Utility of Blood Culture Among Children Hospitalized With Community-Acquired Pneumonia.

2017

2017 Aug 23

1098-4275

<p><strong>BACKGROUND AND OBJECTIVES: </strong>National guidelines recommend blood cultures for children hospitalized with presumed bacterial community-acquired pneumonia (CAP) that is moderate or severe. We sought to determine the prevalence of bacteremia and characterize the microbiology and penicillin-susceptibility patterns of positive blood culture results among children hospitalized with CAP.</p>

<p><strong>METHODS: </strong>We conducted a cross-sectional study of children hospitalized with CAP in 6 children's hospitals from 2007 to 2011. We included children 3 months to 18 years of age with discharge diagnosis codes for CAP using a previously validated algorithm. We excluded children with complex chronic conditions. We reviewed microbiologic data and classified positive blood culture detections as pathogens or contaminants. Antibiotic-susceptibility patterns were assessed for all pathogens.</p>

<p><strong>RESULTS: </strong>A total of 7509 children hospitalized with CAP were included over the 5-year study period. Overall, 34% of the children hospitalized with CAP had a blood culture performed; 65 (2.5% of patients with blood cultures; 95% confidence interval [CI]: 2.0%-3.2%) grew a pathogen. Streptococcus pneumoniae accounted for 78% of all detected pathogens. Among detected pathogens, 50 (82%) were susceptible to penicillin. Eleven children demonstrated growth of an organism nonsusceptible to penicillin, representing 0.43% (95% CI: 0.23%-0.77%) of children with blood cultures obtained and 0.15% (95% CI: 0.08%-0.26%) of all children hospitalized with CAP.</p>

<p><strong>CONCLUSIONS: </strong>Among children without comorbidities hospitalized with CAP in a non-ICU setting, the rate of bacteremia was low, and isolated pathogens were usually susceptible to penicillin. Blood cultures may not be needed for most children hospitalized with CAP.</p>

10.1542/peds.2017-1013

Pediatrics

28835382

Impact of a National Guideline on Antibiotic Selection for Hospitalized Pneumonia.

2017

2017 Mar 08

1098-4275

<p><strong>BACKGROUND: </strong>We evaluated the impact of the 2011 Pediatric Infectious Diseases Society/Infectious Diseases Society of America pneumonia guideline and hospital-level implementation efforts on antibiotic prescribing for children hospitalized with pneumonia.</p>

<p><strong>METHODS: </strong>We assessed inpatient antibiotic prescribing for pneumonia at 28 children's hospitals between August 2009 and March 2015. Each hospital was also surveyed regarding local implementation efforts targeting antibiotic prescribing and organizational readiness to adopt guideline recommendations. To estimate guideline impact, we used segmented linear regression to compare the proportion of children receiving penicillins in March 2015 with the expected proportion at this same time point had the guideline not been published based on a projection of a preguideline trend. A similar approach was used to estimate the short-term (6-month) impact of local implementation efforts. The correlations between organizational readiness and the impact of the guideline were estimated by using Pearson's correlation coefficient.</p>

<p><strong>RESULTS: </strong>Before guideline publication, penicillin prescribing was rare (&lt;10%). After publication, an absolute increase in penicillin use was observed (27.6% [95% confidence interval: 23.7%-31.5%]) by March 2015. Among hospitals with local implementation efforts (n = 20, 71%), the median increase was 29.5% (interquartile range: 19.6%-39.1%) compared with 20.1% (interquartile rage: 9.5%-44.5%) among hospitals without such activities (P = .51). The independent, short-term impact of local implementation efforts was similar in magnitude to that of the national guideline. Organizational readiness was not correlated with prescribing changes.</p>

<p><strong>CONCLUSIONS: </strong>The publication of the Pediatric Infectious Diseases Society/Infectious Diseases Society of America guideline was associated with sustained increases in the use of penicillins for children hospitalized with pneumonia. Local implementation efforts may have enhanced guideline adoption and appeared more relevant than hospitals' organizational readiness to change.</p>

10.1542/peds.2016-3231

Pediatrics

28275204

Intravenous Versus Oral Antibiotics for Postdischarge Treatment of Complicated Pneumonia.

