When Do I Change to Oral Antibiotics?
One of the most difficult questions facing a hospitalist is when to transition to oral antibiotics. Osteoarticular infections continue to be one of the diagnoses that pit infectious disease (ID), hospitalists, and surgeons against each other, with varying degrees of comfort with duration of oral versus intravenous antibiotics. A group out of Singapore has been using C-reactive proteins (CRPs) to help make the decision and have some exciting findings.1
This was a retrospective case series of all pediatric patients aged 6 weeks to 18 years admitted to the KK Women’s and Children’s Hospital from 2007 to 2013 with a diagnosis of osteoarticular infection. Intravenous antibiotics were used until clinical improvement was noted, and the CRP level decreased by half over a period of 4 days, at which time they switched to oral antibiotics. Patient follow-up was conducted via chart review for a period of 18 months to assess for complications.
The key findings
A total of 37 patients were included, 24 with osteomyelitis only, 11 with septic arthritis only, and 2 with both. Of these, 34 patients transitioned to oral antibiotics after a 50% decline in CRP over 4 days. One of these patients developed complications (2.94%). The average hospitalization was 11.5 ± 6.55 days. None of the 37 patients switched back to intravenous antibiotics after transitioning to PO. Of the 37 patients, 95% had an uncomplicated outcome. Total antibiotic therapy for these patients was 39.16 ± 9.08 days.
Why do we care?
Decreasing hospital costs and harm to patients is a priority for pediatric hospitalists. Using a biomarker such as CRP to help make the transition to oral antibiotics earlier in bone and joint infection would decrease length of stay and side effects and potentially improve patient satisfaction. This study had a small sample size and lacked a control group, both large limitations that limit firm conclusions. However, the overwhelming success rate invites a larger randomized study using a similar protocol with a nationwide cohort. Standardization of bone and joint infection care has the potential to significantly alter our practice for these infections.
1. Chen Chou AC, Mahadev A. The use of C-reactive protein as a guide for transitioning to oral antibiotics in pediatric osteoarticular infection [published online ahead of print April 24, 2015]. J Pediatr Orthop.
Another Functional Abdominal Pain?
Taking care of a child with functional abdominal pain can be stressful for hospitalists, families, and patients. The burden on the medical system has not been described. R. Park et al1 attempted to describe this burden using the Kids’ Inpatient Sample Database (KID).
This was an analysis of patients with a primary diagnosis of constipation, abdominal pain, irritable bowel syndrome, abdominal migraine, dyspepsia, or fecal incontinence from 1997 to 2009. Information on admission rate, length of stay, and cost was examined.
The key findings
The total number of patients admitted with functional gastrointestinal complaints increased only slightly, whereas the average cost per hospitalization increased significantly, from $6115 to $18 058. Mean total cost increased from $3558 to $13 331. Length of stay increased slightly, from 1.7 to 2.0 days. There was a 22% decline in admissions for abdominal pain beginning in 2003. Overall, children were more likely to be admitted to a children’s hospital than a nonchildren’s hospital and a teaching versus nonteaching hospital. The frequency of constipation admissions increased by 112% from 1997 to 2009.
Why do we care?
The rising cost of care for this population is concerning, with >6 million admissions per year. Why we are spending more on these diagnoses is not clear, but our desire to rule out all possibilities with functional abdominal complaints may play a role. The increase in constipation is also distressing and raises the question of whether hospitalists focused on providing the best inpatient care can also provide assistance and strategies for keeping this challenging population out of the hospital.
1. Park R, Mikami S, LeClair J, et al. Inpatient burden of childhood functional GI disorders in the USA: an analysis of national trends in the USA from 1997 to 2009. Neurogastroenterol Motil. 2015;27(5):684–692
Why Are There So Many Interruptions?
The practice of hospital medicine lends itself to frequent work flow interruptions. This is a stressful experience and one we commonly encounter. But what, exactly, is the impact of this stress? Matthias Weigl and his team from Munich offer this observation.1
This was a prospective observational study evaluating the prevalence of workflow interruptions and the effects on mental workload. It was conducted at a pediatric training hospital in Germany and included 7 ward pediatricians, 4 junior level and 3 senior level. The physicians were asked midway and at the end of their 8-hour shifts to report on their mental workload. Each physician was followed during his or her shift by a trained observer.
The Key Findings
A total of 28 observations were made, with an average shift duration of 10 hours, 13 minutes. During that time there were 1353 workflow interruptions, which equates to 4.72 interruptions per hour. The most common interruption was caused by colleagues, including nursing staff. These interruptions were correlated with increased frustration (β = 0.37; P < .01). Mental demands and effort were higher in the afternoon than in the morning.
Why Do We Care?
This study provides a peek at the stressors related to providing inpatient hospital care. One burning question in hospital medicine has been and will continue to be the longevity of a hospitalist in the field. With the possibility of an interruption in workflow every 15 minutes, creating and enhancing systems to decrease the number of negative interruptions while keeping those that are beneficial to our workflow is crucial to preserve the career longevity of a practicing pediatric hospitalist.
1. Weigl M, Müller A, Angerer P, Hoffmann F. Workflow interruptions and mental workload in hospital pediatricians: an observational study. BMC Health Serv Res. 2014;14:433
FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.
FUNDING: No external funding.
POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.
- Copyright © 2015 by the American Academy of Pediatrics