Respiratory virus testing and clinical outcomes among children hospitalized with pneumonia.

2022

693-701

06/2022

1553-5606

BACKGROUND: Despite the increased availability of diagnostic tests for respiratory viruses, their clinical utility for children with community-acquired pneumonia (CAP) remains uncertain.

OBJECTIVE: To identify patterns of respiratory virus testing across children's hospitals prior to the COVID-19 pandemic and to determine whether hospital-level rates of viral testing were associated with clinical outcomes.

DESIGN, SETTING, AND PARTICIPANTS: Multicenter retrospective cohort study of children hospitalized for CAP at 19 children's hospitals in the United States from 2010-2019.

MAIN OUTCOMES AND MEASURES: Using a novel method to identify the performance of viral testing, we assessed time trends in the use of viral tests, both overall and stratified by testing method. Adjusted proportions of encounters with viral testing were compared across hospitals and were correlated with length of stay, antibiotic and oseltamivir use, and performance of ancillary laboratory testing.

RESULTS: There were 46,038 hospitalizations for non-severe CAP among children without complex chronic conditions. The proportion with viral testing increased from 38.8% to 44.2% during the study period (p < .001). Molecular testing increased (27.2% to 40.0%, p < .001) and antigen testing decreased (33.2% to 7.8%, p < .001). Hospital-specific adjusted proportions of testing ranged from 10.0% to 83.5% and were not associated with length of stay, antibiotic use, or antiviral use. Hospitals that performed more viral testing did not have lower rates of ancillary laboratory testing.

CONCLUSIONS: Viral testing practices varied widely across children's hospitals and were not associated with clinically important process or outcome measures. Viral testing may not influence clinical management for many children hospitalized with CAP.

10.1002/jhm.12902

J Hosp Med

35747928

Associations between comorbidity-related functional limitations and pneumonia outcomes.

2022

527-533

06/2022

1553-5606

BACKGROUND: Underlying comorbidities are common in children with pneumonia.

OBJECTIVE: To determine associations between comorbidity-related functional limitations and risk for severe pneumonia outcomes.

DESIGN, SETTING, AND PARTICIPANTS: We prospectively enrolled children <18 years with and without comorbidities presenting to the emergency department with clinical and radiographic pneumonia at two institutions. Comorbidities included chronic conditions requiring daily medications, frequent healthcare visits, or which limited age-appropriate activities. Among children with comorbidities, functional limitations were defined as none or mild, moderate, and severe.

MAIN OUTCOMES AND MEASURES: Outcomes included an ordinal severity outcome, categorized as very severe (mechanical ventilation, shock, or death), severe (intensive care without very severe features), moderate (hospitalization without severe features), or mild (discharged home), and length of stay (LOS). Multivariable ordinal logistic regression was used to examine associations between comorbidity-related functional limitations and outcomes, while accounting for relevant covariates.

RESULTS: A cohort of 1116 children, including 452 (40.5%) with comorbidities; 200 (44.2%) had none or mild functional limitations, 93 (20.6%) moderate, and 159 (35.2%) had severe limitations. In multivariable analysis, comorbidity-related functional limitations were associated with the ordinal severity outcome and LOS (p < .001 for both). Children with severe functional limitations had tripling of the odds of a more severe ordinal (adjusted odds ratio [aOR]: 3.01, 95% confidence interval [2.05, 4.43]) and quadrupling of the odds for longer LOS (aOR: 4.72 [3.33, 6.70]) as compared to children without comorbidities.

CONCLUSION: Comorbidity-related functional limitations are important predictors of disease outcomes in children with pneumonia. Consideration of functional limitations, rather than the presence of comorbidity alone, is critical when assessing risk of severe outcomes.

10.1002/jhm.12904

J Hosp Med

35761790

Antibiotics and outcomes of CF pulmonary exacerbations in children infected with MRSA and Pseudomonas aeruginosa.

