Management of infection (H@H)

• Initial diagnosis of infection in the community setting is based on symptoms and signs
• Samples should be taken to help direct therapy when results are available
• When treatment plans are unlikely to involve escalation in care, taking of blood cultures is not recommended
• Diagnosing and managing infections out-of-hospital may be less successful where some diagnostic or therapeutic options are not available
• If a patient has severe infection and admission to hospital is not thought appropriate then the initial assessment and discussion should include the appropriateness of antibiotic therapy and consideration for symptomatic care
• Advancing age is a risk factor for Clostridioides difficile infection (CDI) and use of any antibiotic will increase their risk of developing CDI
• This document aims to provide a safe treatment guide for patients in the community with frailty or multi-morbidity where admission can be prevented
• Oral antibiotic prescribing should be in line with the East Region Formulary
• If intravenous antibiotics are used they should be converted to oral as soon as possible; 24-48 hours after temperature has normalised and the patient is showing signs of improvement
• If the oral route is not available after 24-48 hours then consider if continuation of any antibiotic therapy is appropriate
• Patients discharged home from hospital on intravenous antibiotics for longer than four days must be referred to the Outpatient Parenteral Antibiotic Therapy (OPAT) service for shared care
• Patients with multiple or prolonged courses of antibiotics for a presumed infection, who are not improving, should be discussed with a Medicine of the Elderly (MoE) consultant working within the H@H service in the first instance. Subsequent options may include hospital admission and discussion with an infection specialist (Infectious diseases or Microbiology on-call) whether continuing antibiotics is appropriate

Risk factors for CDI include:

• Age >65 years old
• Recent (<12 weeks) or current antibiotic exposure, including Watch and Reserve antibiotics:
  • cephalosporins
  • co-amoxiclav
  • ciprofloxacin and other fluoroquinolones
  • clindamycin
• Recent admission to hospital/from a nursing home
• Previous CDI
• Frailty
• Serious underlying illness or immunosuppression (including chronic liver disease and transplants)
• Recent bowel surgery
• Use of proton pump inhibitors (PPI)/H2 antagonists (drugs which reduce the production of stomach acid)

Once daily broad-spectrum antibiotics, such as ceftriaxone and ertapenem are available.  Patients with infections that warrant IV therapy delivered traditionally in a hospital setting are more commonly offered Outpatient Parenteral Antimicrobial Treatment (OPAT), including soft tissue and skin infection, bone and joint infections.  The benefits for OPAT include specialist infectious diseases input and follow up where appropriate, and often improve patient satisfaction and outcomes.

OPAT in NHS Lothian is managed by the Infectious Diseases team. The ambulatory patient group typically referred to OPAT may differ from patients managed within the Hospital at Home setting, although OPAT will work with the Hospital 2 Home (H2H) team to deliver IV antibiotics in the patient’s home on discharge from hospital where appropriate.

Frailty and multi-morbidity may be more common in patients managed by Hospital at Home and prior exposure to antibiotics may mean they are at greater risk from harm from IV antibiotics such as ceftriaxone and ertapenem.

It is recommended that any patient with a complex or deep site of infection (i.e., osteomyelitis, prosthetic joint infection, endocarditis etc.)

OR requiring more than 4 days IV antibiotic therapy is discussed with OPAT for input and advice.