scholarly journals Intravenous versus Oral Step-Down for the Treatment of Staphylococcus aureus Bacteremia in a Pediatric Population

Pharmacy ◽  
2022 ◽  
Vol 10 (1) ◽  
pp. 16
Author(s):  
Sarah Grace Gunter ◽  
Mary Joyce B. Wingler ◽  
David A. Cretella ◽  
Jamie L. Wagner ◽  
Katie E. Barber ◽  
...  

Limited data are available regarding optimal antimicrobial therapy for Staphylococcus aureus bacteremia (SAB) in pediatric patients. The purpose of this study was to assess clinical characteristics and outcomes associated with intravenous (IV) versus oral step-down treatment of pediatric SAB. This study evaluated patients aged 3 months to 18 years that received at least 72 h of inpatient treatment for SAB. The primary endpoint was 30-day readmission. Secondary endpoints included hospital length of stay and inpatient mortality. One hundred and one patients were included in this study. The median age was 7.9 years. Patients who underwent oral step-down were less likely to be immunocompromised and more likely to have community-acquired SAB from osteomyelitis or skin and soft tissue infection (SSTI). More patients in the IV therapy group had a 30-day readmission (10 (25.6%) vs. 3 (5.3%), p = 0.006). Mortality was low (5 (5%)) and not statistically different between groups. Length of stay was greater in patients receiving IV therapy only (11 vs. 7 days, p = 0.001). In this study, over half of the patients received oral step-down therapy and 30-day readmission was low for this group. Oral therapy appears to be safe and effective for patients with SAB from osteomyelitis or SSTIs.

2019 ◽  
Vol 6 (Supplement_2) ◽  
pp. S550-S550
Author(s):  
Sarah G Gunter ◽  
Kayla R Stover ◽  
Katie Barber ◽  
Jamie Wagner ◽  
Mary Joyce Wingler ◽  
...  

Abstract Background Staphylococcus aureus bacteremia (SAB) is a well-known cause of morbidity in pediatric patients; however, limited data are available regarding optimal antimicrobial therapy. The purpose of this study was to assess treatment outcomes associated with intravenous (IV) vs. oral (PO) stepdown treatment of SAB in a pediatric population. Methods This study evaluated patients who were admitted between July 2012 and August 2018, between the ages of 3 months and 18 years, had a blood culture positive for S. aureus, and received at least 72 hours of inpatient treatment. Exclusion criteria were as follows: pregnancy, death within 72 hours of initial culture, hospice/palliative care, polymicrobial bacteremia, and previous SAB within the study period. The primary endpoint was 30-day readmission rates. Secondary endpoints included hospital length of stay and all-cause inpatient mortality. Results In total, 101 patients were included (43 IV therapy alone; 58 PO stepdown). The median age was 7.9 years (IQR, 3.0, 12.2; range 4 months to 16.7 years), and 52.5% were male. The most common primary foci of infection were osteomyelitis (n = 32), device-associated infections (n = 23), and skin/soft-tissue infections (n = 8). Most patients (56.4%) had no comorbidities. There were no significant differences in comorbidities between groups except the IV group had significantly more immunosuppressed patients (30.2% vs. 1.7%; P < 0.001). Methicillin resistance was noted in 56.4% of patients (62.8% IV group vs. 51.7% PO stepdown; P = 0.313). The most common IV agents were vancomycin (n = 51) and anti-Staphylococcal penicillins (n = 21), while the most common PO agents were clindamycin (n = 29) and cephalexin (n = 20). Thirty-day readmission occurred in 25.6% (n = 10) of patients receiving full-course IV therapy and 5.3% (n = 3) in the PO stepdown group among survivors (P = 0.006; n = 96). Median length of stay was 11.0 days (IQR, 8.0, 21.0) in the IV group and 7.0 days (IQR, 5.0, 11.0) in the PO stepdown group (P = 0.001). All-cause inpatient mortality occurred in four patients (9.3%) in the IV group compared with one (1.7%) in the PO stepdown group (P = 0.160). Conclusion Patients in the PO stepdown group had a low rate of 30-day readmissions and had a significantly shorter hospital length of stay than patients who received a full IV course. Disclosures All authors: No reported disclosures.


