1
|
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).
Collapse
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
| |
Collapse
|
2
|
Tanner E, Munro APS, Gray J, Green H, Rutter M, Jones CE, Faust SN, Alderton M, Patel SV. Improving paediatric antimicrobial stewardship in hospital-based settings: why, where and how? JAC Antimicrob Resist 2020; 2:dlaa011. [PMID: 34222969 PMCID: PMC8210213 DOI: 10.1093/jacamr/dlaa011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2019] [Revised: 01/13/2020] [Accepted: 01/16/2020] [Indexed: 11/13/2022] Open
Abstract
Background Antimicrobial resistance (AMR) is being recognized as a priority by healthcare organizations across the world. However, many children are managed on IV antimicrobials in hospital with very little consideration of antimicrobial stewardship issues. Objectives A nurse-led paediatric ambulatory outpatient parenteral antimicrobial therapy (OPAT) service, managing children with common infections being ambulated on short courses of IV antimicrobials, was introduced within Southampton Children’s Hospital in January 2018. We evaluated the impact of this service in terms of the quality of antimicrobial prescribing and timing of ambulation in children presenting with common infections. Methods All cases managed within the service were reviewed in two separate 2 month time periods: prior to introduction of the service (September–October 2016) and then prospectively after its introduction (September–October 2018). Results A total of 96% of IV antibiotic management decisions at 48 h were deemed appropriate in 2018, compared with 75% in 2016. A total of 64% of patients were ambulated on IV antibiotics at some point during their treatment course in 2018, compared with 19% in 2016. However, a significant proportion of antimicrobial decisions made at the point of presentation to hospital remained suboptimal in 2018. Conclusions Children are commonly managed with IV antibiotics in hospital. We demonstrate marked improvements in appropriate antimicrobial use through the introduction of a nurse-led ambulatory OPAT service. In addition, such a service can promote a greater proportion of children being ambulated from hospital, freeing up valuable inpatient beds and potentially delivering cost savings that can be used to fund such services.
Collapse
Affiliation(s)
- E Tanner
- University of Southampton Medical School, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - A P S Munro
- Department of Paediatric Immunology & Infectious Diseases, University Hospital Southampton NHS Foundation Trust, Southampton, UK.,NIHR Wellcome Trust Clinical Research Facility, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - J Gray
- Department of Paediatric Immunology & Infectious Diseases, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - H Green
- Department of Paediatric Immunology & Infectious Diseases, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - M Rutter
- Department of Paediatric Immunology & Infectious Diseases, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - C E Jones
- Department of Paediatric Immunology & Infectious Diseases, University Hospital Southampton NHS Foundation Trust, Southampton, UK.,NIHR Wellcome Trust Clinical Research Facility, University Hospital Southampton NHS Foundation Trust, Southampton, UK.,Faculty of Medicine and Institute for Life Sciences, University of Southampton, Southampton, UK
| | - S N Faust
- Department of Paediatric Immunology & Infectious Diseases, University Hospital Southampton NHS Foundation Trust, Southampton, UK.,NIHR Wellcome Trust Clinical Research Facility, University Hospital Southampton NHS Foundation Trust, Southampton, UK.,Faculty of Medicine and Institute for Life Sciences, University of Southampton, Southampton, UK
| | - M Alderton
- Department of Paediatrics, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - S V Patel
- Department of Paediatric Immunology & Infectious Diseases, University Hospital Southampton NHS Foundation Trust, Southampton, UK.,NIHR Wellcome Trust Clinical Research Facility, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| |
Collapse
|
3
|
Assessing appropriateness of pediatric emergency department visits: is it even possible? CAN J EMERG MED 2020; 22:661-664. [PMID: 32009600 DOI: 10.1017/cem.2019.473] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVES Numerous studies reported on the frequency of, and factors associated with inappropriate or unnecessary emergency department (ED) visits using clinician judgment as the gold standard of appropriateness. This study evaluated the reliability of clinician judgment for assessing appropriateness of pediatric ED visit. METHODS We conducted a retrospective cohort study comparing 3 clinicians' determination of ED visit appropriateness with and without guidance from a three-question structured algorithm. We used a cohort of scheduled ED return visits deemed appropriate by the index treating clinician between May 1, 2012, and April 30, 2013. We measured the level of agreement among three clinician investigators with and without use of the structured algorithm. RESULTS A total of 207 scheduled ED return visits were reviewed by the primary clinician reviewer who agreed with the index treating clinician for 79/207 visits (38.2%). Among a random subset of 90 return visits reviewed by all three clinicians, agreement was 67% with a Fleiss' Kappa of 0.30 (0.17-0.44). Using a three-question algorithm based on objective criteria, agreement with the index treating provider increased to 115/207 (55.6%). CONCLUSIONS Although an important contributor to pediatric ED overcrowding, unnecessary or inappropriate visits are difficult to identify. We demonstrated poor reliability of clinician judgment to determine appropriateness of ED return visits, likely due to variability in clinical decision-making and risk-tolerance, social and systems factors impacting access and use of health care. We recommend that future studies evaluating the appropriateness of ED use standardized, objective criteria rather than clinician judgment alone.
Collapse
|
4
|
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: 56] [Impact Index Per Article: 11.2] [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.
Collapse
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
| |
Collapse
|
5
|
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.
Collapse
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
| |
Collapse
|