Infection Control & Hospital Epidemiology (2019), 40, 248–249 doi:10.1017/ice.2018.329
Research Brief
Route of administration for antibiotics with high oral bioavailability
Michael J. Smith MD, MSCE1, Cary Thurm PhD2, Samir S. Shah MD, MSCE3, Sameer J. Patel MD4, Matthew P. Kronman MD, MSCE5, Jeffrey S. Gerber MD, PhD6, Joshua D. Courter PharmD7,
Brian R. Lee MPH, PhD8, Jason G. Newland MD, MEd9 and Adam L. Hersh MD, PhD10 1Division of Pediatric Infectious Diseases, Duke University Medical Center, Durham, North Carolina, 2Children’s Hospital Association, Overland Park, Kansas, 3Divisions of Hospital Medicine and Infectious Diseases, Cincinnati Children’s Hospital Medical Center and the University of Cincinnati College of Medicine,
Cincinnati, Ohio, 4Division of Pediatric Infectious Disease, Ann & Robert H. Lurie Children’s Hospital, Chicago, Illinois, 5Division of Infectious Diseases, Seattle Children’s Hospital, University of Washington School of Medicine, Seattle, Washington, 6Division of Infectious Diseases, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, 7Division of Pharmacy, Cincinnati Children’s Hospital Medical, Cincinnati, Ohio, 8Division of Infectious Diseases, Children’s Mercy
Hospital-Kansas City, Kansas City, Missouri, 9Division of Pediatric Infectious Diseases, Washington University School of Medicine, St Louis, Missouri and 10Department of Pediatrics, Division of Pediatric Infectious Diseases, University of Utah, Salt Lake City, Utah (Received 12 June 2018; accepted 16 September 2018)
National stewardship guidelines recommend that hospitals develop interventions to increase use of oral antibiotics.1 Transition from intravenous to oral route of administration for antibiotics with high oral bioavailability (HOB) is a simple intervention shown to decrease cost and length of hospitalization.We sought to determine the prevalence of use and route of administration of HOB anti- biotics at children’s hospitals to determine how frequently intra- venous to oral switch might be feasible and to quantify potential cost savings of this strategy in hospitalized children.
Methods
We used 2015 data from the Pediatric Health Information System (PHIS), an administrative and clinical database maintained by the Children’s Hospital Association.2 Patients were included if they were potentially eligible for intravenous to oral switch as defined by (1) receipt of an HOB antibiotic, (2) receipt of ≥1 nonantibiotic oral medication on the same day as the antibiotic, and (3) hospital stay >2 days. The HOB antibiotics includedclindamycin,metronidazole, ciprofloxacin, levofloxacin, doxycycline, linezolid and rifampin, all of which have ≥80% oral bioavailability.3 Antimicrobials typically used for prophylaxis (azithromycin, trimethoprim-sulfamethoxazole, and azoles) were excluded because they are usually given orally and it is difficult to distinguish treatment from prophylaxis using PHIS data. Days of therapy (DOT) for each drug were reported overall
and stratified by route and hospital. Oral administration of HOB antibiotics was reported using 2 metrics: (1) the percentage of all
Author for correspondence: Michael J. Smith, MD, MSCE, Pediatric Infectious
Diseases, Box 3499 Duke University Medical Center, Durham, North Carolina, 27710. E-mail:
michael.j.smith@
duke.edu PREVIOUS PRESENTATION: These data were presented in part at IDWeek on October 6, 2017, in San Diego, California.
Cite this article: Smith MJ, et al. (2019). Route of administration for antibiotics with
high oral bioavailability. Infection Control & Hospital Epidemiology 2019, 40, 248–249. doi: 10.1017/ice.2018.329
© 2018 by The Society for Healthcare Epidemiology of America. All rights reserved. Results
Data from 48 freestanding children’s hospitals were included: 38,933 children received 221,535 DOT of HOB antibiotics and at least 1 nonantibiotic oral medication, accounting for ~17% of all PHIS antibiotic use. Overall, 35.8% of all HOB DOT were administered orally, ranging from 21.3% to 63.8% across institu- tions. Clindamycin was the most commonly prescribed HOB antibiotic, accounting for nearly half of all HOB DOT (Table 1). However, it had the lowest percentage of oral DOT (21.7%) and the highest percentage (63.0%) of intravenous-only receipt. Cellulitis was the most common diagnosis associated with clindamycin use, for which 27.6% of DOT were oral. Other common diagnoses included pneumonia (26% oral DOT) and musculoskeletal infec- tions (16% oral DOT). The HOB antibiotics most likely to be prescribed orally were
rifampin (80.5% of all DOT) and doxycycline (70.8% of all DOT). Fluoroquinolones were administered orally for only half of all DOT. However, there was significant variation in the proportion of oral fluoroquinolone use across institutions, ranging from 27.0% to 98.3% for ciprofloxacin and from 0 to 100% for levo- floxacin. Similarly, less than one-third of linezolid DOT were administered orally, ranging from 0 to 100% across institutions.
HOB antibiotic DOT that were administered orally (% PO DOT) and (2) the percentage of all patients receiving HOB antibiotics who received doses orally, either completely or in combination with intravenous therapy. If children received antibiotic doses via both routes on the same day it was counted as an oral DOT. Specific diagnoses were identified using All Patient Refined Diagnosis Related Groups (APR-DRGs). Antibiotic costs were estimated using institution-specific cost-
to-charge ratios. Maximal cost-savings were estimated using the same institution-specific cost-to-charge ratios under the alternate case of administering all doses of HOB antibiotics orally.
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