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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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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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Usefulness of Routine Laboratory Tests for Follow up of Patients Receiving Outpatient Parenteral Antimicrobial Therapy Run by Infectious Diseases Fellows. Antibiotics (Basel) 2023; 12:antibiotics12020330. [PMID: 36830241 PMCID: PMC9952172 DOI: 10.3390/antibiotics12020330] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2022] [Revised: 02/01/2023] [Accepted: 02/02/2023] [Indexed: 02/09/2023] Open
Abstract
BACKGROUND The infectious disease society of America (IDSA) recommends routine laboratory tests for all patients receiving outpatient parenteral antimicrobial therapy (OPAT) to monitor for adverse events. There are no data to support how often patients should take monitoring laboratory tests. In addition, the relevance of different laboratory tests commonly used for OPAT follow up is not clearly known. METHODS We conducted a retrospective observational cohort study over a 7-year study interval (1 January 2014 to 31 December 2021). Clinical data were obtained to identify the risk factors associated with abnormal laboratory tests and determine if abnormal laboratory tests led to antibiotic change or hospital readmission. RESULTS Two hundred and forty-six patients met the inclusion criteria for this study. In our multivariate analysis, the Charlson comorbidity index (CCI) of 0-4 (aOR 0.39, 95%Cl 0.18-0.86), the use of ceftriaxone without vancomycin (aOR 0.47, 95%Cl 0.24-0.91) and an OPAT duration of 2-4 weeks (aOR 0.47, 95%Cl 0.24-0.91) were associated with a lower risk of OPAT complications. A CCI of 5 or more (aOR 2.5, 95%Cl (1.1-5.7)) and an OPAT duration of 5 or more weeks (aOR 2.7, 95% Cl 1.3-5.6) were associated with a higher risk of OPAT complications. An abnormal complete metabolic panel or vancomycin levels, but not an abnormal complete blood count, were associated with antibiotic change or readmission. CONCLUSION Patients with fewer comorbidities, ceftriaxone and short OPAT durations are at lower risk for OPAT complications. These patients could be followed with less frequent laboratory monitoring.
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Lawrence J, Walpola R, Boyce SL, Bryant PA, Sharma A, Hiscock H. Home Care for Bronchiolitis: A Systematic Review. Pediatrics 2022; 150:189386. [PMID: 36065737 DOI: 10.1542/peds.2022-056603] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/18/2022] [Indexed: 11/24/2022] Open
Abstract
CONTEXT Bronchiolitis is the leading cause of pediatric hospital admissions. Hospital-at-Home (HAH) delivers hospital-level care at home, relieving pressure on the hospital system. OBJECTIVES We aimed to review the feasibility, acceptability, and safety of HAH for bronchiolitis, and assess the cost-impact to hospitals and society. DATA SOURCES Ovid Medline, Embase, Pubmed, Cochrane Library, CINAHL, and Web of Science. STUDY SELECTION Studies (randomized control trials, retrospective audits, prospective observational trials) of infants with bronchiolitis receiving HAH (oxygen, nasogastric feeding, remote monitoring). Studies were limited to English language since 2000. DATA EXTRACTION We reviewed all studies in duplicate for inclusion, data extraction, and risk of bias. RESULTS Ten studies met inclusion criteria, all for home oxygen therapy (HOT). One abstract on nasogastric feeding did not meet full inclusion criteria. No studies on remote monitoring were found. HOT appears feasible in terms of uptake (70%-82%) and successful completion, both at altitude and sea-level. Caregiver acceptability was reported in 2 qualitative studies. There were 7 reported adverse events (0.6%) with 0 mortality in 1257 patients. Cost studies showed evidence of savings, although included costs to hospitals only. LIMITATIONS Small number of studies with heterogenous study design and quality. No adequately powered randomized control studies. CONCLUSIONS Evidence exists to support HOT as feasible, acceptable, and safe. Evidence of cost-effectiveness remains limited. Further research is needed to understand the relevant impact of HAH versus alternative interventions to reduce oxygen prescribing. Other models of care looking at nasogastric feeding support and remote monitoring should be explored.
