A 17-month-old boy born at term presented to a pediatric emergency department with respiratory distress in the setting of fever for 2 weeks. He presented with a maximum temperature of 38.3°C, decreased oral intake, lethargy, and work of breathing for 2 days. In the emergency department, he was toxic appearing and had tachypnea with retractions. He received a dose of ceftriaxone, fluid replacement for dehydration, and had a chest radiograph notable for left hydropneumothorax with mediastinal shift. He was transferred to the PICU and underwent endotracheal intubation. On admission, surgery at bedside was performed to place a left pigtail catheter that evacuated 500 mL of purulent fluid; because of persistent tension physiology secondary to bronchopulmonary fistula, a second chest tube was placed with clinical improvement. A central venous catheter was inserted in the left subclavian vein. Antibiotic therapy in the PICU was initiated with vancomycin and piperacillin-tazobactam. Blood cultures and studies of his chest tube drainage were sent. Pleural fluid subsequently grew Prevotella melaninogenicus and Streptococcus pneumoniae. Blood cultures remained negative for bacterial growth for the duration of his hospitalization.
He was extubated 2 days later and was stable on room air 4 days after presentation. His subclavian line was removed, and a peripherally inserted central catheter (PICC) was placed in anticipation of long-term antibiotic therapy. S pneumoniae was susceptible to penicillin (minimum inhibitory concentration <0.03 μg/mL). Prevotella species sensitivity was unknown because the sample sent for susceptibility was not viable. On the basis of the sensitivities of his pleural fluid culture, piperacillin-tazobactam and vancomycin were discontinued, and he was started on ampicillin-sulbactam. When he continued to have fevers, ampicillin-sulbactam was discontinued, and he was started on ceftriaxone (for S pneumoniae) and metronidazole (for Prevotella). The patient was transferred from the PICU to the floors on hospital day 6 in stable condition. His chest tubes were removed on hospital day 8.
The question arose of whether he required parenteral therapy or if oral therapy would suffice after his initial PICC was dislodged on day 10. His chest imaging (radiograph and ultrasound) at this point revealed small to moderate residual effusion. He was continuing to spike fevers, but his overall fever curve was trending down, and his last documented fever was on day 12. He was otherwise clinically well appearing and did not require supplemental oxygen or intravenous (IV) fluids. C-reactive protein was also trending down for the duration of his hospitalization, consistent with his clinical improvement. The decision was made to transition his previously IV metronidazole to oral therapy but to continue IV ceftriaxone because of the fact that he had a complicated pneumonia and continued to be febrile. While on ceftriaxone, the PICC was also deemed necessary for outpatient follow-up and laboratory monitoring. After 1 unsuccessful attempt under sedation, his PICC was replaced on day 12. He was discharged from the hospital after 2 weeks of hospitalization with a plan to complete 3 additional weeks of IV ceftriaxone and oral metronidazole and to follow-up with infectious diseases as an outpatient. He completed 25 days of IV antibiotics before his PICC line was removed in outpatient follow-up. He was discharged from the infectious disease clinic at that time with further appointments only as needed for recurring symptoms.
