Clinical Controversies: IV Antibiotics Before Discharge: Think Before You Stick : Emergency Medicine News

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Clinical Controversies

Clinical Controversies

IV Antibiotics Before Discharge: Think Before You Stick

Briggs, Blake MD

doi: 10.1097/01.EEM.0000898244.83292.5a
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    Figure:
    IV antibiotics, prescription, doxycycline
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    How many times have you had this situation? A patient with a urinary tract infection, cellulitis, or pneumonia receives one IV antibiotic dose prior to discharge. You don't want to admit the patient but simply kickstart that bactericidal action into high gear.

    To be clear, we are talking about patients who can be immediately discharged with commonly treated infections: cystitis, community-acquired pneumonia, and soft tissue infections like cellulitis, erysipelas, and abscesses. We are not talking about toxic-appearing patients, those who are being observed in the ED for several hours to monitor for disease progression, or ones who cannot tolerate oral intake (actively vomiting, nonfunctional GI tract, or aspiration risk).

    Many arguments are used to justify administering IV antibiotics prior to discharge. Perhaps the most quoted reason for giving predischarge IV antibiotics is that they “work faster and stronger.” Unfortunately, a multitude of studies go against this anecdotal thinking. Many commonly used oral antibiotics have excellent absorption, and their bioavailability is almost identical to the IV route. The bioavailability of clindamycin, doxycycline, trimethoprim-sulfamethoxazole, metronidazole, and levofloxacin, for example, are all more than 90 percent. (J Pharmacol Pharmacother. 2014;5[2]:83; https://bit.ly/3BottLR.)

    Beyond just bioavailability, multiple studies have directly compared IV antibiotics with oral antibiotics for various conditions, measuring readmission rates and recurrence rates of infection. One review of 25 studies including 2488 patients compared oral with IV antibiotics for uncomplicated cellulitis, finding no difference in clinical outcomes, including readmission rates. (Cochrane Database Syst Rev. 2010 Jun 16;[6]:CD004299; https://bit.ly/3xwjvHc.)

    Oral as Good as IV

    The role of oral antibiotics in other types of infections has also been extensively studied. Multiple randomized, controlled trials showed that oral antibiotics are as effective as IV in adults with community-acquired pneumonia and UTIs. (Cochrane Database Syst Rev. 2014 Oct 9;[10]:CD002109; https://bit.ly/3LhtNAF; Chest. 1996;110[4]:965; Arch Intern Med. 1999;159[1]:53; https://bit.ly/3BKNT2U.) Two randomized, controlled studies also showed oral and IV equivalence for patients with pediatric pneumonia. (Eur Respir J. 2010;35[4]:858; https://bit.ly/3BIbG3A.)

    A retrospective analysis of 30,000 children from age 29 days to 2 years with pediatric urinary tract infections found that 36 percent received a single IV antibiotic dose before discharge. The rates of ED revisits within three days and ED revisits with admission were low in both groups, with no significant difference. (Pediatrics. 2018;142[3]:e20180900; https://bit.ly/3qGUDbN.)

    Taking this one step further, a review of 15 randomized, controlled trials looking at 1743 children and adults with UTIs had pooled outcomes with no significant differences between oral and IV antibiotics in clinical and bacteriological cure (RR 0.97, 95% CI 0.81 to 1.17), and no patients had reinfection in either group. (Cochrane Database Syst Rev. 2007[4]:CD003237; https://bit.ly/3BjXpJ6.)

    Cost, Time, and Risk

    IV antibiotics are expensive. You might be surprised how costly if you look up the price at your own shop. One U.K. study found the cost of administering IV antibiotics was considerably higher than the medications themselves. (Crit Care. 2003;7[6]:R184; https://bit.ly/3xuN5ga.) They take longer to administer than oral antibiotics, and their administration also occupies health care staff more, keeping them from other patient care duties. IV placement can be tedious in some patients and painful in most, and antibiotics do not promote patient ambulation and faster time to discharge. With the staff shortages hurting many EDs, any chance to reduce nurse workload is welcome.

    IV antibiotic administration is also not without risk to the patient. Phlebitis and extravasation occurred in less than five percent of cases measured in one non-ED study. (PLoS Med. 2015;12[5]:e1001825; https://bit.ly/3QJhONn; Scand J Infect Dis. 2002;34[7]:512.) Bacteremia can result from peripheral IVs in as many as 0.1 percent of cases. (Mayo Clin Proc. 2006;81[9]:1159.) These numbers are low, but they must be seriously considered for a patient who does not actually need IV antibiotics for a dischargeable condition.

    Another unfortunate point about IV antibiotics is the risk of gastrointestinal illness. We already know that antibiotics predispose patients to higher rates of diarrheal illness and Clostridium difficile, but the parenteral route may be worse. One prospective multicenter cohort study of 247 adult patients showed a significantly higher rate of antibiotic-associated diarrhea with just one dose of IV antibiotics in the ED (25.7% vs. 12.3%). (Mayo Clin Proc. 2006;81[9]:1159.)

    Anecdotal thinking holds that patients who are discharged from the ED and do not fill their prescription are at risk for readmission unless they receive an IV dose in the ED. It is difficult to study this, but if we are inclined to give a predischarge antibiotic dose in the ED, why not give the oral antibiotic that we are sending home with the patient?

    If you are writing a prescription for doxycycline for cellulitis but want to give a predischarge dose in the ED, for example, skip the vancomycin and give a dose of doxycycline instead. We should be reserving broad-spectrum antibiotics for when they are needed in sicker patients. Giving a patient IV ceftriaxone for a UTI prior to discharge or vancomycin to treat minor nonpurulent cellulitis is a misuse of resources and is antagonistic to antibiotic stewardship.

    IV antibiotics are not that magical. We have a commitment to our patients and the antimicrobial community we live in. Think before you stick next time.

    Dr. Briggsis an assistant professor of emergency medicine at the University of Tennessee Medical Center in Knoxville. He is the founder, a podcast host, and the editor-in-chief of EM Board Bombs (https://www.emboardbombs.com), a multiplatform educational tool designed to provide board prep and focus on what EPs need to know for the practice of emergency medicine. Follow him on Twitter@blakebriggsmd.

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