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ObjectiveTo report the use, and assess the efficacy and outcomes of outpatient parenteral antimicrobial therapy (OPAT) in neonates (≤28 days of age), compared with older infants (1–12 months of age).DesignA prospective 8-year observational study from September 2012 to September 2020.SettingThe Hospital-in-the-Home (HITH) programme of the Royal Children’s Hospital Melbourne.PatientsNeonatal patients (≤28 days of age) were compared with older infants (1–12 months of age) receiving OPAT.InterventionsData were collected including demographics, diagnosis, type of venous access and antibiotic choice.Main outcome measuresSuccess of OPAT, antibiotic appropriateness, complications and readmission rate.ResultsThere were 76 episodes for which neonates were admitted to HITH for OPAT, and 405 episodes for older infants. Meningitis was the most common diagnosis in both groups (59% and 35%, respectively); the most frequently prescribed antibiotic was ceftriaxone for both groups (61% and 49%). A positive bacterial culture was less frequent in neonates (38% vs 53%, p=0.02). Vascular access complication rate was 19% in neonates compared with 13% in older infants (p=0.2) with no central line-associated bloodstream infection in either group. Rates of appropriate antibiotic prescribing were similarly high between groups (93% vs 90%, p=0.3). The OPAT course was successfully completed in 74 of 74 (100%) neonates and 380 of 396 (96%) older infants (p=0.09). The unplanned readmission rate was low: 4 of 76 (5%) neonates and 27 of 405 (7%) older infants.ConclusionsOPAT is a safe and effective way of providing antibiotics to selected clinically stable neonatal patients. While appropriate antibiotic use was common, improvements can still be made.

Aim Low-value care (LVC) is common. We aimed, using infants presenting to a major tertiary paediatric hospital with bronchiolitis between April 2016 and July 2018, to: (i) assess rates of chest X-ray (CXR) and medication use; (ii) identify associated factors; and (iii) measure the harm of not performing these practices. Methods We extracted data from the electronic medical record for all children aged 1-12 months given a diagnosis of bronchiolitis in the emergency department. Factors potentially associated with LVC practices were extracted, including patient demographics, ordering physician characteristics, order indication, medications prescribed and admission ward. To assess for harm, a radiologist, blinded to CXR indication, reviewed all CXRs ordered over the winter of 2017 for infants with bronchiolitis. Results A CXR was ordered for 439 (11.2%) infants, most commonly to rule out consolidation and collapse (65%). CXRs were more likely to be ordered for admitted infants (40.9% admitted to the general medical ward), and 62% were ordered by emergency department staff. Salbutamol was prescribed for 9.3% (n = 199). Amongst those who had a CXR, 28% were prescribed an antibiotic compared to 2.1% for those who did not. In an audit of 98 CXRs ordered over the winter of 2017, there were no CXR findings that meaningfully affected patient outcomes. Conclusion Using electronic medical record data, we found that CXR and medication use in bronchiolitis were higher than expected given our hospital guideline advice. Future research needs to understand why and develop interventions to reduce LVC.

BACKGROUND: Outpatient parenteral antimicrobial therapy offers the option of treating children requiring intravenous antibiotics for acute urinary tract infection (UTI)/pyelonephritis at home. We aimed to determine the outcomes of treating patients with UTI/pyelonephritis using outpatient parenteral antimicrobial therapy directly from the emergency department (ED) without admission to hospital. METHODS: This was a retrospective study (August 2012-July 2016) of children with UTI/pyelonephritis treated with parenteral antibiotics via a peripheral cannula directly from ED to home under a hospital-in-the home (HITH) program. Data collection included demographics, clinical features, length of stay, complications, and readmissions to hospital. RESULTS: There were 62 patient episodes of UTI/pyelonephritis transferred directly from ED to HITH. Fifty-eight (94%) had systemic features including fever, vomiting and/or tachycardia. Eighteen (29%) patients had an underlying condition. Nine (15%) received intravenous fluids and 8 (13%) antiemetics in ED. The outpatient parenteral antimicrobial therapy course was successfully completed in 56 (90%) patients. Of 6 (10%) patients who were readmitted, 2 were discharged within 24 hours, and none were severely unwell. Two (3%) had a blocked cannula, with no antibiotic complications. HITH patients were treated for a combined total of 142 days at home resulting in a cost saving of Australian dollar 108,914 (US dollar 82,775). However, only 8% of children deemed to require a course of intravenous antibiotics were transferred directly home from ED. Compared with patients concurrently admitted to hospital, fewer on HITH were less than 1 year of age (13% vs. 33%; odds ratio: 0.3; P < 0.01). CONCLUSIONS: Selected patients presenting to ED with UTI/pyelonephritis may be treated directly via HITH, including some with underlying conditions and/or systemic features.

