Paediatric OPAT provision the challenges and opportunities. Dr Sanjay Patel Consultant in Paediatric Infectious Diseases

Transcription

1 Paediatric OPAT provision the challenges and opportunities Dr Sanjay Patel Consultant in Paediatric Infectious Diseases

2 Challenges:- Contents 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

3 Challenges in introducing a p-opat 920 adult beds service: economies of scale 124 paediatric beds

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

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

6 Challenges in p-opat: IV access Van Winkle ( ) Number of PICCs 39 (5 midlines) 104 Mean age (years) Duration (days) (mean and SD) Mechanical complications Time to mechanical complication (days) Hussain ( ) Mean 41 (range 0-80) 11 (28%) 28 (27%) N/A 54 Infective complications 2 (5%) 13 (12.5%) Time to infective complication (days) N/A 42 Total complication rate 33% 39.5% 1. Van Winkle P et al. PIDJ Hussain S et al. Clinical Pediatrics. 2007

7 Challenges in introducing a p-opat service: paucity of evidence Adult OPAT papers published in P-OPAT papers published in

8 The Southampton p-opat journey Tertiary Children s Hospital Serves a population of 500,000 children 124 in-patient beds 9000 admissions per year

9 Geographical area covered

10 Southampton tertiary p-opat service Introduced July 2012 Impact over a 30 month period:- Period Patient episodes Bed days saved Year 1 (July 12 July 13) Year 2 (July 13 July 14) Year 3 (July 14 Dec 14) Total: 30 months

11 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

12 IV Access 6% 13% PICC (91) Cannula (15) Tunnelled CVC (7) 81% Mechanical complications 10% Infective complications 2%

13 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. 6% Success (93) Partial Success (7) Failure (6) Indeterminate (4) 5% 4% 85% Indeterminate: Readmission due to unrelated event eg. Chest pain.

14 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. Cured (89) Improved (12) Failure (6) Indeterminate (3) 3% 5% 11% 81% Indeterminate: There was a non-infective pathology responsible for persisting symptoms.

15 Opportunities expanding p-opat to other tertiary hospitals

16 Expanding p-opat beyond tertiary hospitals

17 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 6 month period Total 266

18 Opportunities and challenges prospective data collection

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