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Affiliation(s)
- Joanna Lawrence
- Hospital in the Home.,Health Services Research Unit.,Department of Paediatrics, University of Melbourne, Melbourne, Australia.,School of Population Health, Faculty of Medicine, University of New South Wales, Sydney, Australia
| | - Ramesh Walpola
- School of Population Health, Faculty of Medicine, University of New South Wales, Sydney, Australia
| | - Suzanne L Boyce
- Hospital in the Home.,Department of General Paediatrics.,Clinical Paediatrics Group, Murdoch Children's Research Institute, Melbourne, Australia
| | - Penelope A Bryant
- Hospital in the Home.,Infectious Disease Unit, Royal Children's Hospital, Melbourne, Australia.,Clinical Paediatrics Group, Murdoch Children's Research Institute, Melbourne, Australia.,Department of Paediatrics, University of Melbourne, Melbourne, Australia
| | - Anurag Sharma
- School of Population Health, Faculty of Medicine, University of New South Wales, Sydney, Australia
| | - Harriet Hiscock
- Health Services Research Unit.,Department of Paediatrics, University of Melbourne, Melbourne, Australia
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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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Scally BJ, Buxton G, Smith JK. Five years of outpatient parenteral antibiotic therapy with ceftriaxone in the paediatric emergency department: what clinical features are associated with need for admission? Emerg Med J 2022; 39:emermed-2021-211928. [PMID: 35879045 DOI: 10.1136/emermed-2021-211928] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2021] [Accepted: 06/29/2022] [Indexed: 11/03/2022]
Abstract
BACKGROUND More children presenting to Emergency Departments (EDs) with acute infections are now directly referred for outpatient parenteral antibiotic therapy (OPAT). Sparse data exist on what clinical features in these children are associated with OPAT failure. We hypothesised that children who were younger or presented with systemic features of infection would be more likely to need admission. METHODS We conducted a service evaluation over a 5-year period (12 September 2015-12 September 2020) at a single UK tertiary centre paediatric ED formally known as the Royal Hospital for Sick Children Edinburgh. All children referred from the ED for OPAT with ceftriaxone were included. OPAT failure was defined as a decision by a senior clinician of need for admission. Univariate statistical testing and multivariate logistic regression modelling were performed. RESULTS 754 children received OPAT in the ED over a 5-year period. 95 children (13%) required admission for inpatient management. Need for admission was independently associated with having a positive blood culture (adjusted OR (aOR) 8.9; 95% CI 1.49 to 47; p=0.01) or an ultrasound performed (aOR 6.8; 95% CI 3.74 to 12.7; p<0.001). We observed no significant association between age and systemic features (fever, white cell count or C reactive protein) with need for admission in our multivariate analysis. CONCLUSION In children presenting with acute infections to our paediatric ED who were deemed suitable by senior clinicians to be managed using OPAT with ceftriaxone, younger age (above 3 months) and the presence of systemic features were not independently associated with need for admission. Overall, our service was safe and no child came to harm from early ambulation during this evaluation.
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Affiliation(s)
- Benjamin J Scally
- Emergency Department, Victoria Hospital Kirkcaldy, NHS Fife, Kirkcaldy, UK
| | - Gemma Buxton
- Immunology and Infectious Diseases Department, Royal Hospital for Children and Young People, Edinburgh, UK
| | - Jennifer K Smith
- Emergency Department, Royal Hospital for Children and Young People, Edinburgh, UK
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8
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Zikri A, Al-Faraj H, Kamas N, AlZahrani J, BuKhamseen H, Alshahoub W, Beltran A, Fatih D, AlMusa Z. Implementing the First Outpatient Parenteral Antimicrobial Therapy (OPAT) Program to Utilize Disposable Elastomeric Pumps in the Gulf Region: Results From a Tertiary Teaching Hospital in the Kingdom of Saudi Arabia. Cureus 2021; 13:e20179. [PMID: 34900504 PMCID: PMC8649972 DOI: 10.7759/cureus.20179] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/05/2021] [Indexed: 11/05/2022] Open
Abstract
Objectives To describe the implementation process, safety, and efficacy outcomes, as well as cost-effectiveness, of the first outpatient parenteral antimicrobial therapy (OPAT) program to utilize disposable elastomeric pumps in the Kingdom of Saudi Arabia and the entire Gulf region. Methods This OPAT program was initiated in May 2018 and was administered through a multidisciplinary team that included the home medicine department, pharmacy department, nursing department, and the infectious diseases service. The device used was the Intermate® (Baxter, Deerfield, Illinois) elastomeric pump. After consultation with an infectious diseases physician, eligible patients were discharged home to complete the remainder of their antimicrobial treatment, which was self-administered via the elastomeric devices. Results From May 2018 to December 2019, 47 patients received 55 courses of OPAT via the new program. A total of 2,869 pumps were used during that period to provide 927 days of antimicrobial therapy in the home setting. Most patients completed the program successfully with no reported significant OPAT-related complications such as catheter-related infections. Four patients were re-admitted for relapse of infections and one patient was re-admitted for colistin-induced nephrotoxicity. No mortality was reported for any patient during OPAT treatment and 30 days after program completion. Conclusions The implementation of this novel OPAT program was safe, effective, and offered significant cost-savings to our institution. The entire process was very dynamic and was centered around proper patient selection and education as well as excellent communication between patients and the entire multidisciplinary team involved in the program. We hope that these results will encourage other institutions in the region to implement similar OPAT programs to alleviate the existing bed crisis due to the ongoing COVID-19 pandemic.
