Angela L. Myers

Accuracy of Administrative Billing Codes to Detect Urinary Tract Infection Hospitalizations

BACKGROUND: Hospital billing data are frequently used for quality measures and research, but the accuracy of the use of discharge codes to identify urinary tract infections (UTIs) is unknown. OBJECTIVE: To determine the accuracy of International Classification of Diseases, 9th revision (ICD-9) discharge codes to identify children hospitalized with UTIs. METHODS: This multicenter study conducted in 5 childrens hospitals included children aged 3 days to 18 years who had been admitted to the hospital, undergone a urinalysis or urine culture, and discharged from the hospital. Data were obtained from the pediatric health information system database and medical record review. With the use of 2 gold-standard methods, the positive predictive value (PPV) was calculated for individual and combined UTI codes and for common UTI identification strategies. PPV was measured for all groupings for which the UTI code was the principal discharge diagnosis. RESULTS: There were 833 patients in the study. The PPV was 50.3% with the use of the gold standard of laboratory-confirmed UTIs but increased to 85% with provider confirmation. Restriction of the study cohort to patients with a principle diagnosis of UTI improved the PPV for laboratory-confirmed UTI (61.2%) and provider-confirmed UTI (93.2%), as well as the ability to benchmark performance. Other common identification strategies did not markedly affect the PPV. CONCLUSIONS: ICD-9 codes can be used to identify patients with UTIs but are most accurate when UTI is the principal discharge diagnosis. The identification strategies reported in this study can be used to improve the accuracy and applicability of benchmarking measures.

Influenza Coinfection and Outcomes in Children With Complicated Pneumonia

OBJECTIVE To determine the impact of influenza coinfection on outcomes for children with complicated pneumonia. DESIGN Retrospective cohort study. SETTING Forty childrens hospitals that contribute data to the Pediatric Health Information System. PARTICIPANTS Children discharged from participating hospitals between January 1, 2004, and June 30, 2009, with complicated pneumonia requiring a pleural drainage procedure. MAIN EXPOSURE Influenza coinfection. MAIN OUTCOME MEASURES Intensive care unit admission, receipt of mechanical ventilation, receipt of vasoactive infusions, receipt of blood product transfusions, in-hospital death, readmission within 14 days of hospital discharge, hospital length of stay, and cost of hospitalization. RESULTS Overall, 3382 of 9680 children with complicated pneumonia underwent pleural fluid drainage; 105 patients (3.1%) undergoing pleural drainage had influenza coinfection. A bacterial pathogen was identified in 1201 cases (35.5%); the most commonly identified bacteria were Staphylococcus aureus in children with influenza coinfection (22.9% of cases) and Streptococcus pneumoniae in children without coinfection (20.0% of cases). In multivariable analysis, influenza coinfection was associated with higher odds of intensive care unit admission and receipt of mechanical ventilation, vasoactive infusions, and blood product transfusions as well as higher costs and a longer hospital stay. Children with influenza coinfection were less likely to require readmission, although there was a trend toward higher odds of mortality for patients with coinfection. In a subanalysis stratified by bacteria, outcomes remained worse for coinfected children in the subgroups of children with S aureus and with no specified bacteria. CONCLUSIONS Influenza coinfection occurred in 3.1% of children with complicated pneumonia. Clinical outcomes for children with complicated pneumonia and influenza coinfection were more severe than for children without documented influenza coinfection.

Controversies in Vaccine Mandates

Policies that mandate immunization have always been controversial. The controversies take different forms in different contexts. For routine childhood immunizations, many parents have fears about both short- and long-term side effects. Parental worries change as the rate of vaccination in the community changes. When most children are vaccinated, parents worry more about side effects than they do about disease. Because of these worries, immunization rates go down. As immunization rates go down, disease rates go up, and parents worry less about side effects of vaccination and more about the complications of the diseases. Immunization rates then go up. For teenagers, controversies arise about the criteria that should guide policies that mandate, rather than merely recommend and encourage, certain immunizations. In particular, policy makers have questioned whether immunizations for human papillomavirus, or other diseases that are not contagious, should be required. For healthcare workers, debates have focused on the strength of institutional mandates. For years, experts have recommended that all healthcare workers be immunized against influenza. Immunizations for other infections including pertussis, measles, mumps, and hepatitis are encouraged but few hospitals have mandated such immunizations-instead, they rely on incentives and education. Pandemics present a different set of problems as people demand vaccines that are in short supply. These issues erupt into controversy on a regular basis. Physicians and policy makers must respond both in their individual practices and as advisory experts to national and state agencies. The articles in this volume will discuss the evolution of national immunization programs in these various settings. We will critically examine the role of vaccine mandates. We will discuss ways that practitioners and public health officials should deal with vaccine refusal. We will contrast responses of the population as a whole, within the healthcare setting, and in the setting of pandemic influenza.

