Discussion

This study describes the role of ASP review of pediatric OPAT orders at our institution and highlights the opportunity for other ASP programs to implement a similar practice to optimize OPAT orders. Broad-spectrum gram-negative agents were significantly associated with a higher odds of intervention by the ASP when used for OPAT, even when inpatient use of these medications had been previously reviewed by the ASP. This may be due to specific intervention opportunities available for agents within this category. For example, cefepime and piperacillin-tazobactam were frequently changed from intermittent to prolonged infusion to optimize pharmacokinetics and promote ease of administration. These findings underscore the importance of discharge antimicrobial stewardship, even at institutions with robust inpatient stewardship processes.

Compared to earlier reports of pediatric OPAT utilization, we found little use of OPAT for either osteoarticular infections or pneumonia. ^{Reference Madigan and Banerjee6,Reference Goldman, Richardson and Newland7} This is likely driven by contemporary literature supporting the use of enteral agents for these indications. ^{Reference Keren, Shah and Srivastava9} Importantly, we found that prophylaxis was the second most common indication for OPAT. Orders for prophylaxis were per protocol as supportive care for patients with acute lymphoblastic leukemia and lymphoma (eg, caspofungin antifungal prophylaxis). There was no statistically significant difference in the rate of ASP intervention for these OPAT prescriptions. ASP review of all prescriptions may be beneficial, particularly at centers with large numbers of immunocompromised children.

Only 55% of OPAT orders in this study were associated with an ID consultation, despite IDSA guidelines recommending one for all OPAT courses. ^{Reference Norris, Shrestha and Allison3} Though ID consultation has been noted to improve outcomes with OPAT orders, in our study, it did not affect whether OPAT recommendations were made by the ASP at the time of discharge. ^{Reference Conant, Erdman and Osterholzer10} Similarly, prior inpatient PAF of OPAT orders was not associated with lower rates of ASP recommendation, highlighting unique opportunities for ASP review of discharge OPAT prescriptions.

Our study had a higher rate of ASP recommendations (68%) than previously published. ^{Reference Hersh, Olson and Stockmann5} Most ASP recommendations were for care coordination, a recommendation category not captured in prior studies. Although these recommendations were primarily for additional outpatient monitoring, 20% were to discontinue unnecessary lab monitoring. ASP review of OPAT orders may be the only opportunity to ensure appropriate toxicity monitoring plans for the outpatient setting.

This was a single-center study, which limits the generalizability of our findings to other institutions. Only OPAT orders through CHP (90% of total orders) were captured in this study. A formal power calculation was not performed, and the study sample size was small. As a result, some confidence intervals within the multivariate logistic regression analysis were markedly wide, making it difficult to draw definitive conclusions.

Our study demonstrates that ASP review of discharge orders can potentially improve the quality of OPAT prescribing, even for patients followed by ID, and should be considered by pediatric ASPs. Prospective studies with larger sample sizes and that assess clinical outcomes are needed to better characterize the impact of this intervention in pediatric patients.