Paediatric OPAT provision – the challenges and opportunities

Dr Sanjay Patel

Consultant in Paediatric Infectious Diseases

Contents

• Challenges:-

– Economies of scale

– Where can p-OPAT be delivered?

– Risk averse behaviour

– Practical issues: IV access

– Paucity of evidence

• Opportunities:-

– Tertiary p-OPAT: the Southampton experience

– Expanding p-OPAT beyond tertiary hospitals

Challenges in introducing a p-OPAT service: economies of scale

920 adult beds

124 paediatric beds

Challenges in introducing a p-OPAT service: where can it be delivered?

versus

Unique challenges in introducing a p-OPAT service: overcoming risk averse

behaviour

1. Van Winkle P et al. PIDJ 2008 2. Hussain S et al. Clinical Pediatrics. 2007

Van Winkle

(2003-06)

Hussain

(1995-99)

Number of PICCs 39 (5 midlines) 104

Mean age (years) 4.4 7.5

Duration (days) 21.7 +-14.1

(mean and SD)

Mean 41

(range 0-80)

Mechanical

complications 11 (28%) 28 (27%)

Time to mechanical

complication (days) N/A 54

Infective complications 2 (5%) 13 (12.5%)

Time to infective

complication (days) N/A 42

Total complication rate 33% 39.5%

Challenges in p-OPAT: IV access

0

5

10

15

20

25

30

35

Challenges in introducing a p-OPAT service: paucity of evidence

31

2 Adult OPAT

papers published in 2014 P-OPAT papers

published in 2014

The Southampton p-OPAT journey

• Tertiary Children’s Hospital

• Serves a population of 500,000 children

• 124 in-patient beds

• 9000 admissions per year

Geographical area covered

• Introduced July 2012

Southampton tertiary p-OPAT service

Period Patient episodes Bed days saved

Year 1 (July 12 – July 13) 48 497

Year 2 (July 13 – July 14) 42 641

Year 3 (July 14 – Dec 14) 20 278

Total: 30 months 110 1416

Impact over a 30 month period:-

Diagnosis Number of Patients

Osteomyelitis 28

Septic arthritis 24

Respiratory 12

Bacteraemia 10

CNS infection 9

Mastoiditis / sinusitis 8

Infected prosthetic material 7

Deep seated wound 2

Skin and soft tissue 3

Infective endocarditis 3

Pyomyositis 3

Intra-abdominal 1

Total 110

IV Access

81%

13%

6%

PICC (91)

Cannula (15)

Tunnelled CVC (7)

Mechanical complications 10% Infective complications 2%

pOPAT Outcomes (BSAC definitions)

Success: Completed therapy in OPAT with no

change in antimicrobial agent, no

adverse events, cure or improvement of

infection and no readmission.

Partial success: Completed therapy in OPAT with

either change in antimicrobial

agent or adverse event not

requiring admission.

Failure: Readmitted due to infection worsening

or due to adverse event. Death due to

any cause during OPAT.

Indeterminate: Readmission due to unrelated

event eg. Chest pain.

85%

6% 5%

4%

Success (93)

Partial Success (7)

Failure (6)

Indeterminate (4)

Patient Infection Outcomes Cure: Completed +/- oral step down for defined duration with resolution of infection and no requirement for long term antibiotic therapy. Improved:

i. Complete +/- oral step down with partial resolution of infection but need for further follow up OR

ii. Completed but required escalation of antimicrobial therapy during OPAT (without admission) +/- oral step down with ultimate cure or partial improvement (as above).

Failure: Progression or non-response of infection despite OPAT, required admission, surgical intervention or died for any reason. Indeterminate: There was a non-infective pathology responsible for persisting symptoms.

81%

11%

5%

3%

Cured (89)

Improved (12)

Failure (6)

Indeterminate (3)

Opportunities – expanding p-OPAT to other tertiary hospitals

Expanding p-OPAT beyond tertiary hospitals

Expanding p-OPAT beyond tertiary hospitals Diagnostic category Number bed days saved

Pyrexia 62

UTI 37

ENT 33

Skin & Soft tissue 30

Bacteremia 27

Lymphadenitis 15

Periorbital / pre-septal cellulitis 12

Osteoarticular 11

Respiratory 11

Other 11

Gastrointestinal 10

Rashes 7

Total 266 6 month period

Opportunities and challenges– prospective data collection

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