Oral or IV Antibiotics for Children With Osteomyelitis?
Oral or IV Antibiotics for Children With Osteomyelitis?
Keren R, Shah SS, Srivastava R, et al; Pediatric Research in Inpatient Settings Network
JAMA Pediatr. 2015;169:120-128
The treatment of osteomyelitis is clearly evolving, with increasingly greater acceptance of (and data supporting) therapy with oral or enteral antibiotics after acute hospitalization of a child and resolution of acute symptoms. The current dilemma facing clinicians is whether to continue the posthospital treatment course intravenously or orally. Intravenous treatment is typically administered through a peripherally inserted central catheter (PICC).
This study used data from 38 US children's hospitals from 2009 through 2012 to evaluate the outcomes of children treated with oral antibiotics for osteomyelitis after hospitalization compared with those treated intravenously using PICC lines. The investigators used a research database compiled by the 38 hospitals and supplemented those data with chart reviews by physicians at each hospital. The chart reviews confirmed the eligibility of the children, determined the postdischarge antibiotic treatment modality and culture results, and counted follow-up visits to the emergency department or repeat hospitalizations within 6 months of the index hospitalization.
The children were aged 2 months to 18 years. Only children admitted to the hospital through the respective hospital emergency departments were included. Children were excluded for previous cardiac, hematologic, immunologic, or other chronic conditions that might affect outcomes. Other exclusion criteria included a length of stay of 2–14 days; cellulitis or septic arthritis as the primary discharge diagnosis; orthopedic hardware; and fractures, pressure ulcers, or craniofacial osteomyelitis.
The children were divided into two groups: those who left the hospital on intravenous antibiotic therapy (n = 1055) and those who were discharged on oral antibiotic therapy (n = 1005). The outcome of interest was treatment failure, a composite outcome of either an emergency department visit or a rehospitalization that resulted in a change in antibiotic from the oral to the PICC route; osteomyelitis that required further drainage, debridement, or biopsy; abscess drainage; arthrocentesis; or a pathologic fracture. Secondary outcomes included adverse drug reactions, PICC complications (eg, fever or insertion-site infection), bloodstream infection, thrombosis, or mechanical failure.
To account for differences between the groups, the investigators conducted propensity-score–based full matching, attempting to find children in each of the groups who most matched each other. The propensity score accounted for age, race, insurance status, length of stay, infection location, surgical procedures needed, and pathogens isolated (if applicable). The investigators matched children both within and across hospitals. In particular, they wanted to account for differences in age, dichotomized at 5 years, and whether the isolate was methicillin-resistant Staphylococcus aureus (MRSA).
Comparative Effectiveness of Intravenous Versus Oral Antibiotics for Postdischarge Treatment of Acute Osteomyelitis in Children
Keren R, Shah SS, Srivastava R, et al; Pediatric Research in Inpatient Settings Network
JAMA Pediatr. 2015;169:120-128
Study Summary
The treatment of osteomyelitis is clearly evolving, with increasingly greater acceptance of (and data supporting) therapy with oral or enteral antibiotics after acute hospitalization of a child and resolution of acute symptoms. The current dilemma facing clinicians is whether to continue the posthospital treatment course intravenously or orally. Intravenous treatment is typically administered through a peripherally inserted central catheter (PICC).
This study used data from 38 US children's hospitals from 2009 through 2012 to evaluate the outcomes of children treated with oral antibiotics for osteomyelitis after hospitalization compared with those treated intravenously using PICC lines. The investigators used a research database compiled by the 38 hospitals and supplemented those data with chart reviews by physicians at each hospital. The chart reviews confirmed the eligibility of the children, determined the postdischarge antibiotic treatment modality and culture results, and counted follow-up visits to the emergency department or repeat hospitalizations within 6 months of the index hospitalization.
The children were aged 2 months to 18 years. Only children admitted to the hospital through the respective hospital emergency departments were included. Children were excluded for previous cardiac, hematologic, immunologic, or other chronic conditions that might affect outcomes. Other exclusion criteria included a length of stay of 2–14 days; cellulitis or septic arthritis as the primary discharge diagnosis; orthopedic hardware; and fractures, pressure ulcers, or craniofacial osteomyelitis.
The children were divided into two groups: those who left the hospital on intravenous antibiotic therapy (n = 1055) and those who were discharged on oral antibiotic therapy (n = 1005). The outcome of interest was treatment failure, a composite outcome of either an emergency department visit or a rehospitalization that resulted in a change in antibiotic from the oral to the PICC route; osteomyelitis that required further drainage, debridement, or biopsy; abscess drainage; arthrocentesis; or a pathologic fracture. Secondary outcomes included adverse drug reactions, PICC complications (eg, fever or insertion-site infection), bloodstream infection, thrombosis, or mechanical failure.
To account for differences between the groups, the investigators conducted propensity-score–based full matching, attempting to find children in each of the groups who most matched each other. The propensity score accounted for age, race, insurance status, length of stay, infection location, surgical procedures needed, and pathogens isolated (if applicable). The investigators matched children both within and across hospitals. In particular, they wanted to account for differences in age, dichotomized at 5 years, and whether the isolate was methicillin-resistant Staphylococcus aureus (MRSA).
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