Aims Using intravenous (IV) antibiotics to treat urinary tract infection (UTI)/pyelonephritis places a significant burden on patients, their families and health care resources. Despite a recent Cochrane review, guidelines do not clearly state the criteria for IV antibiotics in children with UTI/pyelonephritis. We aim to derive and validate a clinical score that incorporates clinical features and patients complexities to guide the decision on the route of antibiotics. Methods This was an observational study (May 2016 – March 2018) of all children (3m-18y) diagnosed in ED with UTI/pyelonephritis and subsequently confirmed on urine culture. To derive the score, only those aged 12m-12y were included who meet criteria from a recent systematic review. Patients were divided into two groups using the pre-determined gold standard for the ‘true’ need for IV antibiotics, which was based on the evidence from the Cochrane review and route of antibiotic at 24 hours. Features which were significantly different between the groups were identified. Various combinations of these differentiating features were used to generate receiver operating characteristics (ROC) curves, table 1. To validate this score, children aged 3m-18y were included. Results 1237 patients had a confirmed UTI/pyelonephritis: 833 (67%) aged 12m-12y, 271 (22%) aged 3–12 m and 133 (11%) aged 12–18y. Of those aged 12m-12y, 335 (27%) met the definition for inclusion, half of which were used to derive the RUPERT score (Rigor, Urological abnormality, Pyrexia/fever (≥38°C), Emesis/vomiting, Recurrent (>2) UTI, Tachycardia – one point each – maximum of 6 points), area under curve (AUC) of 0.81. A cut-off score of ≥4 to commence IV antibiotics would result in correct classification of 80% of patients (sensitivity 29% and specificity 95%). This score was then validated on a separate cohort and maintained an AUC of 0.81 (sensitivity 50% and specificity 90%). Conclusion This score can aid clinicians in deciding an appropriate route of antibiotics for UTI/pyelonephritis in children aged 12m-18y.

Background Febrile UTI/pyelonephritis is a common diagnosis for children presenting to the Emergency Department (ED). A Cochrane review of the management of pyelonephritis in children showed no difference between intravenous (IV) and oral antibiotics. Despite this, many children are treated with at least initial IV antibiotics. The reasons are often unclear and it is uncertain whether this is appropriate as the Cochrane review excluded children at the worse end of the clinical spectrum. Our aim was to determine why physicians made these decisions as a first step in determining whether this is necessary. Methods A prospective observational study of children presenting to the ED at the Royal Children’s Hospital with UTI/pyelonephritis from Oct 2016 – Apr 2017. Data collection included demographic, clinical features, microbiology, treatment and outcomes. ED physicians were asked to record reasons for prescribing IV antibiotics and for treating the patient in hospital vs. in hospital-in-the-home (HITH). Results 170 children were included, 123 (72%) were treated with oral antibiotics, 43 (25%) IV and 4 (3%) intramuscular – these are now included in the IV group. In the IV group, 32 (19%) were admitted, 3 (2%) were transferred directly to HITH from ED and 13 had a single dose of IV antibiotics in ED and were discharged. A comparison of the clinically significant features between the two groups is outlined (Table 1). The commonest reasons cited for using IV antibiotics and for hospital admission vs. HITH is shown (fig 1 and 2). Conclusion This is the first study of decision-making for IV antibiotics and hospital admission for UTI/pyelonephritis in children. The fact that the reasons cited for IV antibiotics were often not evident on objective clinical data suggests that there may be overuse of IV antibiotics. We will present an assessment of appropriateness and suggest alternatives to the traditional IV and hospital admission route. Disclosures All authors: No reported disclosures.

Background A 2014 Cochrane review of acute UTI/pyelonephritis in children reported no difference between intravenous (IV) and oral (PO) antibiotics and the AAP recommends the routes as equally efficacious. Despite this, many children continue to be treated with IV antibiotics, with the appropriateness of this unclear. The Cochrane review was based on studies that excluded children with features including vomiting, urological abnormality, previous UTI, or pre-treatment with antibiotics. We aimed to compare: PO vs. IV antibiotics; 1 vs. 2–3 days IV antibiotics; and all patients compared with those in the Cochrane review. Methods A prospective observational study of children presenting to the ED at a tertiary children’s hospital in Australia with UTI/pyelonephritis from May 2016 to November 2017. Data included demographic, clinical features, microbiology, treatment and outcomes. Key features and outcomes were compared. Results Of 541 children, 378 (70%) received PO antibiotics and 163 (30%) IV/IM. Patients were significantly more likely to receive IV antibiotics if they presented with fever, vomiting, rigors or lethargy, had a history of previous UTI, or were pre-treated with PO antibiotics (P < 0.05). Of those treated with IV antibiotics, the majority received 1 (38%) or 2 (36%) days prior to PO switch. The only difference in those treated at with 1-day vs. 2–3 days of IV antibiotics was the proportion receiving maintenance IV fluids (table). A substantial number of our patients (n = 390, 72%) had a urological abnormality, vomiting, previous UTI or were pre-treated with PO antibiotics and therefore the Cochrane recommendations are not applicable. Table: 1 vs. 2–3 days IV antibiotics 1 day IV 2–3 days IV P values No. (%) No. (%) Total patients 64 (39) 74 (45) Age Mean 4.8 4.3 0.55 Fever 52 (81) 61 (80) 0.88 Vomiting 29 (45) 45 (59) 0.10 Urological abnormality 9 (15) 19 (26) 0.12 Maintenance fluids 13 (21) 33 (45) 0.003 Readmission 5 (8) 3 (4) 0.47 Conclusion Patients treated with initial IV appear different from those treated with PO antibiotics. However, 1 vs. 2–3 days IV appeared to be similar, suggesting an opportunity for shortening duration. We have provided the first prospective data since the Cochrane review in patients not included in it, showing the gap in evidence. Disclosures All authors: No reported disclosures.

A previously healthy 6-year-old boy presented with a 2-week history of vague pain in his abdomen, arm, neck and legs, which became more localised to the right side of the neck and right tibial plateau. Over the 6 days prior to admission, nocturnal bone pain was recorded. He was also lethargic, irritable and felt warm; however, temperature >37.7°C was not documented. Intermittent limping was reported. Physical examination was unremarkable, apart from exquisite tenderness on right tibial tuberosity and severe neck …