Does Initial Antibiotic Route Matter for Children Hospitalized with Pneumonia?
Authors: Cotter Jillian M , Zaniletti Isabella , Williams Derek J , Ramgopal Sriram , Fritz Cristin Q , Taft Maia , Hall Matt , Temte Elizabeth , Stassun Justine , Trivedi Krishna , Kapes Jack , Lavey Jack , Kempe Allison , Ambroggio Lilliam 
Published: January 2025

Abstract

Corresponding Author: Jillian M. Cotter, MD, MSCS; Assistant Professor, Department of Pediatrics, Section of Hospital Medicine; Children’s Hospital Colorado and University of Colorado School of Medicine; 13123 E 16th Ave, Box B302, Aurora, CO 80045; jillian.cotter@childrenscolorado.org; 720-777-5241
Alternate Corresponding Author: Lilliam Ambroggio, PhD, Associate Professor, Department of Pediatrics, Section of Emergency Medicine and Hospital Medicine; Children’s Hospital Colorado and University of Colorado School of Medicine; 13123 E 16th Ave, Box B302, Aurora, CO 80045; lilliam.ambroggio@childrenscolorado.org; 720-777-5241
Conflicts of interest/disclosures: Drs. Cotter and Ambroggio receive grant support from Pfizer Inc for a study unrelated to this manuscript. The authors have no other conflicts of interest or financial disclosures to disclose.
Funding sources: Dr. Cotter’s effort contributing to this article was in part funded by a career development award from Children’s Hospital Colorado and an Academic Pediatric Association Young Investigator Award. This publication was also supported by NIH/NCATS Colorado CTSA Grant Number UL1 TR002535. Its contents are the authors’ sole responsibility and do not necessarily represent official NIH views. The other authors received no external funding that contributed to this work.

Background
Initial oral antibiotics may be as effective as intravenous (IV) antibiotics for children hospitalized with community-acquired pneumonia (CAP), but further data are needed. We evaluated for associations of initial antibiotic route (IV vs. oral) with length of stay (LOS) and secondary outcomes for children hospitalized with CAP.

Methods
We performed a multicenter, retrospective cohort study of children diagnosed with CAP who were hospitalized for &gt;48 hours, had chest radiographs, and received antibiotics at four children’s hospitals between 2014-2020. Data were obtained from the Pediatric Health Information System and manual chart review. The exposure was initial antibiotic route (i.e., first antibiotic given intravenously or orally). Outcomes included LOS (primary), duration of supplemental oxygen, cost, care escalation, and readmission or emergency department revisit. We performed multivariable regression modeling using inverse probability treatment weights from propensity scores.

Results
Of 1,147 included children, 37% received initial oral antibiotics. Within the propensity balanced sample, LOS was 73.5 hours (IQR 61.0, 99.5) and 78.7 (61.0, 118.0) for patients with initial oral and IV antibiotics, respectively. Children receiving initial oral antibiotics had an 8% reduction in LOS (OR 0.92 [95% CI: 0.87, 0.94]) and 14% reduction in cost (OR 0.86 [95% CI 0.79, 0.94]) vs. those receiving initial IV antibiotics (Table 1). There were no differences in other outcomes.

Conclusion
Children with CAP receiving initial oral antibiotics had shorter LOS and reduced hospital cost without differences in escalated care or return visits. Starting hospitalized children on oral antibiotics is likely a safe and effective alternative to IV treatment.
Table 1. Outcomes Using Propensity Weighted Regression Model