Laila F Ibrahim

The use, appropriateness and outcomes of outpatient parenteral antimicrobial therapy

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 Childrens 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.

Who Can Have Parenteral Antibiotics at Home?: A Prospective Observational Study in Children with Moderate/Severe Cellulitis.

Background: The benefits of treating children at home or in an ambulatory setting have been well documented. We aimed to describe the characteristics and evaluate the outcomes of children with moderate/severe cellulitis treated at home with intravenous (IV) ceftriaxone via direct referral from the Emergency Department to a hospital-in-the-home (HITH) program. Methods: Patients aged 3 months to 18 years with moderate/severe cellulitis referred from a tertiary pediatric Emergency Department to HITH from September 2012 to January 2014 were prospectively identified. Data collection included demographics, clinical features, microbiological characteristics and outcomes. To ensure home treatment did not result in inferior outcomes, these patients were retrospectively compared with patients who were hospitalized for IV flucloxacillin, the standard-of-care over the same period. The primary outcome was home treatment failure necessitating hospital admission. Secondary outcomes included antibiotic changes, complications, length of stay and cost. Results: Forty-one (28%) patients were treated on HITH and 103 (72%) were hospitalized. Compared with hospitalized patients, HITH patients were older (P < 0.01) and less likely to have periorbital cellulitis (P = 0.01) or fever (P = 0.04). There were no treatment failures under HITH care. The rate of antibiotic changes was similar in both groups (5% vs. 7%, P = 0.67), as was IV antibiotic duration (2.3 vs. 2.5 days, P = 0.23). Conclusion: Older children with moderate/severe limb cellulitis without systemic symptoms can be treated at home. To ascertain if this practice can be applied more widely, a comparative prospective, ideally randomized, study is needed.

PS-374 A Comparison Of Treatment At Home Or In Hospital For Moderate/severe Cellulitis In Children

Background and aims Adults with cellulitis are commonly receive IV antibiotics via hospital-in-the-home (HITH). Children are usually admitted to hospital. Royal Children’s Hospital (RCH) HITH and offers once daily IV ceftriaxone for cellulitis. Concerns remain for some physicians about its anti-staphylococcal activity. We aim to compare the clinical features and outcomes of patients with cellulitis admitted to hospital with IV flucloxacillin to those treated via HITH with IV ceftriaxone. Methods A retrospective chart review of patients with cellulitis treated with IV antibiotics. Exclusions- complicated cellulitis (abscess, orbital cellulitis, post-operative cellulitis, bites and immunosuppression). Demographics, clinical and microbiological features, antibiotic management and outcomes are related to two groups: inpatients treated with IV flucloxacillin and HITH patients treated with IV ceftriaxone. Results Over 17 months (2012–2014), 745 children presented to ED with cellulitis: 353 (47%) received IV antibiotics; 169 were excluded (complicated cellulitis, comorbidities, misdiagnosis or miscoding), leaving 184. 47 (26%) were admitted to HITH and 137 (74%) were admitted as inpatients. Initial treatment was IV ceftriaxone in 41 (87%) of HITH patients and IV flucloxacillin in 103 (75%) of inpatients. HITH patients were older, more likely to have failed prior oral antibiotics, less likely to have periorbital rather than limb cellulitis. Inpatients required longer IV treatment. Readmission rates, adverse events and rates of change of treatment were similar. Conclusion Some children with moderate/severe cellulitis can be treated via HITH with IV ceftriaxone in this non-randomised study however further prospective work is required to define the most appropriate sub-group.

Cellulitis: Home Or Inpatient in Children from the Emergency Department (CHOICE): protocol for a randomised controlled trial.

