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“Litz” Blitz 2013Top Articles in Pediatric Hospital Medicine

A review of recent literature impacting the practice of pediatric medicine

Benjamin D. Bauer, MD, FAAP June 1st, 2013

Disclosure Statement

• Benjamin D. Bauer:–Has no relevant financial

relationships to disclose.–Has no conflicts of interest to

resolve.• This presentation will not involve

discussion of unapproved, off-label, or experimental interventions or medications.

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Strategy & Criteria for Article Selection:

• Reviewed literature from the past 18 months:– Pediatrics, Hospital Pediatrics, JAMApeds, JAMA,

NEJM<, Archives of Pediatrics & Adolescent Med, Journal of Pediatrics, Pediatric Infectious Disease, Journal of Hospital Medicine, Pediatric Emergence Care

• Selection based on general interest and potential to impact practice of pediatric hospital medicine

• General guidelines of the 3 R’s:– Recent, Relevant and Reputable.

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Strategy & Criteria for Article Selection:

• Final selection of articles, also considered ‘clinical grouping’ based on areas of interest to pediatric hospitalists

• Here are the clinical topics that will be covered in today’s talk:

1. Febrile Neonate / SBI

2. Fluid management

3. Failure to Thrive

4. Gastroesophageal Reflux

5. Hyperbilirubinemia

6. Bronchiolitis

7. Pneumonia04/19/2023 4

Disclaimer:

• Literature presented was chosen based general interest of the presenter

• No claim made regarding whether these are the most well-designed studies on a given topic

• The literature discussed should be critically and individually reviewed before change in practice is implemented

• Feel free to throw rotten fruit… but kindly wait until the end of the presentation

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The Febrile Infant

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Background

• Serious Bacterial Infection (SBI) evaluation remains a challenge

• SBI Rates as high as 10-12% <3mo of age– UTI accounts for majority of SBI– Bacteremia and meningitis are less

common

• Risk stratification strategies have been developed; remain controversial

• Even those suggesting less invasive strategies push for LP prior to starting antibiotics

Background / Study Objective• Rochester Criteria for Febrile

Infants:– Infant appears well– Infant has been previously healthy– No evidence of skin, bone, joint or ear

infection – Labs: WBC 5K – 15K; Bands < 1,500;

< 10 WBCs in U/A; No pus in stool– When ALL criteria met; NPV for SBI is

98.9%

• Study Aim: Necessity of performing routine LP in well appearing 30-90 day old febrile infant with U/A suggestive of UTI

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Study Methods• Retrospective Study• Tertiary care children’s hospital ED; 200

pt/day• 4 year period; October 2001 – August

2005• Identified all febrile infants 30-90 days

of life:– underwent full sepsis work-up: LP for

culture, blood culture, urine culture and urinalysis.

• Exclusion Criteria: Premature (<35wk), chronic conditions, pre-culture antibiotics, or localizing infection on presentation

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Results:

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•Highlights:• 392 patients included • 61% male (241/392)• Mean age 56 days• Overall Rates of

Infection:• SBI: 60/392 (15.3%)• UTI: 52/392 (13.3%)• Sepsis: 13/392

(3.3%)• Meningitis: 4/392

(1%)• Only 1 patient with

both abnormal U/A and Meningitis

N = 39230-90 day febrile

infants full sepsis evaluation

Urine only46 patients

Urine & Blood5 patients

Urine, Blood & CSF

1 Patient

1 + Culture52 patients

2 + Cultures7 patients

3 + Cultures1 patient

Blood & Urine5 patients

Blood & CSF2 patients

Blood, Urine & CSF

1 patient

CSF only1 patients

CSF & Blood2 patients

CSF, Blood & Urine

1 patient

Blood only5 patients

CSF, Blood & Urine

1 patient

Results

• 1 patient with both abnormal U/A and meningitis

• 71 day old female:– Urinalysis: LE+, Nitrite+, 4WBCs/HPF– WBC: 2.9 x 109

– Cultures: E. coli (Blood, Urine and CSF)– Clinical: 38.5◦C, irritable, lethargic,

mottled

• NOT Low Risk by Rochester: Based on signs/sx would have undergone full sepsis work up

