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Shortened IV Antibiotic Course for

Uncomplicated, Late-Onset Group


B Streptococcal Bacteremia
Eric R. Coon, MD, MS,​a,​b Raj Srivastava, MD, MPH,​a,​b,​c Greg Stoddard, MS,​b,​d Jacob Wilkes, BS,​c
Andrew T. Pavia, MD,​b,​e Samir S. Shah, MD, MSCEf,​g

BACKGROUND: Guidelines recommend a prolonged course (10 days) of intravenous (IV) abstract
antibiotic therapy for infants with uncomplicated, late-onset group B Streptococcus (GBS)
bacteremia. Our objective was to determine the frequency with which shorter IV antibiotic
courses are used and to compare rates of GBS disease recurrence between prolonged and
shortened IV antibiotic courses.
METHODS: We performed a multicenter retrospective cohort study of infants aged 7 days to
4 months who were admitted to children’s hospitals in the Pediatric Health Information
System database from 2000 to 2015 with GBS bacteremia. The exposure was shortened
IV antibiotic therapy, defined as discharge from the index GBS visit after a length of stay
of ≤8 days without a peripherally inserted central catheter charge. The primary outcome
was readmission for GBS bacteremia, meningitis, or osteomyelitis in the first year of life.
Outcomes were analyzed by using propensity-adjusted, inverse probability–weighted
regression models.
RESULTS: Of 775 infants who were diagnosed with uncomplicated, late-onset GBS bacteremia,
612 (79%) received a prolonged IV course of antibiotic therapy, and 163 (21%) received a
shortened course. Rates of treatment with shortened IV courses varied by hospital (range:
0%–67%; SD: 20%). Three patients (1.8%) in the shortened IV duration group experienced
GBS recurrence, compared with 14 patients (2.3%) in the prolonged IV duration group
(adjusted absolute risk difference: −0.2%; 95% confidence interval: −3.0% to 2.5%).
CONCLUSIONS: Shortened IV antibiotic courses are prescribed among infants with
uncomplicated, late-onset GBS bacteremia, with low rates of disease recurrence and
treatment failure.

WHAT’S KNOWN ON THIS SUBJECT: Experts


aDivision bUniversity
recommend 10 days of intravenous (IV) antibiotic
of Inpatient Medicine, of Utah School of Medicine, Primary Children's Hospital, and
Divisions of dEpidemiology and eInfectious Diseases, cIntermountain Healthcare, Salt Lake City, Utah; and
therapy for the treatment of late-onset group B
Divisions of fHospital Medicine and gInfectious Diseases, Cincinnati Children’s Hospital Medical Center, Streptococcus bacteremia. Prolonged IV courses
Cincinnati, Ohio increase the risk of central line complications,
including line breakage, thrombosis, and infection.
Dr Coon designed the study, wrote the statistical analysis plan, cleaned and analyzed the data,
and drafted and revised the manuscript; Drs Srivastava, Pavia, and Shah designed the study and WHAT THIS STUDY ADDS: Despite recommendations
revised the manuscript; Mr Wilkes cleaned and analyzed the data and revised the manuscript; to treat uncomplicated, late-onset group B
Mr Stoddard wrote the statistical analysis plan and revised the manuscript; and all authors Streptococcus bacteremia with prolonged IV antibiotic
approved the final manuscript as submitted and agree to be accountable for all aspects of the work. therapy, shortened courses are prescribed, with low
DOI: https://​doi.​org/​10.​1542/​peds.​2018-​0345 rates of disease recurrence and treatment failure.
Accepted for publication Jun 29, 2018
Address correspondence to Eric R. Coon, MD, MS, Division of Inpatient Medicine, Department To cite: Coon ER, Srivastava R, Stoddard G, et al. Short­
of Pediatrics, Primary Children’s Hospital, University of Utah School of Medicine, 100 N. Mario ened IV Antibiotic Course for Uncomplicated, Late-Onset
Capecchi Dr, Salt Lake City, UT 84113. E-mail: eric.coon@hsc.utah.edu Group B Streptococcal Bacteremia. Pediatrics. 2018;142(5):
e20180345

