December 2016/January 2017

Trio of Studies Shows Oral Antibiotics Are As Good As IV Antibiotics After Discharge

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When a family takes a child home from the hospital after treatment for a serious infection, some worrying about how well and how quickly the child will recover may be inevitable. But families may find some reassurance in the new knowledge that if their child has a prescription for oral antibiotics, they are receiving sound medicine.

For the most serious infections, instead of oral antibiotics, which are easy and safe to take at home, some doctors prefer to prescribe continued intravenous (IV) antibiotics inserted through a peripherally inserted central catheter (PICC) line. Because they tap directly into the circulatory system, PICC lines offer maximum drug delivery. But they also require significant maintenance by caregivers and come with risks of dangerous complications, like infection, clotting, and dislodgement. Many clinicians have wondered but for a long time lacked a solid answer to the question: Are IV or oral antibiotics better for use at home?

“Oral antibiotics work just as well and have far fewer complications. You get a lot of complications from the PICC line,” said Ron Keren, MD, MPH, an attending physician, vice president of quality, and chief quality officer at Children’s Hospital of Philadelphia.

That is the bottom line from a set of three large, rigorous, multi-institution studies for which Dr. Keren was principal investigator. The research, funded by the Patient-Centered Outcomes Research Institute (PCORI), included data about children hospitalized for each of three types of serious infections that require a long-term course of antibiotics. Data came from the Pediatric Health Information System® database of the Children’s Hospital Association. The research team, including co-leaders Samir Shah, MD, MSCE, director of the division of Hospital Medicine at Cincinnati Children’s Hospital; Shawn Rangel, MD, MSCE, a surgeon at Boston Children’s Hospital; and Rajendu Srivastava, MD, MPH, assistant  vice president of research at Intermountain Healthcare; organized a massive chart review across the 36 hospitals whose records were included. The review ensured that their database accurately and consistently captured essential details about the antibiotic delivery method each child received and key variables such as complications for children who had all three types of infections they studied.

Dr. Keren’s analysis of bone infections, called acute osteomyelitis, was completed first and published in JAMA Pediatrics in 2015. Dr. Rangel’s analysis of complicated appendicitis — cases with a perforated appendix, not just routine appendectomies — was published in Annals of Surgery in July 2016. And the final word on this set of studies came with Dr. Shah’s analysis of complicated pneumonia, published early online in Pediatrics in November 2016. The three analyses consistently showed that oral antibiotics were safe and effective, while IV antibiotics came with risks of complications.

“That’s what we hypothesized, but we needed to do a study to prove to physicians that they should feel comfortable transitioning kids to oral antibiotics after they’ve received an adequate IV course in the hospital,” said Dr. Keren, who is also a professor of Pediatrics at the Perelman School of Medicine at the University of Pennsylvania.

Parents should also know that they have other options that are effective and less risky than IV antibiotics at home, and discuss those options with their child’s doctor.

Fortunately, the researchers found that in the case of complicated appendicitis, prescribing IV antibiotics had already declined to a low rate by the time of the study. However, PICC lines remained common in acute osteomyelitis and moderately so in complicated pneumonia.

The researchers found that there was a high degree of variability between hospitals in the type of antibiotics they prescribed at discharge for children with serious infections, though not much variability within each hospital. Some hospitals regularly prescribed IV antibiotics at high rates, while some rarely did so, and others fell somewhere in the middle. Dr. Keren said that he and his collaborators hope to work with the Children’s Hospital Association to share data through their quality and safety programs. When hospitals and physicians see their performance and how their prescribing rate compares to recommended practices, they are likely to change their practices. Dr. Keren was part of a team at CHOP that demonstrated this principle in improving antibiotic prescribing for common infections in primary care.

As for why physicians might have missed the non-trivial rate of complications among their patients who received IV antibiotics at home after discharge, the structure of the healthcare system may be to blame.

“This is likely a symptom of the fragmentation of the way that healthcare is delivered,” Dr. Keren said. “If the same doctor who put in the PICC lines, with the best of intentions thinking it’s the best way to get antibiotics to kids with serious infections, then kept seeing that 16 percent of the time the same patients kept coming back with problems, they would notice. But there is often no feedback loop to that provider if parents show up in the emergency department or kids are readmitted to the hospital weeks later.”

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