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.

FIG

Heat Map of Percent Opportunity by Diagnosis and Hospital. Hospital-level variation in percent opportunity, or percent of antibiotic days with opportunity to transition from intravenous to enteral antibiotics, are displayed as a heat map. Individual hospitals are displayed in the rows, and diagnoses by column. Hospitals are ordered from highest opportunity (top of map) to lowest opportunity (bottom of map). Color values within each diagnosis correspond to percent opportunity (in order, red representing highest opportunity and green representing lowest opportunity). The variation across hospitals was statistically significant (P < .001) for all diagnoses. Forty-five percent of the variability in percent opportunity was attributable to the hospital-effect and 35% to the diagnosis-effect. Abbreviations: CAP, community-acquired pneumonia; SSTI, skin and soft tissue infection; UTI, urinary tract infection.