Pediatric Hospital MedicineTop 10 Articles

Elena AragonaJamie Librizzi

Objectives

• Summarize important evidence-based literature relating to pediatric hospital medicine

• Appraise key PHM articles as they relate to clinical practice

Apparent Life-Threatening Events

• Patient 1: 5 month old female p/w ALTE– Difficulty catching breath– Face turned red– Lasted ~10 seconds– 15min after feed

• Patient 2: Ex 34 wk 2mo M p/w ALTE– Hx ALTE 2 wks ago– Went limp for ~30

seconds– Not associated with feed

P: In infants presenting with ALTE

I/C: are there any factors

O: that increase risk of subsequent event?

Management of Apparent Life-Threatening Events in Infants: A Systematic Review

• Objective: lit review to determine– Hx and PE features that suggest inc risk of future adverse event and/or

serious dx– What testing is indicated

• Methods: – Pertinent articles identified and critically appraised

• 1970-2011• ALTE in children <24mo

• Results:– 37 studies identified

• 14 investigated history/PE features• 31 evaluated diagnostic testing• All studies observational; none well suited to define w/u or determine

prognosis…

Management of Apparent Life-Threatening Events in Infants: A Systematic Review

• Results:– Features associated with future adverse event

and/or serious underlying diagnosis• Prematurity• Multiple ALTE• Suspected child abuse

– Little evidence to support routine testing of all patients without these risk factors

Meningitis

• ED calls re: 6yo M with fever & headache found to have CSF pleocytosis, would like to admit on IV abx for bacterial meningitis r/o

P: In children presenting pleocytosis

I/C: Is there a clinical score to identify children with high risk for

O: Bacterial Meningitis

JAMA

Clinical Prediction Rule for Identifying Children with CSF Pleocytosis at Very Low Risk of

Bacterial Meningitis• Objective:

– To validate clinical prediction rule (Bacterial Meningitis Score)• Methods:

– Review records of children with meningitis evaluated in ED of 20 academic medical centers over 4 years• Inclusion: 29d – 19yo with ICD9 diagnosis of meningitis• Exclusion:

– Critical illness, purpura, VP shunt, recent neurosurgery, immunosuppression, other bacterial infection requiring inpt abx, active lyme disease, pts with abx within 72h of LP

• Bacterial meningitis: + CSF culture OR CSF pleocytosis with + BCx OR CSF pleocytosis with + CSF latex agllutination test for bacteria

– N = 2903 (met inclusion criteria, data available)

Clinical Prediction Rule for Identifying Children with CSF Pleocytosis at Very Low Risk of

Bacterial Meningitis• Results:

– 1714 low risk patients• 2 had bacterial meningitis (infants 1-2mo w E

Coli meningitis and UTI; neg UA at presentation)– NPV: 99.9%, (95% CI 99.6%-100%)

– 1189 not low risk• 119 (10%) had bacterial meningitis• >/= 1 risk factor

– Sensitivity 98.3% (95% CI 94.2%-99.8%)– Specificity 61.5% (95% CI 59.7%-63.3%

– Use caution when applying to infants <2mo • In patients >2mo, >/=1 risk factor had

sensitivity 100%• Pts <2mo, >/=1 risk factor had sensitivity

92.3%

Blood Cultures

• 20mo M with L thigh cellulitis– Failed outpt therapy; plan to admit on

clindamycin• Blood culture?

P: In patients with asthma, bronchiolitis, pneumonia, SSTI

I: does obtaining blood culture

C: versus no blood culture

O: affect outcomes?

Do We Need This Blood Culture?Kavita Parikh, Aisha Barber Davis, Padmaja PavuluriHospital Pediatrics 2014; 4; 78DOI: 10.1542/hpeds.2013-0053

Do We Need This Blood Culture?

• Objective:– To assess BCx rates & results for 4 leading

pediatric diagnoses in low-risk patients• Methods: – Retrospective cohort– Review records over 1 y at CNMC• Inclusion: 6mo – 18yo with bronchiolitis, asthma, SSTI,

CAP• Exclusion: complex pts• N = 5159 (1629 inpt, 3530 outpt/ED)

Do We Need This Blood Culture?