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Patients with meningitis

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Results

• Of the 388 infants without meningitis:– 56 (14%) had an abnormal U/A– 51 (13%) had a culture positive UTI

• Negative Predictive Value (NPV): – 98.2% NPV– 100% NPV, if Rochester ‘low risk’ criteria

are met

• Does not change the overall NPV of the Rochester criteria, but does potentially add to discussion regarding risk of meningitis

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Study Limitations

• May not generalize: Tertiary Care ED vs.. outpatient

• Small sample size: Decreases power to identify the potential case of meningitis in this population

• Retrospective design: Impossible to confirm that all “NON-low risk” infants actually underwent full septic work-up.

• Underestimates downstream impact: Does not acknowledge difficulty for those making decisions regarding management, if LP not done at antibiotic initiation.

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Clinical Bottom Line

• Study confirms findings of others:– Combined UTI and meningitis is

uncommon in infants <90 days of age ( 0% – 0.3%)

• Routine LPs may not be necessary in infants 30-90 days of life, if otherwise low-risk based on Rochester criteria

• If any uncertainty, or patient not well appearing then an LP MUST BE DONE prior to starting antibiotics

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In search of the 24 hour discharge…

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Background

• The management of the febrile infant is evolving

• Still common for infants with fever and no clear source to remain in hospital receiving empiric treatment for 48hrs while culture results mature

• Some institutions have used available evidence to push the LOS envelope for these patients…

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Evidence Based Care Process Model

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Study Objectives

• To determine if bacterial cultures in young infants would produce results in <36 hours

• With enough reliability to allow for discharge of otherwise healthy infants earlier than the standard 48 hour observation period

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Methods• Retrospective chart review• Oct 2007 – Feb 2011 (3 yrs 4 months)• All positive culture results (Blood, Urine,

CSF)• Drawn on infants 0 – 90 days of age

during the evaluation of SBI in ED or as inpatient

• Exclusion: Any indwelling lines, shunts, catheters; any cultures drawn while in ICU setting; significant underlying condition; repeat cultures taken from same patient during same stay

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Results• 283 patients with positive cultures• 2092 Blood cultures were drawn

– 38% (38/101) of blood cultures = true pathogens

– Mean time to detection (TTD) 13.3 hours (vs.. 25 hrs)

• 2283 Urine cultures were drawn– 58% (111/192) of urine cultures = true

pathogens– Mean TTD 21 hours (vs.. 26.7 hrs)

• 1159 CSF cultures were drawn– 50% (7/14) of CSF cultures = true pathogens– Mean TTD 28.9 hours (vs.. 57.7 hrs)

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Time To Detection of Bacterial Cultures

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Bottom Line

• This article adds to existing data about management of febrile neonate– Already excellent data to help with risk

stratification (Rochester criteria…)– Those infants admitted to the hospital

as ‘Low Risk’ have SBI rates in range of 1-3%

• In the appropriate clinical and social context – May consider discontinue antibiotics

therapy at 36 hours 04/19/2023 24

Fluids Management

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Background

• Hospital acquired hyponatremia is common

• Neurologic morbidity and death have been documented as a result of iatrogenic hyponatremia

• Has raised questions regarding 50yr standard of using Holliday-Segar recommendations for calculating parenteral maintenance fluids

• Growing evidence emerging that the use of isotonic fluids may decrease risk

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Study Objectives

• Fully blinded, randomized controlled trial

• Determine whether isotonic solution administered as maintenance IV fluids decrease the risk of hyponatremia when compared to hypotonic fluids

• Population: euvolemic pediatric patients in the acute post-operative period, with non-emergent reasons for surgery; requiring MIVF for 48hrs