2022

08/2022

1873-5010

BACKGROUND: Limited data exist to inform antibiotic selection among people with cystic fibrosis (CF) with airway infection by multiple CF-related microorganisms. This study aimed to determine among children with CF co-infected with methicillin-resistant Staphylococcus aureus (MRSA) and Pseudomonas aeruginosa (Pa) if the addition of anti-MRSA antibiotics to antipseudomonal antibiotic treatment for pulmonary exacerbations (PEx) would be associated with improved clinical outcomes compared with antipseudomonal antibiotics alone.

METHODS: Retrospective cohort study using data from the CF Foundation Patient Registry-Pediatric Health Information System linked dataset. The odds of returning to baseline lung function and having a subsequent PEx requiring intravenous antibiotics were compared between PEx treated with anti-MRSA and antipseudomonal antibiotics and those treated with antipseudomonal antibiotics alone, adjusting for confounding by indication using inverse probability of treatment weighting.

RESULTS: 943 children with CF co-infected with MRSA and Pa contributed 2,989 PEx for analysis. Of these, 2,331 (78%) PEx were treated with both anti-MRSA and antipseudomonal antibiotics and 658 (22%) PEx were treated with antipseudomonal antibiotics alone. Compared with PEx treated with antipseudomonal antibiotics alone, the addition of anti-MRSA antibiotics to antipseudomonal antibiotic therapy was not associated with a higher odds of returning to ≥90% or ≥100% of baseline lung function or a lower odds of future PEx requiring intravenous antibiotics.

CONCLUSIONS: Children with CF co-infected with MRSA and Pa may not benefit from the addition of anti-MRSA antibiotics for PEx treatment. Prospective studies evaluating optimal antibiotic selection strategies for PEx treatment are needed to optimize clinical outcomes following PEx treatment.

10.1016/j.jcf.2022.08.001

J Cyst Fibros

35945130

Association Between Procalcitonin and Antibiotics in Children With Community-Acquired Pneumonia.

2022

384-391

2022 Apr 01

2154-1671

<p><strong>OBJECTIVE: </strong>To determine whether empirical antibiotic initiation and selection for children with pneumonia was associated with procalcitonin (PCT) levels when results were blinded to clinicians.</p>

<p><strong>METHODS: </strong>We enrolled children &lt;18 years with radiographically confirmed pneumonia at 2 children's hospitals from 2014 to 2019. Blood for PCT was collected at enrollment (blinded to clinicians). We modeled associations between PCT and (1) antibiotic initiation and (2) antibiotic selection (narrow versus broad-spectrum) using multivariable logistic regression models. To quantify potential stewardship opportunities, we calculated proportions of noncritically ill children receiving antibiotics who also had a low likelihood of bacterial etiology (PCT &lt;0.25 ng/mL) and those receiving broad-spectrum therapy, regardless of PCT level.</p>

<p><strong>RESULTS: </strong>We enrolled 488 children (median PCT, 0.37 ng/mL; interquartile range [IQR], 0.11-2.38); 85 (17%) received no antibiotics (median PCT, 0.32; IQR, 0.09-1.33). Among the 403 children receiving antibiotics, 95 (24%) received narrow-spectrum therapy (median PCT, 0.24; IQR, 0.08-2.52) and 308 (76%) received broad-spectrum (median PCT, 0.46; IQR, 0.12-2.83). In adjusted analyses, PCT values were not associated with antibiotic initiation (odds ratio [OR], 1.02, 95% confidence interval [CI], 0.97%-1.06%) or empirical antibiotic selection (OR 1.07; 95% CI, 0.97%-1.17%). Of those with noncritical illness, 246 (69%) were identified as potential targets for antibiotic stewardship interventions.</p>

<p><strong>CONCLUSION: </strong>Neither antibiotic initiation nor empirical antibiotic selection were associated with PCT values. Whereas other factors may inform antibiotic treatment decisions, the observed discordance between objective likelihood of bacterial etiology and antibiotic use suggests important opportunities for stewardship.</p>

10.1542/hpeds.2021-006510

Hosp Pediatr

35362055

Factors Associated With COVID-19 Disease Severity in US Children and Adolescents.

