Samir S. Shah

The Management of Community-Acquired Pneumonia in Infants and Children Older Than 3 Months of Age: Clinical Practice Guidelines by the Pediatric Infectious Diseases Society and the Infectious Diseases Society of America

Abstract Evidenced-based guidelines for management of infants and children with community-acquired pneumonia (CAP) were prepared by an expert panel comprising clinicians and investigators representing community pediatrics, public health, and the pediatric specialties of critical care, emergency medicine, hospital medicine, infectious diseases, pulmonology, and surgery. These guidelines are intended for use by primary care and subspecialty providers responsible for the management of otherwise healthy infants and children with CAP in both outpatient and inpatient settings. Site-of-care management, diagnosis, antimicrobial and adjunctive surgical therapy, and prevention are discussed. Areas that warrant future investigations are also highlighted.

Antibiotic Prescribing in Ambulatory Pediatrics in the United States

BACKGROUND: Antibiotics are commonly prescribed for children with conditions for which they provide no benefit, including viral respiratory infections. Broad-spectrum antibiotic use is increasing, which adds unnecessary cost and promotes the development of antibiotic resistance. OBJECTIVE: To provide a nationally representative analysis of antibiotic prescribing in ambulatory pediatrics according to antibiotic classes and diagnostic categories and identify factors associated with broad-spectrum antibiotic prescribing. PATIENTS AND METHODS: We used the National Ambulatory and National Hospital Ambulatory Medical Care surveys from 2006 to 2008, which are nationally representative samples of ambulatory care visits in the United States. We estimated the percentage of visits for patients younger than 18 years for whom antibiotics were prescribed according to antibiotic classes, those considered broad-spectrum, and diagnostic categories. We used multivariable logistic regression to identify demographic and clinical factors that were independently associated with broad-spectrum antibiotic prescribing. RESULTS: Antibiotics were prescribed during 21% of pediatric ambulatory visits; 50% were broad-spectrum, most commonly macrolides. Respiratory conditions accounted for >70% of visits in which both antibiotics and broad-spectrum antibiotics were prescribed. Twenty-three percent of the visits in which antibiotics were prescribed were for respiratory conditions for which antibiotics are not clearly indicated, which accounts for >10 million visits annually. Factors independently associated with broad-spectrum antibiotic prescribing included respiratory conditions for which antibiotics are not indicated, younger patients, visits in the South, and private insurance. CONCLUSIONS: Broad-spectrum antibiotic prescribing in ambulatory pediatrics is extremely common and frequently inappropriate. These findings can inform the development and implementation of antibiotic stewardship efforts in ambulatory care toward the most important geographic regions, diagnostic conditions, and patient populations.

Reference Range for Cerebrospinal Fluid Opening Pressure in Children

To the Editor: A reference range for cerebrospinal fluid (CSF) opening pressure in children undergoing diagnostic lumbar puncture has not been established.1 The influence of age, body-mass index (B...

Corticosteroids and Mortality in Children With Bacterial Meningitis

CONTEXT In adults, adjuvant corticosteroids significantly reduce mortality associated with bacterial meningitis; however, in children, studies reveal conflicting results. OBJECTIVE To determine the association between adjuvant corticosteroids and clinical outcomes in children with bacterial meningitis. DESIGN, SETTING, AND PATIENTS A retrospective cohort study conducted between January 1, 2001, and December 31, 2006, of 2780 children discharged with bacterial meningitis as their primary diagnosis from 27 tertiary care childrens hospitals located in 18 US states and the District of Columbia that provide data to the Pediatric Health Information Systems administrative database. MAIN OUTCOME MEASURES Propensity scores, constructed using patient demographics and markers of illness severity at presentation, were used to determine each childs likelihood of receiving adjuvant corticosteroids. Primary outcomes of interest, time to death and time to hospital discharge, were analyzed by using propensity-adjusted Cox proportional hazards regression models stratified by age categories. RESULTS The median age was 9 months (interquartile range, 0-6 years); 57% of the patients were males. Streptococcus pneumoniae was the most commonly identified cause of meningitis. Adjuvant corticosteroids were administered to 248 children (8.9%). The overall mortality rate was 4.2% (95% confidence interval [CI], 3.5%-5.0%), and cumulative incidences were 2.2% and 3.1% at 7 days and 28 days, respectively, after admission. Adjuvant corticosteroids did not reduce mortality, regardless of age (children <1 year: hazard ratio [HR], 1.09; 95% CI, 0.53-2.24; 1-5 years: HR, 1.28; 95% CI, 0.59-2.78; and >5 years: HR, 0.92; 95% CI, 0.38-2.25). Adjuvant corticosteroids were also not associated with time to hospital discharge. In subgroup analyses, the results did not change in either children identified with pneumococcal or meningococcal meningitis or children with a cerebrospinal fluid culture performed at the admitting hospital. CONCLUSION In this multicenter observational study of children with bacterial meningitis, adjuvant corticosteroid therapy was not associated with time to death or time to hospital discharge.