Introduction Children needing intravenous antibiotics for cellulitis are usually admitted to hospital, whereas adults commonly receive intravenous treatment at home. This is a randomised controlled trial (RCT) of intravenous antibiotic treatment of cellulitis in children comparing administration of ceftriaxone at home with standard care of flucloxacillin in hospital. The study aims to compare (1) the rate of treatment failure at home versus hospital (2) the safety of treatment at home versus hospital; and (3) the effect of exposure to short course ceftriaxone versus flucloxacillin on nasal and gut micro-organism resistance patterns and the clinical implications. Methods and analysis Inclusion criteria: children aged 6 months to <18 years with uncomplicated moderate/severe cellulitis, requiring intravenous antibiotics. Exclusions: complicated cellulitis (eg, orbital, foreign body) and immunosuppressed or toxic patients. The study is a single-centre, open-label, non-inferiority RCT. It is set in the emergency department (ED) at the Royal Childrens Hospital (RCH) in Melbourne, Australia and the Hospital-in-the-Home (HITH) programme; a home-care programme, which provides outreach from RCH. Recruitment will occur in ED from January 2015 to December 2016. Participants will be randomised to either treatment in hospital, or transfer home under the HITH programme. The calculated sample size is 188 patients (94 per group) and data will be analysed by intention-to-treat. Primary outcome: treatment failure defined as a change in treatment due to lack of clinical improvement according to the treating physician or adverse events, within 48 h Secondary outcomes: readmission to hospital, representation, adverse events, length of stay, microbiological results, development of resistance, cost-effectiveness, patient/parent satisfaction. This study has started recruitment. Ethics and dissemination This study has been approved by the Human Research Ethics Committee of the RCH Melbourne (34254C) and registered with the ClinicalTrials.gov registry (NCT02334124). We aim to disseminate the findings through international peer-reviewed journals and conferences. Clinical trial Pre-results.

Acute medical review by mobile telemedicine for children in hospital-in-the-home: an innovation

Where treatment allows, children do better at home than in hospital.1 The Royal Childrens Hospital (RCH) Melbourne has a hospital-in-the-home (HITH) programme that provides acute medical care to children at home (eg, intravenous antibiotics for cellulitis, pneumonia). However, there is a risk of ‘out of sight, out of mind’ for clinicians.2 We aimed to increase the visibility of children treated at home by piloting mobile telemedicine for patients on HITH. Objectives were to assess the acceptability and feasibility of acute medical review by telemedicine and to explore the technologys uses. We undertook a prospective pilot study from February to June 2013. Several hardware solutions were assessed for weight, data transfer method, videoconferencing specifics, compatibility with departmental software and price. The Acer Iconia tablet was selected, …

Evaluating an admission avoidance pathway for children in the emergency department: outpatient intravenous antibiotics for moderate/severe cellulitis

Objective Children with moderate/severe cellulitis requiring intravenous antibiotics are usually admitted to hospital. Admission avoidance is attractive but there are few data in children. We implemented a new pathway for children to be treated with intravenous antibiotics at home and aimed to describe the characteristics of patients treated on this pathway and in hospital and to evaluate the outcomes. Methods This is a prospective, observational cohort study of children aged 6 months–18 years attending the ED with uncomplicated moderate/severe cellulitis in March 2014–January 2015. Patients received either intravenous ceftriaxone at home or intravenous flucloxacillin in hospital based on physician discretion. Primary outcome was treatment failure defined as antibiotic change within 48 hours due to inadequate clinical improvement or serious adverse events. Secondary outcomes include duration of intravenous antibiotics and complications. Results 115 children were included: 47 (41%) in the home group and 68 (59%) in the hospital group (59 hospital-only, 9 transferred home during treatment). The groups had similar clinical features. 2/47 (4%) of the children in the home group compared with 8/59 (14%) in the hospital group had treatment failure (P=0.10). Duration of intravenous antibiotics (median 1.9 vs 1.8 days, P=0.31) and complications (6% vs 10%, P=0.49) were no different between groups. Home treatment costs less, averaging

Blood Cultures in Cellulitis are not Cost Effective and Should Prompt Investigation for an Alternative Focus.

A1166 (£705) per episode compared with

Once Daily Ceftriaxone for Children with Moderate/Severe Cellulitis at Home

A2594 (£1570) in hospital. Conclusions Children with uncomplicated cellulitis may be able to avoid hospital admission via a home intravenous pathway. This approach has the potential to provide cost and other benefits of home treatment.