title: Comparative effectiveness of intravenous vs oral antibiotics for postdischarge treatment of acute osteomyelitis in children.
abstract: OBJECTIVE
  Postdischarge treatment of acute osteomyelitis in children requires weeks of antibiotic therapy, which can be administered orally or intravenously via a peripherally inserted central catheter (PICC). The catheters carry a risk for serious complications, but limited evidence exists on the effectiveness of oral therapy.
  
  
  OBJECTIVE
  To compare the effectiveness and adverse outcomes of postdischarge antibiotic therapy administered via the PICC or the oral route.
  
  
  METHODS
  We performed a retrospective cohort study comparing PICC and oral therapy for the treatment of acute osteomyelitis. Among children hospitalized from January 1, 2009, through December 31, 2012, at 36 participating children's hospitals, we used discharge codes to identify potentially eligible participants. Results of medical record review confirmed eligibility and defined treatment group allocation and study outcomes. We used within- and across-hospital propensity score-based full matching to adjust for confounding by indication.
  
  
  METHODS
  Postdischarge administration of antibiotics via the PICC or the oral route.
  
  
  METHODS
  The primary outcome was treatment failure. Secondary outcomes included adverse drug reaction, PICC line complication, and a composite of all 3 end points.
  
  
  RESULTS
  Among 2060 children and adolescents (hereinafter referred to as children) with osteomyelitis, 1005 received oral antibiotics at discharge, whereas 1055 received PICC-administered antibiotics. The proportion of children treated via the PICC route varied across hospitals from 0 to 100%. In the across-hospital (risk difference, 0.3% [95% CI, -0.1% to 2.5%]) and within-hospital (risk difference, 0.6% [95% CI, -0.2% to 3.0%]) matched analyses, children treated with antibiotics via the oral route (reference group) did not experience more treatment failures than those treated with antibiotics via the PICC route. Rates of adverse drug reaction were low (<4% in both groups) but slightly greater in the PICC group in across-hospital (risk difference, 1.7% [95% CI, 0.1%-3.3%]) and within-hospital (risk difference, 2.1% [95% CI, 0.3%-3.8%]) matched analyses. Among the children in the PICC group, 158 (15.0%) had a PICC complication that required an emergency department visit (n = 96), a rehospitalization (n = 38), or both (n = 24). As a result, the PICC group had a much higher risk of requiring a return visit to the emergency department or for hospitalization for any adverse outcome in across-hospital (risk difference, 14.6% [95% CI, 11.3%-17.9%]) and within-hospital (risk difference, 14.0% [95% CI, 10.5%-17.6%]) matched analyses.
  
  
  CONCLUSIONS
  Given the magnitude and seriousness of PICC complications, clinicians should reconsider the practice of treating otherwise healthy children with acute osteomyelitis with prolonged intravenous antibiotics after hospital discharge when an equally effective oral alternative exists.
authors.affiliation: Division of General Pediatrics, Center for Pediatric Clinical Effectiveness, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania2Department of Biostatistics and Epidemiology, Perelman School of Medicine, University of Pennsylvania, Philadelphi.
authors.forename: Ron
authors.initials: R
authors.lastname: Keren
authors.affiliation: Division of Hospital Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio4Division of Infectious Diseases, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio.
authors.forename: Samir S
authors.initials: SS
authors.lastname: Shah
authors.affiliation: Division of Inpatient Medicine, Department of Pediatrics, University of Utah Health Sciences Center, Salt Lake City6Department of Pediatrics, Primary Children's Hospital, Intermountain Healthcare, Salt Lake City, Utah7Institute for Healthcare Delivery Res.
authors.forename: Rajendu
authors.initials: R
authors.lastname: Srivastava
authors.affiliation: Department of Pediatric Surgery, Children's Hospital Boston, Harvard Medical School, Boston, Massachusetts.
authors.forename: Shawn
authors.initials: S
authors.lastname: Rangel
authors.affiliation: Division of Hospital Medicine, Children's Hospitals and Clinics of Minnesota, Minneapolis10Division of Nephrology, Children's Hospitals and Clinics of Minnesota, Minneapolis.
authors.forename: Michael
authors.initials: M
authors.lastname: Bendel-Stenzel
authors.affiliation: Division of Pediatric Infectious Diseases, Department of Pediatrics, University of Arkansas for Medical Sciences, Little Rock.
authors.forename: Nada
authors.initials: N
authors.lastname: Harik
authors.affiliation: Department of Pediatrics, Phoenix Children's Hospital, Phoenix, Arizona.
authors.forename: John
authors.initials: J
authors.lastname: Hartley
authors.affiliation: Section of Hospital Medicine, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston.
authors.forename: Michelle
authors.initials: M
authors.lastname: Lopez
authors.affiliation: Department of Pediatrics, The University of Texas Southwestern Medical Center, Dallas.
authors.forename: Luis
authors.initials: L
authors.lastname: Seguias
authors.affiliation: Division of Hospital Medicine, Seattle Children's Hospital, University of Washington, Seattle.
authors.forename: Joel
authors.initials: J
authors.lastname: Tieder
authors.affiliation: Division of General Pediatrics, Center for Pediatric Clinical Effectiveness, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania2Department of Biostatistics and Epidemiology, Perelman School of Medicine, University of Pennsylvania, Philadelphi.
authors.forename: Matthew
authors.initials: M
authors.lastname: Bryan
authors.affiliation: Division of General Pediatrics, Center for Pediatric Clinical Effectiveness, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania.
authors.forename: Wu
authors.initials: W
authors.lastname: Gong
authors.affiliation: Children's Hospital Association, Overland Park, Kansas.
authors.forename: Matt
authors.initials: M
authors.lastname: Hall
authors.affiliation: Division of General Pediatrics, Center for Pediatric Clinical Effectiveness, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania2Department of Biostatistics and Epidemiology, Perelman School of Medicine, University of Pennsylvania, Philadelphi.
authors.forename: Russell
authors.initials: R
authors.lastname: Localio
authors.affiliation: Division of General Pediatrics, Center for Pediatric Clinical Effectiveness, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania.
authors.forename: Xianqun
authors.initials: X
authors.lastname: Luan
authors.affiliation: Division of General Pediatrics, Center for Pediatric Clinical Effectiveness, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania.
authors.forename: Rachel
authors.initials: R
authors.lastname: deBerardinis
authors.affiliation: Division of General Pediatrics, Center for Pediatric Clinical Effectiveness, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania.
authors.forename: Allison
authors.initials: A
authors.lastname: Parker
mesh_terms: D000208:Acute Disease; D000284:Administration, Oral; D000293:Adolescent; D000900:Anti-Bacterial Agents / Q000008:administration & dosage* / Q000009:adverse effects; D002406:Catheterization, Peripheral / Q000009:adverse effects; D002648:Child; D002675:Child, Preschool; D015331:Cohort Studies; D004636:Emergency Service, Hospital / Q000706:statistics & numerical data; D005260:Female; D006801:Humans; D007262:Infusions, Intravenous / Q000379:methods; D008297:Male; D010019:Osteomyelitis / Q000188:drug therapy*; D010351:Patient Discharge; D010359:Patient Readmission / Q000706:statistics & numerical data; D057216:Propensity Score; D012189:Retrospective Studies
chemical_list: D000900:Anti-Bacterial Agents