Improving the Transition of Intravenous to Enteral Antibiotics in Pediatric Patients with Pneumonia or Skin and Soft Tissue Infections

Intravenous antibiotics for urinary tract infections in children with neurologic impairment

BACKGROUND

Children with high-intensity neurologic impairment (HINI) have an increased risk of urinary tract infection (UTI) and prolonged intravenous (IV) antibiotic exposure.

OBJECTIVE

To determine the association between short (≤3 days) and long (>3 days) IV antibiotic courses and UTI treatment failure in hospitalized children with HINI.

METHODS

We performed a retrospective cohort study examining UTI hospitalizations at 49 hospitals in the Pediatric Health Information System from 2016 to 2021 for children (1-18 years) with HINI. The primary outcome was UTI readmission within 30 days. Our secondary outcome was the association of hospital-level variation in short IV antibiotic course use with readmission. Readmission rates were compared between short and long courses using multivariable regression.

RESULTS

Of 5612 hospitalizations, 3840 (68.4%) had short IV antibiotic courses. In our adjusted model, children with short IV courses were less likely than with long courses to have a 30-day UTI readmission (4.0%, 95% CI [3.6%, 4.5%] vs. 6.3%, 95% CI [5.1%, 7.8%]). Despite marked hospital-level variation in short IV course use (50.0%-87.5% of hospitalizations), there was no correlation with readmissions.

CONCLUSIONS

Children with HINI hospitalized with UTI had low UTI readmission rates, but those who received long IV antibiotic courses were more likely to experience UTI readmission versus those receiving short courses. While residual confounding may influence our results, we did not find that short IV courses impacted readmission at the hospital level despite variation in use across institutions. Long IV antibiotic courses are associated with risks and may not confer benefit in this population.

Increasing the Use of Enteral Antibiotics in Hospitalized Children With Uncomplicated Infections

BACKGROUND

Route of administration is an important component of antimicrobial stewardship. Early transition from intravenous to enteral antibiotics in hospitalized children is associated with fewer catheter-related adverse events, as well as decreased costs and length of stay. Our aim was to increase the percentage of enteral antibiotic doses for hospital medicine patients with uncomplicated common bacterial infections (community-acquired pneumonia, skin and soft tissue infection, urinary tract infection, neck infection) from 50% to 80% in 6 months.

METHODS

We formed a multidisciplinary team to evaluate key drivers and design plan-do-study-act cycles. Interventions included provider education, structured discussion at existing team huddles, and pocket-sized printed information. Our primary measure was the percentage of antibiotic doses given enterally to patients receiving other enteral medications. Secondary measures included antibiotic cost, number of peripheral intravenous catheters, length of stay, and 7-day readmission. We used statistical process control charts to track our measures.

RESULTS

Over a 6-month baseline period and 12 months of improvement work, we observed 3183 antibiotic doses (888 in the baseline period, 2295 doses during improvement work). We observed an increase in the percentage of antibiotic doses given enterally per week for eligible patients from 50% to 67%. We observed decreased antibiotic costs and fewer peripheral intravenous catheters per encounter after the interventions. There was no change in length of stay or readmissions.

CONCLUSIONS

We observed increased enteral antibiotic doses for children hospitalized with common bacterial infections. Interventions targeting culture change and communication were associated with sustained improvement.

Modalities of group A streptococcal prevention and treatment and their economic justification

Infection by group A Streptococcus (Strep A) results in a diverse range of clinical conditions, including pharyngitis, impetigo, cellulitis, necrotising fasciitis, and rheumatic heart disease. In this article, we outline the recommended strategies for Strep A treatment and prevention and review the literature for economic evaluations of competing treatment and prevention strategies. We find that most economic evaluations focus on reducing the duration of illness or risk of rheumatic fever among people presenting with sore throat through diagnostic and/or treatment strategies. Few studies have evaluated strategies to reduce the burden of Strep A infection among the general population, nor have they considered the local capacity to finance and implement strategies. Evaluation of validated costs and consequences for a more diverse range of Strep A interventions are needed to ensure policies maximise patient outcomes under budget constraints. This should include attention to basic public health strategies and emerging strategies such as vaccination.

Correlation Analysis of Chaige Qinlian Decoction and Acupuncture Combined Intervention on Prognosis of Children with Pneumonia

Background

Traditional Chinese medicine (TCM) treatment is of great importance to improve the clinical symptoms of children with pneumonia, and this study was conducted in this context.

Methods

The clinical data of 82 child patients with pneumonia admitted to our hospital from February 2019 to February 2020 were retrospectively analyzed, and the patients were divided into the conventional group and the combined group according to the parity of their admission numbers, with 41 cases each. Conventional Western medicine therapy was given to children in the conventional group, and on this basis, acupuncture combined with Chaige Qinlian decoction was performed on children in the combined group, so as to evaluate the clinical application value of combined treatment and analyze its relationship with prognosis by recording the recovery time of each symptom, serum indicators, and immune indicators.