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Study Methods• IRB approved, Blinded, RCT• Tertiary care children’s hospital, Canada• Randomly assigned to receive base

parenteral maintenance solution (PMS) of either 0.45% saline (hypotonic) or 0.9% saline (isotonic)– Dextrose (D5) present in both– Potassium added according treating MD

request

• 6mo – 16yrs; euvolemic; within 6hrs of non-emergent surgery; likely to need MIVF >24hrs04/19/2023 28

Study methods / Outcome measures

• Plasma sodium, Urine sodium/potassium and ADH measured every 12 hours

• Intervention was started immediately post-op and continued for maximum of 48hrs

• Primary Outcome: Hyponatremia; ≤ 134mmol/L

• Secondary Outcomes: Severe hyponatremia (≤ 129mmol/L), hypernatremia (≥ 146mmol/L), plasma ADH levels, adverse events, and patients who changed fluids during study (reason)

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Results • 3/2008 – 12/2009• 728 patients screened• 427 eligible• 258 were enrolled• 128 randomized to

isotonic fluid• 130 randomized to

hypotonic fluid• 4 patents from each

group withdrew during study

• 32 patients lacked data

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18 lackeddata

14 lacked data

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• Baseline characteristics

between groups is similar

• 77 of 258 (29.8%) admitted

to ICU postoperatively

• No differences in baseline

sodium or fluid intake

• Only 16 (6%) had pre-op

sodium levels ordered

• Median time to starting fluid

intervention was 22minutes post operatively (6hrs max)

• Most common surgery: Orthopedic, General, Urologic

Results: Primary Outcome

• Primary Outcomes: Risk of hyponatremia was higher in the hypotonic fluid group:

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Results: Secondary Outcomes

• Plasma ADH levels on POD#1 elevated in both groups, but no difference (P= .208)

• Subgroup analysis showed PICU patients at NO higher risk after adjusting for fluid type (P= .105)

• 15 pts changed to open-label isotonic fluids– 12 (9.2%) vs.. 3 (2.3%); P = .036 (Hypotonic) (Isotonic)

• with ‘Hyponatremia’ most common cited reason– 1 (0.8%) vs.. 7(5.4%); P = .033 (Hypotonic) (Isotonic)

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Study Limitations

• Well-designed, blinded, randomized trial• May Not Generalize: Did not include

patients requiring emergency surgeries; did not include non-surgical patients

• Baseline Comparison Data: Most patients in study did not have ‘baseline’ lab values prior to enrollment

• Missing Data: Not all patients included in study had all planned samples drawn.

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Clinical Bottom Line• Risk of hyponatremia is significantly

higher in post-op patients receiving hypotonic fluids

• Relative risk reduction of 44% with isotonic fluid

• NNT to prevent 1 case of hyponatremia = 6

• Isotonic fluid use does not appear to increase adverse events or lead to hypernatremia

• Current standard of post-operative fluid management should be re-evaluated… – Isotonic fluid may be safer!

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Failure to Thrive

Background

• Failure to Thrive (FTT) is common– As many as 10% of general pediatric patients

• Outpatient management of failure to thrive “is fraught with difficulties because trying to organize a cohesive approach… is logistically challenging.”

• Often assumed that admission may be the more efficient approach, with goal of coordinating multiple resources needed to diagnose and treat

• FTT: Up to 5% of all admissions for children less than 2 years of age

Background

• Heavy resource utilization for these patients:– Labs, imaging, speech, nutrition, social

work, and subspecialist consultation

• Limited access to many of these resources during the weekend; even at large tertiary referral centers

• Is the weekend the best time to admit these patients to the hospital?

