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

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

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

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

Predictors of Bacteremia in Children Hospitalized With Community-Acquired Pneumonia.

2019

2019 Sep 13

2154-1671

<p><strong>BACKGROUND AND OBJECTIVES: </strong>The yield of blood cultures in children hospitalized with community-acquired pneumonia (CAP) is low. Characteristics of children at increased risk of bacteremia remain largely unknown.</p>

<p><strong>METHODS: </strong>We conducted a secondary analysis of a retrospective cohort study of children aged 3 months to 18 years hospitalized with CAP in 6 children's hospitals from 2007 to 2011. We excluded children with complex chronic conditions and children without blood cultures performed at admission. Clinical, laboratory, microbiologic, and radiologic data were assessed to identify predictors of bacteremia.</p>

<p><strong>RESULTS: </strong>Among 7509 children hospitalized with CAP, 2568 (34.2%) had blood cultures performed on the first day of hospitalization. The median age was 3 years. Sixty-five children with blood cultures performed had bacteremia (2.5%), and 11 children (0.4%) had bacteremia with a penicillin-nonsusceptible pathogen. The prevalence of bacteremia was increased in children with a white blood cell count &gt;20 × 10 cells per µL (5.4%; 95% confidence interval 3.5%-8.1%) and in children with definite radiographic pneumonia (3.3%; 95% confidence interval 2.4%-4.4%); however, the prevalence of penicillin-nonsusceptible bacteremia was below 1% even in the presence of individual predictors. Among children hospitalized outside of the ICU, the prevalence of contaminated blood cultures exceeded the prevalence of penicillin-nonsusceptible bacteremia.</p>

<p><strong>CONCLUSIONS: </strong>Although the prevalence of bacteremia is marginally higher among children with leukocytosis or radiographic pneumonia, the rates remain low, and penicillin-nonsusceptible bacteremia is rare even in the presence of these predictors. Blood cultures should not be obtained in children hospitalized with CAP in a non-ICU setting.</p>

10.1542/hpeds.2019-0149

Hosp Pediatr

31519736

Epidemiology of Staphylococcus aureus infections in patients admitted to freestanding pediatric hospitals, 2009-2016.

2018

1-4

2018 Oct 29

1559-6834

<p>We observed pediatric S. aureus hospitalizations decreased 36% from 26.3 to 16.8 infections per 1,000 admissions from 2009 to 2016, with methicillin-resistant S. aureus (MRSA) decreasing by 52% and methicillin-susceptible S. aureus decreasing by 17%, among 39 pediatric hospitals. Similar decreases were observed for days of therapy of anti-MRSA antibiotics.</p>

10.1017/ice.2018.259

Infect Control Hosp Epidemiol

30370879

Variability in Antibiotic Use Across PICUs.

2018

519-27

2018 Jun

1529-7535

<p><strong>OBJECTIVES: </strong>To characterize and compare antibiotic prescribing across PICUs to evaluate the degree of variability.</p>

<p><strong>DESIGN: </strong>Retrospective analysis from 2010 through 2014 of the Pediatric Health Information System.</p>

<p><strong>SETTING: </strong>Forty-one freestanding children's hospital.</p>

<p><strong>SUBJECTS: </strong>Children aged 30 days to 18 years admitted to a PICU in children's hospitals contributing data to Pediatric Health Information System.</p>

<p><strong>INTERVENTIONS: </strong>To normalize for potential differences in disease severity and case mix across centers, a subanalysis was performed of children admitted with one of the 20 All Patient Refined-Diagnosis Related Groups and the seven All Patient Refined-Diagnosis Related Groups shared by all PICUs with the highest antibiotic use.</p>

<p><strong>RESULTS: </strong>The study included 3,101,201 hospital discharges from 41 institutions with 386,914 PICU patients. All antibiotic use declined during the study period. The median-adjusted antibiotic use among PICU patients was 1,043 days of therapy/1,000 patient-days (interquartile range, 977-1,147 days of therapy/1,000 patient-days) compared with 893 among non-ICU children (interquartile range, 805-968 days of therapy/1,000 patient-days). For PICU patients, the median adjusted use of broad-spectrum antibiotics was 176 days of therapy/1,000 patient-days (interquartile range, 152-217 days of therapy/1,000 patient-days) and was 302 days of therapy/1,000 patient-days (interquartile range, 220-351 days of therapy/1,000 patient-days) for antimethicillin-resistant Staphylococcus aureus agents, compared with 153 days of therapy/1,000 patient-days (interquartile range, 130-182 days of therapy/1,000 patient-days) and 244 days of therapy/1,000 patient-days (interquartile range, 203-270 days of therapy/1,000 patient-days) for non-ICU children. After adjusting for potential confounders, significant institutional variability existed in antibiotic use in PICU patients, in the 20 All Patient Refined-Diagnosis Related Groups with the highest antibiotic usage and in the seven All Patient Refined-Diagnosis Related Groups shared by all 41 PICUs.</p>

<p><strong>CONCLUSIONS: </strong>The wide variation in antibiotic use observed across children's hospital PICUs suggests inappropriate antibiotic use.</p>

10.1097/PCC.0000000000001535

Pediatr Crit Care Med

29533352

Trends in Intravenous Antibiotic Duration for Urinary Tract Infections in Young Infants.

2017

2017 Nov 02

1098-4275

<p><strong>OBJECTIVES: </strong>To assess trends in the duration of intravenous (IV) antibiotics for urinary tract infections (UTIs) in infants ≤60 days old between 2005 and 2015 and determine if the duration of IV antibiotic treatment is associated with readmission.</p>

<p><strong>METHODS: </strong>Retrospective analysis of infants ≤60 days old diagnosed with a UTI who were admitted to a children's hospital and received IV antibiotics. Infants were excluded if they had a previous surgery or comorbidities, bacteremia, or admission to the ICU. Data were analyzed from the Pediatric Health Information System database from 2005 through 2015. The primary outcome was readmission within 30 days for a UTI.</p>

<p><strong>RESULTS: </strong>The proportion of infants ≤60 days old receiving 4 or more days of IV antibiotics (long IV treatment) decreased from 50% in 2005 to 19% in 2015. The proportion of infants ≤60 days old receiving long IV treatment at 46 children's hospitals varied between 3% and 59% and did not correlate with readmission (correlation coefficient 0.13; P = .37). In multivariable analysis, readmission for a UTI was associated with younger age and female sex but not duration of IV antibiotic therapy (adjusted odds ratio for long IV treatment: 0.93 [95% confidence interval 0.52-1.67]).</p>

<p><strong>CONCLUSIONS: </strong>The proportion of infants ≤60 days old receiving long IV treatment decreased substantially from 2005 to 2015 without an increase in hospital readmissions. These findings support the safety of short-course IV antibiotic therapy for appropriately selected neonates.</p>

10.1542/peds.2017-1021

Pediatrics

29097611

Accuracy of Administrative Data for Antimicrobial Administration in Hospitalized Children.

2017

2017 Aug 18

2048-7207

<p>Administrative data are often used as a proxy for medication-administration record (MAR) data. Multicenter MAR data were compared retrospectively with administrative data from January 2010 through June 2013 from the Pediatric Health Information Systems database. We found that administrative data were more concordant with bill-upon-administration than bill-upon-dispense data.</p>

10.1093/jpids/pix064

J Pediatric Infect Dis Soc

28992185