• Results:– BCx in 343 pts:

• 21% of inpts, 3% of ED/outpts– 4% in asthma– 15% in bronchiolitis– 36% in pna– 46% in SSTI

– BCx results• Asthma – all neg• Bronchiolitis – all neg• SSTI – 98% neg or contaminant

– 2 MRSA, 1 GAS• CAP – 99% neg or contaminant

– 1 strep pneumo, 1 moraxella

• BCx– Longer LOS in asthma,

bronchiolitis– If + (n=5), no change in

management• Some got rpt BCx though

• ~$100,000 microbiology costs at our institution

SBI Rule Out in Infant

• 3 wk M with fever– Well appearing, labs reassuring– Admitted on IV antibiotics

P: Neonates <1 mo admitted w/fever for IV antibiotics

I: Discharge at 36h

C: Discharge at 48 hour

O: No missed/untreated SBI

Time to Detection of Bacterial Cultures in Infants Aged 0-90 daysRianna C. Evans and Brian FineHospital Pediatrics 2013;3;97DOI: 10.152/hpeds.2012-0025

Time to Detection of Bacterial Cultures in Infants Aged 0-90 days

• Objective: determine if bacterial cultures in infants <90d would grow pathogenic bacteria in <36h

• Methods– Retrospective Chart Review over 3.5y @ single institution– Infants 0 to 90 d evaluated in ED or inpt for SBI– Excluded: indwelling catheters, ‘sick’, rpt cx

• Data Collection– Manual chart review of all blood, urine, CSF cultures

• True + vs. contaminant - Determined based on tx

Time to Detection of Bacterial Cultures in Infants Aged 0-90 days

• CNMC:– BCx: checked q10min, alarm if + gram stain, team

called• First subsequent read at 16-18 hours, then q24h

– CSF cultures• Goal gram stain within 1 hour• First time to check culture: 16-18 hours, then q24h

– Urine cultures• First read at 16-18 hours, then daily

– Can call at night and ask someone to check if still neg

Time to Detection of Bacterial Cultures in Infants Aged 0-90 days

• Results– 2092 blood cultures; 101/115 + blood cultures

included in analysis• 97% true pathogen (n=38) Bcx grew in 36h

– 2283 urine cultures; 192/232 + urine cultures included in analysis• 95% true pathogen (n=111) Ucx grew in 36h

– 1159 csf cultures; all 14+ included in analysis• 86% true pathogen (n=7) CSFcx grew in 36h

UTI Length of Treatment in Infant

• 3mo F with fever found to have UTI– Admitted on Ceftriaxone

P: Infants admitted with UTI

I: Transition to oral antibiotics after 3d

C: versus longer IV therapy

O: Treatment failure

Length of Intravenous Antibiotic Therapy and Treatment Failure in Infants with Urinary Tract InfectionsPatrick W. Brady, Patrick J. Conway and Anthony GoudiePediatrics 2010; 126; 196DOI: 10.1542/peds.2009-2948

Length of IV Abx Therapy in Infants with UTI

• Objective:– To assess short (<=3d) v long (>=4d) IV abx therapy

and treatment failure in infants <6mo admitted with UTI• Treatment failure = readmit within 30d

• Methods: – Retrospective cohort, infants <6mo admitted to 24

children's hospitals over 5y with UTI or pyelo (PHIS)• Excluded kids w complex conditions

Length of IV Abx Therapy in Infants with UTI

• Results: 12,333 kids met inclusion criteria– Male gender, neonatal status, black, Hispanic, non-private

insurance, known bacteremia, GU abnormality – inc likelihood of receiving IV abx

Length of IV Abx Therapy in Infants with UTI

• Results– Treatment failure overall: 1.9%

• 1.6% in short-course, 2.2% in long-course– Ie maybe sicker pts got long iv abxs and more likely to fail

• Outcome by pt characteristic and length of IV abx » ie gender, age by 1month intervals, race, bacteremia, GU

abnormality)– Only GU abnormality and severity of illness associated w

treatment failure

– Multivariate adjustment (addressed confounders ie severity of illness) – no association between treatment group and outcome

Osteomyelitis

• 10y male admitted for fever, L foot pain– MRI confirmed evidence of osteomyelitis– Patient started on Clinda IV

P: In patients with osteomyelitis does

I: Early transition to PO Abx

C: Versus prolonged IV therapy

O: Affect clinical outcomes?

