P3.J184: Can Severity Stratification in Clinical Practice Guidelines Aid in Initiation or Early Conversion of IV to Enteral Antibiotics in Hospitalized Pediatric Patients with Community Acquired Pneumonia?

Background: Community acquired pneumonia (CAP) is among the most prevalent and expensive conditions to treat at pediatric hospitals in the United States. Oral and IV antibiotics are equally efficacious treatments for non-severe CAP, with initial oral therapy recommended over IV due to lower associated hospitalization costs and shorter median length of stay. This recommendation and current practice patterns has made appropriate transition to oral antibiotics an emerging quality and value focus. There is however little published research supporting development of Clinical Practice Guidelines (CPGs) stratifying CAP to appropriately recommend initiation or transition to oral therapy.

Methods: An exempt IRB was approved prior to this retrospective study for a local QI project performed for all children hospitalized with CAP from July 1 2021 to June 30 2022 at our hospital. Patients with complicated pneumonia or pre-existing conditions impairing bronchial motility were excluded. The primary measure of opportunity days was identified by cross-referencing patients receiving other oral medications, having an age-appropriate diet ordered, and otherwise having no contraindication to oral therapy. Secondary measures of length of stay (LOS), and patient characteristics per our current clinical practice guidelines such as O2 utilization and patient age were obtained. CAP clinical severity was determined by both O2 utilization and PICU utilization.

Results: We identified 56 patients who met inclusion criteria; 14 required oxygen, 5 required PICU utilization, and 7 were under 6 months of age. Of patients requiring oxygen, mean opportunity days was 1.95 days compared to 1.5 days in patients not requiring oxygen (p=0.34). Patients with oxygen requirement had a statistically significant longer LOS compared to patients without O2 requirement (46.9 hours v. 74.5 hours; p=0.01). 11.9% of patients with oxygen requirement needed care in the PICU, and no patients without oxygen requirement needed care in the PICU. Of the patients under 6m of age, mean opportunity days was 1.43 days compared to 1.9 (p=0.29) in those > 6m (p=0.1). Patients < 6m did not have a statistically significant longer LOS compared to patients > 6m, though 100% of children < 6m required oxygen.

Conclusion: This study demonstrates that stratification of pneumonia is an important tool that has not yet been assessed or utilized to develop CPGs that include appropriate timing of initiation or transition to oral antibiotics. Patients with oxygen requirements are more likely to have increased LOS and need for care in the PICU, supporting the presence of oxygen requirement as a marker for severity. Age and O2 requirement both have an effect on mean opportunity days of making the IV to oral antibiotic switch and can therefore be used to both stratify pneumonia and make recommendations for initiation or transition to oral antibiotics in hospitalized pediatric patients.