Sandra Bott, Sharryn McLaughlin and Christine Hanley. September, 2001. Home intravenous antibiotic treatment [online]. Seacroft and St James's University Hospitals, Leeds, UK. Available from http://www.cysticfibrosismedicine.com

Introduction

Several studies have demonstrated that adequately supervised home iv antibiotic treatment is a practical, effective and acceptable alternative to hospital treatment for many CF patients (Gilbert et al, 1988; Pond et al, 1994). Many children and adults previously requiring hospital admission for intravenous antibiotics are now receiving this treatment at home and the facility is generally popular with families. The reduced risk of cross infection in the hospital environment is an important advantage as is the reduction in disturbance to family life and the patient's employment and education. While home care has been shown to be less expensive than hospital treatment, cost should not be a reason for instigating such therapy (Balinssky et al 1989).

In this section we describe the Leeds approach to home intravenous antibiotics. Although there are varying protocols between specialist CF centres, the fundamental principles are similar.

Any patient wishing to participate in home iv treatment is made known to the Cystic Fibrosis Nurse Specialist. Parents of our children with CF are invited to an iv study evening which is held in the CF Unit. Both units follow up initial contact with a home visit by the CF nurse specialist. During this visit, the CF Nurse Specialist can assess the home environment and discuss issues such as safe storage and preparation areas for the drugs as well as discuss timing of therapy to fit around existing treatment (eg physiotherapy, nebuliser therapy and of course work and education).

Both units have developed a fast-track teaching program which eliminates the need for even a few days hospital admission, to consolidate teaching at the beginning of the first course of HIVT (McLaughlin et al, 1999). An alternative route for adult patients being taught HIVT is for them to become an in-patients. During the first week of treatment the patient is taught the practicalities of iv therapy by both the nurse specialist and the ward nursing staff. In the second week the patient is discharged to continue their therapy at home supported by the nurse specialist.

The start of treatment

At the beginning of the iv course the patient and parent/carer attend the CF Unit where the patient will have their height, weight and respiratory function tests carried out, and see a physiotherapist. The patient is examined by the CF doctor and relevant blood tests taken. Venous access is obtained and the parent/patient taught how to administer the iv antibiotics safely. For the first course the parent/parent is supervised during the administration of a minimum of three doses. The nurse specialist demonstrates the first dose and observes the patient/parent administer subsequent doses. These doses may be given on the unit and subsequently in the patients home. Support should only be withdrawn once both professional and patient/parent are confident in administering the treatment. For drugs which are administered once daily (eg tobramycin) practicalities dictate that the second dose are observed being administered in the patients home. Observing the patient/parent in their own home allows problems and practicalities to be addressed from the outset. For subsequent courses of treatment only the first dose is required to be administered under supervision, unless the antibiotic is being prescribed for the first time, in which case two doses are supervised to reduce any risk of a bad allergic reaction occurring at home. The second dose can be administered either on the ward or in an alternative, controlled, safe environment, which is closer to the patients home eg GP surgery, local hospital ward or A&E department. The patient is required to stay within the CF unit during administration of the antibiotic and for half an hour following completion of the dose. During this time instructions are given on the relevant charts which are completed for home treatment. An information booklet is also given to the patient detailing the various steps involved in administering iv treatment. All patients are issued with an anaphylaxis kit and concise written instructions in case of adverse reaction.

Mid treatment

After 7 days either a home visit is made by the Cystic Fibrosis Nurse Specialist or the patient attends the Unit for a check on the iv technique. A home visit will be used to review the storage and preparation areas of the drugs. Respiratory function tests are repeated and sputum or throat swab specimens collected. An assessment of progress is made and any relevant action is taken. If the patient lives a long way from the CF unit, the Nurse specialist may co-op the support of colleagues to help care for the patient during their two weeks of treatment. This can involve obtaining aminoglycoside levels and generally monitoring the patients condition. Close contact is maintained via the telephone between the nurse specialist, the patient and nursing colleagues.

End of treatment: At the end of the two week course of home iv antibiotics the patient attends the CF Unit . Respiratory function tests are done, the patient is weighed and height and a sputum sample is obtained. The patient is also seen by the doctor, physiotherapist, and dietitian if required. The CF staff decide whether maximal improvement has occurred and whether further treatment is required.

The role of the Cystic Fibrosis Nurse Specialist is central to a satisfactory home iv treatment service. If this type of treatment is to be undertaken it is essential that there is adequate support from the hospital (McLaughlin & Haase, 1994). Home IV services should be frequently audited and strive to expand, develop and improve to provide easy, flexible, safe and effective home treatment (McLaughlin et al, 1999).

References

Balinsky W and Nesbitt S (1989). Cost effectiveness of outpatient parenteral antibiotics: a review of the literature. 87(3) 301-305)

Gilbert J, Robinson T, Littlewood JM. Home intravenous antibiotic treatment in cystic fibrosis. Arch Dis Child 1988; 63:512-517

Littlewood JM. The benefits of having a cystic fibrosis nurse specialist. In: David EJ, editor. The Role of the Cystic Fibrosis Nurse Specialist. Medicine Group (Education) Ltd. 1992; pp46-52

McLaughlin S, Brownlee KG, Conway SP. Homecare - optimising, enhancing and simplifying intravenous treatment. The Netherlands J Med 1999; 54(Suppl): S77.

McLaughlin S, Haase E. Home is where the heart is. CF News, No 4, Winter 1994.

Pond MN, Newport M, Joannes D, Conway SP. Home versus hospital intravenous antibiotic therapy in the treatment of young adults with cystic fibrosis. Eur Respir J 1994; 7: 1640-1644

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