静脉用与口服抗生素用于预防复杂性阑尾炎患儿治疗失败：是否有理由放弃外周静脉置入中心静脉导管？

Intravenous Versus Oral Antibiotics for the Prevention of Treatment Failure in Children With Complicated Appendicitis: Has the Abandonment of Peripherally Inserted Catheters Been Justified?

机构信息

*Department of Pediatric Surgery, Children's Hospital Boston-Harvard Medical School, Boston, MA †Division of Pediatric Cardiology, Columbia University Medical Center, New York-Presbyterian, Morgan Stanley Children's Hospital, New York, NY ‡Division of Inpatient Medicine, Department of Pediatrics, University of Utah Health, Sciences Center, Salt Lake City, UT §Primary Children's Hospital, Intermountain Healthcare, Salt Lake City, UT ¶Institute for Healthcare Delivery Research, Intermountain Healthcare, Salt Lake City, UT ||Divisions of Hospital Medicine and Infectious Diseases, Cincinnati Children's Hospital Medical Center, Cincinnati, OH **Department of Pediatrics, Washington University School of Medicine, St. Louis, MO ††Division of General Pediatrics, Center for Pediatric Clinical Effectiveness, Children's Hospital of Philadelphia, Philadelphia, PA ‡‡Department of Biostatistics and Epidemiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA §§Children's Hospital Association, Overland Park, KS ¶¶Rady Children's Hospital, San Diego, CA.

出版信息

Ann Surg. 2017 Aug;266(2):361-368. doi: 10.1097/SLA.0000000000001923.

DOI:10.1097/SLA.0000000000001923

PMID:27429024

Abstract

OBJECTIVE

To compare treatment failure leading to hospital readmission in children with complicated appendicitis who received oral versus intravenous antibiotics after discharge.

BACKGROUND

Antibiotics are often employed after discharge to prevent treatment failure in children with complicated appendicitis, although existing studies comparing intravenous and oral antibiotics for this purpose are limited.

METHODS

We identified all patients aged 3 to 18 years undergoing appendectomy for complicated appendicitis, who received postdischarge antibiotics at 35 childrens hospitals from 2009 to 2012. Discharge codes were used to identify study subjects from the Pediatric Health Information System database, and chart review confirmed eligibility, treatment assignment, and outcomes. Exposure status was based on outpatient antibiotic therapy, and analysis used optimal and full matching methods to adjust for demographic and clinical characteristics. Treatment failure (defined as an organ-space infection) requiring inpatient readmission was the primary outcome. Secondary outcomes included revisits from any cause to either the inpatient or emergency department setting.

RESULTS

In all, 4579 patients were included (median: 99/hospital), and utilization of intravenous antibiotics after discharge ranged from 0% to 91.7% across hospitals. In the matched analysis, the rate of treatment failure was significantly higher for the intravenous group than the oral group [odds ratio (OR) 1.74, 95% confidence interval (CI) 1.05-2.88; risk difference: 4.0%, 95% CI 0.4-7.6%], as was the rate of all-cause revisits (OR 2.11, 95% CI 1.44-3.11; risk difference: 9.4%, 95% CI 4.7-14.2%). The rate of peripherally inserted central catheter line complications was 3.2% in the intravenous group, and drug reactions were rare in both groups (intravenous: 0.7%, oral: 0.5%).

CONCLUSIONS

Compared with oral antibiotics, use of intravenous antibiotics after discharge in children with complicated appendicitis was associated with higher rates of both treatment failure and all-cause hospital revisits.

摘要

目的

比较患有复杂性阑尾炎的儿童在出院后接受口服和静脉用抗生素治疗后导致再次住院的治疗失败情况。

背景

在患有复杂性阑尾炎的儿童中，常使用抗生素来预防治疗失败，尽管现有比较这两种方法的研究有限。

方法

我们在 2009 年至 2012 年间，从 35 家儿童医院的儿科健康信息系统数据库中确定了所有接受阑尾切除术治疗复杂性阑尾炎且在出院后接受抗生素治疗的 3 至 18 岁患者。出院代码用于从数据库中识别研究对象，病历审查确认了入选标准、治疗分配和结局。暴露状况基于门诊抗生素治疗，分析采用最优和完全匹配方法来调整人口统计学和临床特征。需要再次住院的治疗失败（定义为器官间隙感染）为主要结局。次要结局包括因任何原因到住院或急诊部门就诊的复诊情况。

结果

共纳入 4579 例患者（中位数：每家医院 99 例），出院后静脉使用抗生素的比例在各医院从 0%至 91.7%不等。在匹配分析中，静脉组的治疗失败率明显高于口服组[比值比（OR）1.74，95%置信区间（CI）1.05-2.88；风险差异：4.0%，95%CI 0.4-7.6%]，所有原因的复诊率也更高（OR 2.11，95%CI 1.44-3.11；风险差异：9.4%，95%CI 4.7-14.2%）。静脉组的外周静脉置入中心导管相关并发症发生率为 3.2%，两组均罕见药物反应（静脉组：0.7%，口服组：0.5%）。