Trust Guideline for the Management of: Condition or Procedure in Adults and / or Children A clinical guideline recommended For use in: By: For: Division responsible for document: Key words: Name of document author: Job title of document author: Name of document author s Line Manager: Job title of document author s Line Manager: Supported by: Acute Medicine Unit Medical Staff Adult patients with confirmed multi-resistant urinary tract infection suitable for outpatient Division 1 - Medical ESBL, UTI, multi-resistant, parenteral, outpatient Tomography Pulmonary Angiogram Dr Reham Soliman and Caroline Hallam Computerised (CTPA), Thrombolysis Consultant Microbiologist and Specialist Pharmacist, Antimicrobial Dr Catherine Tremlett Consultant Microbiologist Dr James Edwards, Consultant, AMU Assessed and approved Catherine Tremlett for the Antimicrobial sub Group and By Dr L Barker by: xxxxx for the Clinical Guidelines Assessment Panel Date of approval: 14 December 2017 Ratified by or reported as approved to the (if applicable): To be reviewed before: This document remains current after this date but will be under review Reference and / or Trustdocs ID No: Version No: 2 Description of changes: Compliance links: (is there any NICE related to guidance) If Yes does the strategy/policy deviate from the recommendations of NICE? If so, why? Author/s: (Insert names) Valid until: (Insert Month and year) Clinical Standards Group and Clinical Safety and Effectiveness Sub- Board 14 December 2020 CA6002 ID No: 10793 Document updated and will replace ID No s: 10794,10795 and 10796 No N/A Document: (Insert name of guideline) 10793.docx Copy of complete document available from: Trust Intranet Page 1 of 7 Date of issue: (Insert Month and year) Guideline Ref No (Ref) Version (No)
Trust Guideline for the Management of Multi-resistant Urinary Tract Infection with Outpatient Parenteral Antibiotic Therapy (OPAT) in Adults 1. Quick reference guideline Clinical Guideline for: Management of Multi-resistant UTI with OPAT in Adults Author/s: Dr R Soliman and C Hallam Author/s title: Consultant Microbiologist and Specialist Pharmacist, Antimicrobial Approved by: CGAP Date approved: 14/12/2017 Review date: 14/12/2020 Available via Trust Docs Version: 2 Trust Docs ID: 10793 Page 3 of 7
2. Objectives of Guideline OPAT (Outpatient Parenteral Antibiotic Therapy) guidelines for the treatment of multiresistant and extended spectrum beta-lactamase (ESBL) producing urinary tract infections. These guidelines are for the outpatient treatment of multi-resistant and ESBL producing UTI s, for in-patient management please refer to the general antibiotic guidelines on the intranet. 3. Recommendations Once patients are clinically stable but still require IV (Intra-venous) therapy, assess suitability for OPAT. Refer to Prescribers Checklist on the intranet for full details. Exclusion Criteria: If any of the following are present, patients are normally not suitable unless the consultant in charge of the patient and Consultant Microbiologist deems patient suitable and : Sepsis - 2 or more signs: temperature >38 or <36, HR >90/min, respiratory rate >20, systolic BP <100, Marked inflammatory response - WCC >15 Immunosuppression or leucopaenia - WCC >4 & <15 IVDU Psychiatric history (unstable) Pregnancy Renal Function: For patients with a CrCL of <30mL/min or those on dialysis then ertapenem is contraindicated. Previous anaphylaxis to penicillin Other factors influencing the decision to treat at home are: Frailty Confusion Home circumstances Obesity Alcoholism Patient choice. OPAT Management: 4
Trust Guideline for the Management of Multi-resistant Urinary Tract Infection with Outpatient Parenteral Antibiotic Therapy (OPAT) in Adults On Acute Medical Unit or OPM Ward: Confirm microbiology MSU result, taking note of susceptibilities of organism isolated. Confirm clinical picture that patient has symptoms of an upper or lower urinary tract infection: e.g. frequency, dysuria, haematuria, abdominal (flank or suprapubic) pain, fever, confusion If there are no symptoms consider colonisation with multi-resistant or ESBL producing organism. Colonisation without symptoms of infection does not require treatment. Discussion with Microbiology may be required, in particular if the patient is pregnant. Prescribe antibiotic on EPMA and give the 1st dose Treatment for uncomplicated UTI: Indication Antibiotic course length review date UTI:ESBL producer Or Multi-resistant UTI Ertapenem 1g OD 7 days day 8 Insert cannula, test blood for FBC, U+E, LFT, CRP, and print form for repeat bloods (see below) Refer to OPAT team on ICE. Wait for patient to be accepted before they are discharged. Give the patient letter, and patient information leaflet to patient with instructions of cannula care, plan and date/time of return to ambulatory clinic, and the MAR chart for the community IV nurses. Community IV nurses: Administer treatment daily and check vital signs. Check cannula daily and change appropriately A day prior to review date, repeat bloods: FBC, U+E, LFT, CRP Clinical Guideline for: Management of Multi-resistant UTI with OPAT in Adults Author/s: Dr R Soliman and C Hallam Author/s title: Consultant Microbiologist and Specialist Pharmacist, Antimicrobial Approved by: CGAP Date approved: 14/12/2017 Review date: 14/12/2020 Available via Trust Docs Version: 2 Trust Docs ID: 10793 Page 5 of 7
Dear Date: (dd/mm/yyyy) Home IV treatment for urinary tract infection: We have arranged for you to have your infection treated at home. We hope you will find this more convenient then having to stay in hospital. Please return to the ambulatory clinic, reporting to AMU at the following times: Date (dd/mm/yyyy) Time (24hr clock) Call us at any time, on the number above, if you are feeling unwell or having problems with your cannula, to speak to the nurse in charge. Alternatively you can call the IV nurses between 8am and 8pm If you feel very unwell call an ambulance or go to the Emergency Department in the usual way. Cannula care Your cannula sits in a blood vessel for up to 72 hours, following which it will be removed and changed if necessary. There is no needle present but it is important you look after it. Keep your cannula dry and covered with the dressing provided If your cannula does come out apply pressure with a clean dressing. A new cannula will be inserted the next day Sometimes the cannula site becomes infected. If skin around the cannula becomes red or painful call the above number for advice. If you are concerned in anyway feel free to call on the above numbers. 6
Trust Guideline for the Management of Multi-resistant Urinary Tract Infection with Outpatient Parenteral Antibiotic Therapy (OPAT) in Adults OPAT UTI Pathway Check List (please circle as appropriate) Attendance with a symptoms of urinary tract infection Yes No Suitable for OPAT service (See criteria in policy) Yes No Ensure MSU result reviewed and susceptibilities confirm multi-resistant UTI or UTI secondary to ESBL producing organism Yes No Patient given information letter with return date/time added Yes No Patient given MAR chart Yes No Cannula secure and flushed with saline Yes No Insertion date is present and VIP score completed Yes No Blood sent for FBC, U+E, LFT, CRP Yes No Form printed for repeat FBC, U+E, LFT, CRP Yes No Allergy status checked Yes No 1st dose of antibiotic given Yes No Home IV antibiotic doses prescribed Yes No Book patient into ambulatory clinic Yes No Discharge letter Yes No Signature:... Print Name:... Date: (dd/mm/yyyy)... Clinical Guideline for: Management of Multi-resistant UTI with OPAT in Adults Author/s: Dr R Soliman and C Hallam Author/s title: Consultant Microbiologist and Specialist Pharmacist, Antimicrobial Approved by: CGAP Date approved: 14/12/2017 Review date: 14/12/2020 Available via Trust Docs Version: 2 Trust Docs ID: 10793 Page 7 of 7