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Mohammed SA, Cotta MO, Assefa GM, Erku D, Sime F. Barriers and facilitators for the implementation and expansion of outpatient parenteral antimicrobial therapy: a systematic review. J Hosp Infect 2024; 147:1-16. [PMID: 38423135 DOI: 10.1016/j.jhin.2024.02.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2023] [Revised: 02/05/2024] [Accepted: 02/09/2024] [Indexed: 03/02/2024]
Abstract
Outpatient parenteral antimicrobial therapy (OPAT) has been expanding in recent years and serves as a viable solution in reducing the shortage of hospital beds. However, the wider implementation of OPAT faces numerous challenges. This review aimed to assess implementation barriers and facilitators of OPAT services. Studies describing barriers and facilitators of the OPAT service were retrieved from PubMed, Scopus, MEDLINE, EMBASE, CINAHL, Cochrane Library, Web of Science Proceedings, International Pharmaceutical Abstracts and PsycINFO. All types of study designs published in the English language were included. Studies that did not mention any barrier or facilitator, did not differentiate OPAT and inpatient, focused on specific antimicrobials or diseases, and made no distinction between parenteral and other treatments were excluded. Qualitative analysis was performed using the 'best-fit' framework approach and the Consolidated Framework for Implementation Research (CFIR). The review was PROSPERO registered (CRD42023441083). A total of 8761 studies were screened for eligibility and 147 studies were included. Problems in patient selection, lack of awareness, poor communication and co-ordination, lack of support, lack of structured service and inappropriate prescriptions were identified. OPAT provides safe, effective and efficient treatment while maintaining patients' privacy and comfort, resulting in less daily life disruption, and reducing the risk of infection. Satisfaction and preference for OPAT were very high. Initiatives in strengthening OPAT such as antimicrobial stewardship and telemedicine are beneficial. Challenges to and facilitators of OPAT were identified among patients, health professionals, OPAT service providers and healthcare administrators. Understanding them is crucial to designing targeted initiatives for successful OPAT service implementation.
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Affiliation(s)
- S A Mohammed
- UQ Centre for Clinical Research, The University of Queensland, Brisbane, Australia; Department of Pharmacy, Wollo University, Dessie, Ethiopia
| | - M O Cotta
- UQ Centre for Clinical Research, The University of Queensland, Brisbane, Australia; Herston Infectious Diseases Institute, Metro North Health, Brisbane, Australia
| | - G M Assefa
- UQ Centre for Clinical Research, The University of Queensland, Brisbane, Australia; Department of Pharmacy, Wollo University, Dessie, Ethiopia
| | - D Erku
- Centre for Applied Health Economics, Griffith University, Nathan, Australia
| | - F Sime
- UQ Centre for Clinical Research, The University of Queensland, Brisbane, Australia.
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2
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Fernandez-Sanchez J, Rodgers R, Maknojia AA, Shaikh N, Yan H, Mejia ME, Hendricks H, Jenq RR, Reddy P, Banerjee R, Schraw JM, Baldridge MT, King KY. Antibiotic-associated neutropenia is marked by depletion of intestinal Lachnospiraceae in pediatric patients. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2024:2024.04.25.24306386. [PMID: 38712139 PMCID: PMC11071563 DOI: 10.1101/2024.04.25.24306386] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/08/2024]
Abstract
Hematologic side effects are associated with prolonged antibiotic exposure in up to 34% of patients. Neutropenia, reported in 10-15% of patients, increases the risk of sepsis and death. Murine studies have established a link between the intestinal microbiota and normal hematopoiesis. We sought to identify predisposing factors, presence of microbiota-derived metabolites, and changes in intestinal microbiota composition in otherwise healthy pediatric patients who developed neutropenia after prolonged courses of antibiotics. In this multi-center study, patients with infections requiring anticipated antibiotic treatment of two or more weeks were enrolled. Stool samples were obtained at the start and completion of antibiotics and at the time of neutropenia. We identified 10 patients who developed neutropenia on antibiotics and 29 controls matched for age, sex, race, and ethnicity. Clinical data demonstrated no association between neutropenia and type of infection or type of antibiotic used; however intensive care unit admission and length of therapy were associated with neutropenia. Reduced intestinal microbiome richness and decreased abundance of Lachnospiraceae family members correlated with neutropenia. Untargeted stool metabolomic profiling revealed several metabolites that were depleted exclusively in patients with neutropenia, including members of the urea cycle pathway, pyrimidine metabolism and fatty acid metabolism that are known to be produced by Lachnospiraceae . Our study confirms a relationship between intestinal microbiota disruption and abnormal hematopoiesis and identifies taxa and metabolites likely to contribute to microbiota-sustained hematopoiesis. As the microbiome is a key determinant of stem cell transplant and immunotherapy outcomes, these findings are likely to be of broad significance. Key Points Neutropenia occurred in 17% of patients receiving prolonged antibiotic therapy.We found no association between neutropenia and type of infection or class of antibiotic used. Development of neutropenia after prolonged antibiotic treatment was associated with decreased prevalence of Lachnospiraceae and Lachnospiraceae metabolites such as citrulline.
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Fläring U, Lundevall H, Norberg Å, Andersson A. The success rate and complications of midline catheters in pediatric outpatient parenteral antibiotic therapy (OPAT). Eur J Pediatr 2024; 183:1703-1709. [PMID: 38227054 PMCID: PMC11001649 DOI: 10.1007/s00431-024-05432-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2023] [Revised: 01/09/2024] [Accepted: 01/10/2024] [Indexed: 01/17/2024]
Abstract
The use of outpatient parenteral antimicrobial therapy (OPAT) for children has several advantages, including reduced length of hospital stay and costs. A reliable vascular access is key to delivering safe and effective pediatric OPAT. In recent years, midline catheters (MC) have been increasingly used for short-term intravenous antibiotic therapy in children. However, there are no studies investigating the use of MCs in the OPAT setting. The main aim of this paper was to evaluate the success and complications of using MCs for pediatric OPAT. This was a retrospective cohort study from a tertiary academic pediatric hospital. All MCs inserted at the hospital and used for OPAT were eligible for study inclusion. The primary objective was to describe the percentage of patients able to complete OPAT without the need for additional venous access. Forty-one MCs were included in the study. Patient mean (SD) age was 5.9 (4.9) years. In 31 cases (76%, 95% CI 62-86%), the iv therapy could be successfully completed using only the MC. Imbalances between the groups suggested unfavorable outcome for saphenous vein catheters as well as for shorter and smaller-sized catheters. Fourteen patients (34%) were subjected to a MC-related complication. Pain on injection in the MC was the most frequent complication (n = 10, 24%). Conclusion: Midline catheters could be an alternative to central venous access for pediatric OPAT. Avoiding saphenous vein insertion and using longer and larger-sized catheters could increase MC success rate. No severe MC-related complication was found. Further randomized studies comparing different catheter types are needed. What is Known: • For selected patients, pediatric outpatient parenteral antimicrobial therapy (OPAT) is safe and provides health-economic, psychosocial, and medical advantages compared to in-hospital care. • A reliable venous access is one of the key factors to the success of OPAT, but this can be a challenge in children. What is New: • Using midline catheters, 76% of patients could complete their intended iv therapy without the need for additional venous access. Avoiding saphenous vein insertion and using longer and larger-sized catheters could increase the success rate. • Thirty-four percent of catheters were subject to some kind of complication, the most common being pain on injection in the catheter.
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Affiliation(s)
- Urban Fläring
- Department of Pediatric Perioperative Medicine and Intensive Care, Astrid Lindgren Children's Hospital, Karolinska University Hospital, Stockholm, Sweden
- Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden
| | - Henrik Lundevall
- Department of Pediatric Perioperative Medicine and Intensive Care, Astrid Lindgren Children's Hospital, Karolinska University Hospital, Stockholm, Sweden
- Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden
| | - Åke Norberg
- Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
| | - Andreas Andersson
- Department of Pediatric Perioperative Medicine and Intensive Care, Astrid Lindgren Children's Hospital, Karolinska University Hospital, Stockholm, Sweden.
- Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden.
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Agúndez Reigosa B, Cabrera López IM, Sánchez Marcos E, Galán-Olleros M, Sánchez Olivier M, Calleja Gero L, Jiménez García R. Hospital at Home Program for the Treatment of Pediatric Osteoarticular Infections. Hosp Pediatr 2024; 14:75-83. [PMID: 38186289 DOI: 10.1542/hpeds.2023-007265] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2024]
Abstract
OBJECTIVES Hospital at home (HAH) replaces acute inpatient hospital care for selected patients by providing care in their homes. We sought to describe the characteristics, management, and complications of patients with osteoarticular infections (OAIs) treated in an HAH program and its economic impact. METHODS We conducted a retrospective observational study evaluating an HAH program in a pediatric hospital in Spain, describing the characteristics of patients with confirmed OAIs requiring intravenous antibiotic therapy admitted to this program between January 2019 and December 2022. The program operates as a virtual ward with possible daily visits by physicians and nurses and 24/7 telephone contact. RESULTS A total of 88 patients (median age, 4.1 years; interquartile range [IQR], 1.7-10.6) with OIAs were admitted to the HAH program. Osteomyelitis (57%) and septic arthritis (29%) were the most frequent infections. Cefuroxime (42%) and cefazolin (39%) were the most frequently prescribed antibiotics. Caregiver self-administration was performed in 99%, allowing multiple daily doses of antimicrobial therapy, 80% by peripheral line. Thirteen patients (15%) had drug-related adverse events, only 3 requiring drug modification. Two patients (2%) were readmitted during HAH, and 1 was readmitted within 30 days of HAH discharge. The median HAH stay was 7 days (IQR, 4-8.75). For osteomyelitis, hospital days lowered from 8.5 days (IQR, 4.5-12) to 4 days (IQR, 3-7) after HAH implementation (P = .005) with 68% per-patient estimated cost savings. CONCLUSIONS HAH treatment of OAIs is effective and cost-efficient. Patient support by medical and nursing staff, adequate family training, and regular communication are essential to ensure safe home admission.
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Affiliation(s)
| | | | | | | | - Monica Sánchez Olivier
- Hospital at Home Program, Department of Pediatrics
- Department of Pediatrics, Hospital Infantil Universitario Niño Jesús, Madrid, Spain
| | - Lourdes Calleja Gero
- Department of Pediatrics, Hospital Infantil Universitario Niño Jesús, Madrid, Spain
| | - Raquel Jiménez García
- Hospital at Home Program, Department of Pediatrics
- Department of Pediatrics, Hospital Infantil Universitario Niño Jesús, Madrid, Spain
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Hodgson KA, Lim R, Huynh J, Nind B, Katz N, Marlow R, Hensey CC, Scanlan B, Ibrahim LF, Bryant PA. Outpatient parenteral antimicrobial therapy: how young is too young? Arch Dis Child 2022; 107:884-889. [PMID: 35537826 DOI: 10.1136/archdischild-2022-324143] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Accepted: 04/27/2022] [Indexed: 11/04/2022]
Abstract
OBJECTIVE To report the use, and assess the efficacy and outcomes of outpatient parenteral antimicrobial therapy (OPAT) in neonates (≤28 days of age), compared with older infants (1-12 months of age). DESIGN A prospective 8-year observational study from September 2012 to September 2020. SETTING The Hospital-in-the-Home (HITH) programme of the Royal Children's Hospital Melbourne. PATIENTS Neonatal patients (≤28 days of age) were compared with older infants (1-12 months of age) receiving OPAT. INTERVENTIONS Data were collected including demographics, diagnosis, type of venous access and antibiotic choice. MAIN OUTCOME MEASURES Success of OPAT, antibiotic appropriateness, complications and readmission rate. RESULTS There were 76 episodes for which neonates were admitted to HITH for OPAT, and 405 episodes for older infants. Meningitis was the most common diagnosis in both groups (59% and 35%, respectively); the most frequently prescribed antibiotic was ceftriaxone for both groups (61% and 49%). A positive bacterial culture was less frequent in neonates (38% vs 53%, p=0.02). Vascular access complication rate was 19% in neonates compared with 13% in older infants (p=0.2) with no central line-associated bloodstream infection in either group. Rates of appropriate antibiotic prescribing were similarly high between groups (93% vs 90%, p=0.3). The OPAT course was successfully completed in 74 of 74 (100%) neonates and 380 of 396 (96%) older infants (p=0.09). The unplanned readmission rate was low: 4 of 76 (5%) neonates and 27 of 405 (7%) older infants. CONCLUSIONS OPAT is a safe and effective way of providing antibiotics to selected clinically stable neonatal patients. While appropriate antibiotic use was common, improvements can still be made.