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Affiliation(s)
- Ahmed Zikri
- Department of Pharmacy, King Fahad Specialist Hospital, Dammam, SAU
| | - Hassan Al-Faraj
- Department of Internal Medicine, King Fahad Specialist Hospital, Dammam, SAU
| | - Nabil Kamas
- Department of Pharmacy, King Fahad Specialist Hospital, Dammam, SAU
| | - Jumaan AlZahrani
- Department of Pharmacy, King Fahad Specialist Hospital, Dammam, SAU
| | | | - Wasan Alshahoub
- Department of Pharmacy, King Fahad Specialist Hospital, Dammam, SAU
| | - Arlene Beltran
- Department of Home Medicine, King Fahad Specialist Hospital, Dammam, SAU
| | - Dalia Fatih
- Department of Home Medicine, King Fahad Specialist Hospital, Dammam, SAU
| | - Zainab AlMusa
- Department of Internal Medicine/Infectious Diseases, King Fahad Specialist Hospital, Dammam, SAU
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Sadler ED, Avdic E, Cosgrove SE, Hohl D, Grimes M, Swarthout M, Dzintars K, Lippincott CK, Keller SC. Failure modes and effects analysis to improve transitions of care in patients discharged on outpatient parenteral antimicrobial therapy. Am J Health Syst Pharm 2021; 78:1223-1232. [PMID: 33944904 DOI: 10.1093/ajhp/zxab165] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
PURPOSE To identify barriers to safe and effective completion of outpatient parenteral antimicrobial therapy (OPAT) in patients discharged from an academic medical center and to develop targeted solutions to potentially resolve or improve the identified barriers. SUMMARY A failure modes and effects analysis (FMEA) was conducted by a multidisciplinary OPAT task force to evaluate the processes for patients discharged on OPAT to 2 postdischarge dispositions: (1) home and (2) skilled nursing facility (SNF). The task force created 2 process maps and identified potential failure modes, or barriers, to the successful completion of each step. Thirteen and 10 barriers were identified in the home and SNF process maps, respectively. Task force members created 5 subgroups, each developing solutions for a group of related barriers. The 5 areas of focus included (1) the OPAT electronic order set, (2) critical tasks to be performed before patient discharge, (3) patient education, (4) patient follow-up and laboratory monitoring, and (5) SNF communication. Interventions involved working with information technology to update the electronic order set, bridging communication and ensuring completion of critical tasks by creating an inpatient electronic discharge checklist, developing patient education resources, planning a central OPAT outpatient database within the electronic medical record, and creating a pharmacist on-call pager for SNFs. CONCLUSION The FMEA approach was helpful in identifying perceived barriers to successful transitions of care in patients discharged on OPAT and in developing targeted interventions. Healthcare organizations may reproduce this strategy when completing quality improvement planning for this high-risk process.