Study Objectives

• To evaluate whether weekend admission of Failure to Thrive:1. Affects the length of stay (LOS)2. Affects the overall cost of the

admission

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Methods

• PHIS database– Administrative data from 43 free-

standing children’s hospitals

• Inclusion Criteria:– 2003-2011 (9 years of data)– All Children <2 years with primary admit

diagnosis of Failure to Thrive

• Data: Demographics, LOS, day of admit, diagnoses, procedures, tests, charges/costs

Results

• 23,332 patients met inclusion criteria• Median age: 7.5 months

– 43.8 % (10,222) less than 6 months of age

• Weekend admissions STAYED LONGER– LOS increased by 1.93 days (IRR: 1.20

[95% CI 1.18-1.22]

• Weekend admissions COST MORE– Mean cost increase of $2785 per

admission

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FTT on Weekends: Cost More, Stay Longer

Results

Limitations:

• PHIS database limitations• Used surrogate data to make

assumptions about how ‘sick’ patients were

• Institutional bias in financial reporting is possible

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Author Bottom Line

•Acknowledging that some of the weekend admissions had medical issues requiring immediate inpatient attention…•If HALF of the weekend admissions over the study period were simply converted to Monday admissions:

– total savings in health care dollars would be in excess of $500,000 per year– or > $3.5 Million over the study period

Gastroesophageal Reflux

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Background

• Diagnosis and management of GERD remains challenging for families and pediatricians

• From 1999 to 2004, 7-fold increase in use of prescription medication in infants with GERD

• Growing evidence that acid reducing medications are NO BETTER than placebo in treating symptoms of GERD

• Growing concern regarding safety of these agents in both adults and children

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Mechanism for increased infection Risk?

• Gastric Acid is a known non-selective barrier to infection

• Most pathogens will not survive at pH < 4 (normal gastric acidity)

• Suppression of acid production may allow bacterial colonization and overgrowth (including pathogenic organisms)

• PPIs & H2 Blockers may also directly inhibit leukocyte activity; thereby blunt immune response

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Objectives & Methods• Review of literature• Evaluate potential serious adverse

effects associated with acid-suppressing medications in the pediatric population

• PubMed Search: English Language, 0-18 yrs

• Limited to original placebo controlled studies OR studies with comparison to non-acid suppression which specifically evaluated adverse events as part of study04/19/2023 49

Results

• 14 studies met inclusion criteria• 6 NICU studies• 5 PICU studies• 3 Non-Critical Care Population Studies• Both H2 Blockers and PPIs represented• Associate adverse events primarily

‘infectious’ in nature

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14 Studies Reviewed

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NICU Population• Necrotizing Enterocolitis (NEC): 2 Studies

1. Retrospective Case-Control Study of H2-blockers:• 787 infants with NEC• Use of H2-Blocker increased risk of

NEC– OR: 1.71 [95% CI: 1.34-2.19], P<.001

2. Prospective Multicenter Observation, ranitidine• 274 infants; 91 got ranitidine, 183 did not• Increased risk of infection; Sepsis

and pneumonia– OR 5.5 [95% CI: 2.9-10.4], P<.001

• Increased risk of NEC– OR 6.6 [95% CI: 1.7-25], P=.003

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NICU Population

• Infection Risk: 4 Additional Studies1. H2 Blockers & Blood Infections:

• Prospective Study: 376 infants, 42 bacteremia

• H2 Blocker increased risk: OR 2.9; P=.0082. Nosocomial Bacterial Infections:

• Prospective Study: 1504 infants, 127 infections

• H2 Blockers incr. risk: OR 7.3 [95% CI 3.9-13.6]

3. Late Onset Sepsis:• Retrospective review: 569 infants; 74

sepsis• Sepsis pts more likely to have received

ranitidine– OR 6.99 [95% CI: 3.78-12.94], P<.0001

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PICU Population• 4 Studies: Ventilator-Associated

Pneumonia (VAP) and Acid Suppressor medication

• 2 Studies found association:– Prospective Study: 595 ventilated

patients• 34 VAP episodes; univariate analysis

showed association with H2 blockers• 47% of VAP patients had received H2

blockers vs. 24% of Non-VAP patients; P=.006

– Prospective Study: 40 patients; 8/40 with VAP• 63% of VAP patients had received H2

blockers vs. 22% of Non-VAP patients; P=.025

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Non-Critical Care Population• PNEUMONIA: 2 Studies