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Affiliation(s)
- Kate Alison Hodgson
- Hospital in the Home Department, The Royal Children's Hospital Melbourne, Parkville, Victoria, Australia
- Newborn Research Centre, The Royal Women's Hospital, Parkville, Victoria, Australia
| | - Ruth Lim
- Newborn Research Centre, The Royal Women's Hospital, Parkville, Victoria, Australia
| | - Julie Huynh
- Hospital in the Home Department, The Royal Children's Hospital Melbourne, Parkville, Victoria, Australia
| | - Ben Nind
- Hospital in the Home Department, The Royal Children's Hospital Melbourne, Parkville, Victoria, Australia
| | - Naomi Katz
- Hospital in the Home Department, The Royal Children's Hospital Melbourne, Parkville, Victoria, Australia
| | - Robin Marlow
- Bristol Royal Hospital for Children, Bristol, UK
| | - Conor C Hensey
- Department of General Paediatrics, National Maternity Hospital, Dublin, Ireland
| | - Barry Scanlan
- Hospital in the Home Department, The Royal Children's Hospital Melbourne, Parkville, Victoria, Australia
| | - Laila F Ibrahim
- Hospital in the Home Department, The Royal Children's Hospital Melbourne, Parkville, Victoria, Australia
| | - Penelope A Bryant
- General Medicine, The Royal Children's Hospital Melbourne, Parkville, Victoria, Australia
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6
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Olson J, Franz-O'Neal E, Cipriano FA, Ou Z, Presson AP, Thorell EA. Impact of Early Oral Antibiotic Therapy in Infants With Bacteremic Urinary Tract Infections. Hosp Pediatr 2022; 12:632-638. [PMID: 35726551 DOI: 10.1542/hpeds.2021-006479] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
OBJECTIVES To determine the effect of early conversion to oral antibiotics in infants ≤90 days with gram-negative bacteremia and concomitant urinary tract infection on hospital length of stay (LOS) and 30-day revisits for urinary tract infection. DESIGN This retrospective cohort study included infants ≤ 90 days who had concomitant positive blood and urine cultures with gram-negative bacteremia at 22 hospitals from January 1, 2002 through January 31, 2020. Early oral conversion was defined as a maximum intravenous (IV) duration of 4 days. We conducted a noninferiority test to compare early oral conversion to long IV therapy. A propensity score framework was used to assess comparisons in survey-weighted regression models using matched weights. RESULTS Among 174 infants, 73 infants received early oral conversion. The LOS was shorter in infants receiving early oral conversion compared to long IV therapy (median 2 days [interquartile range 2, 3] vs 4 days [3, 5]), descriptively (P < .001) and in noninferiority analysis (ratio = 0.43; 90% CI 0.35, 0.53, P < .001). Thirty-day revisits occurred in 5 of 174 (2.8%) of total patients. Early oral conversion did not meet our noninferiority criteria for the 30-day revisits (odds ratio: 4.22, 90%; confidence interval: 0.83, 21.34, P = .91). CONCLUSIONS Early oral conversion was associated with shorter LOS. The rate of 30-day revisit rates overall was low.
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Affiliation(s)
- Jared Olson
- Division of Pediatric Infectious Disease, Department of Pediatrics, University of Utah, Salt Lake City.,Division of Pediatric Hospital Medicine, Department of Pediatrics, University of Utah, Salt Lake City
| | - Erika Franz-O'Neal
- Division of Pediatric Infectious Disease, Department of Pediatrics, University of Utah, Salt Lake City.,Division of Pediatric Hospital Medicine, Department of Pediatrics, University of Utah, Salt Lake City
| | - Frank A Cipriano
- Division of Pediatric Infectious Disease, Department of Pediatrics, University of Utah, Salt Lake City.,Division of Pediatric Hospital Medicine, Department of Pediatrics, University of Utah, Salt Lake City
| | - Zhining Ou
- Division of Epidemiology, Department of Internal Medicine, School of Medicine, University of Utah, Salt Lake City, Utah
| | - Angela P Presson
- Division of Epidemiology, Department of Internal Medicine, School of Medicine, University of Utah, Salt Lake City, Utah
| | - Emily A Thorell
- Division of Pediatric Infectious Disease, Department of Pediatrics, University of Utah, Salt Lake City.,Division of Pediatric Hospital Medicine, Department of Pediatrics, University of Utah, Salt Lake City
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7
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Battini V, Mari A, Gringeri M, Casini F, Bergamaschi F, Mosini G, Guarnieri G, Pozzi M, Nobile M, Zuccotti G, Clementi E, Radice S, Fabiano V, Carnovale C. Antibiotic-Induced Neutropenia in Pediatric Patients: New Insights From Pharmacoepidemiological Analyses and a Systematic Review. Front Pharmacol 2022; 13:877932. [PMID: 35721197 PMCID: PMC9201445 DOI: 10.3389/fphar.2022.877932] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2022] [Accepted: 04/19/2022] [Indexed: 12/04/2022] Open
Abstract
Aim: to characterize pediatric cases of antibiotic-associated neutropenia through a multidisciplinary approach, focusing on the temporal association between the wide spectrum of treatment options and the occurrence of this relatively uncommon but potentially clinically relevant adverse event. Methods: we carried out a pharmacoepidemiological analysis based on the FDA Adverse Event Reporting System (FAERS) database, a retrospective chart review and a systematic review of the literature, focusing on the time to onset (TTO) of this side effect, in the pediatric clinical setting. Results: A total of 281 antibiotic-related neutropenia events, involving 11 categories of antibiotics, were included in the time to onset analysis. The median TTO ranged from 4 to 60 days after the start of the therapy. A shorter median TTO was found from the retrospective chart review [16 patients: median days (25th-75th percentiles) = 4 (3–5)], compared to 15 (9–18) vs. 10 (6–18) for literature (224 patients) and FAERS (41 cases), respectively. The Anatomical Therapeutic Chemical classes, J01X, J01F, J01E and J04A, and the median TTOs retrieved from more than one source revealed high accordance (p > 0.05), with J01X causing neutropenia in less than a week and J01F/J01E/J04A in more than 10 days. Antibiotics were discontinued in nearly 34% of cases. In FDA Adverse Event Reporting System reports, half of the patients experiencing neutropenia were hospitalized. Conclusion: Whereas antibiotic associated neutropenia is benign in the majority of cases, yet it should not be neglected as, even if rarely, it may put children at higher risk of clinical consequences. Clinicians’ awareness of antibiotic-associated neutropenia and its mode of presentation contributes to the continuous process of monitoring safety of antibiotics.
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Affiliation(s)
- Vera Battini
- Unit of Clinical Pharmacology, Department of Biomedical and Clinical Sciences, "Luigi Sacco" University Hospital, Università degli Studi di Milano, Milan, Italy
| | - Alessandra Mari
- Unit of Pediatrics, Department of Biomedical and Clinical Sciences, "Vittore Buzzi" Children's University Hospital, Università degli Studi di Milano, Milan, Italy
| | - Michele Gringeri
- Unit of Clinical Pharmacology, Department of Biomedical and Clinical Sciences, "Luigi Sacco" University Hospital, Università degli Studi di Milano, Milan, Italy
| | - Francesca Casini
- Unit of Pediatrics, Department of Biomedical and Clinical Sciences, "Vittore Buzzi" Children's University Hospital, Università degli Studi di Milano, Milan, Italy
| | - Francesco Bergamaschi
- Unit of Pediatrics, Department of Biomedical and Clinical Sciences, "Vittore Buzzi" Children's University Hospital, Università degli Studi di Milano, Milan, Italy
| | - Giulia Mosini
- Unit of Clinical Pharmacology, Department of Biomedical and Clinical Sciences, "Luigi Sacco" University Hospital, Università degli Studi di Milano, Milan, Italy
| | - Greta Guarnieri
- Unit of Clinical Pharmacology, Department of Biomedical and Clinical Sciences, "Luigi Sacco" University Hospital, Università degli Studi di Milano, Milan, Italy
| | - Marco Pozzi
- Scientific Institute IRCCS E. Medea, Bosisio Parini, Lecco, Italy
| | - Maria Nobile
- Scientific Institute IRCCS E. Medea, Bosisio Parini, Lecco, Italy
| | - Gianvincenzo Zuccotti
- Unit of Pediatrics, Department of Biomedical and Clinical Sciences, "Vittore Buzzi" Children's University Hospital, Università degli Studi di Milano, Milan, Italy
| | - Emilio Clementi
- Unit of Clinical Pharmacology, Department of Biomedical and Clinical Sciences, "Luigi Sacco" University Hospital, Università degli Studi di Milano, Milan, Italy.,Scientific Institute IRCCS E. Medea, Bosisio Parini, Lecco, Italy
| | - Sonia Radice
- Unit of Clinical Pharmacology, Department of Biomedical and Clinical Sciences, "Luigi Sacco" University Hospital, Università degli Studi di Milano, Milan, Italy
| | - Valentina Fabiano
- Unit of Pediatrics, Department of Biomedical and Clinical Sciences, "Vittore Buzzi" Children's University Hospital, Università degli Studi di Milano, Milan, Italy
| | - Carla Carnovale
- Unit of Clinical Pharmacology, Department of Biomedical and Clinical Sciences, "Luigi Sacco" University Hospital, Università degli Studi di Milano, Milan, Italy
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8
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Duzgun AC, Ilkeli E. Guidewire lost during endovenous intervention. Niger J Clin Pract 2021; 24:1859-1860. [PMID: 34889798 DOI: 10.4103/njcp.njcp_349_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Central venous catheterization is an important vascular access route used in many operations like open-heart surgery, hemodialysis, multiple trauma patients, total parenteral nutrition, and poor peripheral veins. During central venous catheterization, mechanical complications such as catheter thrombosis, infections, and pneumothorax can develop. In this report, we aimed to present a case of guidewire left unrecognized in venous system after central venous catheterization procedure. The guidewire has been extracted under fluoroscopy guidance. This case emphasizes maintaining and improving patient care and safety by doctor and the team.
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Affiliation(s)
- A C Duzgun
- Department of Cardiovascular Surgery, Training and Research Hospital, Ankara, Turkey
| | - E Ilkeli
- Department of Cardiovascular Surgery, Ataturk Government Hospital, Düzce, Turkey
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Müskens KF, Lindemans CA, Belderbos ME. Hematopoietic Dysfunction during Graft-Versus-Host Disease: A Self-Destructive Process? Cells 2021; 10:cells10082051. [PMID: 34440819 PMCID: PMC8392486 DOI: 10.3390/cells10082051] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Revised: 07/27/2021] [Accepted: 08/03/2021] [Indexed: 11/16/2022] Open
Abstract
Graft-versus-host disease (GvHD) is a major complication of allogeneic hematopoietic (stem) cell transplantation (HCT). Clinically, GvHD is associated with severe and long-lasting hematopoietic dysfunction, which may contribute to the high mortality of GvHD after HCT. During GvHD, excessive immune activation damages both hematopoietic stem and progenitor cells and their surrounding bone marrow niche, leading to a reduction in cell number and functionality of both compartments. Hematopoietic dysfunction can be further aggravated by the occurrence—and treatment—of HCT-associated complications. These include immune suppressive therapy, coinciding infections and their treatment, and changes in the microbiome. In this review, we provide a structured overview of GvHD-mediated hematopoietic dysfunction, including the targets in the bone marrow, the mechanisms of action and the effect of GvHD-related complications and their treatment. This information may aid in the identification of treatment options to improve hematopoietic function in patients, during and after GvHD.
