Pneumonia: Children Should Get Oral Antibiotics at Discharge

Troy Brown, RN

November 17, 2016

Most children with complicated pneumonia should be treated with oral antibiotics at discharge, instead of intravenous antibiotics, a new multicenter retrospective cohort study has found.

"Differences in treatment failure rates between [peripherally inserted central catheter (PICC)] and oral antibiotic recipients were not significant. However, adverse drug reactions and PICC-associated complications contributed to the higher rates of reutilization among PICC antibiotic recipients," the researchers write.

Samir S. Shah, MD, MSCE, from the Division of Hospital Medicine and the Division of Infectious Diseases, Cincinnati Children's Hospital Medical Center, and the Department of Pediatrics, University of Cincinnati College of Medicine, both in Ohio, and colleagues report their findings on behalf of the Pediatric Research in Inpatient Settings Network in an article published online November 17 in Pediatrics.

The study included 2123 children aged between 2 months and 17 years who were discharged with a diagnosis of complicated pneumonia between 2009 and 2012. The main exposure was the route of antibiotic administration after discharge, which the researchers classified as PICC (n = 281) or oral (n = 1842).

The study's primary outcome was treatment failure, defined as a revisit to the emergency department or rehospitalization during which the child's antibiotic therapy was extended or changed or the patient underwent pleural drainage.

Treatment failure occurred in 57 children overall (2.7%), including 3.2% of children who received PICC antibiotic therapy, and in 2.6% of children who received oral antibiotic therapy.

The risk for treatment failure was not significantly different between the two groups after matching for patient-level covariates including age, race, insurance, length of stay in days, blood culture results (culture negative vs culture positive), intensive care unit admission, and timing and route of pleural drainage, and there were no significant differences in failure rates between the PICC and oral antibiotic groups (matched odds ratio [OR], 1.26; 95% confidence interval [CI], 0.54 - 2.94).

However, secondary outcomes, which included adverse outcomes, favored oral antibiotics vs intravenous treatment. PICC complications occurred in 20 children (7.1%) and included PICC thrombosis, resulting in malfunction (n = 11), PICC dislodgement or breakage (n = 4), insertion site cellulitis (n = 1), and fever requiring evaluation (n = 1).

Overall, 13 children (0.6%) experienced adverse drug reactions: rash (n = 6), abdominal pain (n = 2), serum sickness (n = 1), drug-induced neutropenia (n = 1), drug fever (n = 1), heparin-induced thrombocytopenia (n = 1), and joint pain (n = 1).

Children who received PICC antibiotics were much more likely to experience an adverse drug reaction across hospital-matched analysis (matched OR, 19.1; 95% CI, 4.2 - 87.3).

The composite outcome of all related revisits among children who received PICC antibiotics was higher compared with that for those who received oral antibiotics (matched OR, 4.71; 95% CI, 2.97 - 7.46). The "high rate of PICC complications and differences in adverse drug reactions," likely contributed to this, the authors write.

The differences in types of antibiotics used, as opposed to the route of administration, may also have played a role in differences in adverse drug reaction rates between those who received PICC compared with those who received oral antibiotics, they add.

"We found substantial variation in PICC use in children with complicated pneumonia. Although patient and disease characteristics contribute to such variation, clustering of treatment strategies by hospital suggests that institutional factors are major determinants of care practices," the researchers explain. "Highlighting these differences in PICC use is a first step toward reducing unwarranted variation."

"Although antibiotics via PICC may be appropriate for select patients, our study highlights the importance of preferentially treating children with complicated pneumonia with oral antibiotics at discharge when effective oral options are available," the researchers conclude.

The authors have disclosed no relevant financial relationships.

Pediatrics. Published online November 17, 2016. Abstract

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