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PEDIATRICS Volume 142, number 5, November 2018:e20180345 ARTICLE
Group B Streptococcus (GBS) courses for other invasive pediatric discharge diagnosis code for GBS
is a leading cause of invasive infections, such as osteomyelitis,​13,​14
‍ disease and bacteremia were eligible
bacterial infections among infants complicated pneumonia,​‍15 and for inclusion (see Supplemental
<3 months of age.‍1,​2‍ Although complicated appendicitis,​‍16 has been Table 3 for ICD-9 code definitions).
intrapartum antibiotic prophylaxis established. We did not include encounters after
has substantially reduced the risk Given the existing ambiguity the implementation of International
of early-onset GBS disease (infants regarding the optimal duration Classification of Diseases, 10th
0–6 days of age), rates of late-onset of IV antibiotic therapy to treat Revision coding in October 2015
GBS disease (infants 7–90 days of uncomplicated, late-onset GBS because the inclusion and exposure
age) have not changed, affecting 1 in bacteremia, we sought to (1) codes that we used were validated
every 3000 infants born in the United determine the frequency with which only for ICD-9 codes. To limit the
States each year.‍3 these infants are treated with IV cohort to infants with uncomplicated
antibiotic durations that are shorter GBS disease for whom providers
Guidelines recommend prolonged than the guideline recommendation would be most likely to consider
intravenous (IV) antibiotic therapy and (2) compare rates of GBS shorter courses of IV antibiotics,
(10 days) to treat uncomplicated, disease recurrence and treatment infants were excluded if any of the
late-onset GBS bacteremia‍4; failure among infants treated with following were present during their
however, no studies have compared prolonged versus shortened IV index admission: (1) a diagnosis of
outcomes among infants who antibiotic courses. invasive bacterial or viral infections
receive prolonged versus shortened that might preclude transition to oral
durations of IV antibiotic therapy. therapy (meningitis, osteomyelitis,
Case reports suggest that infants METHODS septic joint, concomitant non-GBS
who are treated with lower doses bacterial infection, or herpes simplex
or shorter durations of IV antibiotic
Study Design and Setting virus infection), (2) a history of
therapy may be prone to recurrence We identified a retrospective cohort prematurity (gestational age <29
of disease,​‍5,​6‍ although more recent of infants with uncomplicated, late- weeks or birth weight <1500 g), or
evidence has led to challenges to the onset GBS bacteremia using the (3) a complicated or severe hospital
recommendation for prolonged IV Pediatric Health Information System course (index hospitalization >14
therapy.‍7 First, peripherally inserted (PHIS) database. The PHIS database days or receipt of care in an ICU).
central catheters (PICCs) are often provides deidentified information Infants <7 days old at the time of
necessary for these long IV antibiotic that details hospital and patient admission (early-onset GBS disease)
courses, but PICC complications demographic data, administrative were excluded. Patients who were
that necessitate early line removal data, such as discharge diagnosis transferred out of the PHIS hospital
are common, particularly among and procedure coding, and detailed were excluded to mitigate outcome
infants.8 Second, in a prospective billing information, including ascertainment bias.
study published in 2007, 29 infants laboratory, imaging, pharmacy, and
suffering from GBS bacteremia supply charge data, for patients who Exposure Classification
were successfully treated with a are cared for at 49 US stand-alone
conversion to oral antibiotic therapy children’s hospitals. Patients are The exposure of interest was receipt
after 48 hours of IV therapy, and it assigned a single identifier, which of a shortened course of IV antibiotic
was revealed that highly bactericidal allows for longitudinal linkage therapy. We defined a shortened
concentrations were easily of all visits within a single PHIS course as IV antibiotic treatment
achieved with an enteral amoxicillin hospital. Data for the current study ≤8 days, which is 2 days shorter
regimen.‍9 Third, a recurrence of were abstracted from emergency, than the guideline-recommended
GBS disease may be more related inpatient, or observation visits. The minimum duration.‍4 We subtracted
to environmental and host factors PHIS is operated by the Children’s 2 days from the guideline minimum
than the initial antibiotic regimen. Hospital Association (Lenexa, KS). to more conservatively classify a
The mucosal surfaces of infants often shortened course exposure because
remain colonized with GBS after Participants it is possible that patients could
completion of antibiotic treatment,​‍10 Patients ≤4 months of age who have received an additional day or
parents of infants infected with were discharged from a PHIS 2 of parenteral antibiotics before
GBS are frequently colonized with hospital between January 2000 or after their hospitalization (ie,
the same GBS strain,​‍11 and breast and September 2015 with an with intramuscular ceftriaxone).
milk may contain GBS.‍12 Finally, the International Classification of The PHIS database details daily
efficacy of shortened IV antibiotic Diseases, Ninth Revision (ICD-9) medications during hospitalization,