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Affiliation(s)
- Konradin F. Müskens
- Princess Máxima Center for Pediatric Oncology, 3584 CS Utrecht, The Netherlands; (K.F.M.); (C.A.L.)
| | - Caroline A. Lindemans
- Princess Máxima Center for Pediatric Oncology, 3584 CS Utrecht, The Netherlands; (K.F.M.); (C.A.L.)
- Wilhelmina Children’s Hospital, University Medical Center Utrecht, 3584 EA Utrecht, The Netherlands
| | - Mirjam E. Belderbos
- Princess Máxima Center for Pediatric Oncology, 3584 CS Utrecht, The Netherlands; (K.F.M.); (C.A.L.)
- Correspondence:
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10
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Huynh J, Hodgson KA, Boyce S, Ibrahim LF, Bryant PA. Impact of expanding a paediatric OPAT programme with an antimicrobial stewardship intervention. Arch Dis Child 2020; 105:1220-1228. [PMID: 32381516 DOI: 10.1136/archdischild-2019-318091] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2019] [Revised: 04/14/2020] [Accepted: 04/16/2020] [Indexed: 11/04/2022]
Abstract
BACKGROUND As treatment out of hospital with outpatient parenteral antimicrobial therapy (OPAT) increases, so too does the risk for patients of being less visible, with potential for suboptimal care. OBJECTIVES We aimed to compare pre-expansion and post-expansion (1) successful completion, complications and (2) the impact of an OPAT-specific antimicrobial stewardship (AMS) intervention to mitigate inappropriate antibiotic prescribing. DESIGN A prospective longitudinal study during two consecutive 12-month periods: period A (1 August 2012 to 31 July 2013) and period B (1 August 2013 to 31 July 2014). SETTING The Hospital-in-the-Home (HITH) programme at The Royal Children's Hospital Melbourne. PARTICIPANTS All patients who received OPAT during the study period. INTERVENTIONS Between the two periods, the programme expanded from 16 to 32 patients/day. To coincide with this, a combined AMS intervention was introduced: (1) OPAT-specific guidelines and (2) active review of OPAT prescriptions and input by Paediatric Infectious Diseases. MAIN OUTCOMES Successful completion of OPAT, OPAT-related complications, readmission, length of stay and antibiotic appropriateness. RESULTS Over 2 years, 646 patients (47% female, median age 7 years) were treated via OPAT for 754 episodes. Patient episodes increased from 254 in period A to 500 in period B, with proportional increases in infants under 1 month and immunocompromised patients. OPAT was successfully completed in 245/251 (98%) versus 473/482 (98%) (OR 1.8, 95% CI 0.7 to 4.5, p=0.3). OPAT-related complications remained low: intravenous catheter-associated complications 16/138 (12%) versus 41/414 (10%), and antibiotic-associated complications 0/254 (0%) versus 2/500 (0.4%). Despite the increase in activity, with the AMS intervention, overall appropriate antibiotic prescribing remained high: 71% versus 76%. Inappropriately long durations reduced from 30/312 (10%) to 37/617 (6%) (OR 0.6, 95% CI 0.4 to 0.99, p=0.04), and median number of days on broad-spectrum antibiotics from 11 (IQR 8-24.5) to 8 (IQR 5-11). CONCLUSION During a period of substantial expansion, we maintained clinical outcomes. A modest AMS intervention reduced some but not all aspects of inappropriate antibiotic prescribing.
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Affiliation(s)
- Julie Huynh
- Hospital-in-the-Home Department, The Royal Children's Hospital, Parkville, Victoria, Australia.,Discipline of Child and Adolescent Health, The University of Sydney, Westmead, New South Wales, Australia
| | - Kate A Hodgson
- Hospital-in-the-Home Department, The Royal Children's Hospital, Parkville, Victoria, Australia.,Perinatal Infant and Paediatric Emergency Retrieval, The Royal Children's Hospital, Parkville, Victoria, Australia.,Department of Newborn Research, Royal Women's Hospital, Parkville, Victoria, Australia.,Department of Obstetrics and Gynaecology, University of Melbourne, Parkville, Victoria, Australia
| | - Suzanne Boyce
- Hospital-in-the-Home Department, The Royal Children's Hospital, Parkville, Victoria, Australia.,Clinical Paediatrics Group, Murdoch Children's Research Institute, Parkville, Victoria, Australia.,Department of General Medicine, The Royal Children's Hospital, Parkville, Victoria, Australia
| | - Laila F Ibrahim
- Hospital-in-the-Home Department, The Royal Children's Hospital, Parkville, Victoria, Australia.,Clinical Paediatrics Group, Murdoch Children's Research Institute, Parkville, Victoria, Australia.,Department of Paediatrics, University of Melbourne, Parkville, Victoria, Australia
| | - Penelope A Bryant
- Hospital-in-the-Home Department, The Royal Children's Hospital, Parkville, Victoria, Australia .,Clinical Paediatrics Group, Murdoch Children's Research Institute, Parkville, Victoria, Australia.,Department of Paediatrics, University of Melbourne, Parkville, Victoria, Australia.,Infectious Diseases Unit, The Royal Children's Hospital Melbourne, Parkville, Victoria, Australia
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11
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Safety of Nurse- and Self-Administered Paediatric Outpatient Parenteral Antimicrobial Therapy. Antibiotics (Basel) 2020; 9:antibiotics9110761. [PMID: 33143280 PMCID: PMC7694010 DOI: 10.3390/antibiotics9110761] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2020] [Revised: 10/15/2020] [Accepted: 10/29/2020] [Indexed: 12/04/2022] Open
Abstract
This study aimed to compare and contrast the safety and efficacy of nurse- and self-administered paediatric outpatient parenteral antimicrobial therapy (OPAT) models of care and to identify clinical factors associated with documented adverse events (AEs). A total of 100 OPAT episodes among children aged between 1 month and 18 years who were discharged from hospital and who received continuous 24 h intravenous antimicrobial therapy at home via an elastomeric infusion device were included. All documented AEs from the case notes were reviewed by a paediatrician and classified as either major or minor. Multivariable logistic regression was used to determine associations between clinical factors and any AE. A total of 86 patients received 100 treatment OPAT episodes (49 self-administered, 51 nurse administered). The most commonly prescribed antimicrobial via continuous infusion was ceftazidime (25 episodes). Overall, an AE was recorded for 27 (27%) OPAT episodes. Major AEs was recorded for 15 episodes and minor AEs were reported in 14 episodes. The odds of an AE was increased in episodes with self-administration (adjusted odds ratio (aOR) 6.25, 95% confidence interval (CI) 1.44–27.15) and where the duration of vascular access was >14 days (aOR 1.08, 95%CI 1.01–1.15). Our findings suggest minor AEs may be more frequently reported when intravenous antimicrobials are self-administered via 24 h continuous infusions.
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12
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Abstract
BACKGROUND Pediatric returns to the emergency department (RTED) vary between 3% and 13% of the total ED volume of visits. However, the incidence and contribution of scheduled RTED on pediatric emergency department (PED) utilization is less clear. Antimicrobial stewardship programs on inpatient wards have been shown to improve judicious use of outpatient parenteral antimicrobial therapy (OPAT) in upon discharge. The implementation of such programs in PEDs has yet to be reported. The objectives of this study are to quantify the burden of scheduled RTED for OPAT on PED utilization and to examine how frequently OPAT use are supported by published practice standards for 3 common pediatric infections-cellulitis, pneumonia, and urinary tract infections. METHODS We conducted a single-center retrospective cohort study of all visits made to the British Columbia Children's Hospital PED from May 1, 2012, to April 30, 2013. We identified scheduled RTEDs and characterized those associated with OPAT use with regard to their measures of PED utilization and clinical features. RESULTS Of 3904 RTED visits, 1310 (33.6%) were scheduled, of which 1029 were OPAT related. Among the latter, 749 RTEDs (69%) were for cellulitis, pneumonia, or urinary tract infections. The median length of stay for OPAT-related RTEDs was 2.0 hours. For 75 (24%) of 317 index visits and 213 (28%) of 749 subsequent RTEDs, oral antibiotic therapy would have been an appropriate option and OPAT could have been avoided. CONCLUSIONS Our findings suggest that OPAT poses a sizable burden on PED utilization, with a proportion of them potentially preventable.
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13
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Beachum N, Dehority W. Safety of Peripherally Inserted Central Catheter Use in Children From Rural Versus Urban Settings Receiving Long-term Parenteral Antimicrobial Therapy. Hosp Pediatr 2020; 9:51-54. [PMID: 30552090 DOI: 10.1542/hpeds.2018-0196] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
OBJECTIVES To determine the safety of peripherally inserted central catheter (PICC) use for delivery of outpatient parenteral antimicrobial therapy (PAT) in children discharged to rural or urban locales. We hypothesized that children from rural settings would experience higher complication rates. PATIENTS AND METHODS We conducted a retrospective cohort study of children admitted to an academic medical center in the Southwestern United States over 9 years who were discharged with a PICC to complete a course of PAT with follow-up at our institution. To classify rural versus urban residence, we used rural-urban continuum codes from the US Department of Agriculture, the driving time in hours to the nearest trauma center, and the discharging center using Google Maps. RESULTS In total, 221 children met inclusion criteria (mean age 9.8 years). Osteoarticular infections and cystic fibrosis exacerbations were the most common indications for PICC use (68.8%). The mean driving time to the discharging hospital was significantly longer for those children residing in the most rural regions of the state (3.6 vs 0.8 hours; P < .001) as well as to the nearest level 1, 2, or 3 trauma center (2.2 vs 0.4 hours; P < .001). PICC complications occurred in 47 children (21.3%). No association was found between rural-urban continuum codes, driving times to the discharging hospital, or nearest trauma center with any complication nor with complications overall. CONCLUSIONS In our study, we demonstrate an equivalent safety profile for children in rural and urban settings with PICCs for receipt of outpatient PAT.
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Affiliation(s)
- Natasha Beachum
- School of Medicine, The University of New Mexico, Albuquerque, New Mexico
| | - Walter Dehority
- Division of Infectious Diseases, Department of Pediatrics, and
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14
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Markham JL, Goldman JL. To Discharge or Not to Discharge on Outpatient Parenteral Antimicrobial Therapy: That Is the Question. Hosp Pediatr 2020; 9:314-316. [PMID: 30885920 DOI: 10.1542/hpeds.2018-0279] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Affiliation(s)
- Jessica L Markham
- Department of Pediatrics, Children's Mercy Kansas City, Kansas City, Missouri
| | - Jennifer L Goldman
- Department of Pediatrics, Children's Mercy Kansas City, Kansas City, Missouri
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15
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Krah NM, Bardsley T, Nelson R, Esquibel L, Crosby M, Byington CL, Pavia AT, Hersh AL. Economic Burden of Home Antimicrobial Therapy: OPAT Versus Oral Therapy. Hosp Pediatr 2020; 9:234-240. [PMID: 30885919 DOI: 10.1542/hpeds.2018-0193] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND There is increasing evidence that outpatient parenteral antimicrobial therapy (OPAT) is overused for children and that outcomes with oral therapy are equivalent. Our objective was to compare economic burden between OPAT and oral therapy, accounting for direct and indirect costs and caregiver quality of life (QoL). METHODS We conducted a prospective cohort study of caregivers for children after hospitalization who were treated with prolonged antimicrobial therapy. We collected data about missed work and school and time spent administering therapy. Caregivers completed the Pediatric Quality of Life Inventory to assess QoL. Clinical information included length of stay, treatment indication, and type of therapy (OPAT versus oral therapy). Direct medical costs were obtained by using a microcosting system and accounted for medication, supplies, and home-nursing visits. The primary cost outcome was the mean daily cost of therapy. Multivariable models were developed to adjust for potential confounders. RESULTS Two hundred and twelve caregivers completed surveys: 123 (58%) for oral therapy and 89 (42%) for OPAT. Caregivers administering OPAT reported more missed work, missed school for their children, time with daily medication administration (90 vs 6 minutes; P < .01) and lower QoL scores (77.8 vs 68.9) than caregivers administering oral therapy. The mean daily cost was $65 (95% confidence interval: $51-$78) for OPAT and $7 (95% confidence interval: $4-$9) for oral therapy. Relative differences in cost and QoL between groups did not change after model adjustment. CONCLUSIONS The overall burden of OPAT is substantially higher than that of oral therapy, including higher direct and indirect costs and greater impact on caregiver QoL. These findings strongly support efforts to use oral therapy in place of OPAT when clinically appropriate.
