Lilliam Ambroggio

Improvement Methodology Increases Guideline Recommended Blood Cultures in Children With Pneumonia

BACKGROUND AND OBJECTIVE: A national evidence-based guideline for the management of community-acquired pneumonia (CAP) in children recommends blood cultures for patients admitted with moderate to severe illness. Our primary aim was to increase ordering of blood cultures for children hospitalized with CAP from 53% to 90% in 6 months. The secondary aim was to evaluate the effect of obtaining blood cultures on length of stay (LOS). METHODS: At a tertiary children’s hospital, interventions to increase blood cultures focused on 3 key drivers and were tested separately in the emergency department and inpatient units by using multiple plan-do-study-act cycles. The impact of the interventions was tracked over time on run charts. The association of ordering blood cultures and LOS was estimated by using linear regression models. RESULTS: Within 6 months, the percentage of patients admitted with CAP who had blood cultures ordered increased from 53% to 100%. This change has been sustained for 12 months. Overall, 239 (79%) of the 303 included patients had a blood culture ordered; of these, 6 (2.5%) were positive. Patients who had a blood culture did not have an increased LOS compared with those without a blood culture. CONCLUSIONS: Quality improvement methods were used to increase adherence to evidence-based national guidelines for performing blood cultures on children hospitalized with CAP; LOS did not increase. These results support obtaining blood cultures on all patients admitted with CAP without negative effects on LOS in a setting with a reliably low false-positive blood culture rate.

Beta‐lactam versus beta‐ lactam/macrolide therapy in pediatric outpatient pneumonia

The objective was to evaluate the comparative effectiveness of beta‐lactam monotherapy and beta‐ lactam/macrolide combination therapy in the outpatient management of children with community‐acquired pneumonia (CAP).

Biomarkers for Community-Acquired Pneumonia in the Emergency Department

Community-acquired pneumonia is one of the most common reasons for emergency department (ED) visits in children and adults. Despite its prevalence, there are many challenges to proper diagnosis and management of pneumonia. There is no accurate and timely etiologic gold standard to differentiate bacterial from viral disease, and there are limitations with precise risk stratification of patients to ensure appropriate site-of-care decisions. Clinical factors obtained by history and physical examination have limited the ability to diagnose pneumonia etiology and severity. Biomarkers offer information about the host response to infection and pathogen activity within the host that can serve to augment clinical features in decision-making. As science and technology progress, novel biomarkers offer great potential in aiding critical decisions for patients with pneumonia. This review summarizes existing knowledge about biomarkers of host response and pathogen activity, in addition to briefly reviewing emerging biomarkers using novel technologies.

Impact of clinical history on chest radiograph interpretation

BACKGROUND The inclusion of clinical information may have unrecognized influence in the interpretation of diagnostic testing. OBJECTIVE The objective of the study was to determine the impact of clinical history on chest radiograph interpretation in the diagnosis of pneumonia. DESIGN Prospective case-based study. METHODS Radiologists interpreted 110 radiographs of children evaluated for suspicion of pneumonia. Clinical information was withheld during the first interpretation. After 6 months the radiographs were reviewed with clinical information. Radiologists reported on pneumonia indicators described by the World Health Organization (ie, any infiltrate, alveolar infiltrate, interstitial infiltrate, air bronchograms, hilar adenopathy, pleural effusion). SETTING Childrens Hospital of Philadelphia and Boston Childrens Hospital. PARTICIPANTS Six board-certified radiologists. OUTCOME MEASURES Inter- and inter-rater reliability were assessed using the kappa statistic. RESULTS The addition of clinical history did not have a substantial impact on the inter-rater reliability in the identification of any infiltrate, alveolar infiltrate, interstitial infiltrate, pleural effusion, or hilar adenopathy. Inter-rater reliability in the identification of air bronchograms improved from fair (k = 0.32) to moderate (k = 0.53). Intra-rater reliability for the identification of alveolar infiltrate remained substantial to almost perfect for all 6 raters with and without clinical information. One rater had a decrease in inter-rater reliability from almost perfect (k = 1.0) to fair (k = 0.21) in the identification of interstitial infiltrate with the addition of clinical history. CONCLUSIONS Alveolar infiltrate and pleural effusion are findings with high intra- and inter-rater reliability in the diagnosis of bacterial pneumonia. The addition of clinical information did not have a substantial impact on the reliability of these findings.