2021

603-610

2021 10

1553-5606

<p><strong>BACKGROUND: </strong>Little is known about the clinical factors associated with COVID-19 disease severity in children and adolescents.</p>

<p><strong>METHODS: </strong>We conducted a retrospective cohort study across 45 US children's hospitals between April 2020 to September 2020 of pediatric patients discharged with a primary diagnosis of COVID-19. We assessed factors associated with hospitalization and factors associated with clinical severity (eg, admission to inpatient floor, admission to intensive care unit [ICU], admission to ICU with mechanical ventilation, shock, death) among those hospitalized.</p>

<p><strong>RESULTS: </strong>Among 19,976 COVID-19 encounters, 15,913 (79.7%) patients were discharged from the emergency department (ED) and 4063 (20.3%) were hospitalized. The clinical severity distribution among those hospitalized was moderate (3222, 79.3%), severe (431, 11.3%), and very severe (380, 9.4%). Factors associated with hospitalization vs discharge from the ED included private payor insurance (adjusted odds ratio [aOR],1.16; 95% CI, 1.1-1.3), obesity/type 2 diabetes mellitus (type 2 DM) (aOR, 10.4; 95% CI, 8.9-13.3), asthma (aOR, 1.4; 95% CI, 1.3-1.6), cardiovascular disease, (aOR, 5.0; 95% CI, 4.3- 5.8), immunocompromised condition (aOR, 5.9; 95% CI, 5.0-6.7), pulmonary disease (aOR, 5.3; 95% CI, 3.4-8.2), and neurologic disease (aOR, 3.2; 95% CI, 2.7-5.8). Among children and adolescents hospitalized with COVID-19, greater disease severity was associated with Black or other non-White race; age greater than 4 years; and obesity/type 2 DM, cardiovascular, neuromuscular, and pulmonary conditions.</p>

<p><strong>CONCLUSIONS: </strong>Among children and adolescents presenting to US children's hospital EDs with COVID-19, 20% were hospitalized; of these, 21% received care in the ICU. Older children and adolescents had a lower risk for hospitalization but more severe illness when hospitalized. There were differences in disease severity by race and ethnicity and the presence of selected comorbidities. These factors should be taken into consideration when prioritizing mitigation and vaccination strategies.</p>

10.12788/jhm.3689

J Hosp Med

34613896

Mycoplasma Pneumoniae Testing and Treatment Among Children With Community-Acquired Pneumonia.

2021

760-763

2021 Jul

2154-1671

<p><strong>OBJECTIVES: </strong>To describe testing and treatment practices for () among children hospitalized with community-acquired pneumonia (CAP).</p>

<p><strong>METHODS: </strong>We conducted a retrospective cohort study using the Pediatric Health Information Systems database. We included children 3 months to 18 years old hospitalized with CAP between 2012 and 2018 and excluded children who were transferred from another hospital and those with complex chronic conditions. We examined the proportion of patients receiving testing and macrolide therapy at the hospital level and trends in testing and macrolide prescription over time. At the patient level, we examined differences in demographics, illness severity (eg, blood gas, chest tube placement), and outcomes (eg, ICU admission, length of stay, readmission) among patients with and without testing.</p>

<p><strong>RESULTS: </strong>Among 103 977 children hospitalized with CAP, 17.3% underwent testing and 31.1% received macrolides. We found no correlation between testing and macrolide treatment at the hospital level ( = 0.05; = .11). Patients tested for were more likely to have blood gas analysis (15.8% vs 12.8%; &lt; .1), chest tube placement (1.4% vs 0.8%; &lt; .1), and ICU admission (3.1% vs 1.4%; &lt; .1). testing increased (from 15.8% to 18.6%; &lt; .001), and macrolide prescription decreased (from 40.9% to 20.6%; &lt; .001) between 2012 and 2018.</p>

<p><strong>CONCLUSIONS: </strong>Nearly one-third of hospitalized children with CAP received macrolide antibiotics, although macrolide prescription decreased over time. Clinicians were more likely to perform testing in children with severe illness, and testing and macrolide treatment were not correlated at the hospital level.</p>

10.1542/hpeds.2020-005215

Hosp Pediatr

34583319

Short- Versus Prolonged-Duration Antibiotics for Outpatient Pneumonia in Children.