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2 COON et al
but it does not provide information who revisited the hospital in the first urinary tract infection, hospital case
about intended therapy after year of life but were not classified mix index, and the year in which a
hospitalization. Therefore, patients as suffering from a recurrence of patient was admitted to the hospital.
with a procedure code (38.93) or GBS disease. Patients with ICD-9 Complex chronic conditions are
a hospital charge for a PICC were codes for bacteremia, osteomyelitis, defined by ICD-9 codes and derived
assumed to have completed a or meningitis but no accompanying from hospitalization patterns of
prolonged course of IV antibiotics code for GBS disease and patients children with costly illnesses and
regardless of the measured duration with a code for GBS disease but no congenital defects.‍18 The PHIS
while hospitalized. accompanying code for bacteremia, case mix index is determined as
osteomyelitis, or meningitis were the average cost weight after each
Accuracy of Inclusion and Exposure classified as possibly suffering from discharge from a PHIS hospital is
Codes a recurrence. A PICC complication assigned an All-Patient–Refined
Using a manual medical record was defined by using a previously Diagnosis-Related Group and severity
review of infants with blood cultures established set of ICD-9 codes that level.
that were positive for GBS at Primary specified infection or mechanical
complication of a vascular device (see Statistical Analysis
Children’s Hospital (a PHIS center)
as the gold standard, we estimated Supplemental Table 3).‍17 In contrast To account for nonrandom treatment
the sensitivity and positive predictive to the original publication, we did not selection, we estimated the
values of the study’s ICD-9 inclusion include ICD-9 codes for fever because probability of each patient receiving
codes to detect true GBS bacteremia we did not consider this diagnosis a shortened IV course. Propensity
and determined how frequently these alone as sufficient to define a PICC scores were computed with a
patients received antibiotic therapy complication. multivariable logistic regression,
before hospital admission. To account for the possibility with the predicted probability of a
of readmissions for true PICC shortened course as the outcome
We validated our definition of PICC
complications being misclassified and the above covariates as
exposure using a PHIS data set from
as readmissions for GBS disease predictor variables. Patients were
a previously published study of
(falsely elevating the measured rate then weighted by the inverse of
children who were hospitalized for
of recurrence among the prolonged their probability to receive the
complicated pneumonia and whose
IV therapy group), we divided the treatment they actually received.
medical records were manually
prolonged IV therapy group into 2 Inverse probability weighting
reviewed.‍15 We calculated positive
subgroups for further description. maximizes patient inclusion in the
and negative predictive values
One subgroup received a PICC model and can create more balanced
for PICC status in the complicated
and was treated with ≤8 days of comparison cohorts. Finally, the
pneumonia data set according to (1)
IV antibiotics as inpatients (these association between exposure and
presence of a PICC by PHIS charge or
patients were likely discharged with patient outcomes was tested by
procedure code (our study definition)
their PICCs). The second subgroup using logistic regression, with the
or (2) presence of a PICC on chart
did not receive a PICC and was inverse probability weights assigned
review.
treated with >8 days of IV antibiotics to each patient. The association
Outcomes as inpatients (these patients likely between receipt of a shortened IV
completed their antibiotic treatment antibiotic course and time to a GBS
The primary study outcome was recurrence was measured with an
in the hospital).
a recurrence of GBS disease, inverse probability–weighted γ
defined as a hospital revisit with a regression model, which is robust to
Covariates
discharge diagnosis code for GBS nonnormally distributed outcomes.
disease and a discharge diagnosis Covariates included sex, age (in Analyses were performed by
code for bacteremia, meningitis, or days), race and/or ethnicity (non- using Stata version 14 (Stata Corp,
osteomyelitis in a patient’s first year Hispanic white, non-Hispanic College Station, TX) and R statistical
of life. Treatment failure, defined as African American, Hispanic, or software.‍19
a recurrence of GBS disease within other), primary insurance payer
14 days of hospital discharge, was (government, commercial or self-
a secondary outcome. To account pay, or unknown), history of a RESULTS
for the risk of misclassification of birth weight of 1500 to 2499 g
GBS disease recurrence, 1 author or a gestational age of 29 to 36
Study Population
(E.R.C) manually reviewed all of the weeks, history of a complex chronic We identified 1369 infants ≤4
discharge diagnosis codes for patients condition, presence of a concomitant months of age with GBS bacteremia.

