This survey was sent only to EIN members with a pediatric infectious diseases practice.

Infectious Diseases Society of America Emerging Infections Network Report for Query: Pediatric Outpatient Parenteral Antibiotic Therapy (OPAT) Overall response rate: 188/281 (66.9%) physicians responded from 05//12 to 06/13/12. Note: Not all respondents answered all questions, so totals for individual questions vary. This survey was sent only to EIN members with a pediatric infectious diseases practice. Responders as percent of overall members in each category: Region: New England 6 (50% of 12 members) Mid Atlantic 22 (59% of 37 members) East North Central 23 (64% of 36 members) West North Central 11 (73% of 15 members) South Atlantic 41 (77% of 53 members) East South Central 12 (57% of 21 members) West South Central 11 (52% of 21 members) Mountain 17 (77% of 22 members) Pacific 40 (71% of 56 members) Puerto Rico 0 (of 1 member) Canada 5 (71% of 7 members) Years experience since ID fellowship: <5 years 33 (55% of 60 members) 5-14 62 (65% of 96 members) 15-24 55 (79% of 70 members) 25 38 (69% of 55 members) Employment: Hospital/clinic 53 (68% of 78 members) Private/group practice 23 (79% of 29 members) University/medical school 109 (66% of 6 members) Military 0 (of 2 members) State gov t 3 (50% of 6 members) Primary hospital type: Community Non-university teaching University Military City/county Other 13 (87% of 15 members) 61 (75% of 81 members) 112 (63% of 178 members) 0 (of 2 members) 2 (100% of 2 members) 0 (of 3 members) *Respondents were significantly more likely than non-respondents to have at least 15 years of ID experience (p=0.037). Respondents were significantly more likely than non-respondents to practice in a community hospital (p=0.0035). Page 1

Characteristics of OPAT Practice Question 1. At your institution, does the pediatric ID service decide who should receive OPAT? manage patients receiving OPAT? Never 2 (1%) 6 (4%) Rarely 6 (4%) 6 (4%) Sometimes to usually 130 (77%) 118 (72%) Always 30 (18%) 34 (20%) Question 2. Is ID consultation mandatory to initiate OPAT regardless of who follows the patient as an outpatient? No 147 (89%) Yes 19 (11%) Question 3. Number of patients receiving OPAT per month managed by you/members of your group: 47 33 30 57 21 Answer categories None <2 2-5 6-10 >10 Number of respondents choosing each category is shown Note: The 30 members who do not manage OPAT concluded the survey here and are excluded from further analysis. Page 2

Question 4. Frequency with which you initiate OPAT or manage patients receiving OPAT with the following indications: Rarely/Never Sometimes Frequently Cystic fibrosis pulmonary 120 25 9 UTI/pyelonephritis 106 39 10 Intra-abdominal infection 80 Complicated skin/soft tissue infection 80 55 19 CLABSI 55 70 32 Pneumonia (not cystic fibrosis) 49 68 40 CNS infection 52 59 44 Endovascular infection/endocarditis 42 65 49 Osteomyelitis/septic arthritis 32 110 Number of respondents shown for each category OTHER indications: Hardware infections / orthopedic hardware infections (by 3), Febrile neutropenia (by 2), Lyme disease (by 2), Orthopedic wound or postop infection (by 2); 1 each: chronic otorrhea, congenital CMV or herpes, neurosyphilis, orbital cellulitis, mastoiditis, pyogenic liver abscess, sinusitis, transplant CMV infection Question 5. Frequency with which you use the following antibiotics for OPAT: Rarely/Never Sometimes Frequently Piperacillin/tazobactam 62 76 A carbapenem 72 60 20 Nafcillin/oxacillin 69 27 Clindamycin 60 45 48 Vancomycin 28 76 53 Cefazolin 40 Ceftriaxone 14 61 82 Number of respondents shown for each category OTHER antibiotics: penicillin (by 3), ampicillin (by 2), cefepime (by 2), daptomycin (by 2), linezolid (by 2), aminoglycoside / gentamicin (by 2); 1 each: acyclovir, amphotericin B, antifungals in heme/onc, doxycycline, ertapenem, levofloxacin, ceftazidime, meropenem Page 3

