Oral Antibiotics Equally Effective as IVs for Bone Infection Treatment in Kids

Study suggests physicians should reconsider osteomyelitis treatment strategies

Monday, December 15, 2014

CINCINNATI – Researchers report in JAMA Pediatrics that treating osteomyelitis in children with oral antibiotics is equally effective as intravenous antibiotics without the potential complications of using a peripherally inserted central catheter (PICC line).

The multi-institutional study, led by Children’s Hospital of Philadelphia’s (CHOP) and Cincinnati Children’s Hospital Medical Center, appeared Dec. 15 in the journal’s online edition.

Based on their findings, the researchers — all part of the Pediatric Research in Inpatient Settings Network (PRIS) — suggest physicians reconsider using intravenous antibiotics to treat this condition because of that treatment method’s complications.

“Complications such that come with using PICC lines include blood clots, sepsis and are quite serious,” said Samir Shah, MD, MSCE, director of Hospital Medicine at Cincinnati Children’s and study co-author. “We can avoid such complications by using oral antibiotics with excellent outcomes for children.”

A serious infection of the bone, osteomyelitis affects approximately 1 in 5000 children per year. Osteomyelitis can require multi-week regimens of antibiotics, often given intravenously, and in some cases the condition can lead to surgery to remove dead bone tissue.

First author on the study, Ron Keren, MD, MPH, of CHOP, said that once a bone infection improves after a few days of intravenous antibiotics, children can be transitioned to oral antibiotics.

The researchers have been comparing oral antibiotics to those delivered with a PICC line. Because they tap directly into the circulatory system, PICC lines offer maximum drug delivery, and are preferred by many clinicians for long-term treatment of severe infections. However, PICC lines require regular maintenance, and can clot, break, or become dislodged. In addition, any bacteria that are introduced into a PICC line can go directly to the heart and be pumped throughout the body.

In the current study, the researchers performed a retrospective review of medical records of children who were hospitalized between Jan. 1, 2009-Dec. 31, 2012 across 36 pediatric hospitals.

After excluding for a number of criteria, the researchers settled on a final cohort of 2060 children, split almost evenly (1005 oral, 1055 PICC) between those who received antibiotics via a PICC line and those who received treatment orally. The patients, the researchers note, were prescribed antibiotics for a mean of 32 days in the oral group and 27 days in the PICC group.

The investigators found that treatment failure rates were similar across the PICC and oral groups, at 4 and 5 percent, respectively. Adverse drug reactions were similarly low, at less than 4 percent in both groups. But the research group found that of children who received PICC lines, 15 percent developed a PICC-related complication that required a visit to an emergency department, re-hospitalization, or both.

Other key collaborators on the study included Rajendu Srivastava, MD, MPH, University of Utah Health Care, and Shawn Rangel, MD, MPH, Boston Children’s Hospital.

Overall, the researchers showed children prescribed oral antibiotics did not have higher rates of treatment failure than did their peers who received antibiotics via a PICC line. The researchers said it is important to note that isolation of methicillin-resistant Staphylococcus aureus (MRSA) did not modify the benefit of oral antibiotics and that physicians should feel comfortable using oral antibiotics even if MRSA is the cause.

Going forward, the researchers plan to continue their comparison of antibiotic delivery methods, looking at oral and PICC-line antibiotic treatment of complicated pneumonia and appendicitis. For more information about this study, see JAMA Pediatrics.

Support for this research came from the Patient-Centered Outcomes Research Institute.

About Cincinnati Children’s

Cincinnati Children’s Hospital Medical Center ranks third in the nation among all Honor Roll hospitals in U.S. News & World Report’s 2014 Best Children’s Hospitals. It is also ranked in the top 10 for all 10 pediatric specialties. Cincinnati Children’s, a non-profit organization, is one of the top three recipients of pediatric research grants from the National Institutes of Health, and a research and teaching affiliate of the University of Cincinnati College of Medicine. The medical center is internationally recognized for improving child health and transforming delivery of care through fully integrated, globally recognized research, education and innovation. Additional information can be found at www.cincinnatichildrens.org. Connect on the Cincinnati Children’s blog, via Facebook and on Twitter.