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PEDIATRICS Volume 142, number 5, November 2018 3
After applying exclusion criteria,
775 infants with uncomplicated,
late-onset GBS bacteremia remained
(‍Fig 1), of whom 612 (79%) received
prolonged IV therapy, and 163 (21%)
received shortened IV therapy. Late-
onset GBS bacteremia occurred at a
median age of 48 days (interquartile
range [IQR]: 36–68 days). Patients
who received a shortened course of
IV antibiotics were older, more often
admitted in later years, and more
likely to have a concomitant urinary
tract infection (‍Table 1).

Accuracy of Inclusion and Exposure


Codes
FIGURE 1
ICD-9 codes had moderate sensitivity Study flowchart. HSV, herpes simplex virus.
and high positive predictive values
for identifying uncomplicated GBS
bacteremia. The sensitivity of our Children’s Hospital, 23 had verified who were identified by charges and
ICD-9 inclusion codes to detect GBS bacteremia on chart review. procedure codes in the PHIS, 491 had
true GBS bacteremia was 72%; of Among patients with verified GBS a verified PICC on chart review. The
the 32 patients with GBS-positive bacteremia, 22 of 23 (96%) received negative predictive value was 99%;
blood cultures otherwise meeting ≤1 additional day of antibiotic of the 1544 patients without a PICC
inclusion criteria on chart review therapy before hospital admission. who were identified by charges and
at Primary Children’s Hospital, procedure codes in the PHIS, 1522
23 were captured by our ICD-9 The complicated pneumonia data did not have a PICC on chart review.
codes in the PHIS database. The set revealed high positive and
positive predictive value was negative predictive values for our Antibiotic Treatment
96%; of the 24 patients who were study definition of a PICC exposure.
identified by ICD-9 codes in the PHIS The positive predictive value was The most common antibiotics that
database and cared for at Primary 85%; of the 579 patients with a PICC were prescribed empirically at