Prolonged Intravenous Therapy Versus Early Transition to Oral Antimicrobial Therapy for Acute Osteomyelitis in ChildrenTheoklis Zaoutis, et al. Pediatrics 2009; 123;636 DOI: 10.15442/peds.2008-0596

Prolonged Intravenous Therapy Versus Early Transition to Oral Antimicrobial Therapy for Acute Osteomyelitis in ChildrenTheoklis Zaoutis, et al. Pediatrics 2009; 123;636 DOI: 10.15442/peds.2008-0596

Prolonged IV Therapy Versus Early Transition to PO for Osteomyelitis

• Objective: Compare the effectiveness of early transition from IV to PO for acute, uncomplicated osteo

• Methods: Retrospective cohort study (PHIS)– Children aged 2m-17y dx with osteo between 2000-

2005 at 29 free-standing children’s hospitals• Results:– 1o outcome: Tx failure (readmission w/in 6m)– 2o outcome: Readmit w/in 6m for line complication,

adverse drug rxn, C. Diff, agranulocytosis

Prolonged IV Therapy Versus Early Transition to PO for Osteomyelitis

Results: 1021 prolonged IV, 948 PO• Overall readmission rate significantly higher in

prolonged IV group (10% vs 6%, p= 0.017)• 1o outcome– 5% for prolonged IV group; 4% PO group– No significant association btw Tx failure and mode Abx

therapy• 2o outcome– Prolonged IV therapy group more likely to experience Tx-

related complication• 3% readmitted for catheter complications, 1.6% for Abx

complications (vs 0.4% in PO group, p= 0.005)

GERD

• 2m FT male admitted for persistent emesis with feeds associated with back arching, fussiness– Pt growing appropriately– Work-up only reveals reflux

GERD

• 2m FT male admitted for persistent emesis with feeds associated with back arching, fussiness– Pt growing appropriately– Work-up only reveals reflux

Are there risks associated with empiric acid suppression treatment of infants and children suspected of having GERDErica Y. Chung and Jeremy YardleyHospital Pediatrics 2013;3;16DOI: 10.1542/hpeds.2012-0077

Are there risks associated with acid suppression therapy?

• Objective: Evaluate the potential serious adverse effects associated with acid suppressive meds in the pediatric population

• Methods: PubMed search– Ages 0-18y; placebo-controlled or comparisons

with a nonacid suppression arm• Results: 14 studies included– NICU, PICU, non-critical care

Are there risks associated with acid suppression therapy?

Results• NICU– Increased risk NEC, sepsis/bacteremia

• PICU– Mixed results on VAP

• Non-critical care– Increased rate PNA, LRTI, gastroenteritis– Associated with C. Diff associated disease

Bronchiolitis

• 6wk female admitted with URI symptoms, increased WOB and fever found to be RSV+– Should she be evaluated for SBI?

P: In infants with bronchiolitis

I: Is testing for serious bacterial infection

C: Compared to not testing

O: Indicated?

Risk of serious bacterial infection in young febrile infants with RSV infectionsLevine D, et al. Pediatrics 2004; 113;1728-1734 DOI: 10.1542/peds.113.6.1662

Serious Bacterial Infections in Infants with RSV

• Methods: Multi-center prospective, cross-sectional study (1998-2001)– All febrile infants, aged 0-60d undergoing SBI eval– RSV testing by antigen detection from NP swabs

• Results– 1248 enrolled (22% tested + RSV)– Overall SBI rate 11.4% (0.7% meningitis, 2% bacteremia,

9.1% UTI)– RSV+ infants less likely to have SBI (7% vs 12.5%; RR 0.6)

Table 3. SBI by RSV Status

Serious Bacterial Infections in Infants with RSV

Results: Age-stratified• <28d: Overall rate of SBI did not differ

significantly btw those who were RSV+ and RSV- (10.1% vs 14.2%, RR 0.71, 95% CI 0.35-1.5)

• 29-60d: Overall rate of SBI was 5.5% (no bacteremia or meningitis) with statistically significant difference between RSV+ and RSV- (5.5% vs 11.7%, RR 0.47, 85% CI 0.24-0.91)

HSV

• 20d male presenting with fever and irritability– No maternal history of HSV– Full SBI evaluation initiated– Should HSV and empiric Acyclovir be done?

