Brief Report

Feasibility of short-term outpatient Intravenous antibiotic therapy for the management of infectious conditions in pediatric patients

Samuel Reid MD*, William Bonadio MD

The University of Minnesota Medical School, Pediatric Emergency Medicine, Children’s Hospitals and Clinics of Minnesota St. Paul, MN 55102, USA

Received 30 January 2006; revised 21 March 2006; accepted 21 March 2006

Abstract

Objective: The objective of this study was to examine the feasibility of short-term outpatient peripheral intravenous (IV) antibiotic therapy for selected emergency department (ED) patients.

Methods: Retrospective analysis of pediatric ED patients presenting with infections of presumed bacterial etiology who received IV ceftriaxone and were discharged with a bcappedQ IV catheter and instructions to return in 24 hours for reevaluation. Outcome measures included clinical outcome at 24 hours and catheter-related complications.

Results: Twenty-nine patients met study criteria. All returned for reevaluation. In one case, a parent removed the catheter when their child reported bnumbness/sorenessQ at the catheter site. The other 28 patients were judged to be improved, received a second dose of ceftriaxone through the original catheter, and were discharged on oral antibiotic. No adverse events related to the catheter were identified. Conclusion: Outpatient peripheral IV catheter use appears to be a feasible method for providing serial doses of parenteral antibiotic for the treatment of selected pediatric patients with infectious conditions. D 2006

Introduction

Pediatric bacterial infections are commonly managed on an outpatient basis; a subset of these patients will be judged likely to benefit from parenteral antibiotic therapy. Paren- teral antibiotic therapy offers the advantage of ensuring compliance and providing bactericidal serum/tissue concen- trations of drug. For certain patients with a focal bacterial infection (eg, pneumonia, cellulitis, pyelonephritis) who

* Corresponding author. Tel.: +1 651 220 6914; fax: +1 651 220 6999.

E-mail address: [email protected] (S. Reid).

may not otherwise require hospitalization, it can be advantageous to administer several doses of parenteral antibiotics separated by 24 hours on an outpatient basis.

Prior studies have examined long-term outpatient intra- venous (IV) antibiotic therapy, typically using centrally placed venous catheters, for bacterial infections including pneumonia, pyelonephritis, meningitis, osteomyelitis, and endocarditis [1 – 14]. Other studies have shown that serial doses of intramuscular antibiotic administered on an outpatient basis is effective in treating bacterial infections such as preseptal cellulitis and pneumonia [15 – 17]. We know of no prior study examining the feasibility of short- term outpatient peripheral IV antibiotic therapy for treating

0735-6757/$ – see front matter D 2006 doi:10.1016/j.ajem.2006.03.023

common pediatric infections. The purpose of this study is to examine the feasibility of providing 2 doses of IV antibiotic, separated by 24 hours, using a bcappedQ peripheral IV catheter maintained at home between emergency department (ED) visits.

Methods

A review of medical records was conducted of all patients managed by the authors who received placement of an IV catheter, were discharged home, and reevaluated in the ED within 24 hours. The study patients presented to our urban children’s hospital ED between January 1999 and July 2005. Those discharged with a capped IV catheter (defined below) after initial ED visit were studied. The study was approved by the Institutional Review Board of our institution.

At the initial ED visit, all patients were diagnosed with an Acute infection of presumed bacterial etiology (Table 1). All had peripheral IV catheter access established and received a dose of ceftriaxone (50 mg/kg). Ceftriaxone was selected because of its broad-spectrum bactericidal activity against common pediatric pathogens and favorable pharmacokinetics that allow once Daily dosing.

After antibiotic administration, if the patient was stable and did not require in-hospital therapy (to correct fluid deficit, monitor hemodynamic status, or provide respiratory support), the IV catheter was infused with heparin solution (10 U/mL) and capped (a plastic cap was attached to the distal end of the tubing connected to the catheter). This apparatus was secured to a padded arm board with tape and

then wrapped with Coban, a self-adherent wrap (3M, St. Paul, Minn). All patients were instructed to return to the ED within 24 hours for reevaluation of their condition (follow- up ED visit). Patients with cellulitis had an ink line drawn on their skin to demarcate the outer perimeter of the infection. It was standard practice to instruct parents to inspect the IV site every 4 hours and to seek reevaluation if there was swelling, redness, or pain of the contiguous skin, or if the IV catheter apparatus became disconnected. To qualify for outpatient management, parents had to be considered reliable caretakers and to have access to transportation and a telephone. An IV catheter complication was defined to be present at the follow-up ED visit when a nurse or physician documented redness, tenderness, or swelling of the skin/subcutaneous tissues at the IV site; inadvertent removal or disruption of the catheter by the patient; or mechanical inability to infuse the second dose of ceftriaxone through the catheter.

Results

There were 29 patients who met the study criteria. Ages ranged from 1 to 16 years. Their clinical profiles at the initial and follow-up ED visits are given in the Table 1. All patients returned for reevaluation within 24 hours after initial discharge; in one case, a parent removed the IV catheter at home when their child complained of bnumbness/sorenessQ of the skin at the IV site. The other 28 patients received a second dose of IV ceftriaxone through the original catheter and were discharged with a prescription for an oral antibiotic. No patient required hospitalization at the time of follow-up ED visit. For those patients whose cultures subsequently grew a pathogen, none were resistant to ceftriaxone. No patient experienced adverse event related to antibiotic administration (eg, rash, diarrhea, anaphylaxis).

