Improving the Transition of Intravenous to Enteral Antibiotics in Pediatric Patients with Pneumonia or Skin and Soft Tissue Infections

Summary

Using improvement science, we promoted earlier transition to enteral antibiotics for children hospitalized with uncomplicated CAP and SSTI by linking the decision for transition to the ability to take other enteral medications, rather than to discharge readiness. We increased the percentage of enterally administered antibiotic doses in this patient population from 44% to 80% in eight months. Although we did not observe a decrease in LOS as previously noted in a cost analysis study comparing pediatric patients with CAP treated with oral antibiotics versus those treated with IV antibiotics,¹⁵ we did find a decrease in LOS variability and in antimicrobial costs to our patients. These cost savings did not include potential savings from nursing or pharmacy labor. In addition, we noted a decrease in the variability in antibiotic prescribing practice, which demonstrates provider ability and willingness to couple antibiotic route transition to an objective characteristic (administration of other enteral medications).

A strength of our study was that residents, the most frequent prescribers of antibiotics on our HM service, were highly involved in the QI initiative, including defining the SMART aim, identifying key drivers, developing interventions, and completing sequential PDSA cycles. Under the guidance of QI-trained coaches, residents developed feasible interventions and assessed their success in real time. Consistent with other studies,^16,17 resident buy-in and involvement led to the success of our improvement study.

Interpretation

Despite emerging evidence regarding the timing of transition to enteral antibiotics, several factors impeded early transition at our institution, including physician culture, variable practice habits, and hospital workflow. Evidence supports the use of enteral antibiotics in immunocompetent children hospitalized for uncomplicated CAP who do not have chronic lung disease, are not in shock, and have oxygen saturations >85%.⁶ Although existing literature suggests that in pediatric patients admitted for SSTIs not involving the eye or bone, IV antibiotics may be transitioned when clinical improvement, evidenced by a reduction in fever or erythema, is noted,⁶ enteral antibiotics that achieve appropriate concentrations to attain pharmacodynamic targets should have the same efficacy as that of IV antibiotics.⁹ Using the criterion of administration of any medication enterally to identify a patient’s readiness to transition, we were able to overcome practice variation among providers who may have differing opinions of what constitutes clinical improvement. Of note, new evidence is emerging on predictors of enteral antibiotic treatment failure in patients with CAP and SSTI to guide transition timing, but these studies have largely focused on the adult population or were performed in the outpatient and emergency department (ED) settings.^18,19 Regardless, the stable number of encounters between readmissions in our patient population likely indicates that treatment failure in these patients was rare.

Rising healthcare costs have led to concerns around sustainability of the healthcare system;^20,21 tackling overuse in clinical practice, as in our study, is one mitigation strategy. Several studies have used QI methods to facilitate the provision of high-value care through the decrease of continuous monitor overuse and extraneous ordering of electrolytes.^22,23 Our QI study adds to the high-value care literature by safely decreasing the use of IV antibiotics. One retrospective study demonstrated that a one-day decrease in the use of IV antibiotics in pneumonia resulted in decreased costs without an increase in readmissions, similar to our findings.²⁴ In adults, QI initiatives aimed at improving early transition of antibiotics utilized electronic trigger tools.^25,26 Fischer et al. used active orders for scheduled enteral medications or an enteral diet as indication that a patient’s IV medications could be converted to enteral form.²⁶

Our work is not without limitations. The list of ICD-9 and -10 codes used to query the EHR did not capture all diagnoses that would be considered as uncomplicated CAP or SSTI. However, we included an extensive list of diagnoses to ensure that the majority of patients meeting our inclusion criteria were captured. Our process measure did not account for patients on IV antibiotics who were not administered other enteral medications but tolerating an enteral diet. These patients were not identified in our EHR query and were not included in our process measure as a failure. However, in latter interventions, residents identified all patients on IV antibiotics, so that patients not identified by our EHR query benefited from our work. Furthermore, this QI study was conducted at a single institution and several interventions took advantage of preexisting structured huddles and a resident QI curriculum, which may not exist at other institutions. Our study does highlight that engaging frontline providers, such as residents, to review antibiotic orders consistently and question the appropriateness of the administration route is key to making incremental changes in prescribing practices.