Comparative effectiveness of pleural drainage procedures for the treatment of complicated pneumonia in childhood.

OBJECTIVE To determine the comparative effectiveness of common pleural drainage procedures for treatment of pneumonia complicated by parapneumonic effusion (ie, complicated pneumonia). DESIGN Multicenter retrospective cohort study. SETTING Forty childrens hospitals contributing data to the Pediatric Health Information System. PARTICIPANTS Children with complicated pneumonia requiring pleural drainage. MAIN EXPOSURES Initial drainage procedures were categorized as chest tube without fibrinolysis, chest tube with fibrinolysis, video-assisted thoracoscopic surgery (VATS), and thoracotomy. MAIN OUTCOME MEASURES Length of stay (LOS), additional drainage procedures, readmission within 14 days of discharge, and hospital costs. RESULTS Initial procedures among 3500 patients included chest tube without fibrinolysis (n = 1762), chest tube with fibrinolysis (n = 623), VATS (n = 408), and thoracotomy (n = 797). Median age was 4.1 years. Overall, 716 (20.5%) patients received an additional drainage procedure (range, 6.8-44.8% across individual hospitals). The median LOS was 10 days (range, 7-14 days across individual hospitals). The median readmission rate was 3.8% (range, 0.8%-33.3%). In multivariable analysis, differences in LOS by initial procedure type were not significant. Patients undergoing initial chest tube placement with or without fibrinolysis were more likely to require additional drainage procedures. However, initial chest tube without fibrinolysis was the least costly strategy. CONCLUSION There is variability in the treatment and outcomes of children with complicated pneumonia. Outcomes were similar in patients undergoing initial chest tube placement with or without fibrinolysis. Those undergoing VATS received fewer additional drainage procedures but had no differences in LOS compared with other strategies.

Defining Risk Factors for Red Man Syndrome in Children and Adults

Background: Red man syndrome (RMS) is a well-known adverse reaction that occurs in pediatric patients receiving vancomycin, yet reported prevalence is varied, and characteristics and risk factors are not well understood. Our objective was to determine the prevalence, characteristics and risk factors for RMS in pediatric patients receiving vancomycin, including contributing genetic factors. Methods: A multicenter retrospective study of 546 subjects (0.5–21 years) who received at least 1 dose of intravenous vancomycin was conducted. Demographic and symptom data were collected through chart review and parent/nurse report. Genotype analysis included 10 single nucleotide polymorphisms in the histamine pathway. Results: RMS was observed in 77 (14%) subjects receiving vancomycin. Forty percent of subjects with RMS symptoms developed rash, pruritis and flushing, without hypotension. Antecedent antihistamine use was identified as a risk factor for RMS (P < 0.001). Multivariate regression analysis identified age > 2 years (P = 0.008), previous RMS (P < 0.001), vancomycin dose (P = 0.02) and vancomycin concentration (P = 0.017) as RMS risk factors, whereas African American race was protective (P = 0.011). We observed an apparent association between RMS and a single nucleotide polymorphism in the diamine oxidasegene (P = 0.044); however, no associations were revealed by multifactor dimensionality reduction analysis. Conclusions: RMS is a common adverse event in children receiving vancomycin. Identified risk factors are Caucasian ethnicity, age≥ 2 years, previous RMS history, vancomycin dose ≥ 10 mg/kg, vancomycin concentration ≥ 5 mg/mL and antecedent antihistamine use. Known genetic variants in histamine metabolism or receptors do not appear to be substantial contributors to risk of RMS.

