From the Journals

Group B strep: Short-course IV controls infant infection

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What are you waiting for?

The 2007 French study investigating oral amoxicillin for early-onset group B streptococcus is one of the few times in the past 3 decades where I changed my practice based on a single article. It was a large, conclusive study with 222 patients, so it doesn’t need a meta-analysis in the way American research often requires. The research showed that most of what I had been taught about oral amoxicillin was false. Amoxicillin is absorbed well even at doses above 50 mg/kg per day. It is absorbed reliably by neonates, even mildly sick ones. It crosses the blood-brain barrier adequately. The French researchers measured serum levels and proved all this using scientific principles as well as clinical trials.

I have used this oral protocol (10 days total after 2-3 days IV therapy) on two occasions to treat GBS sepsis when I had informed consent of the parents and buy-in from the primary care pediatrician. I waited for the Red Book to update its recommendations. That didn’t happen.

Meanwhile, I saw other babies kept for 10 days in the hospital for IV therapy, with resultant wasted costs and income loss for the parents. I’ve treated complications and readmissions due to PICC line issues. One baby at home got a syringe of gentamicin given IV push instead of a normal saline flush. Mistakes happen at home and in the hospital.

Since late-onset GBS can be acquired environmentally, there will always be recurrences. The issue isn’t the rate of recurrence. It is whether the more invasive intervention reduces that rate. Then balance any measured reduction against the adverse effects of the invasive intervention, like PICC line infections. This Bayesian decision making is hard for some risk-adverse humans to assimilate.

Dr. Coon and associates have confirmed, using Big Data, that prolonged IV therapy of late-onset GBS bacteremia does not generate a clinically significant benefit. It is certainly possible to sow doubt by asking for proof in a variety of subpopulations. But this new article is in the context of multiple articles over the past decade that have disproved the myth of the superiority of IV therapy. Given the known risks and costs of PICC lines and prolonged IV therapy, the default should be, absent a credible rationale to the contrary, that oral therapy at home is better.

Dr. Coon and associates show that, by 2015, 5 of 49 children’s hospitals were early adopters and had made the switch to mostly using short treatment courses. Fourteen of 49 hadn’t changed at all. Given this new analysis, what are you laggards waiting for?

Dr. Kevin Powell is a pediatric hospitalist and clinical ethics consultant living in St. Louis. He reported no relevant financial disclosures.


 

FROM PEDIATRICS

Infants with bacteremia caused by group B streptococcus (GBS) who were treated with intravenous antimicrobial therapy for 8 days or less had similarly successful outcomes, compared with those treated longer, based on data from 775 infants.

Group B strep Janice Haney Carr/CDC

Current guidelines recommend intravenous antibiotics for a prolonged period of 10 days for infants (defined as 7-90 days old) with uncomplicated, late-onset GBS bacteremia, “however, no studies have compared outcomes among infants who receive prolonged versus shortened durations of IV antibiotic therapy,” wrote Eric R. Coon, MD, of the University of Utah, Salt Lake City, and colleagues. In a retrospective study published in Pediatrics, the researchers compared recurrence rates in infants who received prolonged vs. shortened therapy.

The study population included 612 infants with uncomplicated late-onset GBS bacteremia aged 4 months and younger who received prolonged IV therapy and 163 who received shortened therapy (defined as 8 days or less). Demographics were not significantly different between the groups, although infants who received a shortened treatment were more likely to be older, were more often admitted in later years of the study, and more likely to have a concomitant urinary tract infection.

Overall, 17 infants experienced recurrence; 3 in the shortened therapy group (1.8%) and 14 in the prolonged therapy group (2.3%). The average time to recurrence was 25 days.

Of note, 27 infants in the shortened treatment group received oral antibiotics on the day of their hospital discharge, and none of them experienced GBS recurrence, which suggests that “Early transition to oral antibiotic therapy may be appropriate for carefully selected infants with GBS bacteremia,” the researchers wrote.

In the prolonged treatment group, recurrence rates were 4.0% and 1.5%, respectively, for infants discharged with and without a peripherally inserted central catheter (PICC), but complications from the catheter may have been misclassified as disease recurrence to cause the difference in rate, as the noncatheter patients had similar recurrence rates to the shortened treatment group, the researchers noted.

“We found striking variation in IV antibiotic treatment duration by hospital and whether patients received prolonged or shortened IV courses; rates of GBS disease recurrence and treatment failure were low,” the researchers said. The top three antibiotics prescribed were ampicillin plus a third-generation cephalosporin (37%), third-generation cephalosporin monotherapy (28%), and third-generation cephalosporin monotherapy plus vancomycin (7%).

The findings were limited by the observational design, potential for misclassification of outcomes, and a lack of data to address the total duration of antibiotic therapy, the researchers noted. However, the results suggest that shorter treatment can be an informed decision considered in appropriate patients.

“Beyond decreased health care costs, shortened IV antibiotic courses provide the advantage of a diminished burden for families, allowing for patients to leave the hospital sooner, making it easier to administer the antibiotic at home, and decreasing the likelihood that they would develop a treatment-related complication,” the researchers said. The researchers had no financial conflicts to disclose.

SOURCE: Coon E et al. Pediatrics. 2018 Oct 11. doi: 10.1542/peds.2018-0131.

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