Improving the Transition of Intravenous to Enteral Antibiotics in Pediatric Patients with Pneumonia or Skin and Soft Tissue Infections
BACKGROUND: Despite national recommendations for early transition to enteral antimicrobials, practice variability has existed at our hospital.
OBJECTIVE: The aim of this study was to increase the proportion of enterally administered antibiotic doses for Pediatric Hospital Medicine patients aged >60 days admitted for uncomplicated community-acquired pneumonia or skin and soft tissue infections from 44% to 75% in eight months.
METHODS: This quality improvement study was conducted at a large, urban, academic children’s hospital. The study population included Hospital Medicine patients aged >60 days with diagnoses of pneumonia or skin and soft tissue infections. Interventions included education on intravenous and enteral antibiotic charge differentials, documentation of transition plan, structured discussions of transition criteria, and real-time identification of failures with feedback. Our process measure was the total number of enteral antibiotic doses divided by all antibiotic doses in patients receiving enteral medications on the same day. An annotated statistical process control chart tracked the impact of interventions on the administration route of antibiotic doses over time. Additional outcome measures included antimicrobial costs per patient encounter using average wholesale prices and length of stay.
RESULTS: The percentage of enterally administered antibiotic doses increased from 44% to 80% within eight months. Antimicrobial costs per patient encounter and the associated standard deviation of costs for our target diagnoses decreased by 70% and 84%, respectively. Average length of stay did not change.
CONCLUSIONS: Standardized communication about criteria for transition from intravenous to enteral antibiotics can lead to earlier transitions for patients with pneumonia or skin and soft tissue infections, subsequently reducing costs and prescribing variability.
© 2019 Society of Hospital Medicine
Intravenous (IV) antibiotics are commonly used in hospitalized pediatric patients to treat bacterial infections. Antimicrobial stewardship guidelines published by the Infectious Diseases Society of America (IDSA) recommend institutions develop a systematic plan to convert from IV to enteral antibiotics, as early transition may reduce healthcare costs, decrease length of stay (LOS), and avoid prolonged IV access complications1 such as extravasation, thrombosis, and catheter-associated infections.2-5
Pediatric patients with community-acquired pneumonia (CAP) and mild skin and soft tissue infections (SSTI) may not require IV antibiotics, even if the patient is hospitalized.6 Although national guidelines for pediatric CAP and SSTI recommend IV antibiotics for hospitalized patients, these guidelines state that mild infections may be treated with enteral antibiotics and emphasize discontinuation of IV antibiotics when the patient meets discharge criteria.7,8 Furthermore, several enteral antibiotics used for the treatment of CAP and SSTI, such as cephalexin and clindamycin,9 have excellent bioavailability (>90%) or can achieve sufficient concentrations to attain the pharmacodynamic target (ie, amoxicillin and trimethoprim–sulfamethoxazole).10,11 Nonetheless, the guidelines do not explicitly outline criteria regarding the transition from IV to enteral antibiotics.7,8
At our institution, patients admitted to Hospital Medicine (HM) often remained on IV antibiotics until discharge. Data review revealed that antibiotic treatment of CAP and SSTI posed the greatest opportunity for early conversion to enteral therapy based on the high frequency of admissions and the ability of commonly used enteral antibiotics to attain pharmacodynamic targets. We sought to change practice culture by decoupling transition to enteral antibiotics from discharge and use administration of other enteral medications as an objective indicator for transition. Our aim was to increase the proportion of enterally administered antibiotic doses for HM patients aged >60 days admitted with uncomplicated CAP or SSTI from 44% to 75% in eight months.
METHODS
Context
Cincinnati Children’s Hospital Medical Center (CCHMC) is a large, urban, academic hospital. The HM division has 45 attendings and admits >8,000 general pediatric patients annually. The five HM teams at the main campus consist of attendings, fellows, residents, and medical students. One HM team serves as the resident quality improvement (QI) team where residents collaborate in a longitudinal study under the guidance of QI-trained coaches. The focus of this QI initiative was determined by resident consensus and aligned with a high-value care curriculum.12