Association of clinical practice guidelines with emergency department management of febrile infants ≤56 days of age

BACKGROUND Differences among febrile infant institutional clinical practice guidelines (CPGs) may contribute to practice variation and increased healthcare costs. OBJECTIVE Determine the association between pediatric emergency department (ED) CPGs and laboratory testing, hospitalization, ceftriaxone use, and costs in febrile infants. DESIGN Retrospective cross-sectional study in 2013. SETTING Thirty-three hospitals in the Pediatric Health Information System. PATIENTS Infants aged ≤56 days with a diagnosis of fever. EXPOSURES The presence and content of ED-based febrile infant CPGs assessed by electronic survey. MEASUREMENTS Using generalized estimating equations, we evaluated the association between CPG recommendations and rates of urine, blood, cerebrospinal fluid (CSF) testing, hospitalization, and ceftriaxone use at ED discharge in 2 age groups: ≤28 days and 29 to 56 days. We also assessed CPG impact on healthcare costs. RESULTS We included 9377 ED visits; 21 of 33 EDs (63.6%) had a CPG. For neonates ≤28 days, CPG recommendations did not vary and were not associated with differences in testing, hospitalization, or costs. Among infants 29 to 56 days, CPG recommendations for CSF testing and ceftriaxone use varied. CSF testing occurred less often at EDs with CPGs recommending limited testing compared to hospitals without CPGs (adjusted odds ratio: 0.5, 95% confidence interval: 0.3-0.8). Ceftriaxone use at ED discharge varied significantly based on CPG recommendations. Costs were higher for admitted and discharged infants 29 to 56 days old at hospitals with CPGs. CONCLUSIONS CPG recommendations for febrile infants 29 to 56 days old vary across institutions for CSF testing and ceftriaxone use, correlating with observed practice variation. CPGs were not associated with lower healthcare costs.

No Evidence of Vancomycin Minimal Inhibitory Concentration Creep or Heteroresistance Identified in Pediatric Staphylococcus aureus Blood Isolates

We evaluated vancomycin minimum inhibitory concentration (MIC) trends by 3 methods (broth microdilution, Etest and Vitek 2) in 208 Staphylococcus aureus blood isolates from 2006 to 2009 and assessed for heteroresistance. Vancomycin MICs did not increase nor was heteroresistance identified. Etest yielded higher MIC results than the other 2 methods. No MIC was >2 µg/mL by any testing method.

Impact of Body Mass Index on Immunogenicity of Pandemic H1N1 Vaccine in Children and Adults

Obesity emerged as a risk factor for morbidity and mortality related to 2009 pandemic influenza A (H1N1) infection. However, few studies examine the immune responses to H1N1 vaccine among children and adults of various body mass indices (BMI). Pooling data from 3 trials of unadjuvanted split-virus H1N1 A/California/07/2009 influenza vaccines, we analyzed serologic responses of participants stratified by BMI grouping. A single vaccine dose produced higher hemagglutination inhibition antibody titers at day 21 in obese compared to nonobese adults, but there were no significant differences in responses to H1N1 vaccine among children or adults of various BMI following 2 doses.

First use of investigational antiviral drug pocapavir (v-073) for treating neonatal enteroviral sepsis.

Neonatal enteroviral sepsis is a potentially fatal condition. Perinatally acquired infection and severe coagulopathy can be associated with a poor clinical outcome, and antiviral therapy is currently unavailable. Pocapavir (V-073) is an investigational drug candidate being developed for poliovirus indications, but also has variable antiviral activity against nonpolio enteroviruses. We describe the first use of pocapavir in treating a case of severe neonatal enteroviral sepsis due to Coxsackievirus B3.

Association of white blood cell count and C-reactive protein with outcomes in children hospitalized for community-acquired pneumonia

We examined the association between baseline peripheral white blood cell count and C-reactive protein (CRP) values with outcomes among 153 children hospitalized with pneumonia. In multivariable analyses, CRP, but not white blood cell count, was significantly associated with both fever duration and hospital length of stay. For every 1mg/dL increase in CRP, length of stay increased by 1 hour.