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Affiliation(s)
| | - Edina Avdic
- Department of Pharmacy, Department of Antimicrobial Stewardship, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Sara E Cosgrove
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Dawn Hohl
- Transitions and Patient Experience, Johns Hopkins Home Care Group, Baltimore, MD, USA
| | - Michael Grimes
- Johns Hopkins Specialty Infusion Services, Johns Hopkins Home Care Group, Baltimore, MD, USA
| | - Meghan Swarthout
- Department of Pharmacy, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Kathryn Dzintars
- Department of Pharmacy, Department of Antimicrobial Stewardship, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Christopher K Lippincott
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Sara C Keller
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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Carter B, Fisher-Smith D, Porter D, Lane S, Peak M, Taylor-Robinson D, Bracken L, Carrol ED. Paediatric Outpatient Parenteral Antimicrobial Therapy (OPAT): An e-survey of the experiences of parents and clinicians. PLoS One 2021; 16:e0249514. [PMID: 33798226 PMCID: PMC8018658 DOI: 10.1371/journal.pone.0249514] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2019] [Accepted: 03/20/2021] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND Little evidence exists about parental satisfaction and their influence on referral to paediatric Outpatient Parenteral Antimicrobial Therapy (OPAT). AIM This study aimed to examine the experiences of parents, children and clinicians of OPAT at a large tertiary children's hospital. METHOD A prospective e-survey, using closed and open questions, of parents (n = 33) of 33 children who had received OPAT (3 children completed a survey), and clinicians (n = 31) involved in OPAT at a tertiary hospital. Data were collected September 2016 to July 2018. RESULTS Data were analysed using simple descriptive statistics. The results show that OPAT offered benefits (less stress, re-establishment of family life) compared to hospital-based treatment for parents and children, although some were anxious. Clinicians' referral judgements were based on child, home, and clinical factors. Some clinicians found the process of referral complex. CONCLUSION Most parents and children were satisfied with the OPAT service and preferred the option of home-based treatment as it promoted the child's comfort and recovery and supported family routines.
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Affiliation(s)
- Bernie Carter
- Faculty of Health, Social Care and Medicine, Edge Hill University, Ormskirk, United Kingdom
- Alder Hey Children’s NHS Foundation Trust, Liverpool, United Kingdom
| | - Debra Fisher-Smith
- Department of Clinical Infection, Microbiology and Immunology, University of Liverpool, Liverpool, United Kingdom
| | - David Porter
- Department of Infectious Diseases and Immunology, Alder Hey Children’s NHS Foundation Trust, Liverpool, United Kingdom
| | - Steven Lane
- Institute of Translational Medicine, University of Liverpool, Liverpool, United Kingdom
| | - Matthew Peak
- Paediatric Medicines Research Unit, Institute in the Park, Alder Hey Children’s NHS Foundation Trust, Liverpool, United Kingdom
| | - David Taylor-Robinson
- Department of Public Health and Policy, University of Liverpool, Liverpool, United Kingdom
| | - Louise Bracken
- Paediatric Medicines Research Unit, Institute in the Park, Alder Hey Children’s NHS Foundation Trust, Liverpool, United Kingdom
| | - Enitan D. Carrol
- Department of Infectious Diseases and Immunology, Alder Hey Children’s NHS Foundation Trust, Liverpool, United Kingdom
- Department of Clinical Infection, Microbiology and Immunology, Institute of Infection and Global Health, University of Liverpool, Liverpool, United Kingdom
- Liverpool Health Partners, Liverpool Science Park, Liverpool, United Kingdom
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Horner C, Cunney R, Demirjian A, Doherty C, Green H, Mathai M, McMaster P, Munro A, Paulus S, Roland D, Patel S. Paediatric Common Infections Pathways: improving antimicrobial stewardship and promoting ambulation for children presenting with common infections to hospitals in the UK and Ireland. JAC Antimicrob Resist 2021; 3:dlab029. [PMID: 34223103 PMCID: PMC8210287 DOI: 10.1093/jacamr/dlab029] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Accepted: 02/15/2021] [Indexed: 12/19/2022] Open
Abstract
Paediatric common infection pathways have been developed in collaboration between the BSAC and national paediatric groups, addressing the management of cellulitis, lymphadenitis/lymph node abscess, pneumonia/pleural empyema, pyelonephritis, tonsillitis/peritonsillar abscess, otitis media/mastoiditis, pre-septal/post-septal (orbital) cellulitis, and meningitis. Guidance for the management of a child presenting with a petechial/purpuric rash and the infant under 3 months of age with fever is also provided. The aim of these pathways is to support the delivery of high-quality infection management in children presenting to a hospital. The pathways focus on diagnostic approaches, including the recognition of red flags suggesting complex or severe infection requiring urgent intervention, approaches to antimicrobial stewardship (AMS) principles and guidance on safe and timely ambulation aligned with good practice of outpatient parenteral antimicrobial therapy (OPAT).
