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

Abstract

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.

Reducing PICC Placement in Pediatric Osteomyelitis: A Diamond in the Deimplementation Rough?

“…The marked reduction in PICC placement should be celebrated but not met with complacency; current data continue to reveal wide variation in care patterns and opportunities for care improvement among children with osteomyelitis. 9,27 The rapid practice change observed in this study emphasizes the importance of longitudinal measurement of low-value services on a population basis. Regular measurement is needed to establish improvement targets and prioritize deimplementation initiatives.…”

“…"Opportunity days," defined as those during which patients received parenteral antibiotics and at least 1 enteral nonantibiotic medication (supporting the ability to tolerate oral medications), accounted for 69% of osteomyelitis patient days. 27 Although clinical improvement and downtrending inflammatory markers typically guide the transition to oral antibiotics, approaches to this process remain variable. 5,9,27 Continued assessment of the optimal duration of intravenous therapy may identify opportunities to further reduce LOS.…”

“…27 Although clinical improvement and downtrending inflammatory markers typically guide the transition to oral antibiotics, approaches to this process remain variable. 5,9,27 Continued assessment of the optimal duration of intravenous therapy may identify opportunities to further reduce LOS. Given that the cost of bed occupancy composes a majority of total hospitalization cost, 28 this is the most feasible route toward achieving cost reduction associated with the inpatient episode.…”

Missed Opportunities for Transitioning to Oral Antibiotic Therapy

“…Rather, prescribers should apply a structured approach, such as the “Four Moments of Antibiotic Decision Making,” on a daily basis for every hospitalized child receiving antibiotics to prompt timely decisions about discontinuing IV therapy, narrowing IV therapy, or transitioning from IV to oral antibiotic therapy 3 . We applaud Cotter et al for shedding light on an area in need of standardization of care, which could optimize patient outcomes and minimize harm for a large number of children 1 . The “percent opportunity” to switch from IV to oral antibiotic therapy is a promising antibiotic stewardship metric, and its association with clinical outcomes merits further investigation.…”

“…In this issue of the Journal of Hospital Medicine, Cotter et al used an administrative database to investigate opportunities to transition from IV to oral antibiotics for patients across multiple pediatric hospitals. 1 Their novel metric, "percent opportunity," represents the percent of days that there was the opportunity to transition from IV to oral antibiotics. They found that over 50% of the time, IV antibiotics could have been switched to equivalent oral agents.…”