To Discharge or Not to Discharge on Outpatient Parenteral Antimicrobial Therapy: That Is the Question

Hospital at Home Program for the Treatment of Pediatric Osteoarticular Infections

OBJECTIVES

Hospital at home (HAH) replaces acute inpatient hospital care for selected patients by providing care in their homes. We sought to describe the characteristics, management, and complications of patients with osteoarticular infections (OAIs) treated in an HAH program and its economic impact.

METHODS

We conducted a retrospective observational study evaluating an HAH program in a pediatric hospital in Spain, describing the characteristics of patients with confirmed OAIs requiring intravenous antibiotic therapy admitted to this program between January 2019 and December 2022. The program operates as a virtual ward with possible daily visits by physicians and nurses and 24/7 telephone contact.

RESULTS

A total of 88 patients (median age, 4.1 years; interquartile range [IQR], 1.7-10.6) with OIAs were admitted to the HAH program. Osteomyelitis (57%) and septic arthritis (29%) were the most frequent infections. Cefuroxime (42%) and cefazolin (39%) were the most frequently prescribed antibiotics. Caregiver self-administration was performed in 99%, allowing multiple daily doses of antimicrobial therapy, 80% by peripheral line. Thirteen patients (15%) had drug-related adverse events, only 3 requiring drug modification. Two patients (2%) were readmitted during HAH, and 1 was readmitted within 30 days of HAH discharge. The median HAH stay was 7 days (IQR, 4-8.75). For osteomyelitis, hospital days lowered from 8.5 days (IQR, 4.5-12) to 4 days (IQR, 3-7) after HAH implementation (P = .005) with 68% per-patient estimated cost savings.

CONCLUSIONS

HAH treatment of OAIs is effective and cost-efficient. Patient support by medical and nursing staff, adequate family training, and regular communication are essential to ensure safe home admission.

Early switch from intravenous to oral antibiotic treatment in bone and joint infections

OBJECTIVES

The timing of the switch from intravenous (i.v.) to oral antibiotic therapy for orthopaedic bone and joint infections (BJIs) is debated. In this narrative article, we discuss the evidence for and against an early switch in BJIs.

DATA SOURCES

We performed a PubMed and internet search investigating the association between the duration of i.v. treatment for BJI and remission of infection among adult orthopaedic patients.

CONTENT

Among eight randomized controlled trials and multiple retrospective studies, we failed to find any minimal duration of postsurgical i.v. therapy associated with clinical outcomes. We did not find scientific data to support the prolonged use of i.v. therapy or to inform a minimal duration of i.v.

THERAPY

Growing evidence supports the safety of an early switch to oral medications once the patient is clinically stable.

IMPLICATIONS

After surgery for BJI, a switch to oral antibiotics within a few days is reasonable in most cases. We recommend making the decision on the time point based on clinical criteria and in an interdisciplinary team at the bedside.

Implementation of a consensus protocol for antibiotic use for bone and joint infection to reduce unnecessary outpatient parenteral antimicrobial therapy: A quality improvement initiative

Objective:

We aimed to decrease the use of outpatient parenteral antimicrobial therapy (OPAT) for patients admitted for bone and joint infections (BJIs) by applying a consensus protocol to suggest oral antibiotics for BJI.

Design:

A quasi-experimental before-and-after study.

Setting:

Inpatient setting at a single medical center.

Patients:

All inpatients admitted with a BJI.

Methods:

We developed a consensus table of oral antibiotics for BJI among infectious diseases (ID) specialists. Using the consensus table, we implemented a protocol consisting of a weekly reminder e-mail and case-based discussion with the consulting ID physician. Outcomes of patients during the implementation period (November 1, 2020, to May 31, 2021) were compared with those during the preimplementation period (January 1, 2019, to October 31, 2020). Our primary outcome was the proportion of patients treated with OPAT. Secondary outcomes included length of hospital stay (LOS) and recurrence or death within 6 months.

Results:

In total, 77 patients during the preimplementation period and 22 patients during the implementation period were identified to have a BJI. During the preimplementation period, 70.1% of patients received OPAT, whereas only 31.8% of patients had OPAT during the implementation period (P = .003). The median LOS after final ID recommendation was significantly shorter during the implementation period (median 3 days versus 1 day; P < .001). We detected no significant difference in the 6-month rate of recurrence (24.7% vs 31.8%; P = .46) or mortality (9.1% vs 9.1%; P = 1.00).

Conclusions:

More patients admitted with BJIs were treated with oral antibiotics during the implementation phase of our quality improvement initiative.

Risk Factors for Adverse Events in Children Receiving Outpatient Parenteral Antibiotic Therapy

BACKGROUND

Outpatient parenteral antibiotic therapy (OPAT) can decrease length of hospital stay but is associated with adverse events (AEs). The purpose of this study was to quantify and identify risk factors for OPAT-associated AEs in children.

METHODS

Retrospective single-center study of children ≤21 years old discharged on OPAT from January 2016 to April 2019 with infectious diseases follow-up. Demographic and clinical factors and medication and central venous catheter (CVC)-associated AEs were assessed through chart review. Univariable and multivariable analyses were performed.

RESULTS

Among 181 OPAT courses, an AE occurred in 70 (39%). Medication AEs occurred in 30 of 181 courses (16.6%). Children residing in an urban area had a 4.5 times higher risk of having a medication-related AE compared with those in a rural area (odds ratio: 4.51; 95% confidence interval: 1.60-12.77; P = .005). CVC AEs occurred in 47 of 181 courses (26%). Every additional day of OPAT increased the odds of having a CVC-related AE by 4% (odds ratio: 1.04; 95% confidence interval: 1.01-1.07; P = .003). Twenty (11.1%) courses resulted in readmission to the hospital because of an AE.

CONCLUSIONS

In this cohort, 39% of children experienced an OPAT-associated AE, and CVC AEs were more common than medication AEs. Longer duration of intravenous therapy and urban residence were independently associated with OPAT-associated AEs, highlighting the importance of converting to oral antibiotic therapy as soon as feasible to reduce OPAT-associated AEs.