Comparing Oral and Intravenous Antibiotics

When a child who has been hospitalized with a serious infection is sent home to complete a prolonged course of antibiotics, they can receive their medicine in two ways — by mouth, or intravenously, via a peripherally inserted central catheter (PICC) line. Though PICC lines can be scary for pediatric patients, and require caregivers to be trained in their use and care, many doctors often prefer them to oral medicines for long-term antibiotic treatments.

One CHOP researcher, Ron Keren, MD, MPH, director of Clinical Futures, was recently awarded nearly two million dollars from the Patient-Centered Outcomes Research Institute (PCORI) to lead a study examining whether oral antibiotics are as effective at treating infection over an extended period as PICC lines.

“These two antibiotic treatment options have major implications for the overall experience of the child, families and caregivers, but there is a lack of real-world evidence on their benefits and drawbacks to help clinicians and patient families make an informed choice,” said Dr. Keren.

A type of intravenous (IV) catheter, a PICC line is a long, flexible tube that is inserted in a peripheral vein, often in the arm or neck, and advanced until its tip rests near the heart. Because they tap directly into the circulatory system, PICC lines offer maximum drug delivery.

Unlike regular IV catheters, PICC lines can stay in the body for weeks to months, but they require regular maintenance. PICC lines must be flushed daily, their dressings have to be inspected and changed, and patients with PICC lines must avoid getting them wet or dirty — a tall order for some active pediatric patients. In addition, a variety of equipment is required to use and maintain PICC lines, including infusion pumps and portable IV poles.

PICC lines do have some risks. They can clot, break, or become dislodged. And because they sit in large blood vessels directly above the heart, any bacteria that are inadvertently introduced into the catheter go directly to the heart and are pumped throughout the body, which can lead to a dangerous infection called sepsis.

Oral antibiotics, on the other hand, are much easier for patients to take and caregivers to manage. However, because oral medications must pass through the digestive system, to have the same efficacy as IV medications oral antibiotics must have high “bioavailability” — the percentage of the drug that reaches the blood. Drugs administered via PICC lines have, by definition, 100 percent bioavailability.

“If we find that the prolonged IV option is no better than the oral route, we think that most families would prefer for their child to take oral antibiotics,” Dr. Keren noted. “However, if IV antibiotics are marginally better than oral antibiotics, then that benefit will need to be weighed against any reduction in quality of life and complications that we anticipate with the PICC lines.”