Trends in Use of Postdischarge Intravenous Antibiotic Therapy for Children

Abstract

Children with complicated appendicitis, osteomyelitis, and complicated pneumonia have historically been treated with postdischarge intravenous antibiotics (PD-IV) using peripherally inserted central catheters (PICCs). Recent studies have shown no advantage and increased complications of PD-IV, compared with oral therapy, and the extent to which use of PD-IV has since changed for these conditions is not known. We used a national children’s hospital database to evaluate trends in PD-IV during 2000-2018 for each of these three conditions. PD-IV decreased from 13% to 2% (risk ratio [RR], 0.15; 95% CI, 0.14-0.16) for complicated appendicitis, 61% to 22% (RR, 0.41; 95% CI, 0.39-0.43) for osteomyelitis, and 29% to 19% (RR, 0.63; 95% CI, 0.58-0.69) for complicated pneumonia. Despite these overall reductions, substantial variation in PD-IV use by hospital remains in 2018.

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.…”

“…Fenster et al, using the Pediatric Health Information System database, identified a decrease in the percentage of patients with osteomyelitis treated with postdischarge intravenous antibiotics from 61% in 2000 to 22% in 2018. 9 Yi et al identified a decrease in PICC rates for children with osteomyelitis and septic arthritis from 56% in 2009-2012% to 26% in 2012-2015 at 2 large, freestanding children's hospitals. 7 The lower rates of PICC placement at the conclusion of the study period in the National Inpatient Sample data, as compared with those observed in freestanding children's hospitals, may be related to differential acuity between these samples, although further investigation into the drivers of these differences may be informative.…”

“…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.…”

National Trends of Acute Osteomyelitis and Peripherally Inserted Central Catheters in Children

“…These findings were corroborated in another study that revealed a consistent reduction in the use of intravenous antibiotics on discharge in children with osteomyelitis over an 18-year period. 37 The mounting evidence of improved outcomes with early transition to oral antimicrobial therapy demonstrates that despite the rise in acute osteomyelitis in children, national emphasis on value-driven clinical practices and quality improvement initiatives like "Choosing Wisely" may be associated with PICC placement reduction. 38 We found that overall LOS remained stable for acute osteomyelitis hospitalizations at 4.6 days, which is similar to the previous study in which researchers used the Kids' Inpatient Database.…”

Deimplementation of Established Medical Practice Without Intervention: Does It Actually Happen?

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In this edition of the Journal of Hospital Medicine, Fenster and colleagues evaluate the trend of postdischarge intravenous (IV) antibiotic therapy for children with osteomyelitis, complicated pneumonia, and complicated appendicitis. 1 Children requiring prolonged antibiotic therapy were historically discharged home with a peripherally inserted central catheter (PICC) for IV antibiotics. Recent studies suggest that treatment failure occurs uncommonly, and that oral antibiotics are as effective as those administered intravenously.

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