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Affiliation(s)
- Nathan M Krah
- Infectious Disease, Department of Pediatrics, School of Medicine and
| | - Tyler Bardsley
- Divisions of Epidemiology and.,Study Design and Biostatistics Center, University of Utah, Salt Lake City, Utah
| | - Richard Nelson
- Divisions of Epidemiology and.,Informatics, Decision-Enhancement and Analytic Sciences Center, Department of Veterans Affairs Salt Lake City Health Care System, Salt Lake City, Utah
| | - Lawanda Esquibel
- Infectious Disease, Department of Pediatrics, School of Medicine and
| | - Mark Crosby
- Intermountain Homecare Pharmacy, Intermountain Healthcare, Salt Lake City, Utah; and
| | | | - Andrew T Pavia
- Infectious Disease, Department of Pediatrics, School of Medicine and
| | - Adam L Hersh
- Infectious Disease, Department of Pediatrics, School of Medicine and
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16
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Carter B, Fisher-Smith D, Porter D, Lane S, Peak M, Taylor-Robinson D, Bracken L, Carrol E. Being 'at-home' on outpatient parenteral antimicrobial therapy (OPAT): a qualitative study of parents' experiences of paediatric OPAT. Arch Dis Child 2020; 105:276-281. [PMID: 31558443 PMCID: PMC7041500 DOI: 10.1136/archdischild-2019-317629] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2019] [Revised: 08/08/2019] [Accepted: 09/05/2019] [Indexed: 12/13/2022]
Abstract
OBJECTIVE To better understand the factors that facilitate and hinder a positive experience of paediatric outpatient parenteral antimicrobial therapy (OPAT). DESIGN Qualitative study using semistructured interviews. SETTING A dedicated paediatric consultant-led hospital-based, outreach OPAT service in England. PARTICIPANTS Participants were primarily parents of children who had received OPAT; one child participated. METHODS Children and parents of children who received OPAT and who had participated in the survey phase of the larger study were invited to be interviewed. RESULTS 12 parents (10 mothers and 2 fathers) of 10 children participated; one child (aged 15 years). Data analysis resulted in one meta-theme, 'At-homeness' with OPAT, this reflected the overall sense of home being a place in which the children and their parents could be where they wanted to be. Four key themes were identified that reflect the ways in which parents and children experienced being at-home on OPAT: 'Comfort, security, freedom, and control'; 'Faith, trust and confidence'; 'Explanations and communication' and 'Concerns, restrictions and inconveniences'. CONCLUSIONS Despite feeling anxious at times, parents reported that they and their children generally had a positive experience of OPAT; being at-home brought many benefits compared with in-patient care. Recommendations arising from the study include a 'whole-system' approach to discharge home that includes support related to return to school/nursery, reduction in disruptions to home-based routines, more clarity on choice and preparation for managing potential anxiety, better consideration of dose timing and enhanced preparation and information.
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Affiliation(s)
- Bernie Carter
- Faculty of Health, Social Care and Medicine, Edge Hill University, Ormskirk, UK
| | - Debra Fisher-Smith
- Department of Clinical Infection, Microbiology and Immunology, University of Liverpool, Liverpool, UK
| | - David Porter
- Department of Infectious Diseases, Alder Hey Children’s NHS Foundation Trust, Liverpool, UK
| | - Steven Lane
- Biostatistics, University of Liverpool, Liverpool, UK
| | - Matthew Peak
- Research and Development, Alder Hey Children’s NHS Foundation Trust, Liverpool, UK,Cheshire and Merseyside Medicines for Children Research Network, Alder Hey Children’s NHS Foundation Trust, Liverpool, UK
| | | | - Louise Bracken
- Paediatric Medicines Research Unit, Alder Hey Children’s NHS Foundation Trust, Liverpool, UK
| | - Enitan Carrol
- Department of Clinical Infection, Microbiology and Immunology, University of Liverpool, Liverpool, UK
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17
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Norris AH, Shrestha NK, Allison GM, Keller SC, Bhavan KP, Zurlo JJ, Hersh AL, Gorski LA, Bosso JA, Rathore MH, Arrieta A, Petrak RM, Shah A, Brown RB, Knight SL, Umscheid CA. 2018 Infectious Diseases Society of America Clinical Practice Guideline for the Management of Outpatient Parenteral Antimicrobial Therapy. Clin Infect Dis 2020; 68:e1-e35. [PMID: 30423035 DOI: 10.1093/cid/ciy745] [Citation(s) in RCA: 161] [Impact Index Per Article: 40.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2018] [Indexed: 12/16/2022] Open
Abstract
A panel of experts was convened by the Infectious Diseases Society of America (IDSA) to update the 2004 clinical practice guideline on outpatient parenteral antimicrobial therapy (OPAT) [1]. This guideline is intended to provide insight for healthcare professionals who prescribe and oversee the provision of OPAT. It considers various patient features, infusion catheter issues, monitoring questions, and antimicrobial stewardship concerns. It does not offer recommendations on the treatment of specific infections. The reader is referred to disease- or organism-specific guidelines for such support.
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Affiliation(s)
- Anne H Norris
- Division of Infectious Diseases, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | | | - Genève M Allison
- Division of Geographic Medicine and Infectious Diseases, Tufts Medical Center, Boston, Massachusetts
| | - Sara C Keller
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Kavita P Bhavan
- Division of Infectious Diseases, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas
| | - John J Zurlo
- Division of Infectious Diseases, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Adam L Hersh
- Division of Pediatric Infectious Diseases, Department of Pediatrics, University of Utah, Salt Lake City
| | - Lisa A Gorski
- Wheaton Franciscan Home Health & Hospice, Part of Ascension at Home, Milwaukee, Wisconsin
| | - John A Bosso
- Departments of Clinical Pharmacy and Outcome Sciences and Medicine, Colleges of Pharmacy and Medicine, Medical University of South Carolina, Charleston
| | - Mobeen H Rathore
- University of Florida Center for HIV/AIDS Research, Education and Service and Wolfson Children's Hospital, Jacksonville
| | - Antonio Arrieta
- Department of Pediatric Infectious Diseases, Children's Hospital of Orange County Division of Pediatrics, University of California-Irvine School of Medicine
| | | | - Akshay Shah
- Metro Infectious Disease Consultants, Northville, Michigan
| | - Richard B Brown
- Division of Infectious Disease Medical Center, University of Massachusetts School of Medicine, Worcester
| | - Shandra L Knight
- Library & Knowledge Services, National Jewish Health, Denver, Colorado
| | - Craig A Umscheid
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, and Center for Evidence-based Practice, University of Pennsylvania Health System, Philadelphia
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18
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Solis K, Dehority W. Antibiotic-Induced Neutropenia During Treatment of Hematogenous Osteoarticular Infections in Otherwise Healthy Children. J Pediatr Pharmacol Ther 2019; 24:431-437. [PMID: 31598107 DOI: 10.5863/1551-6776-24.5.431] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
OBJECTIVES We studied the frequency and characteristics of antibiotic-induced neutropenia in otherwise healthy children receiving antibiotic therapy for hematogenous osteoarticular infections (OAIs). METHODS We retrospectively enrolled otherwise healthy children between 1 month and 18 years of age discharged with an OAI from our institution over an 11-year period. An absolute neutrophil count (ANC) ≤1500 cells/μL was defined as neutropenia. We recorded demographic and clinical information, as well as the value and timing of each ANC in relation to changes in antibiotic therapy. A multivariable regression model assessed the contributions of various risk factors. RESULTS A total of 186 children were enrolled (mean age, 7.6 years; 67.2% boys). β-Lactams represented 61.2% of all prescriptions. During treatment, 61 subjects (32.8%) developed neutropenia (median time to onset, 24 days). An ANC < 500 cells/μL occurred in 7 subjects (3.8%). Neutropenic subjects (mean age, 6.0 years) were significantly younger than those without neutropenia (mean age, 8.5 years) (OR = 0.86; 95% CI: 0.79-0.93; p < 0.001) and received significantly longer courses of total (89.3 vs. 55.8 days) and parenteral (24.6 vs. 19.9 days) antibiotic therapy (OR = 1.01; 95% CI: 1.01-1.02; p = 0.004 and OR = 1.02; 95% CI: 1.01-1.04; p = 0.041, respectively). Recurrent neutropenia occurred in 23.0% of all neutropenic subjects and was significantly more common in those with a longer mean duration of parenteral therapy (OR = 1.05; 95% CI: 1.02-1.09; p = 0.004.). No complications from neutropenia occurred. CONCLUSIONS Neutropenia was common in our cohort of children receiving prolonged antibiotic therapy for OAIs. Younger age and longer courses of therapy were associated with an increased risk of neutropenia.
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19
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Keller SC, Williams D, Gavgani M, Hirsch D, Adamovich J, Hohl D, Gurses AP, Cosgrove SE. Rates of and Risk Factors for Adverse Drug Events in Outpatient Parenteral Antimicrobial Therapy. Clin Infect Dis 2019; 66:11-19. [PMID: 29020202 DOI: 10.1093/cid/cix733] [Citation(s) in RCA: 74] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2017] [Accepted: 08/12/2017] [Indexed: 12/18/2022] Open
Abstract
Background To better monitor patients on outpatient parenteral antimicrobial therapy (OPAT), we need an improved understanding of risk factors for and timing of OPAT-associated adverse drug events (ADEs). Methods We analyzed a prospective cohort of patients on OPAT discharged from 2 academic medical centers. Patients underwent chart abstraction and a telephone survey. Multivariable analyses estimated adjusted incident rate ratios (aIRR) between clinical and demographic risk factors and clinician-determined clinically significant ADEs. Descriptive data were used to present patient-reported ADEs. Results Of 339 patients enrolled in the study, 18.0% experienced an ADE (N = 65), of which 49 were significant (14.5%, 2.24/1000 home-OPAT days). Patients with longer courses of therapy had lower rates of ADEs compared with patients treated for 0-13 days (14-27 days: aIRR, 0.44; 95% confidence interval [CI], 0.20-0.99; at least 28 days: aIRR, 0.11; 95% CI, 0.056-0.21). Risk factors for ADEs included female gender and receipt of daptomycin or vancomycin, while treatment for uncomplicated bacteremia and empiric treatment were associated with lower rates of ADEs. Conclusions OPAT-related ADEs were common and often occurred within 2 weeks of hospital discharge. Patients on OPAT should be monitored more closely for ADEs, including clinical assessment and laboratory monitoring, especially within the first weeks after hospital discharge and particularly among women and patients who receive vancomycin.
