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JAMA Pediatr. 2015 Feb;169(2):120-8. doi: 10.1001/jamapediatrics.2014.2822.

Comparative effectiveness of intravenous vs oral antibiotics for postdischarge treatment of acute osteomyelitis in children.

Author information

1
Division of General Pediatrics, Center for Pediatric Clinical Effectiveness, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania2Department of Biostatistics and Epidemiology, Perelman School of Medicine, University of Pennsylvania, Philadelphi.
2
Division of Hospital Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio4Division of Infectious Diseases, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio.
3
Division of Inpatient Medicine, Department of Pediatrics, University of Utah Health Sciences Center, Salt Lake City6Department of Pediatrics, Primary Children's Hospital, Intermountain Healthcare, Salt Lake City, Utah7Institute for Healthcare Delivery Res.
4
Department of Pediatric Surgery, Children's Hospital Boston, Harvard Medical School, Boston, Massachusetts.
5
Division of Hospital Medicine, Children's Hospitals and Clinics of Minnesota, Minneapolis10Division of Nephrology, Children's Hospitals and Clinics of Minnesota, Minneapolis.
6
Division of Pediatric Infectious Diseases, Department of Pediatrics, University of Arkansas for Medical Sciences, Little Rock.
7
Department of Pediatrics, Phoenix Children's Hospital, Phoenix, Arizona.
8
Section of Hospital Medicine, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston.
9
Department of Pediatrics, The University of Texas Southwestern Medical Center, Dallas.
10
Division of Hospital Medicine, Seattle Children's Hospital, University of Washington, Seattle.
11
Division of General Pediatrics, Center for Pediatric Clinical Effectiveness, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania.
12
Children's Hospital Association, Overland Park, Kansas.

Abstract

IMPORTANCE:

Postdischarge treatment of acute osteomyelitis in children requires weeks of antibiotic therapy, which can be administered orally or intravenously via a peripherally inserted central catheter (PICC). The catheters carry a risk for serious complications, but limited evidence exists on the effectiveness of oral therapy.

OBJECTIVE:

To compare the effectiveness and adverse outcomes of postdischarge antibiotic therapy administered via the PICC or the oral route.

DESIGN, SETTING, AND PARTICIPANTS:

We performed a retrospective cohort study comparing PICC and oral therapy for the treatment of acute osteomyelitis. Among children hospitalized from January 1, 2009, through December 31, 2012, at 36 participating children's hospitals, we used discharge codes to identify potentially eligible participants. Results of medical record review confirmed eligibility and defined treatment group allocation and study outcomes. We used within- and across-hospital propensity score-based full matching to adjust for confounding by indication.

INTERVENTIONS:

Postdischarge administration of antibiotics via the PICC or the oral route.

MAIN OUTCOMES AND MEASURES:

The primary outcome was treatment failure. Secondary outcomes included adverse drug reaction, PICC line complication, and a composite of all 3 end points.

RESULTS:

Among 2060 children and adolescents (hereinafter referred to as children) with osteomyelitis, 1005 received oral antibiotics at discharge, whereas 1055 received PICC-administered antibiotics. The proportion of children treated via the PICC route varied across hospitals from 0 to 100%. In the across-hospital (risk difference, 0.3% [95% CI, -0.1% to 2.5%]) and within-hospital (risk difference, 0.6% [95% CI, -0.2% to 3.0%]) matched analyses, children treated with antibiotics via the oral route (reference group) did not experience more treatment failures than those treated with antibiotics via the PICC route. Rates of adverse drug reaction were low (<4% in both groups) but slightly greater in the PICC group in across-hospital (risk difference, 1.7% [95% CI, 0.1%-3.3%]) and within-hospital (risk difference, 2.1% [95% CI, 0.3%-3.8%]) matched analyses. Among the children in the PICC group, 158 (15.0%) had a PICC complication that required an emergency department visit (n = 96), a rehospitalization (n = 38), or both (n = 24). As a result, the PICC group had a much higher risk of requiring a return visit to the emergency department or for hospitalization for any adverse outcome in across-hospital (risk difference, 14.6% [95% CI, 11.3%-17.9%]) and within-hospital (risk difference, 14.0% [95% CI, 10.5%-17.6%]) matched analyses.

CONCLUSIONS AND RELEVANCE:

Given the magnitude and seriousness of PICC complications, clinicians should reconsider the practice of treating otherwise healthy children with acute osteomyelitis with prolonged intravenous antibiotics after hospital discharge when an equally effective oral alternative exists.

[Indexed for MEDLINE]

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