2016

2016 Dec

1098-4275

<p><strong>BACKGROUND AND OBJECTIVES: </strong>Postdischarge treatment of complicated pneumonia includes antibiotics administered intravenously via a peripherally inserted central venous catheter (PICC) or orally. Antibiotics administered via PICC, although effective, may result in serious complications. We compared the effectiveness and treatment-related complications of postdischarge antibiotics delivered by these 2 routes.</p>

<p><strong>METHODS: </strong>This multicenter retrospective cohort study included children ≥2 months and &lt;18 years discharged with complicated pneumonia between 2009 and 2012. The main exposure was the route of postdischarge antibiotic administration, classified as PICC or oral. The primary outcome was treatment failure. Secondary outcomes included PICC complications, adverse drug reactions, other related revisits, and a composite of all 4 outcomes, termed "all related revisits."</p>

<p><strong>RESULTS: </strong>Among 2123 children, 281 (13.2%) received antibiotics via PICC. Treatment failure rates were 3.2% among PICC and 2.6% among oral antibiotic recipients and were not significantly different between the groups in across-hospital-matched analysis (matched odds ratio [OR], 1.26; 95% confidence interval [CI], 0.54 to 2.94). PICC complications occurred in 7.1%. Adverse drug reactions occurred in 0.6% of children; PICC antibiotic recipients had greater odds of adverse drug reaction in across hospital matched analysis (matched OR, 19.1; 95% CI, 4.2 to 87.3). The high rate of PICC complications and differences in adverse drug reactions contributed to higher odds of the composite outcome of all related revisits among PICC antibiotic recipients (matched OR, 4.71; 95% CI, 2.97 to 7.46).</p>

<p><strong>CONCLUSIONS: </strong>Treatment failure rates between PICC and oral antibiotics did not differ. Children with complicated pneumonia should preferentially receive oral antibiotics at discharge when effective oral options are available.</p>

10.1542/peds.2016-1692

Pediatrics

27940695

Intravenous Versus Oral Antibiotics for the Prevention of Treatment Failure in Children With Complicated Appendicitis: Has the Abandonment of Peripherally Inserted Catheters Been Justified?

2017

361-8

2017 Aug

1528-1140

<p><strong>OBJECTIVE: </strong>To compare treatment failure leading to hospital readmission in children with complicated appendicitis who received oral versus intravenous antibiotics after discharge.</p>

<p><strong>BACKGROUND: </strong>Antibiotics are often employed after discharge to prevent treatment failure in children with complicated appendicitis, although existing studies comparing intravenous and oral antibiotics for this purpose are limited.</p>

<p><strong>METHODS: </strong>We identified all patients aged 3 to 18 years undergoing appendectomy for complicated appendicitis, who received postdischarge antibiotics at 35 childrens hospitals from 2009 to 2012. Discharge codes were used to identify study subjects from the Pediatric Health Information System database, and chart review confirmed eligibility, treatment assignment, and outcomes. Exposure status was based on outpatient antibiotic therapy, and analysis used optimal and full matching methods to adjust for demographic and clinical characteristics. Treatment failure (defined as an organ-space infection) requiring inpatient readmission was the primary outcome. Secondary outcomes included revisits from any cause to either the inpatient or emergency department setting.</p>

<p><strong>RESULTS: </strong>In all, 4579 patients were included (median: 99/hospital), and utilization of intravenous antibiotics after discharge ranged from 0% to 91.7% across hospitals. In the matched analysis, the rate of treatment failure was significantly higher for the intravenous group than the oral group [odds ratio (OR) 1.74, 95% confidence interval (CI) 1.05-2.88; risk difference: 4.0%, 95% CI 0.4-7.6%], as was the rate of all-cause revisits (OR 2.11, 95% CI 1.44-3.11; risk difference: 9.4%, 95% CI 4.7-14.2%). The rate of peripherally inserted central catheter line complications was 3.2% in the intravenous group, and drug reactions were rare in both groups (intravenous: 0.7%, oral: 0.5%).</p>

