Treatment of complex pneumonia in children

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It’s better to send kids recovering from complext pneumonia home from the hospital with oral instead of intravenous antibiotics, found a multi-institutional US study.

Children with complex pneumonia typically require one to three weeks of antibiotic therapy after hospital discharge to treat residual infection. The relief of going home without a needle and tube stuck to a child’s arm also comes with other benefits, according to a multi-institutional research team led by Cincinnati Children’s Hospital Medical Centre.

The retrospective study of 2,123 children at 36 hospitals found oral antibiotics are as effective as intravenous in managing residual disease. Taking medication by mouth also avoids the risk of infection and other medical complications from peripherally inserted central venous catheters, or PICC lines.

“PICC line complications can be serious, resulting in hospital readmission, additional procedures, and more medications, as well as missed work or school.” Says Dr Samir Shah, the study’s lead author and director of hospital medicine at Cincinnati Children’s. “It’s not surprising that children and families would rather not use PICC lines. Our findings, which provide compelling evidence to support the use of oral antibiotics for children with complex pneumonia, will contribute to safer care for children across the
country.”

The paper is the first multi-centre research project to look at the issue. The study is a collaboration of the Pediatric Research in Inpatient Settings Network – a group of pediatric hospitalists focused on improving care delivery to children.

About 15% of children hospitalised for pneumonia develop complicated pneumonia, which includes the build-up of fluid around the lungs caused by pleural infection, according to the authors.

National treatment guidelines do not call for the use oral antibiotics after leaving the hospital, although they do highlight the risk of giving the medicine intravenously. The researchers report that although PICC use is overall not common, they found substantial variation in post-discharge use across the 36 hospitals in the study with almost three-fourths of children at some hospitals receiving antibiotics by PICC for complex pneumonia. An important goal of the research is helping reduce what the authors call “unwarranted variation” or differences in care that are not related to the child’s illness or underlying medical conditions.

Of the 2,123 children in the study, 281 (13.2%) received antibiotics through a PICC line after release from the hospital, with the rest getting oral antibiotics. Treatment failure rates were not significantly different between the groups – with 3.2% failure rate for kids on a PICC line and 2.6% for the oral antibiotics group. PICC-related complications occurred in 7.1% of children in that group; adverse drug reactions were recorded for 0.6% of children taking oral medication.

This led the authors to conclude that children with complicated pneumonia should “preferentially receive” oral antibiotics when released from the hospital when effective oral options are available.

Abstract
Background and objectives: Postdischarge treatment of complicated pneumonia includes antibiotics administered intravenously via a peripherally inserted central venous catheter (PICC) or orally. Antibiotics administered via PICC, although effective, may result in serious complications. We compared the effectiveness and treatment-related complications of postdischarge antibiotics delivered by these 2 routes.
Methods: This multicenter retrospective cohort study included children ≥2 months and Results: Among 2123 children, 281 (13.2%) received antibiotics via PICC. Treatment failure rates were 3.2% among PICC and 2.6% among oral antibiotic recipients and were not significantly different between the groups in across-hospital-matched analysis (matched odds ratio [OR], 1.26; 95% confidence interval [CI], 0.54 to 2.94). PICC complications occurred in 7.1%. Adverse drug reactions occurred in 0.6% of children; PICC antibiotic recipients had greater odds of adverse drug reaction in across hospital matched analysis (matched OR, 19.1; 95% CI, 4.2 to 87.3). The high rate of PICC complications and differences in adverse drug reactions contributed to higher odds of the composite outcome of all related revisits among PICC antibiotic recipients (matched OR, 4.71; 95% CI, 2.97 to 7.46).
Conclusions: Treatment failure rates between PICC and oral antibiotics did not differ. Children with complicated pneumonia should preferentially receive oral antibiotics at discharge when effective oral options are available.

Authors
SS Shah, R Srivastava, S Wu, JD Colvin, DJ Williams, SJ Rangel, W Samady, S Rao, C Miller, C Cross, C Clohessy, M Hall, R Localio, M Bryan, G Wu, R Keren

Cincinnati Children’s material
Pediatrics


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