1. Canani et al: Prospective multicenter cohort • 4 - 36 mo of age; GERD diagnoses by pH

monitor & esophageal biopsy• H2-Blocker or PPI for 2 month course• 11% of 91 developed pneumonia vs. 2%

of healthy controls (P<.05)2. Orenstein et al: Randomized controlled

trial • Lansoprazole vs. placebo for GERD in

infants• Serious Adverse event in 12% of 81

infants in PPI vs. 2% of 81 patients in placebo; PNA most common

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Non-Critical Care Population• Gastrointestinal Infections: 2 Studies

1. Canani et al: Prospective multicenter cohort • 4 - 36 mo of age; GERD diagnoses by pH

monitor & esophageal biopsy• 91 patients; H2-Blocker or PPI for 2 month

course• 47% those patient developed acute

gastroenteritis vs. 20% of healthy controls – OR: 3.58 [95% CI 1.87-6.85] P=.001

2. Turco et al: Retrospective study: PPI and C.Diff• Higher rates of C.diff associated disease

(CDAD)– OR: 4.52 [95% CI: 1.4-14.4)

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What’s in a Name?

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Bottom Line: First, Do No Harm

• With the Exception of endoscopically confirmed erosive esophagitis, Acid blocking medications have NOT been shown to be of benefit in young infants with GERD symptoms

• Conservative therapies, while more difficult and time consuming do have some evidence behind them (decreased volumes, thickening feeds)

• CHOOSING WISELY: “Don’t treat GER in infants routinely with acid suppression therapy.”04/19/2023 58

Hyperbilirubinemia

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Background

• Jaundice in newborns is incredibly common

• Indirect bilirubin is a neurotoxin that can cause both acute and irreversible injury to the brain

• Phototherapy is the cornerstone of effective treatment of hyperbilirubinemia in newborns; safe & effective

• Evidence based guidelines published by the AAP in 2004 and updated in 2011 Technical report

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Background: Efficacy of Phototherapy• Efficacy of Phototherapy in reducing Total

Serum Bilirubin (TsB) levels depends on 4 factors:– Wavelength of light emitted from source (nm)– Intensity of light (Spectral Irradiance -

µw/cm²/nm)– Surface area exposed to light– Duration of exposure to light

• AAP has defined ‘Optimal Phototherapy’ as:– Visible Blue light (460-490nm), – Delivered at ≥ 30 µw/cm²/nm (Intensive

Phototherapy)– To the largest possible body surface area

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Background: Dose-Response Curve

• Established dose-response data allowed AAP to set 30 µw/cm²/nm as definition of “intensive phototherapy”

• Previous Studies suggest “Saturation Point” above which additional intensity provides no further benefit in terms of rate of TsB drop

• Old data based on equipment with ‘Minimum distances to baby’ based on concern for thermal injury

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Objectives

• To use newer LED technology to investigate Dose-Response curve for hyperbilirubinemia

• To see if increasing intensity (spectral irradiance) of phototherapy is associated with increase rate of drop of TsB in patient

• To see if increasing intensity (spectral irradiance) of phototherapy is associated with a ‘saturation point’

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Methods

• Prospective, randomized treatment trial• NICU in Denmark; July 2009 –

December 2010• Inclusion Criteria: Healthy Neonates,

>33wks , uncomplicated hyperbilirubinemia, open bassinet.

• Exclusion Criteria: Known hemolytic disease, patients requiring exchange transfusion, patients with Total Bili rise > 0.5mg/dl/hr, <24hrs of age at time of initiation of photothx

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Methods• Equipment Used:

– NATUS, neoBLUE LED bank system– ‘High’ setting only

• Randomized to 1 of 4 phototherapy regimens:– Based on distance to mattress in 3.5”

increments: 8”, 11.5”, 15”, 18.5”– Avg to baby: 5”, 8.5” , 1 2”, 15.5”

• Babies received continuous phototherapy x 24h

• Diapers & goggles only, out to feed 30m Q 3h

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Results: 151 infants

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Bottom Line

• As intensity of light increases, the rate of TsB-drop increases.