<p><strong>CONCLUSIONS: </strong>Compared with oral antibiotics, use of intravenous antibiotics after discharge in children with complicated appendicitis was associated with higher rates of both treatment failure and all-cause hospital revisits.</p>

10.1097/SLA.0000000000001923

Ann. Surg.

27429024

Prioritization of comparative effectiveness research topics in hospital pediatrics.

2012

1155-64

2012 Dec

1538-3628

<p><strong>OBJECTIVE: </strong>To use information about prevalence, cost, and variation in resource utilization to prioritize comparative effectiveness research topics in hospital pediatrics.</p>

<p><strong>DESIGN: </strong>Retrospective analysis of administrative and billing data for hospital encounters.</p>

<p><strong>SETTING: </strong>Thirty-eight freestanding US children's hospitals from January 1, 2004, through December 31, 2009.</p>

<p><strong>PARTICIPANTS: </strong>Children hospitalized with conditions that accounted for either 80% of all encounters or 80% of all charges.</p>

<p><strong>MAIN OUTCOME MEASURES: </strong>Condition-specific prevalence, total standardized cost, and interhospital variation in mean standardized cost per encounter, measured in 2 ways: (1) intraclass correlation coefficient, which represents the fraction of total variation in standardized costs per encounter due to variation between hospitals; and (2) number of outlier hospitals, defined as having more than 30% of encounters with standardized costs in either the lowest or highest quintile across all encounters.</p>

<p><strong>RESULTS: </strong>Among 495 conditions accounting for 80% of all charges, the 10 most expensive conditions accounted for 36% of all standardized costs. Among the 50 most prevalent and 50 most costly conditions (77 in total), 26 had intraclass correlation coefficients higher than 0.10 and 5 had intraclass correlation coefficients higher than 0.30. For 10 conditions, more than half of the hospitals met outlier hospital criteria. Surgical procedures for hypertrophy of tonsils and adenoids, otitis media, and acute appendicitis without peritonitis were high cost, were high prevalence, and displayed significant variation in interhospital cost per encounter.</p>

<p><strong>CONCLUSIONS: </strong>Detailed administrative and billing data can be used to standardize hospital costs and identify high-priority conditions for comparative effectiveness research--those that are high cost, are high prevalence, and demonstrate high variation in resource utilization.</p>

10.1001/archpediatrics.2012.1266

Arch Pediatr Adolesc Med

23027409

Dexamethasone and risk of bleeding in children undergoing tonsillectomy.

2014

872-9

2014 May

1097-6817

<p><strong>OBJECTIVE: </strong>To determine whether dexamethasone use in children undergoing tonsillectomy is associated with increased risk of postoperative bleeding.</p>

<p><strong>STUDY DESIGN: </strong>Retrospective cohort study using a multihospital administrative database.</p>

<p><strong>SETTING: </strong>Thirty-six US children's hospitals.</p>

<p><strong>SUBJECTS: </strong>Children undergoing same-day tonsillectomy between the years 2004 and 2010.</p>

<p><strong>METHODS: </strong>We used discrete time failure models to estimate the daily hazards of revisits for bleeding (emergency department or hospital admission) up to 30 days after surgery as a function of dexamethasone use. Revisits were standardized for patient characteristics, antibiotic use, year of surgery, and hospital.</p>

<p><strong>RESULTS: </strong>Of 139,715 children who underwent same-day tonsillectomy, 97,242 (69.6%) received dexamethasone and 4182 (3.0%) had a 30-day revisit for bleeding. The 30-day cumulative standardized risk of revisits for bleeding was greater with dexamethasone use (3.11% vs 2.71%; standardized difference 0.40% [95% confidence interval, 0.13%-0.67%]; P = .003), and the increased risk was observed across all age strata. Dexamethasone use was associated with a higher standardized rate of revisits for bleeding in the postdischarge time periods of days 1 through 5 but not during the peak period for secondary bleeding, days 6 and 7.</p>