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Affiliation(s)
- Carolyne Horner
- The British Society for Antimicrobial Chemotherapy, Birmingham, UK
| | - Robert Cunney
- Temple Street Children's University Hospital, Dublin, Ireland
| | | | | | - Helen Green
- Southampton Children’s Hospital, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | | | | | - Alasdair Munro
- Southampton Children’s Hospital, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Stéphane Paulus
- Children’s Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | | | - Sanjay Patel
- The British Society for Antimicrobial Chemotherapy, Birmingham, UK
- Southampton Children’s Hospital, University Hospital Southampton NHS Foundation Trust, Southampton, UK
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12
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Townsley E, Gillon J, Jimenez-Truque N, Katz S, Garguilo K, Banerjee R. Risk Factors for Adverse Events in Children Receiving Outpatient Parenteral Antibiotic Therapy. Hosp Pediatr 2021; 11:153-159. [PMID: 33446490 DOI: 10.1542/hpeds.2020-001388] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
BACKGROUND Outpatient parenteral antibiotic therapy (OPAT) can decrease length of hospital stay but is associated with adverse events (AEs). The purpose of this study was to quantify and identify risk factors for OPAT-associated AEs in children. METHODS Retrospective single-center study of children ≤21 years old discharged on OPAT from January 2016 to April 2019 with infectious diseases follow-up. Demographic and clinical factors and medication and central venous catheter (CVC)-associated AEs were assessed through chart review. Univariable and multivariable analyses were performed. RESULTS Among 181 OPAT courses, an AE occurred in 70 (39%). Medication AEs occurred in 30 of 181 courses (16.6%). Children residing in an urban area had a 4.5 times higher risk of having a medication-related AE compared with those in a rural area (odds ratio: 4.51; 95% confidence interval: 1.60-12.77; P = .005). CVC AEs occurred in 47 of 181 courses (26%). Every additional day of OPAT increased the odds of having a CVC-related AE by 4% (odds ratio: 1.04; 95% confidence interval: 1.01-1.07; P = .003). Twenty (11.1%) courses resulted in readmission to the hospital because of an AE. CONCLUSIONS In this cohort, 39% of children experienced an OPAT-associated AE, and CVC AEs were more common than medication AEs. Longer duration of intravenous therapy and urban residence were independently associated with OPAT-associated AEs, highlighting the importance of converting to oral antibiotic therapy as soon as feasible to reduce OPAT-associated AEs.
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Affiliation(s)
| | - Jessica Gillon
- Vanderbilt University Medical Center, Nashville, Tennessee
| | | | - Sophie Katz
- Vanderbilt University Medical Center, Nashville, Tennessee
| | | | - Ritu Banerjee
- Vanderbilt University Medical Center, Nashville, Tennessee
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13
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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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14
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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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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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16
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Wong A, Glogolia M, Lange PW, Dale S, Chappell M, Soosay Raj T, Hanna D, Devaraja L, Williams C, Williamson J, Conyers R. A nurse-led paediatric oncology fast-track clinic proves a successful ambulatory intervention for patients. Support Care Cancer 2020; 28:4395-4403. [PMID: 31919665 DOI: 10.1007/s00520-019-05250-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2019] [Accepted: 12/16/2019] [Indexed: 11/25/2022]
Abstract
AIM To assess the impact of a pilot nurse-led paediatric oncology fast-track clinic (OFTC) for complications and side effects following chemotherapy within a paediatric tertiary hospital. METHODS Prospective clinical data from the first 100 patients seen in the OFTC were compared with retrospective data of oncology patient presentations to the emergency department (ED) (over a 1-year period, n = 196) who would have been eligible for review in the OFTC. Parent and patient satisfaction of clinical care were also assessed via surveys pre- and post-OFTC implementation. RESULTS Analysis which achieved statistical difference was a reduction in the number of blood tubes taken in OFTC (average 1.9 for those discharged from clinic, 2.9 for those admitted from clinic) in comparison to those seen in the ED (average 3.2) (p = 0.0027). The average number of interventions per patient seen in the ED were 2.1 (standard deviation 1.64) compared with 1.7 (standard deviation 1.55) interventions per patient seen in the OFTC, and who were not admitted following review. This result approached statistical significance with p = 0.0963. Other results which did not meet statistical significance included a reduction in treatment times, hospital admissions and medical oncology reviews. CONCLUSION Our pilot study implementing an OFTC for the triage and assessment of chemotherapy-related complications has proven successful from an operational and consumer perspective. The clinic improved care by ensuring expedited review, more streamlined interventions, and less overall hospital admissions. The improvements in efficiency were also mirrored by increased parent and patient satisfaction.