• While not specifically studied in this article, it is reasonable to assume that, if TsBili decreases faster, LOS will decrease.

• With NEOblue LED unit a distance of 5” produces spectral irradiance of up to 55 µw/cm²/nm– Which should drop TsB by 50% in 24hrs

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Bronchiolitis• What fun thing should we try this year?• How can we tell which kids are going to

crump?– Could this help us plan for shorter stays

and earlier discharges?

• Hospitalist “Hands Across America”– Can we impact change? Yes we can!– And no body does it better

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Suctioning & LOS in Bronchiolitis:

Background

• The mainstay of bronchiolitis therapy is supportive

• Suctioning management and its efficacy is largely unstudied

• Nasal suction provides a temporary relief of symptoms

• Pharmacologic treatment of nasal obstruction has not been shown to have significant impact on outcomes*

Objectives

• To determine if repeated nasopharyngeal suctioning (“deep suction”) produces worse outcomes (“is harmful”) when compared to noninvasive suctioning

• To determine if frequent suctioning improves clinical outcomes

Methods

• Retrospective cohort study:– Cincinnati Children’s (CCHMC) & Satellite Facility– 2 - 12 month-old infants hospitalized with

bronchiolitis; January 2010 – April 2011– Exclusion: < 2mo old; ICU admit; tracheostomy

• Charts reviewed for:– Suction Device type – Time lapses in suctioning (>4hrs)

• Primary Outcome Measure: Length of Stay (LOS)

Results: 740 infants in Device Type cohort

• Multivariable analysis:

LOS = 0.6 days longer in >60% group vs.. None group

P = <.001

Results: 695 in Suctioning Frequency cohort

• Multivariable analysis:

LOS = 1.02 days longer in > 3 lapses group vs.. 0 lapses group

P = <.001

Limitations

• Device Type Cohort: ‘Confounding by Indication’– Nurses and RTs may have chosen deep

suctioning for patients who were ‘sicker’– “Confounding by indication for deep

suctioning may be a source of systematic error… results should be interpreted with caution in this context.”

– A prospective study that randomizes suction device type is needed

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Bottom line

• Nasopharyngeal suctioning may have negative impact on outcomes & may prolong LOS

• Scheduled, non-invasive nasal suctioning may have a positive impact on length of stay

• Idea for your next study!

Trying to predict who is going to crump?

May be the only study that matters…

• It’s not for lack of trying… but so far, we all know the truth: Nothing that we do clinically seems to change outcomes or LOS

• As we look for ways to safely impact LOS and outcomes in bronchiolitis, One question does become very important…

Which of these little boogers is going to crump and need to go to the ICU?

Objective & Methods• To identify risk factors associated with

progression to need for CPAP and/or intubation for children with bronchiolitis

• Prospective, multicenter cohort study– 16 centers: Multicenter Airway Research

Collaboration (MARC)

• 2007-2010: 3 consecutive winter seasons• Inclusion: <2 yrs admitted with

bronchiolitis

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Results

• 2207 children enrolled in study– 379/2207 (17%) enrolled in the ICU

• Of 379 ICU patients, 161 (42%) required CPAP and/or intubation

• RSV A/B accounted for 73% of detected pathogens – Viral etiology was not an overall

predictor of progression to intubation*

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Independent Predictors of CPAP/ETT• 4 History Predictors:

– Age: < 6mos at presentation– Birth weight: < 7 lbs (3.18kg)– Maternal smoking during pregnancy– Breathing difficulties < 1 day prior to ED

visit

• 4 Clinical Predictors:– Apnea– Severe retractions– Oxygen saturation < 85%– Inadequate oral intake