Lessons Learned: Antibiotic Choice
This patient came in extremely sick with a complicated pneumonia as evidenced by a large pleural effusion with resultant mediastinal shift, requiring chest tube placement and PICU admission. The severity of his illness on presentation likely affected clinical decisions at multiple points during his hospitalization, including antibiotic choice and route of administration. He first received vancomycin and piperacillin-tazobactam for broad coverage before culture sensitivities were obtained. He was then switched to ampicillin-sulbactam briefly before ultimately being switched to ceftriaxone and metronidazole. Pleural fluid cultures revealed S pneumoniae that was sensitive to all antibiotics, including amoxicillin. A switch from ampicillin-sulbactam to ceftriaxone was made without documentation of the rationale; the primary hospitalist team was unclear on why this change happened. Given the culture sensitivities, the antipneumococcal antibiotic could have been narrowed to ampicillin and eventually amoxicillin, in addition to the metronidazole that was prescribed for the Prevotella. The Infectious Diseases Society of America recommends the “narrowest treatment possible” to prevent “pressure for the selection of resistance” in addition to fewer drug reactions and reduced cost.1 This patient presented to the hospital critically ill, and the use of broad-spectrum antibiotics at that time was appropriate; however, with pleural fluid culture and clinical improvement, narrowing to ampicillin would likely have been equally as effective and reduced the risk of antimicrobial resistance. With regard to antibiotic duration, national guidelines recommend 2 to 4 weeks of antibiotic therapy for complicated pneumonia, but evidence for the ideal route of antibiotic delivery remains limited.1 On the basis of guideline recommendations, this patient did not require 5 weeks of therapy. Reducing treatment duration to an eventual 25 days, as opposed to 5 weeks, reduced total cost.
PICC Line for Parenteral Versus Oral Antibiotics
Regarding the use of PICC lines in complicated pneumonia, in a recent multicenter retrospective cohort study, researchers looked at the postdischarge treatment of complicated pneumonia and found no significant difference in treatment failure between those treated with parenteral antibiotics and those treated with oral antibiotics, including after patient matching for rate and timing of surgical drainage and PICU admission.2 However, patients receiving PICC lines for parenteral antibiotics experienced more adverse drug reactions (3.2% vs 0.2%), PICC line complications (7.1% vs 0%), and revisits (17.8% vs 5.8%).2 When our patient lost his initial PICC line on hospital day 10, this was likely an opportunity to prepare for discharge on oral therapy. At the time, he had no supplemental oxygen requirement, adequate oral intake, and no intrathoracic air leak after removal of the chest tube. Although the persistence of fever was the main reason for replacing the PICC line, fever in complicated pneumonias lasts for an average of 7.8 days, with an SD of 5.3; this patient’s resolution of fever occurred on day 12, within the expected range.3 In a case review of 43 children with complicated pneumococcal pneumonia and pulmonary complications, the mean days to defervescence was as high as 16.2 (9.2 ± 7.0).4
In pursuit of reestablishing IV access, our patient underwent 2 conscious sedation sessions to finally get the PICC line replaced. Separate from the PICC line itself, sedation also carries risk. Although complications are fairly rare, common complications include oxygen desaturation, airway obstruction, excessive secretions, vomiting, stridor, and laryngospasm, but more serious events requiring cardiopulmonary resuscitation have been reported.5 In 1 study, PICC complications occurred in over 30% of all PICCs placed for antimicrobial administration, with occlusion as the most common adverse event. Three percent of patients with PICCs had a catheter-associated infection that required further antibiotic treatment or PICC removal.6 Although parenterally-administered antibiotics may seem like a more “conservative” treatment, neither PICC lines nor sedation is without risk or adverse events that include thrombosis and catheter-related bloodstream infections.7
This patient was admitted for a complicated pneumonia that required initial endotracheal intubation, chest tube placement, and PICU admission. This patient had the benefit of cultures that tested positive, which aids the application of guidelines. The presence of Prevotella on culture makes this case unique, but the principles of the guidelines can still be applied. Even without culture data, the clinical improvement despite persistent fevers should not immediately prompt providers to broaden or change coverage. Prolonged fevers are consistent even with adequately treated complicated pneumonia. Once on the general wards and because of his clinical stability, he likely could have been treated more narrowly with ampicillin and metronidazole and transitioned to oral amoxicillin and metronidazole on the basis of culture results. This would have reduced the risks and costs of undergoing multiple sedations and having a PICC line placed, including catheter-related adverse events and their potential costs. Recommended treatment duration for complicated pneumonia is 4 weeks barring any further complications. With the recent study by Shah et al,2 we should use PICCs wisely and replace parenteral antibiotics with the appropriate oral equivalent whenever possible, rather than subject patients to unnecessary sedation and procedures.
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.
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