Outpatient parenteral antimicrobial therapy in a changing NHS: challenges and opportunities

Editor – Dr Chapman made the case for more outpatient parenteral antimicrobial therapy (OPAT) (Clin Med February 2013 pp 35–6). The figures in an earlier paper of hers on the clinical efficacy and cost effectiveness of OPAT state that 59% of the treatment episodes were for soft tissue sepsis.¹ The majority of these patients had cellulitis and were receiving ceftriaxone intravenously (IV) with a mean duration of IV antibiotics exceeding 7 days. There are studies comparing inpatient IV therapy with outpatient IV therapy for cellulitis which demonstrate mutual efficacy,² but Dr Chapman does not supply the data to support the benefit of IV therapy over oral antibiotic therapy. A large study comparing an oral treatment to IV therapy for cellulitis showed marginally improved outcome with oral therapy.³ Why, then, do we need to give patients with cellulitis long courses of broad spectrum IV antibiotics, when we have a range of effective oral antibiotics? It may be that many of these patients, because of very slowly resolving skin damage, are mistakenly regarded as having failed initial oral antibiotic therapy, when in fact the duration of recovery is independent of the route of the antibiotic.

Perhaps, before we encourage the Department of Health and our new commissioners to invest in OPAT services, we ought to produce some evidence that IV therapy is better than oral treatment for those conditions in which we are proposing OPAT?