BACKGROUND AND OBJECTIVES:Self-administration of outpatient parenteral antimicrobial therapy (S-OPAT) aligns with the growing emphasis on patient and caregiver engagement in healthcare. Despite its potential benefits, S-OPAT use varies widely, suggesting that many eligible patients are not offered this option. Insight into S-OPAT decision-making is needed to improve its broader implementation and quality. The objectives of this study were to identify determinants that (i) influence healthcare professionals' (HCPs) decisions to offer S-OPAT and (ii) affect patients' and caregivers' acceptance or refusal of S-OPAT. METHODS:Semi-structured interviews were performed with HCPs involved in S-OPAT and with patients and caregivers who either self-administered OPAT or declined S-OPAT. Participants were recruited from four hospitals and six home care organizations. Transcripts were analysed using thematic analysis. RESULTS:Fifty-one interviews were conducted with HCPs, patients and caregivers. The determinants reported were related to cognitions or affect (e.g. emotions or personality traits, such as patients' reluctance to accept help), skills and capabilities (e.g. patients' perceived skills for S-OPAT, or the ability of HCPs to explain what S-OPAT entails) and collaboration and communication (e.g. between healthcare organizations and between patients and caregivers). CONCLUSIONS:Decisions regarding S-OPAT are influenced by cognitive, skill-related, and collaborative determinants shaping inter-stakeholder cooperation. Addressing these determinants may help create a more person-centred approach and support further expansion of S-OPAT. We recommend increasing HCP awareness of S-OPAT, discussing S-OPAT with all patients or their caregivers, emphasizing the freedom to try S-OPAT, and tailoring the content, timing, and location of the S-OPAT offer to individual needs.

Objectives: Evidence on the optimal frequency of laboratory testing during outpatient parenteral antimicrobial therapy (OPAT) is lacking. Therefore, we investigated how often and when laboratory abnormalities occur during OPAT and which factors are associated with these abnormalities. Methods: We performed a multicenter cohort study in four Dutch hospitals among adult patients receiving OPAT and collected routinely obtained laboratory test results. Incidence and incidence rates were calculated for various laboratory abnormalities. Survival analysis was performed to visualize the time to the first occurrence of laboratory abnormalities and Poisson regression analysis to compare the number of abnormalities in the first and second 30 OPAT days among patients receiving OPAT for >= 60 days. Predictors were identified using a multivariable Cox proportional hazard regression model. Results: 45.1% of 1152 included patients developed laboratory abnormalities, but only 2% led to OPAT discontinuation. Hepatotoxicity was most common (33.9 events/1000 OPAT days), with a time-dependent decrease in the occurrence of the first hepatotoxic event, while hypokalemia was rare (1.7 events/ 1000 OPAT days). In the subgroup of patients receiving >= 60 days of OPAT, nephrotoxicity was more common in days 31-60. We observed partly toxicity-specific associations between antibiotic type, concomitant medication, baseline laboratory values, patient characteristics, and the occurrence of laboratory abnormalities. Conclusions: While laboratory abnormalities are frequently observed during OPAT, they rarely lead to discontinuation of OPAT. Specific patient, treatment and laboratory characteristics were associated with the occurrence of laboratory abnormalities. Based on our results, we recommend a more personalized laboratory monitoring policy with less blood sampling. (c) 2024 The Author(s). Published by Elsevier Ltd on behalf of The British Infection Association. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

Abstract Background We evaluated the success rate of MRSA decolonization directly after treatment and after one year in patients who were treated at the outpatient MRSA clinic of a large university medical centre to identify potential contributing factors to treatment success and failure. Methods Data from November 1, 2013 to August 1, 2020 were used. Only patients who had undergone complete MRSA decolonization were included. Risk factors for MRSA treatment failure were identified using a multivariable logistic regression model. Results In total, 127 MRSA carriers were included: 7 had uncomplicated carriage, 91 had complicated carriage, and 29 patients had complicated carriage in combination with an infection. In complicated carriers and complicated carriers with an infection final treatment was successful in 75.0%. Risk factors for initial treatment failure included having one or more comorbidities and not testing the household members. Risk factors for final treatment failure were living in a refugee centre, being of younger age (0–17 years), and having one or more comorbidities. Conclusions The results of this study indicate that patients with a refugee status and children treated at the paediatric clinic have a higher risk of MRSA decolonisation treatment failure. For this reason, it might be useful to revise decolonization strategies for these subgroups and to refer these patients to specialized outpatient clinics in order to achieve higher treatment success rates.