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Affiliation(s)
- Sara C Keller
- Department of Medicine, Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | | | | | - David Hirsch
- Johns Hopkins Home Care Group, Baltimore, Maryland
| | | | - Dawn Hohl
- Johns Hopkins Home Care Group, Baltimore, Maryland
| | - Ayse P Gurses
- Armstrong Institute of Patient Safety and Quality, Department of Anesthesiology, Baltimore, Maryland
| | - Sara E Cosgrove
- Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, Maryland
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20
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Carter B, Carrol ED, Porter D, Peak M, Taylor-Robinson D, Fisher-Smith D, Blake L. Delivery, setting and outcomes of paediatric Outpatient Parenteral Antimicrobial Therapy (OPAT): a scoping review. BMJ Open 2018; 8:e021603. [PMID: 30446572 PMCID: PMC6252693 DOI: 10.1136/bmjopen-2018-021603] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
BACKGROUND There has been little detailed systematic consideration of the delivery, setting and outcomes of paediatric Outpatient Parenteral Antimicrobial Therapy (OPAT), although individual studies report that it is a safe and effective treatment. OBJECTIVE This scoping review aimed to examine what is known about the delivery, settings and outcomes of paediatric OPAT and to identify key knowledge deficits. DESIGN A scoping review using Arksey and O'Malley's framework was undertaken. DATA SOURCES Keywords were identified and used to search MEDLINE and CINAHL. STUDY APPRAISAL METHODS Primary research studies were included if samples comprised children and young people 21 or under, who had received OPAT at home or in a day treatment centre. The Mixed Methods Appraisal Tool was used to review the methodological quality of the studies MAIN FINDINGS: From a preliminary pool of 157 articles, 51 papers were selected for full review. 19 studies fitted the inclusion criteria. Factors influencing delivery of OPAT were diverse and included child's condition, home environment, child-related factors, parental compliance, training and monitoring. There is little consensus as to what constitutes success of and adverse events in OPAT. CONCLUSIONS Future studies need to clearly define and use success indicators and adverse events in order to provide evidence that paediatric OPAT is safe and effective. IMPLICATIONS Consensus outcomes that include child and parent perspectives need to be developed to allow a clearer appreciation of a successful paediatric OPAT service.
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Affiliation(s)
- Bernie Carter
- Faculty of Health and Social Care, Edge Hill University, Ormskirk, UK
| | - Enitan D Carrol
- Department of Clinical Infection, Microbiology and Immunology, University of Liverpool, Liverpool, UK
| | - David Porter
- Department of Infectious Diseases and Immunology, Alder Hey Children’s Hospital, Liverpool, UK
| | - Matthew Peak
- Paediatric Medicines Research Unit, Alder Hey Children’s Hospital, Liverpool, UK
| | | | - Debra Fisher-Smith
- Department of Clinical Infection, Microbiology and Immunology, University of Liverpool, Liverpool, UK
| | - Lucy Blake
- Faculty of Health and Social Care, Edge Hill University, Ormskirk, UK
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21
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DeRonde KJ, Girotto JE, Nicolau DP. Management of Pediatric Acute Hematogenous Osteomyelitis, Part II: A Focus on Methicillin-Resistant Staphylococcus aureus, Current and Emerging Therapies. Pharmacotherapy 2018; 38:1021-1037. [PMID: 29989190 DOI: 10.1002/phar.2164] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Methicillin-resistant Staphylococcus aureus (MRSA) has become the most prevalent cause of acute hematogenous osteomyelitis (AHO) in pediatric patients. This increase in MRSA is due to the rise in community-acquired MRSA. Therefore, it is important that clinicians are aware of the various and upcoming therapies that cover this bacterium. A literature search of the Medline database was performed from creation through January 2018. Articles chosen for the review emphasize well-established MRSA treatment options for pediatric AHO, newer therapies on the horizon, and important pharmacokinetics and pharmacodynamic concepts for treatment. Traditional therapies, including vancomycin and clindamycin, remain effective for the treatment of pediatric AHO. When these agents cannot be used, evidence in AHO has been growing for daptomycin, linezolid, and ceftaroline. Further initial pediatric data with the long-acting lipoglycopeptides show promise and in the future may provide a role in AHO treatment in children.
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Affiliation(s)
- Kailynn J DeRonde
- Department of Pharmacy Practice, School of Pharmacy, University of Connecticut, Storrs, Connecticut.,Department of Pharmacy, Connecticut Children's Medical Center, Hartford, Connecticut
| | - Jennifer E Girotto
- Department of Pharmacy Practice, School of Pharmacy, University of Connecticut, Storrs, Connecticut.,Department of Pharmacy, Connecticut Children's Medical Center, Hartford, Connecticut.,Division of Infectious Diseases and Immunology, Connecticut Children's Medical Center, Hartford, Connecticut
| | - David P Nicolau
- Center for Anti-Infective Research and Development, Hartford Hospital, Hartford, Connecticut.,Division of Infectious Diseases, Hartford Hospital, Hartford, Connecticut
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22
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DeRonde KJ, Girotto JE, Nicolau DP. Management of Pediatric Acute Hematogenous Osteomyelitis, Part I: Antimicrobial Stewardship Approach and Review of Therapies for Methicillin-Susceptible Staphylococcus aureus, Streptococcus pyogenes, and Kingella kingae. Pharmacotherapy 2018; 38:947-966. [PMID: 29920709 DOI: 10.1002/phar.2160] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Acute hematogenous osteomyelitis (AHO), often occurring in young children, is the most frequently diagnosed type of osteomyelitis in pediatric patients. Optimizing antibiotics is essential as delays to receipt of appropriate therapy can lead to chronic osteomyelitis, as well as impairments in bone growth and development. Antimicrobial stewardship programs (ASPs) are in a key position to help improve the care of patients with AHO as they contain a pharmacist with expertise in antibiotic drug selection, optimization of dosing, and microbiologic test review. A literature search of the MEDLINE database was conducted from initiation through January 2018. Articles selected for the review focus on pathogen identification, pharmacokinetics and pharmacodynamics, efficacy and safety in children, transition from intravenous to oral therapy, duration of treatment, and antimicrobial stewardship interventions. This review will highlight the potential roles ASPs can have in improving the management of AHO in pediatric patients. These roles include the creation of clinical pathways, improving testing algorithms, antibiotic choice and dosing, intravenous to oral transitions, duration of treatment, and therapy monitoring. Overall, patients are most effectively treated by focusing treatments on age, presentation, local sensitivities, and directed therapy with pathogen identification.
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Affiliation(s)
- Kailynn J DeRonde
- Department of Pharmacy Practice, School of Pharmacy, University of Connecticut, Storrs, Connecticut.,Department of Pharmacy, Connecticut Children's Medical Center, Hartford, Connecticut
| | - Jennifer E Girotto
- Department of Pharmacy Practice, School of Pharmacy, University of Connecticut, Storrs, Connecticut.,Department of Pharmacy, Connecticut Children's Medical Center, Hartford, Connecticut.,Division of Infectious Diseases and Immunology, Connecticut Children's Medical Center, Hartford, Connecticut
| | - David P Nicolau
- Center for Anti-Infective Research and Development, Hartford Hospital, Hartford, Connecticut.,Division of Infectious Diseases, Hartford Hospital, Hartford, Connecticut
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23
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Sriskandarajah S, Hobbs J, Roughead E, Ryan M, Reynolds K. Safety and effectiveness of 'hospital in the home' and 'outpatient parenteral antimicrobial therapy' in different age groups: A systematic review of observational studies. Int J Clin Pract 2018; 72:e13216. [PMID: 29920884 DOI: 10.1111/ijcp.13216] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2017] [Accepted: 05/09/2018] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE The aim of this study was .to systematically review the published literature of observational studies evaluating the safety and effectiveness of hospital in the home (HITH) and outpatient parenteral antimicrobial therapy (OPAT) in the general population, older people and children. STUDY DESIGN The review included retrospective studies and prospective studies performed on HITH and OPAT within different age groups. Only the studies that analysed the safety and effectiveness of HITH and OPAT were included for review. DATA SOURCES A literature search of electronic databases CINAHL, Web of Science, PubMed and SCOPUS from 1997 to 2016 was performed. DATA SYNTHESIS Forty-four studies met the inclusion criteria. Five studies were undertaken on HITH within the general population, 26 studies were undertaken on OPAT within the general population, 8 studies were on HITH and OPAT for older people and 5 studies were on OPAT with children. More than 88% of the studies reported a cure or treatment success rate of greater than 80%. Adverse events with drugs ranged from 0% to 30.2%; adverse events with vascular access devices ranged from 0% to 29%; readmission rate varied from 1% to 26%; mortality varied from 0% to 27.5%. CONCLUSIONS This review quantifies the rates of success and harm in real world practice, and demonstrates that while most patients experience treatment success, adverse events may be high in some groups. However, the methodologies used to measure these parameters were inconsistent and some demographic groups had only a small number of studies.
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Affiliation(s)
- Shanthy Sriskandarajah
- Medical Device Research Institute, College of Science and Engineering, Flinders University, Adelaide, SA, Australia
| | - Jodie Hobbs
- Medical Device Research Institute, College of Science and Engineering, Flinders University, Adelaide, SA, Australia
| | - Elizabeth Roughead
- School of Pharmacy and Medical Sciences, University of South Australia, Adelaide, SA, Australia
| | - Melissa Ryan
- Medical Device Research Institute, College of Science and Engineering, Flinders University, Adelaide, SA, Australia
| | - Karen Reynolds
- Medical Device Research Institute, College of Science and Engineering, Flinders University, Adelaide, SA, Australia
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24
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Abstract
Recent studies have revealed that the intestinal bacterial microbiome plays an important role in the regulation of hematopoiesis. A correlation between adverse hematologic effects and imbalance of the intestinal microbiome, or dysbiosis, is evident in several human conditions, such as inflammatory bowel disease, obesity, and, critically, in the setting of antibiotic exposure. Here we review the effects of gut dysbiosis on the hematological compartment and our current understanding of the mechanisms through which changes in the bacterial microbiome affect hematopoiesis.
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Abstract
BACKGROUND AND OBJECTIVE Outpatient parenteral antimicrobial therapy (OPAT) provides numerous benefits but may pose unique risks in children. We aimed to determine rates of OPAT antimicrobial- and intravenous access-related complications and their associations with specific antimicrobials and type of intravenous access in pediatric patients. METHODS Observational cohort study of patients receiving OPAT from August 2008 to May 2015 cared for by the Infectious Diseases service at a tertiary children's hospital. Primary outcome was antimicrobial discontinuation (AD) because of OPAT-associated complications. Secondary outcomes were unplanned outpatient healthcare visits and readmissions from OPAT-associated complications. RESULTS Seven hundred and seven intravenous antimicrobials were prescribed in 540 cases. Nondevice-associated musculoskeletal infection was the most common diagnosis (39%). Ceftriaxone (30%), cefazolin (27%) and vancomycin (22%) were the most commonly used antimicrobials. Complications led to AD, ≥1 unplanned outpatient healthcare visit and ≥1 readmission in 23%, 30% and 17% of cases, respectively. Compared with use of ceftriaxone, use of oxacillin was associated with a significantly higher risk of AD because of any antimicrobial-related complication [hazard ratio (HR), 3.3; 95% confidence interval (CI): 1.2-9.7) and because of hepatic transaminitis (HR, 32.8; 95% CI: 4.02-268.2). Subjects treated with intravenous clindamycin (HR, 2.6; 95% CI: 1.1-5.8) and with a peripherally inserted central catheter (HR, 2.6; 95% CI: 1.04-6.3) were more likely to have unplanned outpatient visits. CONCLUSIONS Use of oxacillin during OPAT was associated with higher rate of AD. Patients treated with clindamycin and those with a peripherally inserted central catheter had higher rates of unplanned outpatient visits. Providers should strongly consider alternative treatment options when possible.
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Mace AO, McLeod C, Yeoh DK, Vine J, Chen YP, Martin AC, Blyth CC, Bowen AC. Dedicated paediatric Outpatient Parenteral Antimicrobial Therapy medical support: a pre-post observational study. Arch Dis Child 2018; 103:165-169. [PMID: 28847879 DOI: 10.1136/archdischild-2017-313071] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2017] [Revised: 05/23/2017] [Accepted: 08/07/2017] [Indexed: 11/03/2022]
Abstract
OBJECTIVE Despite the many benefits of paediatric Outpatient Parenteral Antimicrobial Therapy (OPAT) programmes, there are risks associated with delivering inpatient-level care outside of hospital. There is a paucity of evidence defining how best to mitigate these risks. We examined the impact of introducing a dedicated medical team to OPAT, to define the role of increased medical oversight in improving patient outcomes in this cohort. DESIGN A prospective 24-month pre-post observational cohort study. SETTING The Hospital in the Home (HiTH) programme at Princess Margaret Hospital (PMH) for Children, Western Australia. PATIENTS All OPAT admissions to HiTH, excluding haematology/oncology patients. INTERVENTIONS PMH introduced a dedicated OPAT medical support team in July 2015 to improve adherence to best-practice guidelines for patient monitoring and review. MAIN OUTCOME MEASURES Duration of OPAT, adherence to monitoring guidelines, drug-related and line-related adverse events and readmission to hospital. RESULTS There were a total of 502 OPAT episodes over 24 months, with 407 episodes included in analyses. Following the introduction of the OPAT medical team, adherence to monitoring guidelines improved (OR 4.90, 95% CI 2.48 to 9.66); significantly fewer patients required readmission to hospital (OR 0.45, 95% CI 0.24 to 0.86) and there was a significant reduction in the proportion of patients receiving prolonged (≥7 days) OPAT (OR 0.67, 95% CI 0.45 to 0.99). CONCLUSION The introduction of a formal medical team to HiTH demonstrated a positive clinical impact on OPAT patients' outcomes. These findings support the ongoing utility of medical governance in a nurse-led HiTH service.
