The use, appropriateness and outcomes of outpatient parenteral antimicrobial therapy

Abstract

Objective Outpatient parenteral antimicrobial therapy (OPAT) is increasingly used to treat children at home, but studies in children are scarce. We aimed to describe the use, appropriateness and outcomes of OPAT in children. Design This was a 12-month prospective observational study. Setting The hospital-in-the-home programme of The Royal Children's Hospital Melbourne. Patients All patients receiving OPAT. Interventions Data were collected including demographics, diagnosis, type of venous access and antibiotic choice. Main outcome measures Length of stay, adverse events, readmission rate and appropriateness of antibiotic use. Results 228 patients received OPAT in 251 episodes. The median age was 7.4 years (range 1 week to 21 years), with 22 patients (10%) under 1 year. The most frequent diagnoses were exacerbation of cystic fibrosis (17%), urinary tract infection (12%) and cellulitis (9%). Most patients were transferred from the ward, but 18% were transferred directly from the emergency department, the majority with skin and soft-tissue infection (66%). Venous access was most commonly peripherally inserted central catheter (29%) and peripheral cannula (29%). 309 parenteral antibiotics were prescribed, most frequently ceftriaxone (28%) and gentamicin (19%). The majority of antibiotics (72%) were prescribed appropriately. However, 6% were deemed an inappropriate choice for the indication and 26% had inappropriate dose or duration. The incidence of central line-associated bloodstream infections was 0.9%. The unplanned readmission rate was 4%, with low rates of OPAT-related adverse events. Three children (1%) had an inadequate clinical response. Conclusions OPAT is a safe and effective way of providing antibiotics to children. Despite high rates of appropriate antibiotic use, improvements can still be made. BACKGROUND

Dedicated paediatric Outpatient Parenteral Antimicrobial Therapy medical support: a pre–post observational study

“…Clinicians often fail to provide adequate patient oversight7; Hodgson et al identified that 26% of their paediatric OPAT patients received an incorrect dose, route or duration of antibiotics and an inappropriate indication for treatment was cited in 6% 8. Overall, drug-related and line-related complications are reported to occur in 20% to 30% of paediatric OPAT patients, correlating with increasing intravenous therapy durations 4 9–12…”

The evolution of outpatient parenteral antibiotic therapy

“…Hodgson et al 3 describe a large prospective cohort of children managed within an OPAT service in Australia. They attempted to both quantify their workload and assess the appropriateness of their IVAB prescribing.…”

“…The convenience of OPAT makes it extremely easy to administer long courses of IVABs. Due to the paucity of high-quality evidence available to inform decision making about antibiotic prescribing, including the optimal route and duration of administration, Hodgeson et al 3 have been forced to resort to expert opinion to decide whether prescribing was appropriate or not within their cohort of patients. In their opinion, 8% of IVAB courses were too long and 6% too broad, though infectious diseases specialists are often more likely to err on the side of caution and prescribe longer courses of antibiotics than other doctors 4.…”

“…There is also considerable variation between clinicians in deciding if and when a child is suitable for ambulatory OPAT. In addition, the safety of admission avoidance strategies (ie, sending a child home directly without admission) needs to be established, although the fact that 18% of the cohort described by Hodgson et al 3 were discharged directly from the emergency department is reassuring. The majority of these patients had skin/soft tissue infections or urinary tract infections.…”

“…Only through routine data collection on this cohort of patients, along with qualitative research into the opinions of parents and clinicians, will we be able to identify the potential barriers against the introduction of ambulatory OPAT programmes in all hospitals managing children. Hodgson et al 3 have demonstrated that tertiary OPAT can be safely delivered and this should provide further impetus for introducing them in all regional children's hospitals. What is now urgently needed is more data on the appropriateness and effectiveness of ambulatory OPAT and implementation strategies for ensuring robust clinical governance and effective data collection.…”