<p><strong>CONCLUSIONS: </strong>In a real-world practice setting, dexamethasone use was associated with a small absolute increased risk of revisits for bleeding. However, the upper bound of this risk increase does not cross published thresholds for a minimal clinically important difference. Given the benefits of dexamethasone in reducing postoperative nausea and vomiting and the larger body of evidence from trials, these results support guideline recommendations for the routine use of dexamethasone.</p>

10.1177/0194599814521555

Otolaryngol Head Neck Surg

24493786

Variation in quality of tonsillectomy perioperative care and revisit rates in children's hospitals.

2014

280-8

2014 Feb

1098-4275

<p><strong>OBJECTIVE: </strong>To describe the quality of care for routine tonsillectomy at US children's hospitals.</p>

<p><strong>METHODS: </strong>We conducted a retrospective cohort study of low-risk children undergoing same-day tonsillectomy between 2004 and 2010 at 36 US children's hospitals that submit data to the Pediatric Health Information System Database. We assessed quality of care by measuring evidence-based processes suggested by national guidelines, perioperative dexamethasone and no antibiotic use, and outcomes, 30-day tonsillectomy-related revisits to hospital.</p>

<p><strong>RESULTS: </strong>Of 139,715 children who underwent same-day tonsillectomy, 10,868 (7.8%) had a 30-day revisit to hospital. There was significant variability in the administration of dexamethasone (median 76.2%, range 0.3%-98.8%) and antibiotics (median 16.3%, range 2.7%-92.6%) across hospitals. The most common reasons for revisits were bleeding (3.0%) and vomiting and dehydration (2.2%). Older age (10-18 vs 1-3 years) was associated with a greater standardized risk of revisits for bleeding and a lower standardized risk of revisits for vomiting and dehydration. After standardizing for differences in patients and year of surgery, there was significant variability (P &lt; .001) across hospitals in total revisits (median 7.8%, range 3.0%-12.6%), revisits for bleeding (median 3.0%, range 1.0%-8.8%), and revisits for vomiting and dehydration (median 1.9%, range 0.3%-4.4%).</p>

<p><strong>CONCLUSIONS: </strong>Substantial variation exists in the quality of care for routine tonsillectomy across US children's hospitals as measured by perioperative dexamethasone and antibiotic use and revisits to hospital. These data on evidence-based processes and relevant patient outcomes should be useful for hospitals' tonsillectomy quality improvement efforts.</p>

10.1542/peds.2013-1884

Pediatrics

24446446

Variation in resource use and readmission for diabetic ketoacidosis in children's hospitals.

2013

229-36

2013 Aug

1098-4275

<p><strong>OBJECTIVE: </strong>We sought to characterize variation in hospital resource utilization and readmission for diabetic ketoacidosis (DKA) across US children's hospitals.</p>

<p><strong>METHODS: </strong>The study sample included a retrospective cohort of children aged 2 to 18 years with a diagnosis of DKA at 38 children's hospitals between 2004 and 2009. The main outcomes were resource utilization as determined by total standardized cost per hospitalization, overall and non-ICU length of stay (LOS), and readmission for DKA within 30 and 365 days.</p>

<p><strong>RESULTS: </strong>There were 24,890 DKA admissions, and 20.3% of these were readmissions within 1 year. The mean hospital-level total standardized cost was $7142 (range $4125-$11,916). The mean hospital-level LOS was 2.5 days (1.5-3.7), and the non-ICU portion was 1.9 days (0.7-2.7). The mean hospital-level readmission within 365 days was 18.7% (6.5%-41.1%) and within 30 days was 2.5% (0.0%-7.1%). Hospital bed days overall, and in particular the non-ICU portion, accounted for the majority of the total standardized cost per hospitalization (overall 57%; non-ICU 36%) and explained most of the variation in resource use. Even after adjusting for difference in patient characteristics across hospitals, widespread differences existed across hospitals in total standardized cost, LOS, and readmission rates (P &lt; .001).</p>

