Shawn Ralston

Treatment of Mycoplasma Pneumonia: A Systematic Review

BACKGROUND AND OBJECTIVE: Children with community-acquired lower respiratory tract infection (CA-LRTI) commonly receive antibiotics for Mycoplasma pneumoniae. The objective was to evaluate the effect of treating M. pneumoniae in children with CA-LRTI. METHODS: PubMed, Cochrane Central Register of Controlled Trials, and bibliography review. A search was conducted by using Medical Subject Headings terms related to CA-LRTI and M. pneumoniae and was not restricted by language. Eligible studies included randomized controlled trials (RCTs) and observational studies of children ≤17 years old with confirmed M. pneumoniae and a diagnosis of CA-LRTI; each must have also compared treatment regimens with and without spectrum of activity against M. pneumoniae. Data extraction and quality assessment were completed independently by multiple reviewers before arriving at a consensus. Data were pooled using a random effects model. RESULTS: Sixteen articles detailing 17 studies were included. The most commonly selected primary outcome was symptomatic improvement. Nine studies examined M. pneumoniae treatment in CA-LRTI secondary to M. pneumoniae, and 5 RCTs met criteria for meta-analysis. The suggested pooled risk difference of 0.12 (95% confidence interval, −0.04 to 0.20) favoring treatment was not significantly different and demonstrated significant heterogeneity. Limitations included substantial bias and subjective outcomes within the individual studies, difficulty interpreting testing modalities, and the inability to correct for mixed infections or timing of intervention. CONCLUSIONS: We identified insufficient evidence to support or refute treatment of M. pneumoniae in CA-LRTI. These data highlight the need for well-designed, prospective RCTs assessing the effect of treating M. pneumoniae in CA-LRTI.

A Multicenter Collaborative to Reduce Unnecessary Care in Inpatient Bronchiolitis

BACKGROUND AND OBJECTIVE: Evidence-based gGuidelines for acute viral bronchiolitis recommend primarily supportive care, but unnecessary care remains well documented. Published quality improvement work has been accomplished inchildren’s hospitals, but little broad dissemination has been reported outside of those settings. We sought to use a voluntary collaborative strategy to disseminatebest practices to reduce overuse of unnecessary care in children hospitalized for bronchiolitis in community settings. METHODS: This project was aquality improvement collaborative consisting of monthly interactive webinars with online data collection and feedback. Data were collected by chart review for 2 bronchiolitis seasons, defined as January, February, and March of 2013 and 2014. Patients aged <24 months hospitalized for bronchiolitis and without chronic illness, prematurity, or intensive care use were included. Results were analyzed using run charting, analysis of means, and nonparametric statistics. RESULTS: There were 21 participating hospitals contributing a total of 1869 chart reviews to the project, 995 preintervention and 874 postintervention. Mean use of any bronchodilator declined by 29% (P = .03) and doses per patient decreased 45% (P < .01). Mean use of any steroids declined by 68% (P < .01), and doses per patient decreased 35% (P = .04). Chest radiography use declined by 44% (P = .05). Length of stay decreased 5 hours (P < .01), and readmissions remained unchanged. CONCLUSIONS: A voluntary collaborative was effective in reducing unnecessary care among a cohort of primarily community hospitals. Such a strategy may be generalizable to the settings where the majority of children are hospitalized in the United States.

Association Between Hypertonic Saline and Hospital Length of Stay in Acute Viral Bronchiolitis: A Reanalysis of 2 Meta-analyses.