Background The treatment of persistent symptoms attributed to Lyme disease remains controversial. Recently, the PLEASE study did not demonstrate any additional clinical benefit of longer-term versus shorter-term antibiotic treatment. However, the economic impact of the antibiotic strategies has not been investigated. Methods This prospective economic evaluation, adhering a societal perspective, was performed alongside the PLEASE study, a multicenter, placebo-controlled, double-blind 1:1:1 randomized clinical trial in which all patients received open-label intravenous ceftriaxone for two weeks before the 12-week randomized blinded oral antibiotic regimen (doxycycline, clarithromycin plus hydroxychloroquine, or placebo). Between 2010 and 2013, patients (n = 271) with borreliosis-attributed persistent symptoms were enrolled and followed for one year. Main outcomes were costs, quality-adjusted life years, and incremental net monetary benefit of longer-term versus shorter-term antibiotic therapy. Results Mean quality-adjusted life years (95% CI) were not significantly different (p = 0.96): 0.82 (0.77–0.88) for ceftriaxone/doxycycline (n = 82), 0.81 (0.76–0.88) for ceftriaxone/clarithromycin-hydroxychloroquine (n = 93), and 0.81 (0.76–0.86) for ceftriaxone/placebo (n = 96). Total societal costs per patient (95% CI) were not significantly different either (p = 0.35): €11,995 (€8,823-€15,670) for ceftriaxone/doxycycline, €12,202 (€9,572-€15,253) for ceftriaxone/clarithromycin-hydroxychloroquine, and €15,249 (€11,294-€19,781) for ceftriaxone/placebo. Incremental net monetary benefit (95% CI) for ceftriaxone/doxycycline compared to ceftriaxone/placebo varied from €3,317 (-€2,199-€8,998) to €4,285 (-€6,085-€14,524) over the willingness-to-pay range, and that of ceftriaxone/clarithromycin-hydroxychloroquine compared to ceftriaxone/placebo from €3,098 (-€888-€7,172) to €3,710 (-€4,254-€11,651). For every willingness-to-pay threshold, the incremental net monetary benefits did not significantly differ from zero. Conclusion The longer-term treatments were similar with regard to costs, effectiveness and cost-effectiveness compared to shorter-term treatment in patients with borreliosis-attributed persistent symptoms after one year of follow-up. Given the results of this study, and taking into account the external costs associated with antibiotic resistance, the shorter-term treatment is the antibiotic regimen of first choice.

Objectives Current outpatient parenteral antimicrobial therapy (OPAT) guidelines recommend delivering patient-centred care. However, little is known about what patients define as good quality of OPAT care and what their needs and preferences are. The aim of this qualitative study is to explore the patients’ perspective on high-quality care, and to explore what patient-centred care means to adult OPAT patients. Design and setting This is an explorative, descriptive study using qualitative methods. We conducted focus group interviews with 16 adult patients (5 female, 11 male) from 3 different hospitals, who received OPAT and 2 individual semistructured interviews with their informal caregivers in the Netherlands. We used purposive sampling to ensure diversity of participants. We used the eight Picker principles of patient-centredness to guide data collection and analysis. Results Participants reported several elements considered as important for patient-centred OPAT care, like patient involvement in the decision-making process, a responsible OPAT lead, intensive collaboration between all disciplines involved, information provision and adherence to hygiene guidelines. Two central dimensions emerged as essential constituents of patient-centred OPAT care: freedom and safety. Both are heavily influenced by the behaviours of healthcare professionals and by organisational aspects beyond the direct influence of these professionals. Conclusion This study provides insights into the needs and preferences of adult patients who receive OPAT care. Future interventions directed at the improvement of patient-centredness of OPAT care should focus on elements that enhance patients’ feelings of freedom and safety.

To the Editor: In the placebo-controlled trial by Berende et al. (March 31 issue) 1 involving patients with persistent symptoms attributed to Lyme disease, all the patients received an initial 2-week course of intravenous ceftriaxone.Among the patients who subsequently received placebo, was the 12.6% reduction from baseline in the fatigue score the result of the initial 2-week course of ceftriaxone?The results from other studies that have involved patients with post-treatment symptoms of Lyme disease may help answer this question.In two separate studies, the effect of an intravenous placebo on fatigue was assessed over a 6-month period with the use of an 11-item fatigue-severity scale.In one study, a 9.1% reduction from baseline in the fatigue score was observed in the placebo group, 2 and in the second study, a 14.5% reduction from baseline was observed in the placebo group. 3Thus, the fact that the magnitude of reduction in fatigue score among the participants who were given placebo in other studies of post-treatment Lyme disease symptoms was similar to that observed in the trial by Berende et al. 1 suggests that the 2-week course of ceftriaxone in this trial probably provided no therapeutic benefit with respect to fatigue.