2021 ◽  
Vol 8 (Supplement_1) ◽  
pp. S7-S8
Author(s):  
John Raymond U Go ◽  
Larry M Baddour ◽  
Brian Lahr ◽  
Muhammad R Sohail ◽  
Raj Palraj

Abstract Background Serial blood cultures are integral in managing Staphylococcus aureus bacteremia (SAB) as clinicians rely on the results to determine infectious complication risks and antibiotic duration. Current IDSA guidelines suggest a single set of negative blood cultures is adequate evidence of SAB clearance. Several studies, however, have identified the skip phenomenon (SP), which is the occurrence of intermittent negative blood cultures, and have recommended obtaining additional blood cultures to document bacterial clearance (Table 1). We therefore examined patients who manifested the SP to determine its clinical significance and to study this, associations were tested for SP in relation to various baseline factors as well as clinical outcomes. Methods We performed a retrospective, multicenter study of all patients with a positive blood culture for S. aureus from January 2019 to December 2019 using data collected from electronic health records and the clinical microbiology laboratory. Results A total of 602 patients with SAB were identified and 495 patients were included in the investigation (Figure 1). Overall, 25 (5.1%) patients had the SP. Significant differences between those who did and did not manifest the SP included higher rates of injection drug use, automatic implantable cardioverter defibrillator, and community onset of infection in the SP cohort (Table 2). Moreover, the median duration of SAB was longer (3.2 [2.3-5.4] vs 1.90 [1.2-2.9] days, p=0.002), and high-grade SAB, (88.0% vs 58.7%, p=0.004), complicated bacteremia (92.0% vs 67.9%, p=0.011) and IE diagnosis (28.0% vs 11.3%, p=0.013) were all more common in the SP group. In unadjusted outcome analyses, association of SP with hospital length of stay was not significant, although a higher risk of in-hospital mortality among SP patients approached statistical significance (p=0.055). Analysis of 435 hospital survivors revealed no significant differences in rates of 1-year mortality or 90-day relapse between the two groups (Table 3). Conclusion Findings of the current investigation demonstrates an increased risk of SAB complications in patients with the SP and support the notion that serial negative blood cultures are needed to document clearance of SAB. Disclosures Larry M. Baddour, MD, Boston Scientific (Individual(s) Involved: Self): Consultant; Botanix Pharmaceuticals (Individual(s) Involved: Self): Consultant; Roivant Sciences (Individual(s) Involved: Self): Consultant Muhammad R. Sohail, MD, Medtronic (Consultant)Philips (Consultant)


Author(s):  
Rajiv R. Iyer ◽  
J. Fredrik Grimmer ◽  
Douglas L. Brockmeyer

OBJECTIVE Odontogenic ventral brainstem compression can be a source of significant morbidity in patients with craniocervical disease. The most common methods for odontoidectomy are the transoral and endoscopic endonasal routes. In this study, the authors investigated the use of an institutional protocol for endoscopic transnasal/transoral odontoidectomy in the pediatric population. METHODS From 2007 to 2017, a multidisciplinary institutional protocol was developed and refined for the evaluation and treatment of pediatric patients requiring odontoidectomy. Preoperative assessment included airway evaluation, a sleep study (if indicated), discussion of possible tonsillectomy/adenoidectomy, and thorough imaging review by the neurosurgery and otolaryngology teams. Further preoperative anesthesia consultation was obtained for difficult airways. Intraoperatively, adenoidectomy was performed at the discretion of otolaryngology. The odontoidectomy was performed as a combined procedure. Primary posterior pharyngeal closure was performed by the otolaryngologist. The postoperative protocol called for immediate extubation, advancement to a soft diet at 24 hours, and no postoperative antibiotics. Outcome variables included time to extubation, operative time, estimated blood loss, hospital length of stay, and postoperative complications. RESULTS A total of 13 patients underwent combined endoscopic transoral/transnasal odontoid resection with at least 3 years of follow-up. All patients had stable to improved neurological function in the postoperative setting. All patients were extubated immediately after the procedure. The average operative length was 201 ± 46 minutes, and the average estimated blood loss was 44.6 ± 40.0 ml. Nine of 13 patients underwent simultaneous tonsillectomy and adenoidectomy. The average hospital length of stay was 6.6 ± 5 days. The first patient in the series required revision surgery for removal of a small residual odontoid. One patient experienced pharyngeal flap dehiscence requiring revision. CONCLUSIONS A protocolized, institutional approach for endoscopic transoral/transnasal odontoidectomy is described. The use of a combined, multidisciplinary approach leads to streamlined patient management and favorable outcomes in this complex patient population.


