManuscriptDocX\":true,\"hasOptedInToPreprint\":true,\"hasPassedJournalQc\":\"\",\"hasAnyPriority\":false,\"hideJournal\":true,\"highlight\":\"\",\"institution\":\"\",\"isAcceptedByJournal\":false,\"isAuthorSuppliedPdf\":false,\"isDeskRejected\":\"\",\"isHiddenFromSearch\":false,\"isInQc\":false,\"isInWorkflow\":false,\"isPdf\":false,\"isPdfUpToDate\":true,\"isWithdrawnOrRetracted\":false,\"journal\":{\"display\":true,\"email\":\"info@researchsquare.com\",\"identity\":\"researchsquare\",\"isNatureJournal\":false,\"hasQc\":true,\"allowDirectSubmit\":true,\"externalIdentity\":\"\",\"sideBox\":\"\",\"snPcode\":\"\",\"submissionUrl\":\"/submission\",\"title\":\"Research Square\",\"twitterHandle\":\"researchsquare\",\"acdcEnabled\":true,\"dfaEnabled\":false,\"editorialSystem\":\"\",\"reportingPortfolio\":\"\",\"inReviewEnabled\":false,\"inReviewRevisionsEnabled\":true},\"keywords\":\"OPAT, Republic, Hospital, antibiotics\",\"lastPublishedDoi\":\"10.21203/rs.3.rs-960331/v1\",\"lastPublishedDoiUrl\":\"https://doi.org/10.21203/rs.3.rs-960331/v1\",\"license\":{\"name\":\"CC BY 4.0\",\"url\":\"https://creativecommons.org/licenses/by/4.0/\"},\"manuscriptAbstract\":\"\\u003ch2\\u003eObjectives\\u003c/h2\\u003e \\u003cp\\u003e The aim of this study was to describe current status of outpatient parenteral antimicrobial therapy (OPAT) at a tertiary care hospital in the Republic of Korea.\\u003c/p\\u003e\\u003ch2\\u003eMethods\\u003c/h2\\u003e \\u003cp\\u003eThis retrospective study was conducted on outpatients and referral patients who had a prescription of parenteral antibiotics from July to December 2019. We reviewed the prescribed antimicrobials, the indication of antimicrobial therapy, where patients administered antimicrobial injection and management of pre- and post- prescriptions.\\u003c/p\\u003e\\u003ch2\\u003eResults\\u003c/h2\\u003e \\u003cp\\u003eOf the 577 episodes included in this study, 399 (69.2%) were delivered by referral model, 178 (30.8%) by outpatient model. About 70% of OPATs were prescribed in the pulmonology, infectious diseases, orthopedics, gastroenterology, and hematology departments. Five antibiotics (ertapenem (26.0%), ceftriaxone (12.8%), kanamycin (11.8%), amikacin (10.1%), and cefazolin (8.5%)) accounted for 69.2% of the total OPATs. Urinary tract infections (27.3%), respiratory infections (20.8%), and intra-abdominal infections (15.9%) are the most frequent indications of OPAT. After prescription, there were 295 (73.9%) follow-up visits in referral model and 150 (84.3%) in outpatient model (\\u003cem\\u003ep\\u003c/em\\u003e\\u0026lt;0.05). Laboratory tests necessary for monitoring were totally performed in 274 (47.5%).\\u003c/p\\u003e\\u003ch2\\u003eConclusions\\u003c/h2\\u003e \\u003cp\\u003eWe found that significant number of OPAT was prescribed, follow-up visits were not performed in about a quarter of episodes, and laboratory monitoring was not fully conducted in more than half of the cases. Therefore, it is necessary to establish an appropriate management program for OPAT. Considering limited resources and the distribution of OPAT prescriptions, it may be effective to select frequently used antibiotics or frequently prescribed departments and start the program for them.\\u003c/p\\u003e\",\"manuscriptTitle\":\"Current Status of Outpatient Parenteral Antimicrobial Therapy (OPAT) At a University-Affiliated Acute-Care Hospital in The Republic of Korea\",\"msid\":\"\",\"msnumber\":\"\",\"nonDraftVersions\":[{\"code\":1,\"date\":\"2021-10-28 15:29:44\",\"doi\":\"10.21203/rs.3.rs-960331/v1\",\"editorialEvents\":[{\"type\":\"communityComments\",\"content\":0}],\"status\":\"published\",\"journal\":{\"display\":true,\"email\":\"info@researchsquare.com\",\"identity\":\"researchsquare\",\"isNatureJournal\":false,\"hasQc\":true,\"allowDirectSubmit\":true,\"externalIdentity\":\"\",\"sideBox\":\"\",\"snPcode\":\"\",\"submissionUrl\":\"/submission\",\"title\":\"Research Square\",\"twitterHandle\":\"researchsquare\",\"acdcEnabled\":true,\"dfaEnabled\":false,\"editorialSystem\":\"\",\"reportingPortfolio\":\"\",\"inReviewEnabled\":false,\"inReviewRevisionsEnabled\":true}}],\"origin\":\"\",\"ownerIdentity\":\"db9d32bf-e1c3-43b3-9f42-4d8e375baa33\",\"owner\":[],\"postedDate\":\"October 28th, 2021\",\"published\":true,\"recentEditorialEvents\":[],\"rejectedJournal\":[],\"revision\":\"\",\"amendment\":\"\",\"status\":\"posted\",\"subjectAreas\":[{\"id\":8156051,\"name\":\"General Microbiology\"},{\"id\":8156052,\"name\":\"Infectious Diseases\"}],\"tags\":[],\"updatedAt\":\"2021-11-12T05:24:31+00:00\",\"versionOfRecord\":[],\"versionCreatedAt\":\"2021-10-28 15:29:44\",\"video\":\"\",\"vorDoi\":\"\",\"vorDoiUrl\":\"\",\"workflowStages\":[]},\"version\":\"v1\",\"identity\":\"rs-960331\",\"journalConfig\":\"researchsquare\"},\"__N_SSP\":true},\"page\":\"/article/[identity]/[[...version]]\",\"query\":{\"redirect\":\"/article/rs-960331\",\"identity\":\"rs-960331\",\"version\":[\"v1\"]},\"buildId\":\"_2-kVJe1T_tPrBINL-cwx\",\"isFallback\":false,\"isExperimentalCompile\":false,\"dynamicIds\":[84888],\"gssp\":true,\"scriptLoader\":[]}","source_license":"CC-BY-4.0","license_restricted":false}