Traditionally it has been thought that the administration of intravenous treatment required inpatient care; this situation started to change in 1974, when Rucker and Harrison1 presented their clinical experience with outpatient antibiotic treatment in children with cystic fibrosis. Since then, various publications2,3 have shown that this is a safe and efficacious modality that benefits both the patient and the family members, and that it has a good cost–benefit relationship.4

We define outpatient parenteral antimicrobial treatment (OPAT) as antibiotic, antifungal, or antiviral treatment delivered parenterally to patients who are not hospitalised, that is, who do not spend the night at the hospital, and consisting of at least 2 doses given on different days.5 The administration can be intravenous, intramuscular, or subcutaneous. The latter, while used infrequently, has been described in adult patients receiving palliative care, and requires putting in a request for compassionate use of the selected drug with the Agencia Española de Medicamentos (Spanish Medicines Agency). The term most frequently used to refer to this internationally is the acronym OPAT, which reflects the ambulatory approach to health care delivery of the United States model. In Spain we find the term “home intravenous antimicrobial therapy” (HIVAT) more suitable to refer to the integral at-home treatment of infectious disease in the patient.

There are several models for outpatient treatment administration that adhere to published guidelines for adults.6,7 The setting where the treatment is provided can be the home, day hospitals, freestanding infusion centres, emergency care and observation units, outpatient services, residential facilities and even the work place; and the treatment can be administered by health professionals or self-administered, that is, delivered by the patient or the carers.

There are few publications on this subject in Spain, especially in the paediatric field, and the main purpose of this article is to present our experience as a hospital at home unit (HHU), which is part of the paediatrics department, in parenteral antimicrobial treatment administered at home to paediatric patients with chronic underlying diseases, over the span of 12 years, and to assess its efficacy and safety.

A total of 55 patients (60% male) were included in the period under study. Of all patients, 35 (63.6%) had more than one episode, adding up to a total of 163 episodes of home parenteral treatment.

The mean age of our patients for each episode was 11.1 years (SD 4.85, range 4 months to 19 years) (Fig. 1).

Figure 1.

Age distribution (in bar diagram) of patients who received OPAT.

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In 126 episodes (77.3%), patients were referred from hospital outpatient services, especially from pulmonology (97% of patients referred from outpatient). For the remaining 37 episodes (22.7%), the patients were referred from inpatient wards, most of them from oncology (66% of patients referred from inpatient). The patients that could benefit most from this type of care are found in these settings: patients with chronic diseases that are going to need extended treatment.

The mean length of patient and carer training was 218min per episode.

Of all patients, 27 (49%) had cystic fibrosis (CF), 22 (40%) some type of cancer, 3 (5.6%) gastrointestinal diseases, 1 (1.8%) HIV infection, 1 (1.8%) bronchopulmonary dysplasia, and 1 (1.8%) had hyper IgM syndrome.

The episodes listed in Table 2 were treated at the patient's home.

The most frequently used type of vascular access was peripheral access (94.5%); central access was only used in 4 (2.5%) patients who were chronically ill and already had this device. Treatment was delivered intramuscularly in 5 (3%) episodes.

The causative agent was identified in 64 (39.2%) episodes (Table 3). The pathogen was not isolated in the remaining cases, in 4 because the culture was negative and in 95 because no culture was done.

The most frequently administered antibiotics were amikacin (n=43), ceftazidime (n=41), cefepime (n=40), teicoplanin (n=26), cefotaxime (n=12), tobramycin (n=20), ceftriaxone (n=5) and vancomycin (n=4). A combination of 2 or more antimicrobials was used in 105 episodes (63.2%), and the most common combination was ceftazidime with amikacin.

The mean duration of home treatment in the included patients was of 11.05 days (SD 5.82, range 1–25 days), and the cumulative number of treatment days was 1972 (Fig. 2). We did an estimated cost-analysis based on the costs of public health services in centres overseen by the Servicio Andaluz de Salud (Health Service of Andalusia), and found that the inclusion of patients in this programme could have saved up to 95% of the cost of conventional inpatient treatment.

Figure 2.

Number of outpatient treatment episodes administered at home and number of the hospitalisation days per year.

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The documented complications that arose during treatment were extravasation or accidental displacement of the peripheral line in 12 (7.2%) episodes, development of phlebitis in 5 (3%), exanthema or urticaria concurrent with drug administration in 5 (3%), poor technique in antimicrobial administration due to incorrect flushing of the device in 1 (0.6%), and breakdown of the infusion pump in 1 (0.6%) episode.

While the patients received care from our unit, 16 (9.8%) episodes required admission to the hospital, 4 (2.5%) of them due to poor evolution of the infectious process despite treatment, and 12 (7.4%) due to an exacerbation of the underlying disease.