TABLE 1 Demographics and Clinical Characteristics


Variable Shortened IV Therapy, N = 163 Prolonged IV Therapy, N = 612 P
Female sex, n (%) 81 (50) 289 (47) .58a
Age, d, n (%) <.01b
  7–30 13 (8) 80 (13)
  31–90 124 (76) 475 (78)
  >90 26 (16) 57 (9)
Race and/or ethnicity, n (%) .74a
  Non-Hispanic white 62 (38) 215 (35)
  Non-Hispanic African American 59 (36) 251 (41)
  Hispanic 23 (14) 81 (13)
  Other 19 (12) 65 (11)
Primary payer, n (%) .08a
  Government 111 (68) 367 (60)
  Commercial insurance or self-pay 41 (25) 172 (28)
  Unknown 11 (7) 73 (12)
History of prematurity, n (%) 1 (1) 16 (3) .12a
Complex chronic condition, n (%) 19 (12) 63 (10) .62a
Concomitant urinary tract infection, n (%) 23 (14) 32 (5) <.01a
Case mix index, median (IQR) 1.03 (0.99–1.11) 1.04 (1.00–1.11) .52c
Admission y, median (IQR) 2007 (04–12) 2009 (05–12) <.02c
a χ2 test.
b Mann–Whitney U test.
c t test.

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4 COON et al
FIGURE 2
Distribution of inpatient IV antibiotic therapy duration.

hospital admission were ampicillin 7 days. A proportion of children recurrence were low among
plus a third-generation cephalosporin in the prolonged IV antibiotic patients who received shortened IV
(37%), third-generation therapy group were discharged therapy and prolonged IV therapy:
cephalosporin monotherapy (28%), with a PICC within the first week 3 of 163 (1.8%) compared with
or third-generation cephalosporin of hospitalization, but most (67%) 14 of 612 (2.3%), respectively
monotherapy plus vancomycin completed at least 9 days of (adjusted absolute difference:
(7%). Targeted therapy on the inpatient IV antibiotic therapy. −0.2%; 95% confidence interval
day of discharge was most often [CI]: −3.0% to 2.5%). Overall,
The proportion of children who
ampicillin (47%), penicillin (18%), the mean time to recurrence was
received a shortened IV course
or ceftriaxone (18%). Among 25 days (SD: 17 days), and there
varied considerably by hospital
patients in the shortened IV was no difference by IV treatment
(range: 0%–67%; SD: 20%; ‍Fig 3).
therapy group, 27 (16%) received duration (adjusted absolute
No patients were treated with a
an oral antibiotic on the day of difference: 9 days; 95% CI −13 to
shortened IV course at 14 hospitals,
discharge (23 received amoxicillin, 31 days). None of the 27 patients
whereas 5 hospitals treated >50%
3 received cefdinir, and 1 received in the shortened IV therapy group
of their patients with shortened IV
penicillin). The median duration who received an oral antibiotic
courses.
of inpatient IV antibiotic therapy on the day of discharge suffered
for the whole cohort was 9 days from a recurrence of GBS disease.
GBS Recurrence
(IQR: 4–10 days); the distribution The rates of GBS recurrence
by shortened versus prolonged Overall, 17 (2.2%) patients suffered among patients in the prolonged
IV course is presented in ‍Fig 2. from a recurrence of their GBS IV therapy subgroups who were
Among patients who received disease (‍Table 2). In all but 2 discharged without and with a PICC
shortened IV antibiotic courses, cases, the recurrence was limited were 1.5% and 4.0%, respectively
there are biphasic peaks at 3 and to bacteremia. Rates of disease (Supplemental Table 4).

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PEDIATRICS Volume 142, number 5, November 2018 5
prolonged IV therapy (3.3% vs 3.1%,
respectively).