Table 1 Clinical characteristics of 29 patients on initial and

follow-up ED visit

Initial ED visit Infectious condition

^a Also had white blood cell count N20,000/mm³.

^b Body temperature N38.08C.

^c Overall impression of improved condition by nurse or physician.

Discussion

Of all pediatric patients managed in the Outpatient setting.with suspected bacterial infections, a subset will be judged likely to benefit from parenteral antibiotic therapy. Some of these patients will receive 24 to 48 hours of parenteral antibiotic therapy before transitioning to oral therapy [18]. For these patients, several strategies for the administration of parenteral antibiotics exist:

• 1. Serial intramuscular doses of antibiotic administered in an ambulatory setting;
  2. Serial IV doses of antibiotic administered in a short stay unit or on an inpatient ward;
  3. Serial doses of parenteral antibiotic administered by a home health agency; or
  4. Serial IV doses of antibiotic administered in an ambulatory setting (eg, ED, clinic).

For those patients with infectious conditions who are amenable to initial treatment with outpatient ceftriaxone, serial IV doses of antibiotic administered in an ambulatory setting offer several advantages. Placement of an IV catheter at the initial visit often allows the clinician to perform baseline blood testing (eg, blood culture) without having to perform a separate phlebotomy procedure, and it allows for a second dose of parenteral antibiotic to be administered painlessly to the child. The additional cost, risk of Nosocomial infection, and lifestyle disruption inherent to hospitalization are avoided [19,20]. Given the appropriate equipment and personnel, this strategy could be managed from a clinic, urgent care facility, or ED. During periods of high hospital census, when staffed inpatient and short-stay unit beds are scarce, this option may be particularly attractive.

Outpatient parenteral antibiotic therapy had been dem- onstrated to be effective and less costly than inpatient parenteral antibiotic therapy by previous studies [19 – 23]. Conditions including pneumonia, osteomyelitis, Wound infection, Septic arthritis, sinusitis, urinary tract infection, Pelvic inflammatory disease, endocarditis, fever of unknown origin, and cellulitis have all been effectively treated using outpatient parenteral antibiotic therapy [1 – 17]. For our study, we excluded patients with conditions that require inpatient care during the acute phase of illness (eg, osteomyelitis, septic arthritis, endocarditis). To our knowl- edge, this is the first report of short-term outpatient IV antibiotic therapy initiated by, and managed in, an ED.

The same IV catheter complications that occur in hospitalized patients can occur in outpatients. Phlebitis, thrombosis, local infection, leakage, and bacteremia have been reported [20,23 – 26]. We cannot be certain if caregivers complied with our instructions to examine the IV site every 4 hours after ED discharge. However, none of our patients had experienced a significant catheter-related complication by the time of their follow-up visit. No patient had signs of cellulitis or thrombophlebitis at the IV catheter site, and all catheters, with the exception of the one removed by a parent, were functional for the second antibiotic infusion. Adverse events related to outpatient IV antibiotic therapy reported by previous studies probably relate, in large part, to catheters that are centrally placed (eg, peripherally inserted central catheter lines) and to catheters that remain in place for extended periods [24 – 26]. Because parents were not required to prepare and administer medication at home, the Infection control pitfalls inherent to this process [25] were avoided.

Our study is limited by its retrospective design. Although none of our study patients returned to our hospital after their second visit, it is possible some were treated at other institutions for a deterioration in their condition. Because our study population represents a convenience sample, selection bias may have excluded patients that would have made our results less compelling.

Consistent with typical clinical practice, sputum culture specimens were not routinely obtained from patients with pneumonia nor were cultures routinely obtained from patients

with cellulitis. The child with mastoiditis was treated empirically without aspiration of the mastoid air cells or middle ear. Because all of these patients improved clinically, it is unlikely that significant in vivo ceftriaxone resistance was present. However, in different communities and over time, emerging antibiotic resistance, especially methicillin- resistant Staphylococcus aureus, may limit the usefulness of empiric ceftriaxone therapy for certain conditions.

It is important to emphasize that the patients studied were selected for outpatient IV antibiotic therapy at the discretion of the treating physician. Other treatment strategies, including the administration of an intramuscular dose of antibiotic followed by oral therapy or oral therapy alone, may have been effective. The purpose of our study, however, is to demonstrate that outpatient IV therapy is feasible in selected pediatric patients for whom parenteral antibiotics are judged to be desirable and for whom maintaining IV access pending 24 hour follow-up is considered to be pragmatic.

We feel that peripheral IV catheters for pediatric patients can be successfully secured and maintained at home by reliable caregivers for a period of 24 hours. Their use for short-term parenteral therapy for infectious conditions in pediatric outpatients seems feasible. Further study to examine adverse events, cost, and patient satisfaction is warranted. Further study may also be warranted to determine if the concept of maintaining an IV catheter at home for scheduled ED or clinic follow-up the next day may be applicable to other therapies (eg, serial doses of clotting factor for injured hemophiliacs, IV fluids for children with acute gastroenteritis at risk for failing home therapy, or antibiotics for low-risk febrile infants managed as outpatients).

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