2021 ◽  
Vol 39 ◽  
Author(s):  
Shekhar Gogna ◽  
◽  
Mahir Gachabayov ◽  
Priya Goyal ◽  
Rifat Latifi ◽  
...  

Introduction: Traumatic aortic injuries are devastating events in terms of high mortality and morbidity in most survivors. We aimed to compare the outcomes of endovascular repair (ER) vs. open repair (OR) in the treatment of traumatic aortic injuries. Methods: PubMed, Embase, and Cochrane Library were systematically searched. Postoperative mortality was the primary endpoint. Secondary endpoints included intensive care unit (ICU) length of stay, hospital length of stay, operating time, paraplegia, stroke, acute renal failure, and reoperation rate. The Mantel-Haenszel method (random-effects model) with odds ratios and 95% confidence intervals (OR (95% CI)), and the inverse variance method with the mean difference (MD (95% CI)), were used to measure the effects of continuous and categorical variables, respectively. Results: A total of 49 studies involving 12,857 patients were included. Postoperative mortality was not significantly different between the two groups (p=0.459). Among secondary outcomes, the paraplegia rate was significantly lower after ER (p=0.032). Other secondary endpoints such as ICU length of stay (p=0.329), hospital length of stay (p=0.192), operating time (p=0.973), stroke rate (p=0.121), ARF rate (p=0.928), and reoperation rate (p=0.643) did not significantly differ between the two groups. Conclusion: This meta-analysis found that ER was associated with a reduced paraplegia rate compared to OR for the management of traumatic aortic injury.


2019 ◽  
Vol 6 (Supplement_2) ◽  
pp. S59-S60
Author(s):  
Rachael L Schortemeyer ◽  
Tracy N Zembles ◽  
Glenn Bushee ◽  
Evelyn Kuhn ◽  
Michelle L Mitchell

Abstract Background Infections due to multi-drug-resistant organisms (MDRO) are associated with poor clinical outcomes. Due to limited treatment options for MDROs, it is essential to improve the delivery of available antibiotics. Optimal efficacy of β-lactam antibiotics can be achieved when free drug concentrations exceed the minimum inhibitory concentration of the organism for at least 50% of the dosing interval. This is more feasible when extending the duration of infusion. Adult literature supporting the use of extended infusion β-lactams (EIBL) is robust; however, pediatric data are limited. Furthermore, extended infusions (EI) may be more difficult to achieve in pediatric patients due to limited intravenous line access. The purpose of this study was to determine the feasibility of EIBLs as the standard of care and compare clinical outcomes between standard infusions (SI) and extended infusions (EI). Methods This retrospective chart analysis included hospitalized patients less than 18 years old between October 1, 2017 and March 31, 2019 who received at least 72 hours of cefepime, piperacillin/tazobactam, or meropenem. Patients weighing less than 3.5 kg or requiring continuous renal replacement therapy were excluded. EI were defined as antibiotic delivery over 3–4 hours, while SI were delivered over 30 minutes. The percent of patients completing therapy utilizing EI was measured. Clinical outcomes compared hospital length of stay; time to blood culture clearance, defervescence, inflammatory marker normalization; 30-day readmission rates; and 30-day all-cause mortality between the SI and EI groups. Results A total of 560 patients were included in the interim analysis. Over 90% of patients were able to complete therapy utilizing EI (Figure 1). The EI group had lower readmission rates, but the interim analysis has not yet controlled for planned admissions. A sub-analysis of critically ill patients requiring vasopressors identified a lower mortality rate (5.1% vs. 23.1%, P = 0.023) and decreased the length of stay (554 vs. 1,055 hours, P = 0.035) in the EI compared with SI group (Table 1). Conclusion EIBLs are feasible in the pediatric population and may lead to improved outcomes including decreased all-cause mortality and hospital length of stay, especially in critically ill children. Disclosures All Authors: No reported Disclosures.


