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Outpatient Parenteral Antimicrobial Therapy in Pediatric Medicaid Enrollees.

ABSTRACT: Outpatient parenteral antimicrobial therapy (OPAT) is overused in cases where highly bioavailable oral alternatives would be equally effective. However, the scope of OPAT use for children nationwide is poorly understood. Our objective was to characterize OPAT use and clinical outcomes for a large population of pediatric Medicaid enrollees treated with OPAT.We analyzed the Truven MarketScan Medicaid claims database between 2009 and 2012. An OPAT episode was identified by capturing children with claims data indicating home infusion therapy for an intravenous antimicrobial. We characterized OPAT use by describing patient demographics, diagnoses, and antimicrobials prescribed. We categorized an antimicrobial as highly bioavailable if ?80% systemic exposure was expected from the peroral dose. We also determined the percentage of OPAT recipients in whom a follow-up healthcare encounter occurred during the OPAT episode in either the emergency department or as a hospital admission. We reviewed the primary diagnoses associated with these healthcare encounters to determine whether it was related to OPAT.We identified 3433 OPAT episodes in 2687 patients. A total of 4774 antimicrobials were prescribed during these episodes. Ceftriaxone and vancomycin were the most commonly prescribed antimicrobials. Highly bioavailable antimicrobials accounted for 34% of antimicrobials used for OPAT. An emergency department visit or hospital admission occurred during 38% of OPAT episodes, among which 61% were OPAT-related.The high rate of medical encounters associated with OPAT in this cohort and the common prescribing of highly bioavailable antimicrobials underscore the opportunities for antimicrobial stewardship of pediatric OPAT.

SUBMITTER: Goldman JL

PROVIDER: S-EPMC5907854 | biostudies-other | 2017 Mar

REPOSITORIES: biostudies-other

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Outpatient Parenteral Antimicrobial Therapy in Pediatric Medicaid Enrollees.

Goldman Jennifer L JL Richardson Troy T Newland Jason G JG Lee Brian B Gerber Jeffrey S JS Hall Matt M Kronman Matthew M Hersh Adam L AL

Journal of the Pediatric Infectious Diseases Society 20170301 1

<h4>Background</h4>Outpatient parenteral antimicrobial therapy (OPAT) is overused in cases where highly bioavailable oral alternatives would be equally effective. However, the scope of OPAT use for children nationwide is poorly understood. Our objective was to characterize OPAT use and clinical outcomes for a large population of pediatric Medicaid enrollees treated with OPAT.<h4>Methods</h4>We analyzed the Truven MarketScan Medicaid claims database between 2009 and 2012. An OPAT episode was iden ...[more]

PMID: 26803327

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Project description:Abstract Background Outpatient parenteral antimicrobial therapy (OPAT) has shifted from being a novel concept to an accepted model of care for some conditions. However, concerns remain that have limited its broader roll out: the use of daily ceftriaxone regarding its efficacy and impact on antibiotic resistance, intravenous (IV) catheter complications, risk of treating an acute infection directly from the emergency room (ER), and concern that OPAT has shifted the burden of cost from hospitals to patients. We aimed to address these questions with the first randomized controlled trial (RCT) of OPAT efficacy in children: comparing OPAT directly from the ER using IV ceftriaxone with hospitalization using IV flucloxacillin for moderate/severe cellulitis. Methods The RCT was set at a tertiary pediatric hospital from January 2015 to June 2017. Inclusion criteria: children 6 months–18 years with uncomplicated cellulitis needing IV antibiotics. Patients were randomized to ceftriaxone via OPAT at home or flucloxacillin in hospital, using a peripheral catheter. Primary outcome: treatment failure within 48 hours due to lack of improvement or adverse events. Secondary outcomes: complications, readmission, acquisition of nasal and stool-resistant bacteria and costs. Results A total of 188 children were randomized: 93 to OPAT and 95 to hospital. In the intention-to-treat population, there was no difference in treatment failure between OPAT and hospital (2% vs. 7%, P = 0.09). Per protocol, OPAT had less failure (1% vs. 8%, P = 0.03). There was no increased acquisition of MRSA, ESBL, VRE or C. difficile with OPAT compared with in hospital at 1 week or 3 months (P > 0.05). Complication rates were similar (6% vs. 7%, P = 0.78), and repeat IV catheterization was less with OPAT (3% vs. 15%, P = 0.002). Readmission was 1% on OPAT. The cost to families was significantly less with OPAT (AUD213 vs. AUD733, P < 0.001). Conclusion Despite the acuity of the infection, OPAT with IV ceftriaxone for moderate/severe cellulitis in children is efficacious with complications and readmissions no different from hospital care with IV flucloxacillin. Short-term ceftriaxone use in healthy children on OPAT is not associated with increased acquisition of resistant organisms, and has reduced burden of costs to families (ClinicalTrials.gov NCT02334124). Disclosures All authors: No reported disclosures.

Dataset Information

Outpatient Parenteral Antimicrobial Therapy in Pediatric Medicaid Enrollees.

Publications

Outpatient Parenteral Antimicrobial Therapy in Pediatric Medicaid Enrollees.

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