Independent Risk Factors: By the NumbersCharacteristic Detail Odds Ratio 95% CI

Age (months) < 2 4.29 1.66 – 11.53

2 – 5.9 2.61 1.16 – 6.10

Birth Wt (pounds) < 5 1.70 1.01 – 2.52

≥ 5 - < 7 1.68 1.03 – 2.68

Smoked in Pregnancy

YES 1.38 1.05 – 1.91

Onset Breathing Difficulty

< 1 day 1.58 1.15 – 2.09

Apnea YES 4.78 2.57 -8.50

Retractions Severe 11.14 2.40 – 33.19

Oxygen Saturation, RA

<85% 3.28 2.02 – 4.82

Oral Intake Inadequate 2.51 1.34 – 4.26

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Bottom Line

• Smoking is bad!• There are historical and clinical risk

factors that can be used to predict possible progression of disease and need for ICU

• How can these be used?– As teaching tools for clinicians– As components of evidence-based care

process models used to shorten LOS and decrease hospital admissions…

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Knowing the risk data CAN impact care

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Yes We Can!

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A glimmer of hope…

Percentage Change in Resource Utilization by Year

2007 2008 2009 20100

10

20

30

40

50

60

70

80

Bronchodilators (p<0.01)

Chest Radiography (p=NS)

RSV Testing (p=NS)

Steroids (p=NS)

Chest Physiotherapy (p<0.01)

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And if anybody can do it…

Pneumonia

Objectives & Methods• Describe variability in resource utilization for

children hospitalized with Community-Acquired Pneumonia (CAP)

• Retrospective Cohort study using PHIS database• July 2005 – June 2010 (5 years of study data)• Children 1 – 18 years of age, with “non-severe

CAP”– ( ± effusion or empyema )

• Primary Exposure of Interest: Hospital-Level initial resource utilization on DAY 1

• Measured Outcomes: LOS, Readmission Rates

Results

• 43,819 Children Hospitalized with CAP• After exclusion criteria applied: 21,213

patients• Median Age: 3yrs – 72% were between 1-5

yrs– 22% were 6-12 yrs– 5% were 13-18 yrs

• LOS: 2 days (IQR: 1-3 days)– 25% of <12 yr olds hospitalized > 3 days– 25% of 13-18 yr olds hospitalized > 4 days

• Readmission Rate: Overall 2.3% (higher in 13-18yr)

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Results: Substantial Variation in Resource Utilization seen at the Hospital Level

Results: Variation in antibiotic use

Hospital - level variation in empiric antibiotic therapy among children with CAP. Each column on the x-axis represents data from one hospital.

Institutions that performed more diagnostic testing had longer LOS

Bottom Line

• The more you do… The longer they stay

• Earlier discharge DID NOT correlate with increased 14 day readmission

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Macrolide combination therapy in CAP

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Objective & Methods

• Determine the effectiveness of β-lactam monotherapy when compared with β-lactam PLUS macrolide in pts hospitalized with CAP

• Retrospective Cohort Study Using PHIS• January 2006 – December 2008 (3

years)• Children 1 – 18 yrs; with non-severe

CAP• Primary Exposure of Interest: Empiric

antibiotic• Outcome Measures: LOS, 14-day

Readmissions

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Results

• 37,461 patients eligible based on ICD-9 coding

• After Exclusion Criteria applied: – 20,743 patients included– 76% received β-lactam monotherapy– 24% received β-lactam PLUS macrolide

• Variability across sites:– Combination tx ranged from 17% - 48%

• LOS: Median length of stay for cohort: 2 days

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Results

• In the adjusted analysis:– Average LOS for patients receiving

combination therapy was 20% less than monotherapy

– When age was factored in older children saw largest drop in LOS• 6-11 yr old saw 25% reduction in LOS• 12-18yr old saw 31% reduction in LOS

– 1-5 year olds saw no benefit in LOS reduction

• No significant decrease in readmissions seen04/19/2023 99

Bottom Line

• 5-18 yo CAP inpatients may benefit from addition of macrolide therapy to standard empiric β-lactam therapy (AMPICILLIN!)

• Findings of are in concordance with 2011 IDSA guidelines, which make macrolide a ‘combination option’ for patients in whom atypical organisms “are a significant consideration”– Namely, school age children and

adolescents

• Randomized clinical trials are needed.04/19/2023 100

Thank You!

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