Pathway for OPAT for children on once daily intravenous antibiotics

GGC Paediatric Guidelines
NHS GGC

Objectives

This pathway aims to facilitate and standardise OPAT provision for paediatric patients with complex infection treated with intravenous (IV) antibiotics. It should support the responsible clinical teams to manage their OPAT case load, improve communication with patients and their families, with primary and within secondary care, and facilitate standardised and consistent activity recording and clinical data capture. OPAT outcomes will be monitored and audited by the antimicrobial stewardship (AMS) team.

Outpatient parental antibiotic therapy (OPAT) is shown to be safe and effective for a wide range of infections in adults and children and is now a routine part of patient care in the UK. OPAT has many potential benefits. It allows earlier hospital discharge, moves patient care closer to home, and reduces the risk of hospital-acquired infections. Qualitative surveys have demonstrated increased patient satisfaction with paediatric OPAT in comparison with hospital-based care (1).

OPAT is a key component of the Scottish Government Interface Care Programme, which aims to safely provide an alternative to hospital admission or support early discharge.

The British Society of Antimicrobial Chemotherapy (BSAC) published updated good practice recommendations (GPR) for OPAT in adults and children in the UK in 2019 (2). These underpin the Scottish Antimicrobial Prescribing Group OPAT group key performance indicators (KPI), which aim to support optimum care for patients in Scotland accessing OPAT services. The GPRs and KPIs have informed development of this pathway.

The pathway aims to facilitate and standardise OPAT provision for paediatric patients with complex infection treated with intravenous (IV) antibiotics. It should support the responsible clinical teams to manage their OPAT case load, improve communication with patients and their families, with primary and within secondary care, and facilitate standardised and consistent activity recording and clinical data capture. OPAT outcomes will be monitored and audited by the antimicrobial stewardship (AMS) team.

Complex outpatient antimicrobial therapy (COpAT), defined as prolonged oral antimicrobial therapy with risk of significant side effects, requires regular patient monitoring. This is also included in the pathway.

Roles and responsibilities for OPAT

Responsible Clinical Team

Referral:

Discusses patient suitability for OPAT & treatment plan with the ID team (84939) (Box 1).

Ensures appropriate intravenous access (Box 2).

Discusses OPAT with patient & parents/carers, provides OPAT Patient Information Leaflet.

If parents/carers agree, completes Trakcare request ‘OPAT referral – paediatrics’.

Liaises with ward 1C (84400) on Monday to Friday, with CDU (84672/84670) on Saturday & Sunday, to ensure capacity for OPAT and arrange first appointment.

If patient accepted, asks the ward clerk/nursing colleagues on the ward to discharge the patient, asks the nursing team (ward 1C Mon-Fri or CDU Sat-Sun) to admit the patient to the ‘VIRTUAL ward OPAT-RHC’

On admission to the virtual ward, prescribes antibiotic and flush on HEPMA (Box 3)

Completes the patient-held OPAT plan, & parent/carer declaration.
Discusses follow-up arrangements, safety nets (Box 4).

Completes the discharge letter (IDL), including all oral medications (Box 5).

Marks patient as ‘OPAT’ on the team handover.

 

During OPAT:

Reviews patient at least once weekly, documents all clinical reviews on Clinical Portal.

Reviews patient at the end of treatment & arranges follow-up as required.

If cuffed CVL, refers to the line list for removal (Box 2).

 

Antimicrobial Stewardship (AMS) team

Does twice weekly AMS ward rounds (Monday & Thursday afternoons).
Reviews patients on intravenous antibiotics for 48 hours or more.

Identifies patients suitable for OPAT. Discusses suitability with the responsible clinical team, discusses OPAT treatment plans & facilitates admission to the virtual ward.

Does a weekly OPAT MDT - reviews treatment plans and results for all patients on the Trakcare ‘RHC OPAT’ virtual ward. Documents virtual reviews on Clinical Portal.
Liaises with the responsible clinical team, as appropriate.

Completes the IDL and outcomes patients on discharge from the Trakcare ‘RHC OPAT’ virtual ward.

Prospectively monitors OPAT outcomes.

 

Pharmacy team

Attends a weekly OPAT MDT.

Supports supply, prescribing and monitoring of antibiotics.

 

Ward 1C Nursing Team
Monday to Friday 8.30 – 16.00

Actions Trakcare referrals for ‘OPAT referrals – paediatrics’.
Admits patients to the ‘VIRTUAL ward OPAT-RHC’
Arranges appointment(s) for OPAT Monday to Saturday - Trakcare ‘RHC OPAT’ clinic.

At the first appointment:
‘Arrives’ the patient at the Trakcare ‘RHC OPAT’ clinic. 
Checks IV antibiotic & co-medications are prescribed on HEPMA (Box 2), if not, contacts the responsible to team to prescribe.