P: In infants presenting for evaluation

I/C: What history/PE/labs are associated

O: With HSV infection

HSV

• Methods: Retrospective case study of HSV over 22y (1988-2009) period from single institution– Inclusion: infants <60d with final dx HSV

• Results: – 32 cases included (25 confirmed, 7 probable); all

empirically tx w/ Acyclovir– 75% of cases with CNS disease

HSV• Results:– 1.3% empirically treated infants ultimately

diagnosed with HSV– 90% cases in infants <21d– 50% presented w/ non-specific complaints – 53% presented with fever, 13% hypothermia– HSV meningitis: 1/3 had <20 WBC in CSF– Except in disseminated disease, routinely obtained

labs were not distinctive in HSV-infected infants

Pneumonia

• 4yo M admitted with cough, fever, hypoxia and CXR with RML infiltrate– What is the evidence to support the 2011 IDSA

guideline to use Ampicillin as first-line therapy for CAP?

P: In children hospitalized with community-acquired PNA

I: Does treatment with narrow-spectrum Abx (i.e: Ampicillin)

C: Compared to broad spectrum (i.e: 3rd generation cephalosporin)

O: Have better clinical outcomes?

Narrow vs broad spectrum antimicrobial therapy for children hospitalized with PNAWilliams DJ, et al.* Pediatrics 2013; 132;e1141-8 DOI: 10.1542/peds.2013-1614

* Kavita Parikh, CNMC

Narrow vs Broad Spectrum Abx Tx for PNA

• Methods: Retrospective cohort study; 42 children’s hospitals btw 2005-2011 (PHIS)– Included children aged 6m-18y hospitalized >2d– Excluded potentially severe PNA, pts at risk for

healthcare assoc infections, pleural drainage/PICU/mech vent within first 2 days

• Results:– 1o outcome: LOS– 2o outcome: PICU, 14d readmission, costs

Narrow vs Broad Spectrum Abx Tx for PNA

• Results: 15,564 children included– 89.7% broad-spectrum, 10.3% narrow-spectrum

• No significant difference in LOS btw groups (when adjusted for confounders)

• No significant difference in PICU admits, 14d readmissions

• No significant difference in sub-analysis of wheezers• No significant difference on costs (adjusted analysis)

Runners Up…• Biondi et al. Treatment of Mycoplasma Pneumonia: A Systematic Review. Pediatrics, 2014;

113; 1081.

• Starmer et al. Rates of Medical Errors and Preventable Adverse Events Among Hospitalized Children Following Implementation of a Resident Handoff Bundle (IPASS). JAMA, 2013; 310(21): 2262-2270.

• Mussman et al. Suctioning and Length of Stay in Infants Hospitalized with Bronchiolitis. JAMA Pediatrics, 2013; 167(5): 414-421.

• Fernandes et al. Glucocorticoids for Acute Viral Bronchiolitis in Infants and Young Children. Cochrane Database Syst Rev. 2013; 6: CD004878.

• Salo et al. Childhood Urinary Tract Infections as a Cause of Chronic Kidney Disease. Pediatrics. 2011; 128(5): 840-847.

• Ralston et al. Occult Serious Bacterial Infection in Infants Younger than 60 to 90 Days with Bronchiolitis: a Systemic Review. Arch Pediatr Adolesc Med. 2011; 156(10):951-956.

Next Session: March 2015

• Review Guidelines:– 2006 AAP Bronchiolitis Guidelines– 2011 IDSA PNA Guidelines– 2011 IDSA UTI Guidelines– 2004 AAP Kawasaki Endorsed Clinical Report– 2011 IDSA MRSA Guidelines