DISCUSSION
Among infants with uncomplicated,
late-onset GBS bacteremia who were
cared for at US children’s hospitals,
we found that, contrary to national
recommendations, shortened
IV antibiotic courses are being
prescribed; shortened courses were
prescribed more often among older
infants and those with a concomitant
diagnosis of urinary tract infection.
We found striking variation in IV
antibiotic treatment duration by
hospital and whether patients
received prolonged or shortened
IV courses; rates of GBS disease
FIGURE 3
Proportion of children at each hospital who received a shortened IV antibiotic course. recurrence and treatment failure
were low.
Secondary Outcomes Possible GBS Recurrence The ideal study design to use
Treatment failure was rare Sixty-one patients revisited the to answer the question of the
(whether patients received hospital within their first year of effectiveness of shortened versus
shortened IV therapy [n = 1] life but did not meet our definition prolonged IV antibiotic courses for
or prolonged IV therapy of suffering from a recurrence of the treatment of GBS bacteremia is
[n = 6]) and did not differ GBS disease. In a manual review a randomized trial. Such a trial is
by IV treatment duration of individual discharge diagnosis unlikely given the modest prevalence
(adjusted absolute difference: codes for these 61 patients, we of GBS disease (children’s hospitals
−0.3%; 95% CI: −1.8% to identified 8 patients with a possible in our study treated only 1–3 eligible
1.1%). Eight patients (1%) GBS disease recurrence: 6 patients patients per year) and the rarity of
experienced PICC complications in the prolonged IV therapy group disease recurrence.
during their index admission, and 2 patients in the shortened IV In lieu of a randomized trial, we
7 of whom were in the prolonged therapy group. Classifying these conducted an observational study
IV therapy group. Three patients 8 patients as suffering from a GBS in which common sources of bias
(all from the prolonged IV disease recurrence raised the were addressed. First, to limit
therapy group) were readmitted overall estimate of GBS recurrence confounding by indication, we
to the hospital with a diagnosis to 3.2% (25 of 775) and narrowed employed exclusion criteria that
code for a PICC complication the difference in recurrence rates were used to eliminate higher-risk
within 30 days of their index between patients who received and sicker patients. The potential
hospital discharge. shortened IV therapy versus for confounding by indication is

TABLE 2 Patient Outcomes


Variable Shortened IV Therapy, N = 163 Prolonged IV Therapy, N = 612 Absolute Difference (95% CI)
Any recurrence, n (%) 3 (1.8) 14 (2.3) −0.2% (−3.0% to 2.5%)a
  Bacteremia (alone) 2 (1.8) 13 (2.3)
  Meningitisa 1 (0.6) 1 (0.2)
  Osteomyelitis 0 (0) 0 (0)
Days to recurrence,​b mean (SEM) 28 (15) 24 (8) 9 (−13 to 31)c
Treatment failure, n (%) 1 (0.6) 6 (1.0) −0.3% (−1.8% to 1.1%)d
a Both cases of meningitis were accompanied by bacteremia.
b Descriptive statistics in which patients with recurrence (n = 17) were used.
c Obtained from a propensity-adjusted, inverse probability–weighted γ regression model.
d Obtained from a propensity-adjusted, inverse probability–weighted logistic regression model.