At each appointment:
‘Arrives’ the patient at the Trakcare ‘RHC OPAT’ clinic.
Temperature, heart rate, BP, respiratory rate, 02 saturations.
Checks intravenous access site.
Re-sites cannula if not working, liaises with responsible clinical team if unable to re-site/concerns about other venous access device.
Checks monitoring requirements – blood tests if required (Box 2).
Administers IV antibiotic.
Documents review on Clinical Portal.
Outcomes the patient on the Trakcare ‘RHC OPAT’ clinic.
Arranges next appointment.

Liaises with the responsible clinical team if:
Clinical or parental/carer concerns (e.g., patient unwell, suspected drug allergy).
Difficulties with intravenous access (including line removal).
Monitoring blood tests sent.

At the final appointment:
Liaises with the responsible clinical team - to review.
If PVC, midline, PICC or uncuffed CVL, removes in line with GG&C guideline.
If cuffed CVL refers to the responsible clinical team to arrange removal.
Discharges patient from the Trakcare ‘RHC OPAT’ virtual ward.

Attends weekly OPAT MDT.

 

CDU Nursing Team
Saturday, Sunday & bank holidays

Actions Trakcare referrals for ‘OPAT referrals – paediatrics’.
Admits patients to the ‘VIRTUAL ward OPAT-RHC’
Arranges appointment(s) for OPAT Sunday to Monday - Trakcare ‘RHC OPAT’ clinic.

At the first appointment:

‘Arrives’ the patient at the Trakcare ‘RHC OPAT’ clinic.
Checks IV antibiotic & co-medications are prescribed on HEPMA (Box 2), if not, contacts the responsible to team to prescribe.

At each appointment:
‘Arrives’ the patient at the Trakcare ‘RHC OPAT’ clinic.
Temperature, heart rate, BP, respiratory rate, 02 saturations.
Checks intravenous access site.
Liaises with responsible clinical team if concerns about cannula/other venous access device.
Blood test monitoring only if urgently required as communicated directly by the clinical team.
Administers IV antibiotic.
Documents review on Clinical Portal.
Outcomes the patient on the Trakcare ‘RHC OPAT’ clinic.
Arranges next appointment.

Liaises with the responsible clinical team if:
Clinical or parental/carer concerns (e.g., patient unwell, suspected drug allergy).
Difficulties with intravenous access (including re-siting cannula & line removal).
Monitoring blood tests sent.

At the final appointment:
Liaises with the responsible clinical team - to review.
Removes or appoints to clinic on ward 1C the next day for removal of venous access device.
If cuffed CVL, refers to the responsible clinical team to arrange removal.
Discharges patient from the Trakcare ‘RHC OPAT’ virtual ward.

Roles and responsibilities for COpAT

Responsible Clinical Team

Referral:

Discusses patient suitability for COpAT & treatment plan with the ID team (84939).
If on linezolid, refers to the RHC linezolid guideline.

Completes Trakcare request ‘OPAT referral – paediatrics’.

Liaises with ward 1C Mon-Fri (84400) or with CDU Sat-Sun (84672/84670) to arrange the first appointment for blood tests +/- clinical review.

If an inpatient, asks the ward clerk/nursing colleagues on the ward to discharge the patient, asks the nursing team (ward 1C Mon-Fri or CDU Sat-Sun) to admit the patient to the ‘VIRTUAL ward OPAT-RHC’.

Discusses follow-up arrangements with the patient, parents/carers, safety nets (Box 4).
If on linezolid, provides the patient information leaflet.

If an inpatient, completes the discharge letter (IDL), including all oral medications (Box 5).

Marks patient as ‘COpAT’ on the team handover.

 

During COpAT:

Arranges blood tests +/- clinical review at least once weekly, documents all clinical reviews on Clinical Portal.

Reviews patient at the end of treatment & arranges follow-up as required.

 

Antimicrobial Stewardship (AMS) team

Does a weekly COpAT MDT - reviews treatment plans and results for all patients on the Trakcare ‘RHC OPAT’ virtual ward. Documents virtual reviews on Clinical Portal.
Liaises with the responsible clinical team, as appropriate.

Completes the IDL and outcomes patients on discharge from the Trakcare ‘RHC OPAT’ virtual ward.

Prospectively monitors COpAT outcomes.

 

Pharmacy team

Attends a weekly COpAT MDT.

Supports supply, prescribing and monitoring of antimicrobials.

 

Nursing teams (Ward 1C & CDU)

Ward 1C Monday to Friday 8.30 – 16.00
CDU Saturday, Sunday and bank holidays

Actions Trakcare referrals for ‘OPAT referrals – paediatrics’.
Admits patients to the ‘VIRTUAL ward OPAT-RHC’
Arranges appointment(s) for monitoring (Monday - Friday only) - Trakcare ‘RHC OPAT’ clinic.

At each appointment:
‘Arrives’ the patient at the Trakcare ‘RHC OPAT’ clinic. 
Checks monitoring requirements, as per the referral.
Documents review/monitoring performed on Clinical Portal.
Outcomes the patient on the Trakcare ‘RHC OPAT’ clinic.
Arranges next appointment.

