Transitioning children from intravenous to enteral antibiotics is a daily occurrence for providers caring for children in hospitals. These children have clinically improved but require additional days of medication to complete an effective course of therapy. Some clinicians make the change to enteral antibiotics and discharge the child immediately, whereas others watch the child in the hospital setting on the enteral antibiotic therapy for a day or more. In their study, Stromberg et al1  suggest that prolonged observation is not the national norm, that the practice of observation after transitioning therapy has wide variability nationally, and that observation after transitioning therapy is likely unnecessary for children with skin and soft tissue infections (SSTIs). The authors’ findings beg the question: When do you deviate from the norm?

The Infectious Diseases Society of America’s SSTI guidelines recommend cephalexin or clindamycin for cases of SSTI in which the child is stable and does not have bacteremia or intravascular infection; but vancomycin is listed as first-line therapy for complicated SSTIs.2  In the current study, the authors found that despite the fact that children in this cohort were considered to have “uncomplicated” SSTI, ∼20% of these children received vancomycin during their hospital stay before transitioning to oral therapy. Vancomycin use in SSTIs can add significant cost to a hospitalization,3  entails additional diagnostic testing for safety and therapeutic monitoring, and adds risk of nephrotoxicity4 . This study builds on previous research in adults by revealing that children who received vancomycin were more likely to be observed in the hospital after transition to enteral antibiotic therapy. Because there is no enteral equivalent to intravenous vancomycin, transitioning to enteral therapy would require changing the class of antibiotic being given to the child. Adhering to evidence-based practices for SSTIs would likely limit inpatient observation on oral antibiotics simply by avoiding the need to transition from vancomycin to a different antibiotic class.

In the study, the authors recognize that the motivation for keeping 15% of the children an additional day is not known; retrospective data make it hard to infer the reasons a clinician would choose to observe a child who had transitioned to enteral antibiotics. The data reveal that the tendency to watch longer after transitioning to enteral antibiotic therapy was more pronounced for toddlers (age 1–2 years), suggesting a paternalistic streak, possibly over concerns for tolerating and/or adhering to oral medications. Those children with infections in the neck were also more likely to be observed. Again, the motivation is unclear but could stem from concerns about the number of deep critical structures located within the neck or the potential influence of consultants involved in those cases. Although the motivations cannot be ascertained, the study reveals no outcome differences between those observed and those discharged, highlighting an opportunity for clinicians to standardize practice.

Regardless of the motivation, observing children after transition to an oral antibiotic can have profound consequences for the child and their family. The fact that these children spent nearly a full day longer in the hospital imposes both financial and safety hazards. The increase of $1800 to the cost of the hospitalization primarily reflects the hospital bed charge for the extra day. Additionally, there is an indirect cost the family bears by the additional hospital day. Beyond the immediate costs due to prolonged hospital stay, the extra day offers the opportunity for any of a multitude of negative, iatrogenic events to occur. To Err is Human: Building a Safer Health System,5  published 20 years ago, broke the silence on medical errors. However, authors of a 2017 meta-analysis suggest that 1 in every 5 patients in a hospital experiences an adverse drug event.6  Stromberg et al1  demonstrated that the number of readmissions within 7 days in both groups was small (7 patients total of 3704 patients) and evenly split between the 2 groups. Consistent with many previous studies, this finding suggests that compliance with enteral therapy was adequate after discharge regardless of whether the child was observed.

Although the retrospective use of administrative data sets hinders the interpretation, the authors did a good job of narrowing the study population to eliminate children who likely had more severe disease (ICU stay, placement of a central venous line, etc). Like many studies in which authors have used pediatric administrative data sets over the past decade,710  Stromberg et al1  found wide variability in practice across institutions. Stephens et al,8  published in this journal in April, demonstrated a range of variability between 25% and 81% for obtaining blood cultures from patients admitted with SSTIs. However, the current study may offer a small glimmer of hope in that the variability in blood culture obtainment observed (4%–24%) was less than that observed in previous studies. One can hope that this finding represents intentional efforts to bend the cost curve in a favorable direction through improved resource use.

Large administrative data studies generally do not change practice on their own. For example, as Michelson and Bachur11  noted, “a study of children with osteomyelitis used administrative data to demonstrate that early oral antimicrobial therapy was superior to prolonged intravenous therapy for serious safety outcomes without an increase in treatment failure. However, 6 years passed before a more traditional, confirmatory cohort study demonstrated the same conclusion and led to practice change.” Despite the limitations of the current study, the results strongly suggest that standardizing practice away from inpatient observation after transition to enteral antibiotic therapy is likely reasonable, probably safe, and would have positive impacts locally for the child, family, and hospital, as well as nationally. Hopefully, future dissemination and implementation work, such as the Better Antibiotic Selection in Children project planned by the Value in Inpatient Pediatrics Network, will hasten adoption of more judicious antibiotic and inpatient management choices for children with SSTIs.

In their article, Stromberg et al1  reinforce that retrospective data have value and should give clinicians comfort that observation after transition from intravenous to enteral antibiotic therapy when treating SSTI is usually not necessary. Although we can never know the motivations of the providers who elected observation in this study, the outcomes presented strongly suggest that the motivation is irrelevant. The children discharged from the hospital did as well as the observed children with less direct and indirect costs. Alex Trebek, the host of television’s Jeopardy show, once said, “Don’t tell me what you believe in. I’ll observe how you behave and I will make my own determination.”12  Most hospitalists say they believe in discharging children quickly to their home after transition to oral antibiotics; let’s observe a behavioral change.

Opinions expressed in these commentaries are those of the authors and not necessarily those of the American Academy of Pediatrics or its Committees.

Drs Snow and McCulloh drafted the commentary and approved the final version as submitted.

FUNDING: Dr McCulloh receives support from the Office of the Director of the National Institutes of Health (NIH) under award UG1OD024953. Dr Snow did not receive funding. Development of this commentary and the content in this publication were supported by the Office of the Director of the NIH under award UG1OD024953. The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIH. The funder/sponsor did not participate in the work. Funded by the National Institutes of Health (NIH).

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Competing Interests

POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.

FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relative to this article to disclose.