At-home treatment with short-course ceftriaxone is safe and effective for children requiring intravenous antibiotics for cellulitis, and is less costly and preferred by patients, according to a study published in The Lancet: Infectious Diseases. No increased acquisition of antibiotic-resistant microorganisms was seen in this study of previously healthy children using ceftriaxone at home, but larger studies are needed.
The Cellulitis at Home or Inpatient in Children from the Emergency Department (CHOICE) trial (NCT02334124) was a controlled, randomized, noninferiority trial of at-home intravenous antibiotic therapy for children aged 6 months to 18 years presenting to the emergency department at The Royal Children’s Hospital (Melbourne, VIC, Australia) with uncomplicated, moderate to severe cellulitis. Participants were randomly assigned to an at-home intravenous ceftriaxone group (50 mg/kg once daily) or an in-hospital intravenous flucloxacillin group (50 mg/kg every 6 hours). Randomization was web-based and stratified by the presence of periorbital cellulitis and age. The primary study outcome was treatment failure, ie, no clinical improvements or adverse event occurrence resulting in antibiotic change within 48 hours of the first dose. Secondary outcomes were the acquisition of antibiotic-resistant bacteria and adverse events.
Of a total of 190 children recruited for the study, the intention-to-treat analysis ultimately included 188 children (93 in the at-home group and 95 in the in-hospital group), as 2 of the home group children were found to be ineligible postrandomization. In the home group, treatment failure occurred in 2% (n=2) of the home group and 7% (n=7) of the hospital group (risk difference -5.2%; 95% CI, -11.3 to 0.8; P =.088), meeting the prespecified criterion for noninferiority.
In the per-protocol analysis, treatment failure was seen in 1% (1 of 89) of the at-home group and in 8% (7 of 91) of the in-hospital group (risk difference -6.5%; 95% CI, -12.4 to -0.7). Fewer adverse events occurred in the at-home group compared with the hospital group (2 [2%] vs 10 [11%]; P =.048). After 3 months, no between-group difference was seen in rates of gastrointestinal acquisition of extended-spectrum β-lactamase-producing bacteria or Clostridium difficile or nasal acquisition of methicillin-resistant Staphylococcus aureus.
The study investigators concluded that “this study provides evidence that treatment at home with short-course ceftriaxone is efficacious, safe, preferred by patients, and less costly, allowing children to avoid hospital admission along with the accompanying advantages (such as avoidance of hospital-acquired infections).” They also highlighted that their data did demonstrate an increase in the development of antibiotic-resistant pathogens in previously health children who were treated with ceftriaxone at home, but noted the need for larger studies to support their findings. Researchers did note a caveat in that their results should not be extrapolated to apply to longer courses of ceftriaxone, and stated that robust antimicrobial stewardship should remain a mainstay of outpatient parenteral antimicrobial therapy programs.
Ibrahim LF, Hopper SM, Orsini F, Daley AJ, Babl FE, Bryant PA. Efficacy and safety of intravenous ceftriaxone at home versus intravenous flucloxacillin in hospital for children with cellulitis (CHOICE): a single-centre, open-label, randomised, controlled, non-inferiority trial [published online March 7, 2019]. Lancet Infect Dis. doi: 10.1016/S1473-3099(18)30729-1