2021

2021 Mar 18

1097-6833

<p><strong>OBJECTIVE: </strong>To identify practice patterns in the duration of prescribed antibiotics for the treatment of ambulatory children with community-acquired pneumonia (CAP) and to compare the frequency of adverse clinical outcomes between children prescribed short- versus prolonged-duration antibiotics.</p>

<p><strong>STUDY DESIGN: </strong>We performed a retrospective cohort study from 2010-2016 using the IBM Watson MarketScan Medicaid Database, a claims database of publicly-insured patients from 11 states. We included children 1-18 years old with outpatient CAP who filled a prescription for oral antibiotics (N = 121,846 encounters). We used multivariable logistic regression to determine associations beween the duration of prescribed antibiotics (5-9 days vs 10-14 days) and subsequent hospitalizations, new antibiotic prescriptions, and acute care visits. Outcomes were measured during the 14 days following the end of the dispensed antibiotic course.</p>

<p><strong>RESULTS: </strong>The most commonly prescribed duration of antibiotics was 10 days (82.8% of prescriptions), and 10.5% of patients received short-duration therapy. During the follow-up period, 0.2% of patients were hospitalized, 6.2% filled a new antibiotic prescription, and 5.1% had an acute care visit. Compared with the prolonged-duration group, the adjusted odds ratios for hospitalization, new antibiotic prescriptions, and acute care visits in the short-duration group were 1.16 (95% CI: 0.80-1.66), 0.93 (95% CI: 0.85-1.01), and 1.06 (95% CI: 0.98-1.15), respectively.</p>

<p><strong>CONCLUSIONS: </strong>Most children treated for CAP as outpatients are prescribed at least 10 days of antibiotic therapy. Among pediatric outpatients with CAP, no significant differences were found in rates of adverse clinical outcomes between patients prescribed short- versus prolonged-duration antibiotics.</p>

10.1016/j.jpeds.2021.03.017

J Pediatr

33745996

The COVID-19 Pandemic and Changes in Healthcare Utilization for Pediatric Respiratory and Nonrespiratory Illnesses in the United States.

2021

2021 Mar 08

1553-5606

<p>The impact of COVID-19 public health interventions on pediatric illnesses nationwide is unknown. We performed a multicenter, cross-sectional study of encounters at 44 children's hospitals in the United States to assess changes in healthcare utilization during the pandemic. The COVID-19 pandemic was associated with substantial reductions in encounters for respiratory diseases; these large reductions were consistent across illness subgroups. Although encounters for nonrespiratory diseases decreased as well, reductions were more modest and varied by age. Encounters for respiratory diseases among adolescents declined to a lesser degree and returned to previous levels faster compared with those of younger children. Further study is needed to determine the contributions of decreased illness and changes in care-seeking behavior to this observed reduction.</p>

10.12788/jhm.3608

J Hosp Med

33734976

Pneumonia Severity in Children: Utility of Procalcitonin in Risk Stratification.