Results

Children in the combined group had significantly shorter recovery time of each symptom and lower mean CPIS scores after treatment than the conventional group (P < 0.001); the TCM symptom scores at T1 (1 d after treatment), T2 (3 d after treatment), T3 (7 d after treatment), and T4 (10 d after treatment) of children in the combined group were significantly higher than those in the conventional group (P < 0.05); various immune indicators of the combined group before and after treatment were significantly different (P < 0.001), and after treatment, the combined group obtained significantly higher IgG levels and lower IgA, complement C3, and complement C4 levels than the conventional group (P < 0.001); and there was a positive correlation between the CPIS scores and serum IL-8, IL-6, and CRP levels at the first day (r = 0.706, 0.712, 0.734, P < 0.001).

Conclusion

Acupuncture combined with Chaige Qinlian decoction can effectively shorten the course of disease, reduce the levels of serum inflammatory factors, and improve the immune function of body for child patients with pneumonia. Serum IL-8, IL-6, and CRP levels in child patients can reflect the clinical prognosis, with higher levels indicating worse prognosis.

Impact of Antimicrobial Stewardship Bundle on Inpatient Use of Highly Bioavailable Antibacterials

OBJECTIVES

Intravenous (IV) to enteral transition of highly bioavailable antibacterial drugs is associated with improved safety and lower cost. We evaluated the impact of a bundle of stewardship-driven interventions (including in-person stewardship rounding, clinical pathways, and clinical pharmacist-driven enteral transition workflows) on IV versus enteral administration of highly bioavailable antibacterials at a freestanding children's hospital.

METHODS

We collected 2010-2018 inpatient usage data for clindamycin, levofloxacin, ciprofloxacin, metronidazole, rifampin, linezolid, and trimethoprim-sulfamethoxazole. We analyzed total use (in days of therapy [DOTs] per 1000 patient-days [PDs]) and the percentage of total use administered enterally, both hospital wide and stratified by unit subgrouping, specifically comparing use 1-year prestewardship implementation with year-5 postimplementation.

RESULTS

Across the 8-year study window, clindamycin, fluoroquinolones, and metronidazole, together, accounted for 96% of IV DOTs for highly bioavailable antibacterials. Overall, clindamycin use decreased from 44.4 to 20.2 DOTs per 1000 PDs (P < .001), with the enteral percentage of total use increasing from 23% to 43% (P < .001) hospital wide. Overall, fluoroquinolone use decreased from 33.7 to 19.3 DOTs per 1000 PDs (P < .001), with the enteral percentage increasing from 40.7% to 55.9% (P < .001). Overall, metronidazole use increased, and the enteral percentage decreased (42.0% to 33.7%; P = .007). Low-IV-use antibacterials (rifampin, linezolid, and trimethoprim-sulfamethoxazole) showed no significant changes in total use or the enteral percentage of total use.

CONCLUSIONS

Stewardship interventions were associated with decreased overall use and an increased enteral percentage of total use for both clindamycin and fluoroquinolones, although not metronidazole. These data provide an easy-to-collect benchmark for pediatric hospitals to compare IV with enteral use of highly bioavailable antibacterials within the context of overall antibacterial use.

Opportunities for Stewardship in the Transition From Intravenous to Enteral Antibiotics in Hospitalized Pediatric Patients

BACKGROUND/OBJECTIVE

Pediatric patients hospitalized with bacterial infections often receive intravenous (IV) antibiotics. Early transition to enteral antibiotics can reduce hospital duration, cost, and complications. We aimed to identify opportunities to transition from IV to enteral antibiotics, describe variation of transition among hospitals, and evaluate feasibility of novel stewardship metrics.

METHODS

This multisite retrospective cohort study used the Pediatric Health Information System to identify pediatric patients hospitalized with pneumonia, neck infection, orbital infection, urinary tract infection (UTI), osteomyelitis, septic arthritis, or skin and soft tissue infection (SSTI) between 2017 and 2018. Opportunity days were defined as days on which patients received both IV antibiotics and enteral medications, suggesting enteral tolerance. Percent opportunity was defined as opportunity days divided by days on any antibiotics. Both outcomes excluded IV antibiotics that have no alternative oral formulation. We evaluated outcomes per infection and antibiotic and assessed across-hospital variation.

RESULTS

We identified 88,522 aggregate opportunity days in 100,103 hospitalizations. On 57% of the antibiotic days, there was an opportunity to switch patients to enteral therapy, with greatest opportunity days in SSTI, neck infection, and pneumonia encounters, and with clindamycin, ceftriaxone, and ampicillin-sulbactam. Percent opportunity varied by infection (73% in septic arthritis to 40% in pneumonia). There was significant across-hospital variation in percent opportunity for all infections.

CONCLUSION

This multicenter study demonstrated the potential opportunity to transition from IV to enteral therapy in over half of antibiotic days. Opportunity varied by infection, antibiotic, and hospital. Across-hospital variation demonstrated likely missed opportunities for earlier transition and the need to define optimal transition times. Stewardship efforts promoting earlier transition for highly bioavailable antibiotics could reduce healthcare utilization and promote high-value care. We identified feasible stewardship metrics.