2021 ◽  
Vol 8 (Supplement_1) ◽  
pp. S207-S207
Author(s):  
Heather Savage ◽  
Catherine H Vu ◽  
DeMaurian Mitchner ◽  
Amir Zaki

Abstract Background Bloodstream infections are associated with considerable morbidity and mortality in the United States. Most patients initially receive parenteral antibiotics for gram-negative bacteremia, and more data is emerging supporting de-escalation to oral (PO) antibiotics to complete treatment. Previous studies evaluating PO antibiotics for gram-negative bacteremia often exclude or have underrepresented immunocompromised patients. This study evaluated clinical failure in immunocompromised patients receiving intravenous (IV) antibiotics compared to patients transitioned to PO antibiotics for gram-negative bacteremia. Methods A single center, retrospective cohort study was conducted at 446-bed academic medical center. Patients were included if they were immunocompromised and admitted with a positive blood culture for E. coli, Klebsiella spp., Citrobacter spp., Serratia spp., Enterobacter spp., Proteus spp., P. aeruginosa. between November 4, 2017 to November 4, 2020. Patients were excluded from this study if they had polymicrobial bacteremia, no source control within the first 5 days, or an indication for prolonged duration of treatment. The primary endpoint of this study was clinical failure defined as an escalation from PO to IV antibiotics, worsening clinical status, or readmission for the same infection within 30 days of discharge. The secondary endpoints included 30-day mortality, 90-day mortality, 30-day readmission, and time to microbiologic clearance. Results A total of 31 immunocompromised patients were included in the study with 26 patients receiving PO step-down therapy and 5 patients being continued on IV treatment for gram-negative bacteremia. There was no difference in the primary outcome of clinical failure between the PO step-down group versus the IV therapy group (15.4% vs 20%; p = 0.613). The most common immunocompromised state in both groups was being HIV positive. Patients in the PO step-down group had a significantly shorter hospital length of stay (7.4 days vs. 13.6 days; p = 0.016). Conclusion Oral step-down therapy for gram-negative bacteremia showed similar clinical failure rates to continuous IV therapy in the immunocompromised patient population and may be an option to shorten hospital length of stay. Disclosures All Authors: No reported disclosures


2021 ◽  
Vol 8 (Supplement_1) ◽  
pp. S203-S203
Author(s):  
Kelvin Gandhi ◽  
Magdalena Wrzesinski ◽  
Kristen Bunnell ◽  
Ashley Long ◽  
Vanessa Hutzley ◽  
...  

Abstract Background Bloodstream infections are traditionally treated with intravenous (IV) antimicrobial therapy, which may increase length of stay and healthcare costs. The purpose of this study is to evaluate if oral antibiotic step-down therapy for non-staphylococcal gram-positive bloodstream infections (GP-BSIs) is non-inferior to IV antibiotics. Methods This single-center, retrospective cohort study included patients with a non-Staphylococcus aureus, non-Staphylococcus lugdunensis GP-BSI from January 2017 to December 2019. Patients were excluded if they fit any of the following criteria: organism identified as contaminant, polymicrobial BSI, recurrent BSI within the past 90 days, or receipt of an effective antibiotic for a duration longer than what is indicated for BSI treatment. Patients were categorized into those who received an IV antibiotic for the total duration of therapy and those who received an oral step-down antibiotic for at least one-third of the treatment course. The primary composite outcome was the incidence of 90-day clinical failure consisting of 90-day all-cause mortality, change in therapy due to inadequate clinical response, and 90-day BSI recurrence. The secondary outcomes included the individual components of the primary composite outcome, line-related complications, and hospital length of stay. Bivariate analysis was conducted to assess for predictors of 90-day clinical failure. Results A total of 308 patients were included (oral group, n=94; IV group, n=214). Pitt Bacteremia Scores were low overall, but higher in the IV group (0 vs 1, p=0.045). The oral group had a higher proportion of GP-BSI caused by streptococcal species (76% vs 61%, p&lt; 0.001). The oral group had a lower incidence of 90-day clinical failure and was found to be noninferior to the IV group (9% vs 14%; mean difference -5%, 90% CI -12.7 to 2.6). The IV group had a longer hospital length of stay (4 vs 6 days, p&lt; 0.001), however there were no other significant differences in secondary outcomes. Bivariate analysis found no significant predictors of 90-day clinical failure. Conclusion Oral antibiotic step-down therapy was found to be non-inferior to IV antibiotic therapy, and thus may be an alternative option for the treatment of non-staphylococcal GP-BSIs. Disclosures All Authors: No reported disclosures


Sign in / Sign up

Export Citation Format

Share Document