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Affiliation(s)
- A Wong
- The Children's Cancer Centre, The Royal Children's Hospital, Melbourne, Australia
| | - M Glogolia
- The Children's Cancer Centre, The Royal Children's Hospital, Melbourne, Australia
| | - P W Lange
- Department of Medicine, Melbourne University, Melbourne, Australia
| | - S Dale
- The Children's Cancer Centre, The Royal Children's Hospital, Melbourne, Australia
| | - M Chappell
- The Children's Cancer Centre, The Royal Children's Hospital, Melbourne, Australia
| | - T Soosay Raj
- The Children's Cancer Centre, The Royal Children's Hospital, Melbourne, Australia
| | - D Hanna
- The Children's Cancer Centre, The Royal Children's Hospital, Melbourne, Australia
| | - L Devaraja
- Department of Paediatrics, Melbourne University, Melbourne, Australia
| | - C Williams
- The Children's Cancer Centre, The Royal Children's Hospital, Melbourne, Australia.,The Paediatric Integrated Cancer Service (PICS), Melbourne, Australia
| | - J Williamson
- The Paediatric Integrated Cancer Service (PICS), Melbourne, Australia
| | - R Conyers
- The Children's Cancer Centre, The Royal Children's Hospital, Melbourne, Australia. .,Department of Paediatrics, Melbourne University, Melbourne, Australia. .,Murdoch Children's Research Institute, Melbourne, Australia.
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17
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Chapman ALN, Patel S, Horner C, Green H, Guleri A, Hedderwick S, Snape S, Statham J, Wilson E, Gilchrist M, Seaton RA. Updated good practice recommendations for outpatient parenteral antimicrobial therapy (OPAT) in adults and children in the UK. JAC Antimicrob Resist 2019; 1:dlz026. [PMID: 34222901 PMCID: PMC8209972 DOI: 10.1093/jacamr/dlz026] [Citation(s) in RCA: 48] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
UK good practice recommendations for outpatient parenteral antimicrobial therapy (OPAT) were published in 2012 and 2015 for adult and paediatric patients, respectively. Here we update the initial good practice recommendations in a combined document based on a further review of the OPAT literature and an extensive consultation process. As with the previous good practice recommendations, these updated recommendations are intended to provide pragmatic guidance for new and established OPAT services across a range of settings and to act as a set of quality indicators for service evaluation and quality improvement.
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Affiliation(s)
| | - Sanjay Patel
- Southampton Children’s Hospital, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Carolyne Horner
- The British Society for Antimicrobial Chemotherapy, Birmingham, UK
| | - Helen Green
- Southampton Children’s Hospital, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Achyut Guleri
- Blackpool Teaching Hospitals NHS Foundation Trust, Blackpool, UK
| | | | - Susan Snape
- Nottingham University Hospitals NHS Foundation Trust, Nottingham, UK
| | - Julie Statham
- South Warwickshire NHS Foundation Trust, Warwick, UK
| | | | | | - R Andrew Seaton
- Queen Elizabeth University Hospital, NHS Greater Glasgow and Clyde, Glasgow, UK
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18
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The impact of paediatric antimicrobial stewardship programmes on patient outcomes. Curr Opin Infect Dis 2019; 31:216-223. [PMID: 29570494 DOI: 10.1097/qco.0000000000000449] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
PURPOSE OF REVIEW Although there has been an unprecedented global effort to reduce the spread of antimicrobial resistance, little emphasis has been placed on children. This review aims to evaluate the impact of paediatric antimicrobial stewardship programmes as well as providing a practical approach for effectively implementing them in community-based settings and in hospitals. RECENT FINDINGS Although rates of serious bacterial infection are low in children, the rates of antimicrobial use and resistance are comparable with adults. Different strategies are required to implement antimicrobial stewardship in community-based settings compared to in hospitals. Nationally coordinated, whole-system approaches have achieved long-term, sustainable reductions in antimicrobial prescribing, as well as reductions in resistance rates at population level, with no evidence of an increase in rate of serious infection or bacterial complications. SUMMARY Antimicrobial stewardship programmes in neonates and children have unique characteristics and issues. There is currently no consensus on how to measure consumption of antimicrobials in neonates and children. This is a research priority. Benchmarking and clinical networks in neonates and paediatrics are important to share practice and drive best use of antimicrobials.