How Well Can Hospital Readmission Be Predicted in a Cohort of Hospitalized Children? A Retrospective, Multicenter Study

BACKGROUND. Children with complex chronic conditions depend on both their families and systems of pediatric health care, social services, and financing. Investigations into the workings of this ecology of care would be advanced by more accurate methods of population-level predictions of the likelihood for future hospitalization. METHODS. This was a retrospective cohort study. Hospital administrative data were collected from 38 childrens hospitals in the United States for the years 2003–2005. Participants included patients between 2 and 18 years of age discharged from an index hospitalization during 2004. Patient characteristics documented during the index hospitalization or any previous hospitalization during the preceding 365 days were included. The main outcome measure was readmission to the hospital during the 365 days after discharge from the index admission. RESULTS. Among the cohort composed of 186856 patients discharged from the participating hospitals during 2004, the mean age was 9.2 years, with 54.4% male and 52.9% identified as non-Hispanic white. A total of 17.4% were admitted during the previous 365 days, and among those discharged alive (0.6% died during the admission), 16.7% were readmitted during the ensuing 365 days. The final readmission model exhibited a c statistic of 0.81 across all hospitals, with a range from 0.76 to 0.84 for each hospital. Bootstrap-based assessments demonstrated the stability of the final model. CONCLUSIONS. Accurate population-level prediction of hospital readmissions is possible, and the resulting predicted probability of hospital readmission may prove useful for health services research and planning.

Emergence of Vaccine-Related Pneumococcal Serotypes as a Cause of Bacteremia

BACKGROUND The heptavalent pneumococcal conjugate vaccine (PCV7) has decreased the incidence of invasive pneumococcal disease among children in the United States. In the postlicensure period, the impact of non-PCV7 serotypes against pediatric pneumococcal bacteremia is unknown. METHODS Episodes of bacteremia due to Streptococcus pneumoniae and other respiratory pathogens (ORP), namely Neisseria meningitidis, Haemophilus influenzae, and Moraxella catarrhalis, were identified in children <18 years old at the Childrens Hospital of Philadelphia from January 1999 to May 2005. For pneumococci, serotype distribution and antibiotic resistance were compared. RESULTS A total of 188 episodes of pneumococcal bacteremia and 55 episodes of ORP bacteremia were identified. By comparing data from 1999-2000 with data from 2001 to May 2005, we found that the incidence of pneumococcal bacteremia decreased by 57%. The incidence of bacteremia caused by ORPs was unchanged; 1.43 episodes (95% confidence interval [CI], 0.84-2.29 episodes) to 1.25 (95% CI, 0.88-1.71) per 10,000 emergency department visits. Vaccine serotypes caused 85% of episodes of bacteremia in 1999-2000, compared with 34% of episodes of bacteremia in 2001 to May 2005 (P<.01). The percentage of isolates nonsusceptible to penicillin increased from 25% to 39% (P<.05). The percentage of episodes of pneumococcal bacteremia caused by vaccine-related serotypes--those of the same serogroup but not of the same serotype as PCV7--increased from 6% of episodes in the prelicensure period to 35% of episodes in the postlicensure period (P<.01). Rates of serotype pneumococcal bacteremia caused by nonvaccine serotypes were not statistically different between the 2 periods. CONCLUSIONS The overall incidence of pneumococcal bacteremia decreased by 57% after the introduction of PCV7. During the postlicensure period, there were significant decreases in the incidence of pneumococcal bacteremia caused by vaccine serotypes; however, rates of penicillin resistance and bacteremia due to vaccine-related serotypes increased.

Intravenous Immunoglobulin in Children with Streptococcal Toxic Shock Syndrome

BACKGROUND Streptococcal toxic shock syndrome (TSS) is a rare and severe manifestation of group A streptococcal infection. The role of intravenous immunoglobulin (IVIG) for streptococcal TSS in children is controversial. This study aims to describe the epidemiology of streptococcal TSS in children and to determine whether adjunctive therapy with IVIG is associated with improved outcomes. METHODS A multicenter, retrospective cohort study of children with streptococcal TSS from 1 January 2003 through 31 December 2007 was conducted. Propensity scores were used to determine each childs likelihood of receiving IVIG. Differences in the primary outcomes of death, hospital length of stay, and total hospital costs were compared after matching IVIG recipients and nonrecipients on propensity score. RESULTS The median patient age was 8.2 years. IVIG was administered to 84 (44%) of 192 patients. The overall mortality rate was 4.2% (95% confidence interval, 1.8%-8.0%). Differences in mortality between IVIG recipients (n = 3; 4.5%) and nonrecipients (n = 3; 4.5%) were not statistically significant (p > .99). Although patients receiving IVIG had higher total hospital and drug costs than nonrecipients, differences in hospital costs were not significant once drug costs were removed (median difference between matched patients,

Linking clinical registry data with administrative data using indirect identifiers: Implementation and validation in the congenital heart surgery population

6139; interquartile range, -

Ambulatory visit rates and antibiotic prescribing for children with pneumonia, 1994-2007

8316 to

Corticosteroids and Outcome in Children Undergoing Congenital Heart Surgery Analysis of the Pediatric Health Information Systems Database

25,993; P = .06). No differences were found in length of hospital stay between matched IVIG recipients and nonrecipients. CONCLUSION This multicenter study is, to our knowledge, the largest to describe the epidemiology and outcomes of children with streptococcal TSS and the first to explore the association between IVIG use and clinical outcomes. IVIG use was associated with increased costs of caring for children with streptococcal TSS but was not associated with improved outcomes.