345 - Early Oral Therapy for Streptococcus anginosus Purulent Brain Infections: A Single Center Experience

Background: Pediatric Streptococcus anginosus intracranial pyogenic are commonly treated with prolonged intravenous (IV) antibiotics, exposing patients to risks of a long-term central catheter.  Antibiotics with high oral bioavailability, such as levofloxacin, may allow early oral transition.

Methods: To characterize patients with S. anginosus intracranial infections transitioned to oral therapy, we performed a retrospective review at Children’s Hospital Colorado from 1/2004 to 2/2019.  Inclusion criteria were radiologic evidence of an infected parenchymal, subdural, or epidural fluid collection AND a positive culture for S. anginosus from an intracranial source, specific extracranial sources (sinus, scalp, orbit), or blood.  The primary endpoint was oral antibiotic failure defined as worsening infection on oral therapy.  Comparisons were done using Fisher’s exact test.

Results: 94 patients met inclusion criteria, 57 of whom were transitioned to oral therapy during treatment.  Oral levofloxacin was used in 54 of the 57.  12% of oral transitions occurred in the first 14 days of therapy (range 3-8 days), and 35% in the first 28 days.  Patients transitioned in the first 28 days were more likely to have an epidural collection (p:< 0.01), and less likely to have a subdural collection (p: 0.03) or brain abscess (p:< 0.01).  Of the 57, none had oral antibiotic failure. Contributing reasons for oral transition included central line complications (18%), IV medication reaction (18%), hematologic abnormality presumed secondary to IV antibiotics (33%), and provider judgement (56%). Two patients required re-introduction of IV therapy for reasons other than clinical failure (one for medication non-adherence and one for adverse reaction to levofloxacin).
 
 Characteristics of Patients Transitioned to Oral Therapy (n=57)
Figure 1: Outcomes of oral transition versus timing of oral transition.
Figure 2: Reason for transition to oral therapy verus timing of oral transition. Note that single patients may have had more than one documented reason for transition to oral therapy


Conclusion: We observed success and tolerance of levofloxacin-based oral therapy for pediatric pyogenic intracranial S. anginosus brain infections and confirmed the frequent occurrence of adverse events associated with IV treatment. Transition to oral therapy should be considered, particularly if complications of IV therapy arise in treatment of an epidural infection.  A subset of patients in our study transitioned within the first 14 days of therapy; prospective studies are needed to characterize the safety of such very early transition.