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Abstract
PURPOSE OF REVIEW Over recent years, there has been a marked increase in the number of centres delivering paediatric outpatient parenteral antimicrobial therapy (pOPAT). Various factors have fuelled this drive, including the significant economic pressures faced by high-income countries to contain the cost of healthcare, resulting in a significant reduction of in-patient beds over the past 20 years. It is essential that pOPAT services have formal clinical governance structures in place to ensure the safe and effective management of children being ambulated on intravenous antibiotics. They also require oversight of antimicrobial decisions by a medically qualified infection specialist to ensure that the principles of antimicrobial stewardship are adhered to. This review aims to provide an evidence-based framework for delivering pOPAT services. RECENT FINDINGS There is increasing data supporting the implementation of admission avoidance strategies for children with cellulitis and pyelonephritis. In addition, recent data supports the management of a subset of children with febrile neutropenia within pOPAT services. Above all, there is a clear recognition that embedding antimicrobial stewardship within pOPAT services reduces duration of intravenous antibiotics (IVAbs) and improves patient management. pOPAT services are safe, cost-effective and associated with high levels of parent/patient satisfaction. Further research is required to develop risk prediction models for children being considered for pOPAT. Further data about the use of elastomeric devices in children and the acceptability of parental administration of IVAbs are also required.
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Affiliation(s)
- Sanjay Patel
- Department of Paediatric Infectious Diseases & Immunology, Southampton Children's Hospital, University Hospital Southampton NHS Foundation Trust, Mailpoint 43, Tremona Road, Southampton, SO16 6YD, UK. .,NIHR Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust, Southampton, UK. .,NIHR Wellcome Trust Clinical Research Facility, University Hospital Southampton NHS Foundation Trust, Southampton, UK.
| | - Helen Green
- Department of Paediatric Infectious Diseases & Immunology, Southampton Children's Hospital, University Hospital Southampton NHS Foundation Trust, Mailpoint 43, Tremona Road, Southampton, SO16 6YD, UK
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20
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Bialy LP, Wojcik C, Mlynarczuk-Bialy I. Mucosal delivery systems of antihypertensive drugs: A practical approach in general practice. Biomed Pap Med Fac Univ Palacky Olomouc Czech Repub 2018; 162:71-78. [PMID: 29765168 DOI: 10.5507/bp.2018.022] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2017] [Accepted: 04/16/2018] [Indexed: 12/30/2022] Open
Abstract
Patients who are unable to receive oral medication (p.o.) are a major problem in outpatient settings, especially in home health care systems. Mucosal administration of drugs offers an alternative to the oral route, especially when the parenteral mode cannot be used. There are three main pathways of mucosal administration: sublingual/buccal, intranasal and rectal. We discuss the possibility of mucosal delivery of antihypertensive drugs. Perindopril arginine and Amlodipine besylate are registered in the EU as orodispersible tablets for oromucosal delivery, however, they are not available in all countries. For this reason, we describe other drugs suitable for mucosal delivery: Captopril and Nitrendipine in the sublingual system and Metoprolol tartrate, Propranolol and Furosemide by the transrectal route. Based on the published data and common clinical practice we discuss the use of mucosal delivery systems of all these antihypertensive drugs with special attention to their pharmacokinetics. We illustrate this mini-review with a case report of the prolonged-term use of mucosal delivery of sublingual Captopril and Nitrendipine combined with rectal Metoprolol tartrate and Furosemide in a patient with severe hypertension unable to receive medication p.o. This is also a report on the first human use of Furosemide-containing suppositories as well as prolonged-term transmucosal administration of these four drugs, describing a practical approach leading to successful control of severe hypertension with four antihypertensive drugs delivered via the mucosal route. The treatment was effective and without side effects; however, the long-term safety and efficacy of such therapy must be confirmed by randomized clinical trials.
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Affiliation(s)
- Lukasz P Bialy
- Private General Practice (Praktyka Lekarska dr n. med. Lukasz Bialy), Warsaw, Poland.,Department of Histology and Embryology, Medical University of Warsaw, Warsaw, Poland
| | - Cezary Wojcik
- Department of Family Medicine, Oregon Health and Sciences University, Portland, OR, USA
| | - Izabela Mlynarczuk-Bialy
- Private General Practice (Praktyka Lekarska dr n. med. Lukasz Bialy), Warsaw, Poland.,Department of Histology and Embryology, Medical University of Warsaw, Warsaw, Poland
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