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Pediatric cellulitis: success of emergency department short-course intravenous antibiotics
April J Kam1, Jenine Leal, Stephen B Freedman
1Division of Paediatric Emergency Medicine, Department of Paediatrics, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada.
Insights
Short-course intravenous (IV) antibiotics for pediatric cellulitis in the emergency department (ED) show a high failure rate. This approach may lead to prolonged ED stays compared to oral antibiotics alone, warranting further evaluation.
Area of Science:
- Pediatric Emergency Medicine
- Infectious Diseases
- Antibiotic Stewardship
Background:
- Intravenous (IV) antibiotics administered in the emergency department (ED) followed by oral antibiotics for pediatric cellulitis is a common practice.
- Evidence supporting the efficacy and safety of this short-course IV antibiotic therapy is limited.
Purpose of the Study:
- To determine the failure rate of emergency department short-course intravenous antibiotic therapy (IV-short course) for pediatric cellulitis.
- To compare the outcomes of IV-short course therapy with oral antibiotics alone and admission for IV antibiotics.
Main Methods:
- Retrospective study of children (0-18 years) diagnosed with cellulitis in a pediatric ED in 2005.
- Treatment groups included: outpatient oral antibiotics, IV-short course, and admission for IV antibiotics (IV-admit).
- Failure defined as a return visit within 7 days with altered treatment, IV antibiotics, or hospitalization.
Main Results:
- Of 321 children, 7% met failure criteria. IV-short course had a significantly higher odds ratio of failure (7.2) compared to IV-admit.
- Children receiving IV-short course were more likely to revisit within 7 days than those on oral antibiotics alone (RR 2.4).
- Mean hospital stay was significantly shorter for IV-short course (14.9 hours) versus IV-admit (118.6 hours).
Conclusions:
- Short-course IV antibiotic therapy for pediatric cellulitis is associated with a high failure rate and prolonged ED stay compared to oral antibiotics alone.
- Despite a shorter hospital stay, the high failure rate necessitates further investigation before widespread adoption of IV-short course therapy.
- Clinical similarity to the IV-admit group warrants careful consideration of this treatment strategy.
Objectives:
The administration of 1 to 2 doses of intravenous (IV) antibiotics in the emergency department (ED) followed by discharge on oral antibiotics has become a treatment option for children with cellulitis, despite an absence of evidence supporting this practice. The objective of this study was to determine the failure rate of ED short-course IV antibiotic therapy (IV-short course).
Methods:
This retrospective study included children aged 0 to 18 years diagnosed with cellulitis in a pediatric ED during the 2005 calendar year. Treatment was categorized as (a) discharge on outpatient oral antibiotics, (b) IV-short course, or (c) admission for IV antibiotics (IV-admit). Failure was defined by a subsequent visit less than 7 days since the index visit with a change in antibiotic treatment, the administration of IV antibiotics, or hospitalization. A second data abstractor reviewed 10% of the charts to allow calculation of interobserver scores.
Results:
There were 321 eligible children, of whom 154 children were treated with oral antibiotics, 85 IV-short course, and 82 IV-admit. A total of 23 patients (7%) met criteria for failure. Compared with IV-admit, the odds ratio of failure among those who received IV-short course was 7.2 (95% confidence interval [CI], 1.6-33.1). Those who received IV-short course were more likely to revisit within 7 days than were children treated with oral antibiotics alone (risk ratio, 2.4; 95% CI, 1.2-4.7); however, revisits were no more frequent than among children in the IV-admit group (risk ratio, 2.8; 95% CI, 0.65-12.1). The total mean duration of hospital stay was significantly less in the IV-short course group compared with the IV-admit group (14.9 vs 118.6 hours; P < 0.001).
Conclusions:
Children with cellulitis frequently receive IV antibiotics. Short-course IV antibiotic therapy is associated with a high failure rate and prolonged ED stay compared with those in children treated with oral antibiotics alone. However, their clinical similarity to the IV-admit group, shorter length of hospital stay, but high failure rate mandates further evaluation before widespread adoption.
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