Liaises with the responsible clinical team if:
Clinical or parental/carer concerns (e.g., patient unwell, suspected drug allergy).
Monitoring blood tests sent.

At the final appointment:
Liaises with the responsible clinical team.
Discharges patient from the Trakcare ‘RHC OPAT’ virtual ward.

Attends weekly COpAT MDT (Ward 1C only).

Appendix

Box 1. OPAT criteria

Clinical:

  • Clinically stable (PEWS < 3)
  • Parents/carers and nursing staff have no clinical concerns
  • No need for hospital-based care apart from administration of parenteral antibiotic
  • Treatment plan agreed with responsible consultant & the AMS team

Social:

  • The family has access to transport & can attend the hospital daily
  • There are no child protection concerns

Carer:

  • Understands the commitment and responsibility needed for OPAT
  • Can look after their child’s cannula or other venous access device
  • Understands safety netting instructions; when and how to re-present, including out-of-hours

 

Box 2. Intravenous access device

If patients are likely to require more than 7 days of intravenous antibiotics, please email Dr Phil Bolton and Dr Zuzana Kusnirikova to discuss the most appropriate venous access device and placement.

Please see the GG&C guideline for advice on trouble shooting & removal.

Anything less than a 4Fr line should not be used for blood sampling.

 

Box 3. Treatment recommendations

Antibiotic: according to clinical indication & as discussed with AMS team, include a stop date.

Please also prescribe:

  • 0.9% sodium chloride flush (5ml IV)
  • Heparin sodium flush (50 units in 5ml, 1ml IV)

Monitoring:

  • If more than 7 days parenteral antibiotic – minimum once weekly medical review, weekly FBC, UE, LFT, CRP.

 

Box 4. Safety netting:

Advice provided in the Patient Information Leaflet, to highlight:

Advise parents on safe care of the venous access device, to avoid getting it wet.

Advise parents to monitor for pain, redness or swelling at the venous access site.

If venous access is lost at home, but the child is otherwise well, advise to apply a plaster and to attend the ward as planned.

If concerns but the parent/carer does not think that the child needs urgent medical attention, advise to call the RHC switchboard (0141 2010000) and to ask to speak to the on-call registrar for the team looking after their child (as detailed in the patient-held plan).

Advise to call 999/attend ED if the child is seriously unwell, has RED signs:

  • Has blue lips, is pale, mottled (blotchy) or feels cold to touch
  • Is finding it very hard to breathe - grunting, or is too breathless to talk or feed
  • Has a fit / seizure
  • Is not responding, is hard to wake or cannot stay awake, is confused, or agitated
  • Has a weak, high-pitched, or constant cry
  • Has a rash that does not go away when you press on it (do the Glass Test)
  • Has neck stiffness (doesn’t want to move their head) and/or a bulging ‘soft spot’

Ensure parent/carer has the OPAT patient information leaflet and a completed patient-held OPAT plan, has signed the parent/carer declaration, prior to OPAT start.

Put the signed parent/carer declaration in the clinical notes.

 

Box 5. Information required on the IDL at time of hospital discharge/admission to OPAT

  • Diagnosis
  • Intravenous access device (if CVL – whether it is cuffed)
  • OPAT treatment plan – proposed duration of intravenous antibiotic
  • Date of first clinical review whilst on OPAT
  • Details of monitoring required whilst on OPAT
  • Any concerns/special circumstances that may affect OPAT
  • Any planned follow-up (e.g. with other teams)

Parent information and forms

Paediatric outpatient parenteral antibiotic therapy (pOPAT) Parent information leaflet (pdf)

pOPAT patient-held plan (pdf)

pOPAT parent/carer declaration (pdf)

Editorial Information

Last reviewed: 17/07/2025

Next review date: 01/12/2025

Author(s): Dr Katherine Longbottom, Consultant General Paediatrics and Paediatric Infectious Diseases.

Author email(s): Katherine.longbottom@ggc.scot.nhs.uk.

Co-Author(s): Dr Louisa Pollock, Consultant General Paediatrics and Paediatric Infectious Diseases, Dr Conor Doherty, Consultant Paediatric Infectious Diseases & Immunology.

Approved By: Paediatric Guideline Group / Antimicrobial Therapy Team

References
  1. Carter B, Fisher-Smith D, Porter D, Lane S, Peak M, Taylor-Robinson D, et al. Paediatric Outpatient Parenteral Antimicrobial Therapy (OPAT): An e-survey of the experiences of parents and clinicians. PLoS One [Internet]. 2021 [cited 2023 May 28];16(4):e0249514. 
  2. Chapman ALN, Patel S, Horner C, Green H, Guleri A, Hedderwick S, et al. Updated good practice recommendations for outpatient parenteral antimicrobial therapy (OPAT) in adults and children in the UK. JAC-Antimicrobial Resist [Internet]. 2019 Sep 1 [cited 2023 Jan 21];1(2).