2021

2021 Feb 12

2154-1671

<p><strong>OBJECTIVES: </strong>To determine if serum procalcitonin, an indicator of bacterial etiology in pneumonia in all ages and a predictor of severe pneumonia in adults, is associated with disease severity in children with community-acquired pneumonia.</p>

<p><strong>METHODS: </strong>We prospectively enrolled children 2 months to &lt;18 years with clinical and radiographic pneumonia at 2 children's hospitals (2014-2019). Procalcitonin samples were obtained at presentation. An ordinal outcome scale of pneumonia severity was defined: very severe (intubation, shock, or death), severe (intensive care admission without very severe features and/or high-flow nasal cannula), moderate (hospitalization without severe or very severe features), and mild (discharge). Hospital length of stay (LOS) was also examined. Ordinal logistic regression was used to model associations between procalcitonin and outcomes. We estimated adjusted odds ratios (aORs) for a variety of cut points of procalcitonin ranging from 0.25 to 3.5 ng/mL.</p>

<p><strong>RESULTS: </strong>The study included 488 children with pneumonia; 30 (6%) were classified as very severe, 106 (22%) as severe, 327 (67%) as moderate, and 25 (5%) as mild. Median procalcitonin in the very severe group was 5.06 (interquartile range [IQR] 0.90-16.83), 0.38 (IQR 0.11-2.11) in the severe group, 0.29 (IQR 0.09-1.90) in the moderate group, and 0.21 (IQR 0.12-1.2) in the mild group. Increasing procalcitonin was associated with increasing severity (range of aORs: 1.03-1.25) and increased LOS (range of aORs: 1.04-1.36). All comparisons were statistically significant.</p>

<p><strong>CONCLUSIONS: </strong>Higher procalcitonin was associated with increased severity and LOS. Procalcitonin may be useful in helping clinicians evaluate pneumonia severity.</p>

10.1542/hpeds.2020-001842

Hosp Pediatr

33579748

Antibiotic Choice and Clinical Outcomes in Ambulatory Children with Community-Acquired Pneumonia.

2020

2020 Oct 09

1097-6833

<p><strong>OBJECTIVES: </strong>To describe antibiotic prescribing patterns in ambulatory children with community acquired pneumonia, and to assess the relationship between antibiotic selection and clinical outcomes.</p>

<p><strong>STUDY DESIGN: </strong>This was a retrospective cohort study of ambulatory Medicaid-enrolled children 0-18 years of age diagnosed with CAP from 2010-2016. The exposure was antibiotic class: narrow-spectrum (aminopenicillins), broad-spectrum (amoxicillin/clavulanate and cephalosporins), macrolide monotherapy, macrolides with narrow-spectrum antibiotics, or macrolides with broad-spectrum antibiotics. The associations between antibiotic selection and the outcomes of subsequent hospitalization and development of severe pneumonia (chest drainage procedure, intensive care admission, mechanical ventilation) were assessed, controlling for measures of illness severity.</p>

<p><strong>RESULTS: </strong>Among 252,177 outpatient pneumonia visits, macrolide monotherapy was used in 43.2%, narrow-spectrum antibiotics in 26.1%, and broad-spectrum antibiotics in 24.7%. A total of 1488 children (0.59%) were subsequently hospitalized and 117 (0.05%) developed severe pneumonia. Compared with children receiving narrow-spectrum antibiotics, the odds of subsequent hospitalization were higher in children receiving broad-spectrum antibiotics (aOR=1.34 [95%CI 1.17-1.52]) and lower in children receiving macrolide monotherapy (aOR=0.64 [95%CI 0.55-0.73]) and macrolides with narrow-spectrum antibiotics (aOR=0.62 [95%CI 0.39-0.97]). Children receiving macrolide monotherapy had lower odds of developing severe pneumonia than children receiving narrow-spectrum antibiotics (aOR=0.56, 95%CI 0.33-0.93). However, the absolute risk difference was &lt;0.5% for all analyses.</p>

<p><strong>CONCLUSIONS: </strong>Macrolides are the most commonly prescribed antibiotic for ambulatory children with CAP. Subsequent hospitalization and severe pneumonia are rare. Future efforts should focus on reducing broad-spectrum and macrolide antibiotic prescribing.</p>

10.1016/j.jpeds.2020.10.005

J Pediatr

33045236