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Affiliation(s)
- Ariel O Mace
- Department of General Paediatrics, Princess Margaret Hospital for Children, Perth, Australia
| | - Charlie McLeod
- Department of Paediatric Infectious Diseases, Princess Margaret Hospital for Children, Perth, Australia
| | - Daniel K Yeoh
- Department of Paediatric Infectious Diseases, Princess Margaret Hospital for Children, Perth, Australia
| | - Julie Vine
- Ambulatory Care Service, Princess Margaret Hospital for Children, Perth, Australia
| | - Yu-Ping Chen
- Department of Anaesthesia, Princess Margaret Hospital for Children, Perth, Australia
| | - Andrew C Martin
- Department of General Paediatrics, Princess Margaret Hospital for Children, Perth, Australia.,School of Medicine, University of Western Australia, Perth, Australia
| | - Christopher C Blyth
- Department of Paediatric Infectious Diseases, Princess Margaret Hospital for Children, Perth, Australia.,School of Medicine, University of Western Australia, Perth, Australia.,Wesfarmers Centre for Vaccines and Infectious Diseases, Telethon Kids Institute, University of Western Australia, Perth, Australia.,Department of Microbiology, PathWest Laboratory Medicine, Perth, Australia
| | - Asha C Bowen
- Department of Paediatric Infectious Diseases, Princess Margaret Hospital for Children, Perth, Australia.,School of Medicine, University of Western Australia, Perth, Australia.,Wesfarmers Centre for Vaccines and Infectious Diseases, Telethon Kids Institute, University of Western Australia, Perth, Australia.,Menzies School of Health Research, Charles Darwin University, Darwin, Australia
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A Comparison of Hospital Versus Outpatient Parenteral Antibiotic Therapy at Home for Pyelonephritis and Meningitis. Pediatr Infect Dis J 2017; 36:827-832. [PMID: 28399052 DOI: 10.1097/inf.0000000000001605] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Despite the benefits of home treatment with outpatient parenteral antimicrobial therapy (OPAT), children with pyelonephritis and meningitis are rarely included. We aimed to compare clinical characteristics and outcomes between hospital and home treatment for these conditions and to identify factors influencing home treatment. METHODS Children admitted to the hospital with pyelonephritis or proven and presumed bacterial meningitis from January 1, 2012, to December 31, 2013 were identified retrospectively. Patients who received any OPAT (home group) received daily visits via our Hospital-in-the-Home (HITH) program; inpatients (hospital group) received standard care. Clinical and demographic features, length of stay, readmission rate and cost were compared between hospital and home groups. RESULTS One hundred thirty-nine children with pyelonephritis and 70 with meningitis were identified, of which 127 and 44 were potentially suitable for OPAT, respectively. Of these, 12 (9%) with pyelonephritis received OPAT, contrasting with 29 (66%) with meningitis. Clinical features did not differ between hospital- and home-treated patients for either condition. Patients with meningitis in the hospital group were younger than those transferred to HITH (1 vs. 2 months; P = 0.01). All patients were afebrile before transfer to HITH. Admissions for pyelonephritis were brief with inpatients having a shorter length of stay than home patients (median: 3 vs. 4.5 days; P = 0.002). Unplanned readmission rates were comparable across all groups. Transfer to HITH resulted in a saving of AU$178,180. CONCLUSIONS Children with pyelonephritis and meningitis can feasibly receive OPAT. Age, treatment duration and fever influence this decision. None of these should be barriers to OPAT, and the cost savings support change in practice.
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Funk SS, Copley LAB. Acute Hematogenous Osteomyelitis in Children: Pathogenesis, Diagnosis, and Treatment. Orthop Clin North Am 2017; 48:199-208. [PMID: 28336042 DOI: 10.1016/j.ocl.2016.12.007] [Citation(s) in RCA: 65] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Acute hematogenous osteomyelitis (AHO) in children is an ideal condition to study due to its representation of a wide spectrum of disorders that comprise pediatric musculoskeletal infection. Proper care for children with AHO is multidisciplinary and collaborative. AHO continues to present a significant clinical challenge due to evolving epidemiology and complex pathogenesis. A guideline-driven, multidisciplinary approach has been introduced and shown to effectively reduce hospital stay, improve the timing and selection of empirical antibiotic administration, reduce delay to initial MRI, reduce the rate of readmission, and shorten antibiotic duration.
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Affiliation(s)
- Shawn S Funk
- Department of Orthopaedic Surgery, The Children's Hospital of San Antonio, Baylor College of Medicine, 315 North San Saba Street, Suite 1135, San Antonio, TX 78207, USA
| | - Lawson A B Copley
- Department of Orthopaedic Surgery, Children's Medical Center of Dallas, University of Texas Southwestern, 1935 Medical District Drive, Dallas, TX 75235, USA.
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Goldman JL, Richardson T, Newland JG, Lee B, Gerber JS, Hall M, Kronman M, Hersh AL. Outpatient Parenteral Antimicrobial Therapy in Pediatric Medicaid Enrollees. J Pediatric Infect Dis Soc 2017; 6:65-71. [PMID: 26803327 PMCID: PMC5907854 DOI: 10.1093/jpids/piv106] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2015] [Accepted: 12/14/2015] [Indexed: 11/12/2022]
Abstract
BACKGROUND Outpatient parenteral antimicrobial therapy (OPAT) is overused in cases where highly bioavailable oral alternatives would be equally effective. However, the scope of OPAT use for children nationwide is poorly understood. Our objective was to characterize OPAT use and clinical outcomes for a large population of pediatric Medicaid enrollees treated with OPAT. METHODS We analyzed the Truven MarketScan Medicaid claims database between 2009 and 2012. An OPAT episode was identified by capturing children with claims data indicating home infusion therapy for an intravenous antimicrobial. We characterized OPAT use by describing patient demographics, diagnoses, and antimicrobials prescribed. We categorized an antimicrobial as highly bioavailable if ≥80% systemic exposure was expected from the peroral dose. We also determined the percentage of OPAT recipients in whom a follow-up healthcare encounter occurred during the OPAT episode in either the emergency department or as a hospital admission. We reviewed the primary diagnoses associated with these healthcare encounters to determine whether it was related to OPAT. RESULTS We identified 3433 OPAT episodes in 2687 patients. A total of 4774 antimicrobials were prescribed during these episodes. Ceftriaxone and vancomycin were the most commonly prescribed antimicrobials. Highly bioavailable antimicrobials accounted for 34% of antimicrobials used for OPAT. An emergency department visit or hospital admission occurred during 38% of OPAT episodes, among which 61% were OPAT-related. CONCLUSIONS The high rate of medical encounters associated with OPAT in this cohort and the common prescribing of highly bioavailable antimicrobials underscore the opportunities for antimicrobial stewardship of pediatric OPAT.
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Affiliation(s)
- Jennifer L. Goldman
- Children's Mercy Hospitals and Clinics, Kansas City, Missouri,University of Missouri-Kansas City
| | | | - Jason G. Newland
- Children's Mercy Hospitals and Clinics, Kansas City, Missouri,University of Missouri-Kansas City
| | - Brian Lee
- Children's Mercy Hospitals and Clinics, Kansas City, Missouri,University of Missouri-Kansas City
| | | | - Matt Hall
- Children's Hospital Association, Overland Park, Kansas
| | | | - Adam L. Hersh
- University of Utah School of Medicine, Salt Lake City
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Hodgson KA, Huynh J, Ibrahim LF, Sacks B, Golshevsky D, Layley M, Spagnolo M, Raymundo CM, Bryant PA. The use, appropriateness and outcomes of outpatient parenteral antimicrobial therapy. Arch Dis Child 2016; 101:886-93. [PMID: 27166221 DOI: 10.1136/archdischild-2015-309731] [Citation(s) in RCA: 44] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2015] [Accepted: 04/20/2016] [Indexed: 11/04/2022]
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.
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Affiliation(s)
- Kate A Hodgson
- RCH@Home Department, The Royal Children's Hospital Melbourne, Parkville, Victoria, Australia
| | - Julie Huynh
- RCH@Home Department, The Royal Children's Hospital Melbourne, Parkville, Victoria, Australia
| | - Laila F Ibrahim
- RCH@Home Department, The Royal Children's Hospital Melbourne, Parkville, Victoria, Australia
| | - Bronwyn Sacks
- RCH@Home Department, The Royal Children's Hospital Melbourne, Parkville, Victoria, Australia
| | - Daniel Golshevsky
- RCH@Home Department, The Royal Children's Hospital Melbourne, Parkville, Victoria, Australia
| | - Michael Layley
- RCH@Home Department, The Royal Children's Hospital Melbourne, Parkville, Victoria, Australia
| | - Mark Spagnolo
- RCH@Home Department, The Royal Children's Hospital Melbourne, Parkville, Victoria, Australia
| | - Chin-Mae Raymundo
- RCH@Home Department, The Royal Children's Hospital Melbourne, Parkville, Victoria, Australia
| | - Penelope A Bryant
- RCH@Home Department, The Royal Children's Hospital Melbourne, Parkville, Victoria, Australia Infectious Diseases Unit, Department of General Medicine, The Royal Children's Hospital Melbourne, Parkville, Victoria, Australia Clinical Paediatrics Group, Murdoch Children's Research Institute, The Royal Children's Hospital Melbourne, Parkville, Victoria, Australia Department of Paediatrics, University of Melbourne, The Royal Children's Hospital Melbourne, Parkville, Victoria, Australia
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Murphy JL, Fenn N, Pyle L, Heizer H, Hughes S, Nomura Y, Child J, Parker SK. Adverse Events in Pediatric Patients Receiving Long-term Oral and Intravenous Antibiotics. Hosp Pediatr 2016; 6:330-8. [PMID: 27220835 DOI: 10.1542/hpeds.2015-0069] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
BACKGROUND AND OBJECTIVE Children receiving long-term antibiotic therapy (LTAT) at Children's Hospital Colorado (CHCO) are treated with both oral and intravenous (i.v.) agents and often experience complications not comprehensively described by the literature. We sought to describe adverse drug events (ADEs) and venous access complications (VACs) in pediatric patients managed with oral and i.v. antibiotics so as to inform clinical decision-making, drug monitoring, and patient counseling at CHCO. METHODS We conducted a retrospective review of children receiving LTAT through the CHCO infectious disease service from 2006 to 2012. Demographic, microbiologic, diagnostic data, ADEs, and VACs were recorded for each patient. RESULTS From 2006 to 2012, 521 patients received 1876 courses, accounting for 71,306 days of antimicrobial therapy. A total of 219 patients (42%) developed an ADE with discontinuation of the offending agent in 65% of courses associated with an ADE. The most common ADEs were neutropenia, rash, and diarrhea. Central lines were placed in 376 patients with 106 (28%) experiencing ≥1 VACs. I.v. agents were associated with a fourfold increase in the rate of ADEs compared with oral agents, and a fivefold increase when VACs were included. CONCLUSIONS Practitioners may make more informed decisions and risk assessments by using descriptive ADE information for specific agents and mode of drug delivery to mitigate risk, thereby improving the quality of care. Patients should be counseled regarding risks of LTAT, including increased risk with i.v. therapy, and actively monitored for side effects.
