Multicentre insights into OPAT: A comprehensive analysis of Türkiye's unstructured system 

Technical Summary: Multicentre Insights into OPAT in Türkiye

Problem Statement
Outpatient Parenteral Antimicrobial Therapy (OPAT) is a globally established, cost-effective modality for treating infections requiring long-term intravenous antibiotics, such as chronic osteomyelitis, spondylodiscitis, prosthetic joint infections, and urinary tract infections. In developed nations, structured, multidisciplinary OPAT programs have demonstrated benefits including reduced hospitalization times, decreased bed occupancy, lower out-of-pocket costs, and reduced healthcare-associated infections.

However, in Türkiye, no standardized national OPAT framework exists. Consequently, patients receiving long-term parenteral therapy are managed through fragmented channels, including emergency departments (ED), primary care facilities, or privately funded nursing services. This lack of standardization leads to heterogeneous care practices, limited outcome data, and potential risks regarding patient safety and treatment adherence. The study addresses the urgent need to evaluate the clinical outcomes, implementation practices, and patient experiences of OPAT under these unstructured conditions to inform the development of a national framework.

Methodology
This was a prospective, multicentre study conducted across 20 hospitals in six regions of Türkiye between March 1 and August 1, 2024, with follow-up completed by October 1, 2024. The participating institutions included nine university hospitals, seven secondary-care hospitals, and four tertiary-care hospitals.

• Participants: The study enrolled 265 adult patients (≥18 years) who were clinically stable (afebrile for ≥48 hours, normal vital signs) and initiated OPAT for chronic osteomyelitis, spondylodiscitis, prosthetic joint infection, or urinary tract infection. Patients were excluded if they were under 18, received only a single parenteral dose, or were treated with antibiotics outside national Health Services Regulations (e.g., teicoplanin, ceftriaxone, aminoglycosides, piperacillin-tazobactam).
• Data Collection: Clinical data were extracted from hospital automation systems. Additionally, two structured instruments were utilized:
  1. A 10-question questionnaire assessing treatment adherence, administration methods, access conditions, and payment status.
  2. A 10-item, 5-point Likert-scale survey adapted from existing instruments to measure patient satisfaction regarding follow-up, monitoring, daily activity continuity, and overall experience.
• Outcomes: Primary outcomes included adverse drug events (ADEs), rehospitalization (unplanned), surgical debridement, and treatment non-response. Clinical success was defined as symptom resolution without the need for additional systemic antibacterial therapy.
• Statistical Analysis: Continuous variables were analyzed using Student's t-test or Mann–Whitney U test; categorical variables were analyzed using chi-square or Fisher's exact tests. Logistic regression was employed to identify independent parameters.

Key Results

• Demographics and Indications: The cohort consisted of 265 patients (53.2% male; mean age 61.4 ± 13.5 years). The primary indications were chronic osteomyelitis (39.6%), prosthetic joint infection (25.7%), urinary tract infection (25.7%), and spondylodiscitis (9.1%). Gram-positive pathogens predominated (76%), with teicoplanin (70.5%), ceftriaxone (16.6%), and aminoglycosides (6.8%) being the most frequently used antibiotics.
• Implementation Settings: OPAT was administered in the emergency department (46.7%) or dedicated OPAT units (40.0%). Notably, 96.6% of administrations were nurse-led, though 1.1% were performed by non-healthcare professionals at home.
• Clinical Outcomes: The overall clinical success rate was 94.3%. Treatment discontinuation due to ADEs occurred in only 3 patients (1.1%). Unplanned rehospitalization occurred in 14.0% of patients, primarily due to surgical debridement (n=19) or infection relapse (n=7).
• Adherence and Challenges: 88.2% of patients completed all doses, and 68.7% adhered fully to the dosing schedule. Among those reporting issues, procedure-related problems (6.4%) and antibiotic-related adverse effects (3.8%) were most common. 90.2% of patients reported no additional out-of-pocket costs for the OPAT treatment itself.
• Comparative Findings:
  • Setting Impact: OPAT initiated at university hospitals was significantly more likely to be continued via the emergency department compared to state hospitals (p=0.010).
  • Safety: Treatment-related adverse events occurred significantly more frequently outside dedicated OPAT units (18%) compared to within them (3.1%; p=0.03).
  • Satisfaction: While overall satisfaction was high, patients with urinary tract infections reported significantly higher satisfaction scores across multiple domains (follow-up, physical exam, lab monitoring, physician access, perceived improvement, and willingness to recommend) compared to patients with bone and joint infections (all p ≤ 0.025).

Significance and Claims
This study represents the first multicentre evaluation of OPAT clinical outcomes and patient-reported experiences in Türkiye. The authors claim that the absence of a structured OPAT system in the country forces reliance on emergency departments, which increases the burden on these facilities and elevates the risk of complications, as evidenced by the higher incidence of ADEs in non-dedicated settings.

Despite these structural limitations, the study demonstrates that OPAT remains a viable and effective alternative to inpatient care in Türkiye, evidenced by high clinical success rates (94.3%) and high patient satisfaction. The authors conclude that while OPAT is currently functional, the establishment of a standardized, multidisciplinary national framework is imperative. Such a framework is necessary to mitigate the risks associated with fragmented care, improve patient safety, optimize healthcare resource utilization, and ensure consistent treatment adherence across the country.