<p><strong>CONCLUSIONS: </strong>Readmission for DKA within a year of hospitalization is common. US children's hospitals vary widely in resource use, hospital LOS, and readmission rates for patients with DKA. Our study highlights the need for additional research to understand these differences and to identify the most cost-effective strategies for managing diabetes across the continuum of care.</p>

10.1542/peds.2013-0359

Pediatrics

23878044

Comparative effectiveness of intravenous vs oral antibiotics for postdischarge treatment of acute osteomyelitis in children.

2015

120-8

02/2015

2168-6211

<p><strong>IMPORTANCE: </strong>Postdischarge treatment of acute osteomyelitis in children requires weeks of antibiotic therapy, which can be administered orally or intravenously via a peripherally inserted central catheter (PICC). The catheters carry a risk for serious complications, but limited evidence exists on the effectiveness of oral therapy.</p>

<p><strong>OBJECTIVE: </strong>To compare the effectiveness and adverse outcomes of postdischarge antibiotic therapy administered via the PICC or the oral route.</p>

<p><strong>DESIGN, SETTING, AND PARTICIPANTS: </strong>We performed a retrospective cohort study comparing PICC and oral therapy for the treatment of acute osteomyelitis. Among children hospitalized from January 1, 2009, through December 31, 2012, at 36 participating children's hospitals, we used discharge codes to identify potentially eligible participants. Results of medical record review confirmed eligibility and defined treatment group allocation and study outcomes. We used within- and across-hospital propensity score-based full matching to adjust for confounding by indication.</p>

<p><strong>INTERVENTIONS: </strong>Postdischarge administration of antibiotics via the PICC or the oral route.</p>

<p><strong>MAIN OUTCOMES AND MEASURES: </strong>The primary outcome was treatment failure. Secondary outcomes included adverse drug reaction, PICC line complication, and a composite of all 3 end points.</p>

<p><strong>RESULTS: </strong>Among 2060 children and adolescents (hereinafter referred to as children) with osteomyelitis, 1005 received oral antibiotics at discharge, whereas 1055 received PICC-administered antibiotics. The proportion of children treated via the PICC route varied across hospitals from 0 to 100%. In the across-hospital (risk difference, 0.3% [95% CI, -0.1% to 2.5%]) and within-hospital (risk difference, 0.6% [95% CI, -0.2% to 3.0%]) matched analyses, children treated with antibiotics via the oral route (reference group) did not experience more treatment failures than those treated with antibiotics via the PICC route. Rates of adverse drug reaction were low (&lt;4% in both groups) but slightly greater in the PICC group in across-hospital (risk difference, 1.7% [95% CI, 0.1%-3.3%]) and within-hospital (risk difference, 2.1% [95% CI, 0.3%-3.8%]) matched analyses. Among the children in the PICC group, 158 (15.0%) had a PICC complication that required an emergency department visit (n = 96), a rehospitalization (n = 38), or both (n = 24). As a result, the PICC group had a much higher risk of requiring a return visit to the emergency department or for hospitalization for any adverse outcome in across-hospital (risk difference, 14.6% [95% CI, 11.3%-17.9%]) and within-hospital (risk difference, 14.0% [95% CI, 10.5%-17.6%]) matched analyses.</p>

<p><strong>CONCLUSIONS AND RELEVANCE: </strong>Given the magnitude and seriousness of PICC complications, clinicians should reconsider the practice of treating otherwise healthy children with acute osteomyelitis with prolonged intravenous antibiotics after hospital discharge when an equally effective oral alternative exists.</p>

10.1001/jamapediatrics.2014.2822

JAMA Pediatr

25506733