Question 6. Estimation of the percentage of patients that experience OPAT-related complications of any type (e.g., line or drug-associated): 0-5% 40 (26%) 6-10% 64 (41%) 11-25% 41 (26%) 26-50% 11 (7%) >50% 0 Resources for OPAT Question 7. Do you have AND use any of the following resources at your institution? No Yes Team for PICC placement 10 (6%) 145 (94%) IDSA s OPAT guideline 81 (52%) 76 (48%) Nurse / other health professional to manage OPAT 89 (57%) 68 (43%) Infusion center 103 (66%) 54 (34%) Local OPAT guideline 129 (82%) 28 (18%) Question 8. Revenue sources that help support management of OPAT: [Instructions were to check all that apply; numbers add to more than 100%] [157 respondents] Do not know 50 (32%) Outpatient visit charges 80 (51%) Inpatient consult charges 56 (36%) Support from hospital or health care system 28 (18%) Support from home care agency 19 (12%) None / not financially supported (added to open text field) 8 (5%) Income from infusion center 7 (4%) Vignette: A hospitalized patient with methicillin-sensitive S. aureus osteomyelitis and bacteremia, who has undergone surgical debridement, is responding well to intravenous antimicrobial therapy, whose bacteremia has cleared rapidly with therapy, and whose isolate is susceptible to oral agents. Question 9. For this patient, how often do you do the following? Rarely Sometimes Usually a. Discharge with OPAT for a period of time before 34 (23%) 56 (38%) 59 (39%) transitioning to oral antibiotics b. Use OPAT to complete the entire course of therapy 94 (65%) 36 (25%) 14 (10%) c. Discharge with oral antibiotics and do not use OPAT 45 (30%) 48 (32%) 56 (38%) Question 10. For this patient, how would the following have altered your likelihood of using OPAT? Less likely As likely More likely a. If the isolate was methicillin-resistant S. aureus 14 (9%) 91 (%) 50 (33%) b. If the bone and blood cultures were negative 54 (35%) 63 (42%) 36 (23%) Page 4

Question 11. To what extent are the following factors important considerations in your decision to use or not use OPAT for treatment of osteomyelitis? Compliance - home environment, tolerate PO Evidence of parenteral vs oral therapy efficacy Adequacy of surgical drainage/debridement Resources/staffing for f-up, monitoring Patient age Presence of bacteremia Failure to identify an organism Cost of OPAT vs oral therapy Insurance coverage/home care availability 4.5 4.3 3.97 3.8 3. 3.56 3.19 3.06 3.04 Mean Median 0 2 4 6 Not important Very important OTHER factors: capability/ability of parents/personnel at home to learn IV med administration (by 2), trend of CRP response/inflammatory markers and clinical response (by 2), type/site of infection (by 2), duration of bacteremia (by 2); 1 each: comorbidities, drug that can be given tid or less frequently, education level of parent, geographic of patient which impacts availability of resources (many rural and remote patients), location of the osteo in relation to blood supply to the bone, oral alternative bioavailability for microbe, other subspecialist input, patient weight, pharmacokinetics/dynamics of appropriate agent, presence of venous thrombosis, resistance pattern, severity of inflammation and degree of illness. Question 12. Would you be interested in participating in a more detailed multi-center descriptive study of OPAT use in pediatrics? No 66 (41%) Yes 96 (59%) Comments: Might be interested / depends on how complicated (by 2); Delighted to participate (by 3); Great question but unfortunately no resources/staff to identify and collate cases at our institution and sadly our salaries/promotion are directly tied to performance either in $ or papers generated; We would be happy to consider participating in the study, but there is no central information source of who gets it and who does not; We do not keep specific records on all the patients receiving OPAT that we monitor and other services also monitor OPAT for their own patients so a study of this practice would be difficult at our institution; We are currently reviewing our data, so if overlap helpful would contribute Page 5