Impact of expanding a paediatric OPAT programme with an antimicrobial stewardship intervention.

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.