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Affiliation(s)
| | - Norman Fenn
- Department of Pediatrics, University of Arizona, Tuscan, Arizona; and
| | | | | | | | - Yosuke Nomura
- Department of Pediatrics, and Departments of Pediatrics and
| | - Jason Child
- Pharmacy, Children's Hospital Colorado, Aurora, Colorado
| | - Sarah K Parker
- Section of Infectious Diseases and Section of Infectious Diseases, School of Medicine and
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Espinosa CM, Fallat ME, Woods CR, Weakley KE, Marshall GS. An Approach to the Management of Pleural Empyema with Early Video-assisted Thoracoscopic Surgery and Early Transition to Oral Antibiotic Therapy. Am Surg 2016. [DOI: 10.1177/000313481608200412] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Practice variation exists in the management of children with bacterial pneumonia complicated by empyema. The success of video-assisted thoracoscopic surgery (VATS) versus chest tube insertion for drainage and fibrinolysis may be dependent on the stage of disease. There is little published experience with early transition to oral (PO) antibiotics, and many children are treated with intravenous (IV) antibiotics at home. To describe a cohort of children with pneumonia and empyema in a primarily rural state managed with early VATS and transition to PO antibiotics. This was a retrospective medical record review of children managed by the pediatric infectious diseases and surgery services at Kosair Children's Hospital from 2008 through 2012. Sixty-one children met inclusion criteria. The majority underwent VATS on the first or second hospital day. No organism was identified in 67 per cent of cases. All patients received IVantibiotics at admission and all were discharged on PO antibiotics. The median time to transition was five days (interquartile range [IQR], 4–6), and the median duration of PO therapy was 16 days (IQR, 14–21). Ninety-eight per cent did not require further IV therapy. There were no deaths and clinical outcomes were good. In conclusion, children with pneumonia and empyema can be managed effectively with early VATS and early transition from IV to PO antibiotic therapy.
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Affiliation(s)
- Claudia M. Espinosa
- Departments of Pediatrics and University of Louisville School of Medicine, Louisville, Kentucky
| | - Mary E. Fallat
- Departments of Surgery, University of Louisville School of Medicine, Louisville, Kentucky
| | - Charles R. Woods
- Departments of Pediatrics and University of Louisville School of Medicine, Louisville, Kentucky
| | - Kathryn E. Weakley
- Departments of Pediatrics and University of Louisville School of Medicine, Louisville, Kentucky
| | - Gary S. Marshall
- Departments of Pediatrics and University of Louisville School of Medicine, Louisville, Kentucky
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Abstract
Antibiotic resistance remains a major health threat and the overuse of antimicrobials contributes to this serious problem. Antimicrobial stewardship programs (ASPs) are effective in decreasing the inappropriate use of antimicrobials. The development of pediatric ASPs is increasing and these programs have proven effective in optimizing antimicrobial use in children. The value of ASPs is gaining recognition and the expansion of stewardship into additional health care settings is expected. Collaborative efforts are underway among pediatric ASPs to enhance best practices and develop efficient and effective strategies to minimize unnecessary antimicrobial use in children.
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Affiliation(s)
- Jennifer L Goldman
- Division of Pediatric Infectious Diseases, Department of Pediatrics, Children's Mercy Hospitals & Clinics, University of Missouri-Kansas City School of Medicine, 2401 Gillham Road, Kansas City, MO 64108, USA; Division of Clinical Pharmacology, Department of Pediatrics, Children's Mercy Hospitals & Clinics, University of Missouri-Kansas City School of Medicine, 2401 Gillham Road, Kansas City, MO 64108, USA.
| | - Jason G Newland
- Department of Pediatrics, Children's Mercy Hospitals & Clinics, University of Missouri-Kansas City School of Medicine, 2401 Gillham Road, Kansas City, MO 64108, USA
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34
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Olson SC, Smith S, Weissman SJ, Kronman MP. Adverse Events in Pediatric Patients Receiving Long-Term Outpatient Antimicrobials. J Pediatric Infect Dis Soc 2015; 4:119-25. [PMID: 26407410 PMCID: PMC4608493 DOI: 10.1093/jpids/piu037] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2014] [Accepted: 04/05/2014] [Indexed: 11/13/2022]
Abstract
BACKGROUND Although long treatment courses of outpatient antimicrobials are often used in pediatric patients, few data exist regarding the frequency of adverse events (AEs) associated with these medications. METHODS We performed a retrospective cohort study of all patients seen in the Infectious Diseases clinic at a tertiary referral children's hospital from August 1, 2009 to August 1, 2011. We included patients who received ≥14 days of oral or intravenous antibiotic, antiviral, or antifungal medications. Patients receiving only prophylactic medications or human immunodeficiency virus treatment were excluded. RESULTS Three hundred thirty-five subjects met inclusion criteria, with a median age of 7.4 years at start of therapy. The cohort was predominantly male (60%), white (54%), and previously healthy (59%). A majority (88.4%) of subjects were treated for bacterial infections. β-Lactam agents were the most commonly used antimicrobial class (210 subjects; 62.7%), followed by clindamycin (86; 25.7%), rifampin (76; 22.7%), and vancomycin (62; 18.5%). Overall, 107 (31.9%) subjects experienced 151 distinct AEs. The most common individual AE noted was diarrhea (44; 29.1% of all AEs). Serious AEs developed in 42 (12.5%) subjects, including allergic reactions (15; 11.3% of all AEs), venous catheter-related complications (14; 13.0% of those with catheters), neutropenia (9; 3.0%), renal insufficiency (7; 2.5%), and hepatotoxicity (3; 1.1%). Rates of AEs were similar between those on oral and intravenous antimicrobials. CONCLUSIONS In our study population, patients on prolonged oral or intravenous outpatient antimicrobials experienced AEs frequently. These findings support the need for close monitoring of pediatric patients on prolonged antimicrobial therapy and vigilance for unwanted effects of these medications.
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Affiliation(s)
- Scott C. Olson
- Department of Pediatrics,Division of Infectious Diseases, University of Washington, Seattle
| | - Sherilyn Smith
- Department of Pediatrics,Division of Infectious Diseases, University of Washington, Seattle,Center for Clinical and Translational Research
| | - Scott J. Weissman
- Department of Pediatrics,Division of Infectious Diseases, University of Washington, Seattle,Center for Global Infectious Disease Research, Seattle Children's Hospital Research Institute, Washington
| | - Matthew P. Kronman
- Department of Pediatrics,Division of Infectious Diseases, University of Washington, Seattle,Center for Clinical and Translational Research
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Evaluation of Outpatient Parenteral Antimicrobial Therapy at a Veterans Affairs Hospital. Infect Control Hosp Epidemiol 2015; 36:1103-5. [PMID: 26006046 DOI: 10.1017/ice.2015.131] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
We reviewed outpatient parenteral antimicrobial therapy at a Veterans Affairs Medical Center to identify opportunities for antimicrobial stewardship intervention. A definite or possible modification would have been recommended in 60% of courses. Forty-one percent of outpatient parenteral antimicrobial therapy courses were potentially avoidable, including 22% involving infectious diseases consultation.
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36
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Akar A, Singh N, Hyun DY. Appropriateness and safety of outpatient parenteral antimicrobial therapy in children: opportunities for pediatric antimicrobial stewardship. Clin Pediatr (Phila) 2014; 53:1000-3. [PMID: 24198317 DOI: 10.1177/0009922813507999] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Arezou Akar
- Children's National Medical Center, Washington, DC, USA
| | - Nalini Singh
- Children's National Medical Center, Washington, DC, USA
| | - David Y Hyun
- Children's National Medical Center, Washington, DC, USA
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Peláez Cantero M, Madrid Rodríguez A, Urda Cardona A, Jurado Ortiz A. Domiciliary parenteral antibiotic therapy: A prospective analysis of the last 12 years. ANALES DE PEDIATRÍA (ENGLISH EDITION) 2014. [DOI: 10.1016/j.anpede.2013.05.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
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Banerjee R, Beekmann SE, Doby EH, Polgreen PM, Rathore MH, Hersh AL. Outpatient Parenteral Antimicrobial Therapy Practices Among Pediatric Infectious Diseases Consultants: Results of an Emerging Infections Network Survey. J Pediatric Infect Dis Soc 2014; 3:85-8. [PMID: 26624910 DOI: 10.1093/jpids/pis137] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2012] [Accepted: 11/26/2012] [Indexed: 11/14/2022]
Abstract
We conducted a survey of pediatric members of the Emerging Infections Network regarding outpatient parenteral antimicrobial therapy (OPAT) practices and clinical decision making about OPAT initiation. We identified substantial variation in characteristics and resources of pediatric OPAT practices. Opportunities to improve oversight of OPAT in children should be explored.
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Affiliation(s)
- Ritu Banerjee
- Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, Minnesota
| | - Susan E Beekmann
- Department of Internal Medicine, Carver College of Medicine, University of Iowa, Iowa City
| | - Elizabeth H Doby
- Pediatric Infectious Diseases, University of Utah, Salt Lake City
| | - Philip M Polgreen
- Department of Internal Medicine, Carver College of Medicine, University of Iowa, Iowa City
| | - Mobeen H Rathore
- Pediatric Infectious Diseases and Immunology, University of Florida College of Medicine Wolfson Children's Hospital, Jacksonville, Florida
| | - Adam L Hersh
- Pediatric Infectious Diseases, University of Utah, Salt Lake City
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[Domiciliary parenteral antibiotic therapy: a prospective analysis of the last 12 years]. An Pediatr (Barc) 2013; 81:86-91. [PMID: 24321389 DOI: 10.1016/j.anpedi.2013.05.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2013] [Revised: 05/04/2013] [Accepted: 05/14/2013] [Indexed: 11/20/2022] Open
Abstract
OBJETIVES Parenteral antibiotic treatment has been classically developed in hospitals and is considered as a hospital procedure. The development of Hospital at Home Units (HHU) has led to an increase in outpatient parenteral antibiotic therapy (OPAT) in paediatrics patients. The objective of this study is to describe our experience, as an HHU integrated within a Paediatric Department, in home antimicrobial therapy over a period of 12 years. PATIENTS AND METHODS This prospective and descriptive study included every patient with a disease requiring parenteral antimicrobial therapy who was admitted to our HHU from January 2000 to December 2012. RESULTS During the study there were 163 cases on OPAT. The mean age of the patients was 11.1 years, and the sample group was comprised of 33 males and 22 feamales. The main sources of the treated infections were respiratory tract (76%), catheter-related bloodstream (9.2%), and urinary tract infections (5.5%). Amikacin was the most widely used antibiotic. Almost all treatments (96.6%) were via an intravenous route. Catheter-associated complications were more common than drug-associated complications. Successful at-home treatment was observed in 90.2% of cases. CONCLUSIONS OPAT is a good and safe alternative in many paediatric diseases.
