Outpatient Parenteral Antimicrobial Therapy in Children

A review of paediatric injectable drug delivery to inform the study of product acceptability - an introduction

AIM

The EMA defines acceptability as "the overall ability and willingness of the patient to use, and their caregiver to administer, the medicine as intended" [1]. This paper seeks to outline issues of acceptability in relation to injectable therapy, namely intravenous (IV), intramuscular (IM) and subcutaneous (SC) administration routes, and to lay a foundation to identify a minimum set of data that would satisfy Regulatory Authorities when discussing the acceptability of an injectable product. In addition, it will alert drug product developers to other factors that might contribute to good practice, alternative administration strategies and overall adherence to achieve successful treatment. Whilst the term 'parenteral' means "outside the intestine" [2,3] and so potentially covers a range of administration routes including intranasal and percutaneous administration, this review focuses on IV, IM and SC administration by injection. The use of indwelling canulae or catheters to reduce venepuncture and facilitate prolonged treatment is common and may impact acceptability [4]. This may be influenced by information provided by the manufacturer but is not always in their direct control. Other injectable products suitable for routes such as intradermal, intra-articular, intraosseous and intrathecal, share the requirement to be acceptable but are not specifically covered in this paper [2,5].

Five years of outpatient parenteral antibiotic therapy with ceftriaxone in the paediatric emergency department: what clinical features are associated with need for admission?

BACKGROUND

More children presenting to Emergency Departments (EDs) with acute infections are now directly referred for outpatient parenteral antibiotic therapy (OPAT). Sparse data exist on what clinical features in these children are associated with OPAT failure. We hypothesised that children who were younger or presented with systemic features of infection would be more likely to need admission.

METHODS

We conducted a service evaluation over a 5-year period (12 September 2015-12 September 2020) at a single UK tertiary centre paediatric ED formally known as the Royal Hospital for Sick Children Edinburgh. All children referred from the ED for OPAT with ceftriaxone were included. OPAT failure was defined as a decision by a senior clinician of need for admission. Univariate statistical testing and multivariate logistic regression modelling were performed.

RESULTS

754 children received OPAT in the ED over a 5-year period. 95 children (13%) required admission for inpatient management. Need for admission was independently associated with having a positive blood culture (adjusted OR (aOR) 8.9; 95% CI 1.49 to 47; p=0.01) or an ultrasound performed (aOR 6.8; 95% CI 3.74 to 12.7; p<0.001). We observed no significant association between age and systemic features (fever, white cell count or C reactive protein) with need for admission in our multivariate analysis.

CONCLUSION

In children presenting with acute infections to our paediatric ED who were deemed suitable by senior clinicians to be managed using OPAT with ceftriaxone, younger age (above 3 months) and the presence of systemic features were not independently associated with need for admission. Overall, our service was safe and no child came to harm from early ambulation during this evaluation.

Home-hospital care for children with acute illnesses: A 2-year follow-up study

AIM

Procedures normally performed in the hospital setting are increasingly delivered as part of hospital at home (HAH) programmes. The aim of this study is to describe the procedures and diseases treated during the first 2 years of a new paediatric HAH programme.

METHODS

This is a retrospective, observational study conducted in the HAH programme of Niño Jesús Children's Hospital (Spain). We included demographic data, diagnosis and procedures delivered to patients admitted to the HAH programme from November 2018 to November 2020.

RESULTS

There were 935 admissions of 833 patients. The median age was 5 years (interquartile range 2.3-9.5). Seventy-five percent of patients were previously healthy. The most frequent illnesses were acute infections (37%) (e.g. complicated appendicitis and ENT, genitourinary, skin and soft tissue infections) and acute respiratory diseases (17.3%) (e.g. asthma, bronchiolitis and pneumonia). Thirty-six percent of admissions underwent nocturnal polysomnography. The median length of stay was 4 days (SD 4.9 days). Eight percent of the episodes studied required care in the emergency department due to condition worsening (55.3%) and problems with devices (36.1%). Hospital readmission was required in 5.6% of cases, 42.4% of which later resumed care in the HAH. The estimated daily cost of HAH is 330.65 euros, while the hospital per-day costs of polysomnography, asthma and endovenous therapy are 1899.24, 1402.5, and 976.26 euros. Ninety percent of families reported a high level of satisfaction.

CONCLUSIONS

Paediatric HAH programmes are a feasible, cost-effective alternative to hospital care. Further studies should compare the evolution of patients treated in the traditional hospital setting and those in HAH.

Pediatric Antimicrobial Stewardship Programs: Current Perspectives

With the rapid growth of the field of pediatric antimicrobial stewardship, there has been a marked increase in the establishment of programs dedicated to this specialty. Shared objectives of all pediatric antimicrobial stewardship programs (ASPs) include optimization of antibiotic use and improvement in clinical outcomes for children, while certain core operational strategies and metrics used to measure program effectiveness are typically utilized by pediatric ASPs. Antimicrobial stewardship is the responsibility of every individual who prescribes, dispenses, and administers antibiotics to children, and pediatric ASP principles are rooted in collaboration and cooperation. Pediatric ASPs are uniquely suited to meet the needs of the local populations they serve and the environments within which they practice while also fostering an awareness of the interconnected global nature of pediatric stewardship. As such, pediatric ASPs are well positioned to confront the evolving challenges of antimicrobial overuse and resistance.