Aspiration and Non-Aspiration Pneumonia in Hospitalized Children With Neurologic Impairment

BACKGROUND AND OBJECTIVE: Children with neurologic impairment (NI) are commonly hospitalized for different types of pneumonia, including aspiration pneumonia. We sought to compare hospital management and outcomes of children with NI diagnosed with aspiration versus nonaspiration pneumonia. METHODS: A retrospective study of 27 455 hospitalized children aged 1 to 18 years with NI diagnosed with pneumonia from 2007 to 2012 at 40 children’s hospitals in the Pediatric Health Information System database. The primary exposure was pneumonia type, classified as aspiration or nonaspiration. Outcomes were complications (eg, acute respiratory failure) and hospital utilization (eg, length of stay, 30-day readmission). Multivariable regression was used to assess the association between pneumonia type and outcomes, adjusting for NI type, comorbid conditions, and other characteristics. RESULTS: In multivariable analysis, the 9.7% of children diagnosed with aspiration pneumonia experienced more complications than children with nonaspiration pneumonia (34.0% vs 15.2%, adjusted odds ratio [aOR] 1.2 (95% confidence interval [CI] 1.1–1.3). Children with aspiration pneumonia had significantly longer length of stay (median 5 vs 3 days; ratio of means 1.2; 95% CI 1.2–1.3); more ICU transfers (4.3% vs 1.5%; aOR 1.4; 95% CI 1.1–1.9); greater hospitalization costs (median

Adjunct Systemic Corticosteroid Therapy in Children With Community-Acquired Pneumonia in the Outpatient Setting.

11 594 vs

Hospital outcomes associated with guideline-recommended antibiotic therapy for pediatric pneumonia

5162; ratio of means 1.2; 95% CI 1.2–1.3); and more 30-day readmissions (17.4% vs 6.8%; aOR 1.3; 95% CI 1.2–1.5). CONCLUSIONS: Hospitalized children with NI diagnosed with aspiration pneumonia have more complications and use more hospital resources than when diagnosed with nonaspiration pneumonia. Additional investigation is needed to understand the reasons for these differences.

Pneumonia in Children Presenting to the Emergency Department With an Asthma Exacerbation

BACKGROUND The role of adjunct systemic corticosteroid therapy in children with community-acquired pneumonia (CAP) is not known. The objective was to determine the association between adjunct systemic corticosteroid therapy and treatment failure in children who received antibiotics for treatment of CAP in the outpatient setting. METHODS The study included a retrospective cohort study of children, aged 1-18 years, with a diagnosis of CAP who were managed at an outpatient practice affiliated with Geisinger Health System from January 1, 2008 to January 31, 2010. The primary exposure was the receipt of adjunct corticosteroid therapy. The primary outcome was treatment failure defined as a respiratory-associated follow-up within 14 days of diagnosis in which the participant received a change in antibiotic therapy. The probability of receiving adjunct systemic corticosteroid therapy was calculated using a matched propensity score. A multivariable conditional logistic regression model was used to estimate the association between adjunct corticosteroids and treatment failure. RESULTS Of 2244 children with CAP, 293 (13%) received adjunct corticosteroids, 517 (23%) had underlying asthma, and 624 (28%) presented with wheezing. Most patients received macrolide monotherapy for their CAP diagnosis (n = 1329; 59%). Overall, treatment failure was not associated with adjunct corticosteroid treatment (odds ratio [OR], 1.72; 95% confidence interval [CI], 0.93 and 3.19), but the association was statistically significant among patients with no history of asthma (OR, 2.38; 95% CI, 1.03 and 5.52), with no statistical association among patients with a history of asthma. CONCLUSION Adjunct corticosteroid therapy was associated with treatment failure among children diagnosed with CAP who did not have underlying asthma.

Comparative Effectiveness of Beta-lactam Versus Macrolide Monotherapy in Children with Pneumonia Diagnosed in the Outpatient Setting.

BACKGROUND Recent national guidelines recommend use of narrow-spectrum antibiotic therapy as empiric treatment for children hospitalized with community-acquired pneumonia (CAP). However, clinical outcomes associated with adoption of this recommendation have not been studied. METHODS This retrospective cohort study included children age 3 months to 18 years, hospitalized with CAP from May 2, 2011 through July 30, 2012. Primary exposure of interest was empiric antibiotic therapy, classified as guideline recommended or not. Primary outcomes were length of stay (LOS), total hospital costs, and inpatient pharmacy costs. Secondary outcomes included broadened antibiotic therapy, emergency department revisits, and readmissions. Multivariable linear regression and Fisher exact test were performed to determine the association of guideline-recommended antibiotic therapy on outcomes. RESULTS Empiric guideline-recommended therapy was prescribed to 168 (76%) of 220 patients. Median hospital LOS was 1.3 days (interquartile range [IQR]: 0.9-1.9 days), median total cost of index hospitalization was

Metabolomics as a Driver in Advancing Precision Medicine in Sepsis

4097 (IQR: