Infection Control & Hospital Epidemiology Table 1. Prevalence of High Oral Bioavailability Antibiotic Use and Proportion of Oral Administration Route of Antibiotic Administration, % Patients Drug
Clindamycin Metronidazole Ciprofloxacin Levofloxacin Linezolid
Doxycycline Rifampin Overall
102,628 52,478 26,125 14,341 9,820 8,189 7,954
221,535
DOT % PO DOT Overall Min % Max % No. of Patients 21.7 38.4 55.1 50.4 30.8 70.8 80.5 35.8
4.7
12.3 27.0 0.0 0.0
29.6 0.0
21.3
65.7 71.7 98.3
100.0 100.0 98.3
100.0 63.8
21,956 10,270 5,480 2,496 1,644 1,522 998
38,993
PO Only 9.1
32.1 53.9 48.6 32.3 61.2 75.3 22.9
IV Only 63.0 53.0 29.8 34.6 54.3 20.8 12.8 50.8
Both 27.9 15.0 16.3 16.8 13.4 17.9 11.9 26.3
Note. PO, per oral; DOT, days of therapy; Min %, % PO DOT at hospital with lowest % PO DOT for each drug; Max %, % PO DOT at hospital with highest % PO DOT for each drug; IV, intravenous.
The total hospital cost for all HOB antibiotics administered
during the study period was $11,662,963. The estimated cost had all doses been administered orally was $5,891,137.
Discussion
Only 36% of HOB antibiotic DOT were administered orally in this cohort of children receiving other oral medications. These data suggest that intravenous to oral switch programs should be prioritized in children’s hospitals. Clindamycin should be a priority target for such programs because it is both commonly used and often administered intravenously. It is well-documented that intravenous to oral switch is safe and effective for children with osteomyelitis4,5 and complicated pneumonia,6 2 common indications for clindamycin. However, in this cohort, children with these diagnoses were more likely to be treated with intravenous clindamycin. Intravenous to oral switch programs would be cost saving in
pediatrics. We estimated a nearly 50% decrease in drug cost alone. Although this represents the maximum potential savings in direct drug costs, it does not account for additional cost savings due to drug administration, shorter hospital stays, avoidance of outpatient parenteral antibiotic therapy and catheter-associated infections. The reasons for underutilization of oral administration are
uncertain. Some clinicians and parents may have the perception that intravenous antibiotics are more effective7 or that insurance companies mandate intravenous therapy for reimbursement of hospitalization. Future studies should focus on differences in clinical outcomes between children who received HOB antibiotics via oral as compared to intravenous routes. This analysis has several limitations. We utilized adminis-
trative data to identify children eligible for oral conversion. Although this approach has been used in other studies,8 we could not account for patient factors such as severity of illness or intolerance of oral antibiotics, though inclusion in this cohort required receipt of another oral medication. We did not exclude diagnoses that mandate intravenous therapy such as endovas- cular or central nervous system infections. However, it is unli- kely that differences in the prevalence of these infections would explain more than a minority of the variation in use of oral antibiotic across hospitals. Finally, because PHIS only includes data from freestanding children’shospitals,mostofwhich have
formal ASPs,9 these results may not be generalizable to other settings. In conclusion, we observed frequent intravenous administra-
tion of HOB antibiotics at children’s hospitals. Intravenous to oral conversion programs, with a focus on clindamycin and fluor- oquinolones, are potential high-impact targets for antimicrobial stewardship.
Acknowledgments. None. Financial support. No financial support was provided relevant to this article.
Conflicts of interest. All authors report no conflicts of interest relevant to this article.
References 1. Barlam TF, Cosgrove SE, Abbo LM, et al. Implementing an antibiotic stewardship program: guidelines by the Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America. Clin Infect Dis 2016;62:E51–E77.
2. Pediatric Health Information System (PHIS). Children’s Hospital Association website.
https://www.childrenshospitals.org/programs-and-services/data-analytics- and-research/pediatric-analytic-solutions/pediatric-health-information-system. Accessed March 16, 2018.
3. Goldman JL, Richardson T, Newland JG, et al. Outpatient parenteral antimicrobial therapy in pediatric medicaid enrollees. J Pediatr Infect Dis Soc 2017;6:65–71.
4. Zaoutis T, Localio AR, Leckerman K, Saddlemire S, Bertoch D, Keren R. Prolonged intravenous therapy versus early transition to oral antimicrobial therapy for acute osteomyelitis in children. Pediatrics 2009;123:636–642.
5. Keren R, Shah SS, Srivastava R, et al. Comparative effectiveness of intravenous vs oral antibiotics for postdischarge treatment of acute osteomyelitis in children. JAMA Pediatrics 2015;169:120–128.
6. Shah SS, Srivastava R, Wu S, et al. Intravenous versus oral antibiotics for postdischarge treatment of complicated pneumonia. Pediatrics 2016;138:9.
7. Broom J, Broom A, Adams K, Plage S. What prevents the intravenous to oral antibiotic switch? A qualitative study of hospital doctors’ accounts of what influences their clinical practice. J Antimicrob Chemother 2016;71:2295–2299.
8. Jones M, Huttner B, Madaras-Kelly K, et al. Parenteral to oral conversion of fluoroquinolones: low-hanging fruit for antimicrobial stewardship pro- grams? Infect Control Hosp Epidemiol 2012;33:362–367.
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