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6 COON et al
further limited by the substantial to augment the outcomes to include GBS recurrences will be isolated
hospital-level prescribing variation potential recurrences of GBS. Finally, bacteremia, the number needed to
that was observed in our cohort of we suspect that most patients who treat to prevent a recurrence with
children with uncomplicated disease, received shortened courses of IV GBS meningitis will be much higher.
which suggests that the local hospital antibiotic therapy received further These estimates may be helpful for
culture is a major factor governing treatment with high-dose oral parents and providers as they decide
treatment duration. Second, to antibiotic therapy after discharge. what IV antibiotic duration is optimal
assess the possibility of inclusion But because the PHIS database for a particular child.
and exposure misclassification, provides only inpatient medication
we validated each set of codes. charges, our study does not address
The positive predictive value of the total duration of antibiotic
CONCLUSIONS
our inclusion criteria was 96%, therapy. A portion of infants with
suggesting that virtually all patients uncomplicated, late-onset GBS
who were included in the study truly Infants without a history of bacteremia are treated with
had GBS bacteremia. The negative significant prematurity who do not shortened courses of IV antibiotic
predictive value of our PICC exposure require intensive care for their GBS therapy, and they experience low
definition was 99%, suggesting disease appear to have low rates of rates of disease recurrence and
that virtually all patients in the recurrence, whether treated with treatment failure. Early transition
shortened IV antibiotic group truly shortened or prolonged IV antibiotic to oral antibiotic therapy may be
did not receive a PICC. Nevertheless, courses. Beyond decreased health appropriate for carefully selected
because our PICC definition was care costs, shortened IV antibiotic infants with GBS bacteremia.
validated among a cohort of children courses provide the advantage of
with complicated pneumonia, we a diminished burden for families,
ACKNOWLEDGMENTS
identified a subgroup of patients for allowing for patients to leave the
whom actual receipt of a shortened hospital sooner, making it easier to We thank the members of the
IV antibiotic course was most likely administer the antibiotic at home, Pediatric Research in Inpatient
(patients given an oral antibiotic on and decreasing the likelihood that Settings network for their chart
their final day of hospitalization). they would develop a treatment- review validation of PICC codes and
None of these patients suffered a related complication. On the other Brian Pace, MS, for his guidance in
recurrence of GBS disease. A third hand, it should be acknowledged creating the study figures.
threat to our study’s validity is that the CI around the adjusted
outcome misclassification. Although absolute difference in recurrence
the higher rate of disease recurrence between shortened and prolonged ABBREVIATIONS
among the prolonged IV therapy IV therapy that was found in the
CI: confidence interval
subgroup that was discharged with current study is fairly wide; this will
GBS: group B Streptococcus
a PICC may be partially explained warrant consideration in treatment
ICD-9: International Classification
by misclassified PICC complications, decisions. By using the upper limit
of Diseases, Ninth Revision
the prolonged IV therapy subgroup of the CI, the number needed to treat
IQR: interquartile range
that was discharged without a PICC with prolonged IV therapy to prevent
IV: intravenous
experienced a similar rate of disease 1 recurrence of GBS disease would
PHIS: Pediatric Health
recurrence compared with the be 40. By using the point estimate,
Information System
shortened IV therapy group. Findings which favors shortened IV therapy,
PICC: peripherally inserted
were also similar after a manual the number needed to treat would
central catheter
review of diagnosis codes was used be 500. Given that the majority of

PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275).


Copyright © 2018 by the American Academy of Pediatrics
FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.
FUNDING: No external funding.
POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.
COMPANION PAPER: A companion to this article can be found online at www.​pediatrics.​org/​cgi/​doi/​10.​1542/​peds.​2018-​2623.

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PEDIATRICS Volume 142, number 5, November 2018 7
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8 COON et al
Shortened IV Antibiotic Course for Uncomplicated, Late-Onset Group B
Streptococcal Bacteremia
Eric R. Coon, Raj Srivastava, Greg Stoddard, Jacob Wilkes, Andrew T. Pavia and
Samir S. Shah
Pediatrics originally published online October 11, 2018;

Updated Information & including high resolution figures, can be found at:
Services http://pediatrics.aappublications.org/content/early/2018/10/09/peds.2
018-0345
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018-0345#BIBL
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Shortened IV Antibiotic Course for Uncomplicated, Late-Onset Group B
Streptococcal Bacteremia
Eric R. Coon, Raj Srivastava, Greg Stoddard, Jacob Wilkes, Andrew T. Pavia and
Samir S. Shah
Pediatrics originally published online October 11, 2018;

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http://pediatrics.aappublications.org/content/early/2018/10/09/peds.2018-0345

Data Supplement at:


http://pediatrics.aappublications.org/content/suppl/2018/10/09/peds.2018-0345.DCSupplemental

Pediatrics is the official journal of the American Academy of Pediatrics. A monthly publication, it
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60007. Copyright © 2018 by the American Academy of Pediatrics. All rights reserved. Print ISSN:
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