Background: Although hand hygiene (HH) compliance has been an important issue for years, the compliance rate is still a problem in health care today.Methods: This was an observational, prospective, before-and-after study. We measured HH knowledge and HH compliance before (baseline), directly after (poststrategy), and 6 months after the performance of HH team strategies (follow-up). The study was composed of employed nurses and physicians working in the department of internal medicine of a university hospital. We performed a multifaceted improvement program including HH education, feedback, reminders, social influence activities including the use of role models, and improvement of HH facilities.Results: Ninety-two nurses and physicians were included. Compared with baseline, there was a significant improvement in the overall mean HH knowledge score at poststrategy (from 7.4 to 8.4) and follow-up (from 7.4 to 8.3). The overall HH compliance was 27% at baseline, 83% at poststrategy, and 75% at follow-up. At baseline, the compliance rate was 17% in nurses and 43% in physicians and significantly improved to 63% in nurses and 91% in physicians at follow-up.Conclusion: Our multifaceted HH improvement program resulted in a sustained improvement of HH knowledge and compliance in nurses as well as physicians. Copyright (C) 2012 by the Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved.

Objectives: To investigate whether additional determinations of plasma lipopolysaccharide binding protein (LBP), procalcitonin (PCT), interleukin-6 (IL-6), IL-18, or soluble triggering receptor expressed on myeloid cells-1 (sTREM-1) to C-reactive protein (CRP) improve the discrimination between bacterial and viral lower respiratory tract infections (LRTI).Methods: Out of 342 patients visiting the emergency department because of a suspected infection and >= 2 clinical signs of sepsis, 56 patients with proven bacterial (n = 39) or viral (n = 17) LRTI were included. The area under the ROC curves (AUC) of the five possible combinations of CRP with one other biomarker were compared with the AUC of CRP alone. Next, the same analysis was performed in the group of patients with a CRP concentration with <95% specificity for bacterial LRTI.Results: While CRP, PCT, IL-6, sTREM-1, and LBP concentrations were significantly different between patients with bacterial or viral LRTI, the AUC of CRP (0.82, 95% CI 0.70-0.93) did not increase after combination analyses. After exclusion of patients with a CRP >150 mg/l, biomarker panel analyses did not improve diagnostic accuracy of CRP either.Conclusions: Combining CRP with LBP, PCT, IL-6, IL-18, or sTREM-1 does not improve differentiation between patients with a bacterial or viral LRTI compared with CRP alone. (C) 2012 The British Infection Association. Published by Elsevier Ltd. All rights reserved.

Introduction Anemia is a frequently encountered problem during inflammation. Hepcidin is an interleukin-6 (IL-6)-induced key modulator of inflammation-associated anemia. Human sepsis is a prototypical inflammatory syndrome, often complicated by the development of anemia. However, the association between inflammation, hepcidin release and anemia has not been demonstrated in this group of patients. Therefore, we explored the association between hepcidin and sepsis-associated anemia. Methods 92 consecutive patients were enrolled after presentation on the emergency ward of a university hospital with sepsis, indicated by the presence of a proven or suspected infection and ≥ 2 extended systemic inflammatory response syndrome (SIRS) criteria. Blood was drawn at day 1, 2 and 3 after admission for the measurement of IL-6 and hepcidin-25. IL-6 levels were correlated with hepcidin concentrations. Hemoglobin levels and data of blood transfusions during 14 days after hospitalisation were retrieved and the rate of hemoglobin decrease was correlated to hepcidin levels. Results 53 men and 39 women with a mean age of 53.3 ± 1.8 yrs were included. Hepcidin levels were highest at admission (median[IQR]): 17.9[10.1 to 28.4]nmol/l and decreased to normal levels in most patients within 3 days (9.5[3.4 to 17.9]nmol/l). Hepcidin levels increased with the number of extended SIRS criteria (P = 0.0005). Highest IL-6 levels were measured at admission (125.0[46.3 to 330.0]pg/ml) and log-transformed IL-6 levels significantly correlated with hepcidin levels at admission (r = 0.28, P = 0.015), day 2 (r = 0.51, P < 0.0001) and day 3 (r = 0.46, P < 0.0001). Twelve patients received one or more blood transfusions during the first 2 weeks of admission, not related to active bleeding. These patients had borderline significant higher hepcidin level at admission compared to non-transfused patients (26.9[17.2 to 53.9] vs 17.9[9.9 to 28.8]nmol/l, P = 0.052). IL-6 concentrations did not differ between both groups. Correlation analyses showed significant associations between hepcidin levels on day 2 and 3 and the rate of decrease in hemoglobin (Spearman's r ranging from -0.32, P = 0.03 to -0.37, P = 0.016, respectively). Conclusions These data suggest that hepcidin-25 may be an important modulator of anemia in septic patients with systemic inflammation.