Treatment was completed in the home in 147 episodes (90.2%), after which patients were discharged from our unit because of their favourable clinical outcome.

No deaths occurred during home treatment.

OPAT is a proven efficacious and safe alternative to conventional hospitalisation of patients with bacterial infections.8,9 In our setting, the HHU is the ideal care service to implement and monitor it. Here we present a broad and recent series of paediatric patients with underlying chronic disease who received parenteral treatment at home.

The disease distribution found in our study diverges from that described in other series. In our study, 74.5% of the patients had respiratory tract superinfections, contrary to what has been reported in other publications in which osteoarticular10,11 or soft tissue12 infections were more prevalent. This is due to the chronic underlying disease in our patients, most of whom suffered from CF.

We wish to highlight that carers administered the treatment to most patients, which is why we could use drugs with a schedule of several doses a day. Under different arrangements, the patient needs to visit the emergency department daily for a nurse to administer the treatment,12 or the HHU travels daily to the home to administer it,13 so the most widely used drugs are those with a single-daily-dose schedule.

The antibiotics used most frequently these years were the same as those used by other groups, with third-generation cephalosporins and aminoglycosides being the most widely used. This is because most courses of antibiotherapy administered in the home were used in patients with CF.

As for the type of vascular access used, our data were consistent with most of the published literature14 that establishes peripheral access as the first choice. In case of complicated vascular access or in patients who are receiving frequent courses of antibiotics, a peripherally inserted central catheter or a conventional central catheter are used, although there is an increasing number of publications that propose the peripherally inserted central line as the first-choice route, presenting it as a safer, more effective, and less costly option.15,16

In our study, the rate of complications was 9.8%, far lower than rates reported in the literature.11,17,18 Consistent with the literature, the most frequent complications were extravasation or accidental displacement of the peripheral line, although the percentage was low in our sample, probably because most of our patients are older than 5 years. We did not register any other complications that, while infrequent, are reported in other studies, like neutropenia or fever.17

Our rate of episodes with favourable clinical outcome (90.2%) is very similar to what has been reported in the literature up to date.11,18 We should note that only 16 (9.8%) patients in our study required readmission, and that 12 (7.4%) of them required it unexpectedly for reasons related to their underlying disease, and not to therapeutic failure for the infection for which they were being treated.

Home administration of the prescribed treatment has several advantages. The most obvious advantage for patients is that they remain in their environment, and some can resume their school activities. In addition, evidence from various published studies show that this type of therapy increases the psychological wellbeing of paediatric patients,19 improves the physical, social, and emotional quality of life of adults,20 and results in a reduction in the number of nosocomial infections.21 The advantage over hospitalisation for providers is that they can treat patients in a pleasanter environment for latter, improving provider–patient communication and rapport. Lastly, it is advantageous for the administration, as it has been proven that OPAT results in fewer overnight stays at the hospital and lower costs for the hospital,22,23 in addition to increasing patient satisfaction.

Although at-home OPAT administered by the carers has been established as a safe, efficacious, practical, and cost-effective treatment option,24 and offers an alternative to patients who wish to return to their normal environment, which was supported by the results of our study, there are also disadvantages and risks. Some of these include the decreased ability to monitor the patient properly at home, the lower degree of supervision, the feelings of insecurity of carers at the beginning of treatment, and the medical complications that could arise in relation to the treatment. Although these are inherent risks in OPAT, our unit minimises them by the strict selection of patients and carers, offering intensive, problem-solving training during the hospital stay, and providing a quick means of communication between carers and the team in charge through the phone. Thus, the essential factors for a successful OPAT programme are: to have the appropriate infrastructure, to make a careful selection of patients, to have a multidisciplinary staff with experience both in at-home care delivery and in the diagnosis and treatment of infectious diseases, to provide the necessary information and training, and to properly monitor the patient who is receiving this type of treatment. The hospital must guarantee continued care 24h a day to address any complications that may arise, and ideally there would be HHU coverage for most of these hours. Also, the HHU should work in close collaboration with the referring provider and with the infectious disease and pharmacy services.

There are a growing number of review studies on the home administration of parenteral treatment in children with acute disease such as osteomyelitis,25 cellulitis,26 pneumonia,27 or pyelonephritis.28

Our study has the following limitations: it is a single-centre study and the majority of referrals we receive are CF patients. These limitations may have resulted in biases in our analysis, which could be brought to light when comparing our results with those of other published studies.

This review and analysis has allowed us to identify areas where we are lacking, providing an incentive to try to design protocols based on scientific evidence and our clinical experience in the near future that would include not only patients with underlying chronic disease, but also patients with acute disease that could receive parenteral antimicrobial treatment at home.

The authors have no conflicts of interest to declare.