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Keller SC, Ciuffetelli D, Bilker W, Norris A, Timko D, Rosen A, Myers JS, Hines J, Metlay J. The Impact of an Infectious Diseases Transition Service on the Care of Outpatients on Parenteral Antimicrobial Therapy. J Pharm Technol 2013; 29:205-214. [PMID: 25621307 DOI: 10.1177/8755122513500922] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Many hospitalized patients with complicated infections are discharged on outpatient parenteral antimicrobial therapy (OPAT). However, little is known about how to improve the postdischarge care of OPAT patients. OBJECTIVE The impact of an infectious diseases transitions service (IDTS) on OPAT patient readmissions, as well as on processes of care, was evaluated. METHODS We performed a controlled, quasi-experimental evaluation over 15 months in an academic medical center. Intervention-arm patients, before and after the introduction of an IDTS, were seen by the general infectious diseases consult teams, while control-arm patients (discharged on OPAT after hospitalization with bacteremia) were not. The IDTS prospectively tracked all OPAT patients and coordinated follow-up. The impact of the IDTS was calculated using a differences-in-differences approach where the interaction between time (before vs after the IDTS intervention) and study arm (intervention vs control arm) was the variable of interest. The control arm was used only in primary outcome analyses (readmissions and emergency department visits). Secondary outcomes included process of care measures and non-readmission clinical outcomes. RESULTS Of 488 consecutive patients requiring OPAT, 362 were in the intervention arm (215 pre-intervention and 147 post-intervention) and 126 in the control arm (70 pre-intervention and 56 post-intervention). Compared to the control arm, the IDTS was not associated with changes in 60-day readmissions and/or emergency department visits (adjusted odds ratio [OR] = 0.48; 95% confidence interval [CI] = 0.13-1.79). In the intervention arm, implementation of the IDTS was associated with fewer antimicrobial therapy errors (OR = 0.062; 95% CI = 0.015-0.262), increased laboratory test receipt (OR = 27.85; 95% CI = 12.93-59.99), and improved outpatient follow-up (OR = 2.44; 95% CI = 1.50-3.97). CONCLUSIONS In a controlled evaluation, the IDTS did not affect readmissions despite improving process of care measures for targeted patients. Care coordination services may improve OPAT quality of care, but their relationship to readmissions is unclear.
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Affiliation(s)
- Sara C Keller
- University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | | | - Warren Bilker
- University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Anne Norris
- University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Daniel Timko
- University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Alex Rosen
- University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Jennifer S Myers
- University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Janet Hines
- University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Joshua Metlay
- University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
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Characteristics and outcomes of outpatient parenteral antimicrobial therapy at an academic children's hospital. Pediatr Infect Dis J 2013; 32:346-9. [PMID: 23249915 DOI: 10.1097/inf.0b013e31827ee1c2] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Use of outpatient parenteral antimicrobial therapy (OPAT) in pediatrics is widespread and may be increasing. Recent data quantifying use and characteristics of pediatric OPAT are lacking. METHODS To evaluate the number of children receiving OPAT each year and their associated characteristics and outcomes, we conducted a retrospective review of all patients discharged with OPAT from the Mayo Clinic Children's Hospital between August 1, 2010 and December 31, 2011. RESULTS During the study period, there were 126 pediatric hospital discharges with OPAT (2.5% of all discharges). OPAT was used most commonly to treat bone and joint (21%), bloodstream (15%), intra-abdominal (13%) and soft tissue (9%) infections. A positive culture or serology result was found in 86 (68%) OPAT courses. The most frequently used antibiotics were ceftriaxone (17%), cefazolin (16%) and cefepime (13%). The median duration of OPAT was 12 days. Thirty-six courses (29%) resulted in catheter- or antibiotic-associated complications. Weekly laboratory monitoring was more common when OPAT was managed by the infectious disease service (88%) versus other services (20%). Among 123 courses with follow-up, 109 (89%) resulted in cure, and 13 (11%) were treatment failures. CONCLUSION At our children's hospital, 2.5% of hospitalized patients were discharged with OPAT. In one-third of OPAT courses children developed catheter- or antibiotic-associated complications. Opportunities to increase the role of pediatric infectious disease in OPAT initiation and management should be explored.
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Gunduz Y, Vatan MB, Osken A, Cakar MA. A delayed diagnosis of a retained guidewire during central venous catheterisation: a case report and review of the literature. BMJ Case Rep 2012; 2012:bcr-2012-007064. [PMID: 23166171 DOI: 10.1136/bcr-2012-007064] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Central venous catheterisation allows delivery of medications, intravenous fluids, parenteral nutrition, haemodialysis and monitoring of haemodynamic variables. Various complications may occur during and after the procedure. However, the complete guidewire retention has rarely been reported. In this report, we have presented a complete guidewire retention as a result of inadvertent catheter insertion. After 17 months of the first operation performed upon the diagnosis of Fournier's gangrene, the patient was admitted to the cardiology polyclinic with a recurrent chest pain. Echocardiography showed a wire-shaped foreign body within the right part of the heart, and a fluoroscopic examination showed a guidewire reaching from the superior vena cava to the right external iliac vein. In retrospect, the wire was already visible on the postoperative chest x-rays and CT taken while the patient was still in intensive care unit, but its presence was overlooked at that time. The guidewire was retrieved completely during a surgery.
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Affiliation(s)
- Yasemin Gunduz
- Department of Radiology, Sakarya University Medical Faculty, Sakarya, Turkey.
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43
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Moore D, Bortolussi R. Home intravenous therapy: Accessibility for Canadian children and youth. Paediatr Child Health 2012; 16:105-14. [PMID: 22294870 DOI: 10.1093/pch/16.2.105] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
The administration of intravenous (IV) therapy at home is an alternative to hospitalization for treatment of infection and a number of other conditions, and has been demonstrated to be effective and safe, to reduce cost and to improve quality of life. While home IV therapy has many advantages for children, it is not uniformly available and access may be limited by age, geographical location and ability to pay. Physicians caring for children need to be aware of the indications for home IV therapy, its requirements and limitations, as well as whether this option is available for children in their care. Where access is limited, physicians should advocate for home IV therapy for children when it is medically indicated.
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44
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Wheeler AM, Heizer HR, Todd JK. Influence of Culture Results on Management and Outcome of Pediatric Osteomyelitis and/or Septic Arthritis. J Pediatric Infect Dis Soc 2012; 1:152-6. [PMID: 26619168 DOI: 10.1093/jpids/pis035] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2011] [Accepted: 01/23/2012] [Indexed: 11/12/2022]
Abstract
Children with uncomplicated osteomyelitis and/or septic arthritis were more likely (P < .01) to have positive focus than blood cultures. Those who grew a pathogen and/or started on a single antibiotic were more likely to be discharged on a single antibiotic, and those sent home on oral therapy had fewer adverse events.
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Affiliation(s)
| | - Heather R Heizer
- Department of Pediatrics, University of Colorado School of Medicine Department of Epidemiology, Children's Hospital Colorado, Aurora
| | - James K Todd
- Colorado School of Public Health Department of Pediatrics, University of Colorado School of Medicine Department of Epidemiology, Children's Hospital Colorado, Aurora
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45
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Abstract
Peripherally inserted central catheters are increasingly used in the pediatric and adolescent population for long-term central access. This article reviews the indications, insertion techniques, and complications of peripherally inserted central catheter lines.
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46
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Moore DL, Bortolussi R. L’accessibilité de la thérapie intraveineuse à domicile pour les enfants et adolescents canadiens. Paediatr Child Health 2011. [DOI: 10.1093/pch/16.2.110] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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47
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Le J, San Agustin M, Hernandez EA, Tran TT, Adler-Shohet FC. Complications associated with outpatient parenteral antibiotic therapy in children. Clin Pediatr (Phila) 2010; 49:1038-43. [PMID: 20724346 DOI: 10.1177/0009922810374210] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
BACKGROUND The authors sought to determine the prevalence, risk factors, and clinical impact of complications associated with outpatient parenteral antimicrobial therapy (OPAT) in children. METHODS A cohort of patients ≤18 years old with infections, who received OPAT were evaluated retrospectively. Antibiotic-associated complications (AACs), catheter-associated complications (CACs), and unplanned medical care visits were the main outcome measures. RESULTS Overall, 36 complications (25 CACs and 11 AACs) occurred in 32 of 98 patients. Mean age of patients, race, gender, and infecting organism did not differ between study groups. The use of OPAT for osteomyelitis was associated with complications (odds ratio = 2.69; 95% confidence interval = 0.99-7.35; P = .05). All patients, except for 4 who had complications, clinically improved by the end of OPAT. Unplanned medical visits occurred in 17 patients, 15 of which were because of CACs. CONCLUSION Complications occurred commonly in children receiving OPAT and resulted in unplanned medical visits.
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Affiliation(s)
- Jennifer Le
- University of California San Diego, La Jolla, USA.
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48
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Maraqa NF, Rathore MH. Pediatric outpatient parenteral antimicrobial therapy: an update. Adv Pediatr 2010; 57:219-45. [PMID: 21056740 DOI: 10.1016/j.yapd.2010.09.002] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Nizar F Maraqa
- Pediatric Infectious Diseases and Immunology, University of Florida-Jacksonville, 653-1 West 8th Street, LRC-3, Pediatrics, L-13, Jacksonville, FL 32209, USA
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49
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The high rate of adverse drug events in children receiving prolonged outpatient parenteral antibiotic therapy for osteomyelitis. Pediatr Infect Dis J 2009; 28:539-41. [PMID: 19483522 DOI: 10.1097/inf.0b013e318193ef38] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Forty-five children treated with 82 courses of 15 different antibiotics over 344 weeks during outpatient parenteral antibiotic therapy were evaluated for adverse drug events (ADE). Fifty-one percent of the courses had an associated ADE and 32.5% of the antibiotic courses were discontinued because of ADE. Vancomycin had the highest ADE rate at 85.7% and ceftriaxone had the highest ADE-related discontinuation rate at 66.7%. Cefazolin had the lowest rate of ADE and ADE-related discontinuation rates at 0% for both.
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50
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Zaoutis T, Localio AR, Leckerman K, Saddlemire S, Bertoch D, Keren R. Prolonged intravenous therapy versus early transition to oral antimicrobial therapy for acute osteomyelitis in children. Pediatrics 2009; 123:636-42. [PMID: 19171632 PMCID: PMC3774269 DOI: 10.1542/peds.2008-0596] [Citation(s) in RCA: 141] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
OBJECTIVES Early transition from intravenous to oral antimicrobial therapy for acute osteomyelitis in children has been suggested as a safe and effective alternative to traditional prolonged intravenous therapy via central venous catheter, but no studies have directly compared these 2 treatment modalities. We sought to compare the effectiveness of early transition from intravenous to oral antimicrobial therapy versus prolonged intravenous antimicrobial therapy for the treatment of children with acute osteomyelitis. METHODS We conducted a retrospective cohort study of children aged 2 months to 17 years diagnosed with acute osteomyelitis between 2000 and 2005 at 29 freestanding children's hospitals in the United States to confirm the extent of variation in the use of early transition to oral therapy. We used propensity scores to adjust for potential differences between children treated with prolonged intravenous therapy and logistic regression to model the association of outcome (treatment failure rates within 6 months of diagnosis) and difference in the mode of therapy within hospitals and across hospitals. RESULTS Of the 1969 children who met inclusion criteria, 1021 received prolonged intravenous therapy and 948 received oral therapy. The use of prolonged intravenous therapy varied significantly across hospitals (10%-95%). The treatment failure rate was 5% (54 of 1021) in the prolonged intravenous therapy group and 4% (38 of 948) in the oral therapy group. There was no significant association between treatment failure and the mode of antimicrobial therapy. Thirty-five (3.4%) children in the prolonged intravenous therapy group were readmitted for a catheter-associated complication. CONCLUSIONS Treatment of acute osteomyelitis with early transition to oral therapy is not associated with a higher risk of treatment failures and avoids the risks of prolonged intravenous therapy through central venous catheters.
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Affiliation(s)
- Theoklis Zaoutis
- Division of Infectious Diseases, Children's Hospital of Philadelphia, 34th Street and Civic Center Boulevard, CHOP North, Suite 1527, Philadelphia, PA 19104, USA.
| | - A. Russell Localio
- Department of Biostatistics and Epidemiology, University of Pennsylvania School of Medicine, Philadelphia, PA,Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania School of Medicine
| | - Kateri Leckerman
- Division of Infectious Diseases, The Children’s Hospital of Philadelphia, Philadelphia, PA
| | - Stephanie Saddlemire
- Division of General Pediatrics, The Children’s Hospital of Philadelphia, Philadelphia, PA
| | | | - Ron Keren
- Division of General Pediatrics, The Children’s Hospital of Philadelphia, Philadelphia, PA,Center for Pediatric Clinical Effectiveness, The Children’s Hospital of Philadelphia, Philadelphia, PA,Department of Pediatrics, University of Pennsylvania School of Medicine, Philadelphia, PA,Department of Biostatistics and Epidemiology, University of Pennsylvania School of Medicine, Philadelphia, PA,Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania School of Medicine
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