Background In 2004 the Surviving Sepsis Campaign (SSC) a global initiative to reduce mortality from sepsis was launched Although the SSC supplies tools to measure and improve the quality of care for patients with sepsis effective implementation remains troublesome and no recommendations concerning the role of nurses are givenObjectives To determine the effects of a multifaceted implementation program including the introduction of a nurse-driven care bundle based sepsis protocol followed by training and performance feedbackDesign and setting A prospective before-and-after intervention study conducted in the emergency department (ED) of a university hospital in the NetherlandsParticipants Adult patients (>= 16 yea's old) visiting the ED because of a known or suspected infection to whom two or mole of the extended systemic inflammatory response syndrome (SIRS) criteria applyMethods We measured compliance with six bundled SSC recommendations for early recognition and treatment of patients with sepsis measure serum lactate within 6 h obtain two blood cultures before starting antibiotics take a chest radiograph take urine for urinalysis and culture start antibiotics within 3 h and hospitalize or discharge the patient within 3 hResults A total of 825 patients were included in the study Compliance with the complete bundle significantly improved from 3 5% at baseline to 12 4% after our entire implementation program was put in place The completion of four of six individual elements improved significantly namely measure serum lactate (improved from 23% to 80%) take a chest radiograph (from 67% to 83%) take urine for urinalysis and culture (from 49% to 67%) and start antibiotics within 3 h (from 38% to 56%) The mean number of performed bundle elements lint:moved significantly from 3 0 elements at baseline to 4 2 elements after intervention [1 2 95% confidence interval = 0 9-1 5]Conclusions Early recognition of sepsis in patients presenting to the ED and compliance with SSC recommendations significantly improved after the introduction of a predominantly nurse-driven care bundle based sepsis protocol followed by training and performance feedback (C) 2010 Elsevier Ltd All rights reserved

In 2004, the Surviving Sepsis Campaign (SSC) was launched to improve the recognition, diagnosis, management, and treatment of sepsis. From that moment on a vast amount of articles concerning the early recognition and treatment of patients with sepsis and different tools to measure and improve the quality of care for patients with sepsis have been published. Although the SSC supplies tools to measure and improve the quality of care for patients with sepsis, no recommendations concerning the role of the nurses are given and effective implementation remains troublesome.This chapter will mainly focus on the fact that early recognition and treatment of septic patients admitted to the ED can significantly improve after introduction of a predominantly nurse-driven sepsis registration protocol and education and feedback regarding its performance. An overview of the existing literature concerning general implementation techniques, focusing on different steps in the implementation process, is given. Apart from this overview, the effects of a predominantly nurse-driven prospective before-and-after intervention study at the emergency department are described. Compared to previous performed studies, this described new implementation technique was very successful. After the performance of the entire implementation program, four out of six recommendations and the compliance with the bundle of six recommendations improved significantly. It was demonstrated that four patient characteristics influenced the overall compliance rate to the sepsis protocol: patients' age, CRP result, ICU admission, and the final diagnosis.In addition, following an educational intervention about sepsis, it was possible to improve residents' knowledge about sepsis definitions, and diagnosis and treatment of sepsis. Apart from the short-term effects, the improved test results were sustained after 4-6 months.

Objectives This paper reports on a pilot study examining the incidence of nurses’ errors in preparation and administration of intravenous drugs. Furthermore, the study aimed to evaluate the short-term effects of implementation of a new protocol for preparation and administration of intravenous drugs. Setting Two nursing departments of internal medicine at a 953 beds University Medical Centre in The Netherlands. Methods By means of a prospective, quasi-experimental design, nurses were observed during the process of preparation and administration of intravenous drugs. Observation was performed before and after the implementation of a new protocol. Seventy-two nurses at two nursing departments were observed during the study. Main outcome measure A mean pre-test and post-test quality score at two departments of internal medicine. Results At baseline, average quality scores for nurses at the two departments were 64 (intervention ward) and 67 (control ward) on a 0–100 quality scale. The pre-test quality scores were not statistically significant for the two nursing wards ( T = 1.36, df = 55, P = 0.18). After the implementation of the new protocol, nurses at the intervention ward scored better (72) than nurses at the control ward (69). The mean score at the intervention ward was significantly higher than the score in nurses of the control ward ( T = −2.20, df = 53, P = 0.04). Conclusions The number of errors in the preparation and administration of intravenous drugs is high. This study shows that implementing a protocol for the preparation and administration of these drugs can reduce the number of errors.