IMPORTANCEnTwo previous meta-analyses of nebulized hypertonic saline (HS) on hospital length of stay (LOS) in acute viral bronchiolitis have suggested benefit. Neither study fully addressed the issue of excessive heterogeneity in the cohort of studies, indicating that it may be inappropriate to combine such dissimilar studies to estimate a common treatment effect.nnnOBJECTIVEnTo reanalyze the existing data set for sources of heterogeneity to delineate the population most likely to benefit from HS.nnnDATA SOURCESnWe used the previously analyzed cohort of randomized trials from 2 published meta-analyses comparing HS with normal saline (or, in 1 case, with standard of care) in infants hospitalized for bronchiolitis. We also repeated the search strategy used by the most recent Cochrane Review in the Medline database through September 2015.nnnSTUDY SELECTIONnEighteen randomized clinical trials of HS in infants with bronchiolitis reporting LOS as an outcome measure were included.nnnDATA EXTRACTION AND SYNTHESISnThe guidelines used for abstracting data included LOS, study year, setting, sample size, type of control, admission/discharge criteria, adjunct medications, treatment frequency, mean day of illness at study enrollment, mean severity of illness scores, and mean age.nnnMAIN OUTCOMES AND MEASURESnWeighted mean difference in LOS and study heterogeneity as measured by the I2 statistic.nnnRESULTSnThere were 18 studies included of 2063 infants (63% male), with a mean age of 4.2 months. The mean LOS was 3.6 days. Two main sources of heterogeneity were identified. First, the effect of HS on LOS was entirely sensitive to the removal of one study population, noted to have a widely divergent definition of the primary outcome. Second, there was a baseline imbalance in mean day of illness at presentation between treatment groups. Controlling for either of these factors resolved the heterogeneity (I2u2009=u2009reduced from 78% to 45% and 0%, respectively) and produced summary estimates in support of the null hypothesis (that HS does not affect LOS). There was a weighted mean difference in LOS of -0.21 days (95% CI, -0.43 to +0.02) for the sensitivity analysis and +0.02 days (95% CI, -0.14 to +0.17) for studies without unbalanced treatment groups on presentation.nnnCONCLUSIONS AND RELEVANCEnPrior analyses were driven by an outlier population and unbalanced treatment groups in positive trials. Once heterogeneity was accounted for, the data did not support the use of HS to decrease LOS in infants hospitalized with bronchiolitis.

Use of Intermittent vs Continuous Pulse Oximetry for Nonhypoxemic Infants and Young Children Hospitalized for Bronchiolitis: A Randomized Clinical Trial

IMPORTANCEnClinical practice guidelines for managing infants and children hospitalized for bronchiolitis recommend only obtaining intermittent or spot check pulse oximetry readings for those who show clinical improvement. The effect of such monitoring is currently unknown.nnnOBJECTIVEnTo determine the effect of intermittent vs continuous pulse oximetry monitoring on hospital length of stay among nonhypoxemic infants and young children hospitalized for bronchiolitis.nnnDESIGN, SETTING, AND PARTICIPANTSnRandomized, parallel-group, superiority clinical trial of otherwise healthy infants and children 2 years of age or younger hospitalized for bronchiolitis during the period from 2009 to 2014 at 1 of 4 childrens hospitals in the United States. Parents or guardians were blinded to allocation assignment until informed consent was obtained; study personnel and outcome assessors were not.nnnINTERVENTIONSnPatients were randomly assigned to undergo continuous or intermittent pulse oximetry monitoring (ie, pulse oximetry measurements were obtained along with a scheduled check of vital signs or for clinical suspicion of deterioration) during hospitalization when oxygen saturation levels were 90% or higher.nnnMAIN OUTCOMES AND MEASURESnLength of hospital stay was the primary outcome. Secondary outcome measures included duration of supplemental oxygen use and rate of escalation of care (defined as transfer to an intensive care unit).nnnRESULTSnA total of 449 infants and young children were screened for inclusion; 288 infants and young children were excluded, resulting in 161 patients who were enrolled in the study (80 patients underwent continuous monitoring, and 81 patients intermittent). The mean length of stay did not differ based on pulse oximetry monitoring strategy (48.9 hours [95% CI, 41.3-56.5 hours] for continuous monitoring vs 46.2 hours [95% CI, 39.1-53.3 hours] for intermittent monitoring; Pu2009=u2009.77). The rates of escalation of care and duration of supplemental oxygen use did not differ between groups.nnnCONCLUSIONS AND RELEVANCEnIntermittent pulse oximetry monitoring of nonhypoxemic patients with bronchiolitis did not shorten hospital length of stay and was not associated with any difference in rate of escalation of care or use of diagnostic or therapeutic measures. Our results suggest that intermittent pulse oximetry monitoring can be routinely considered in the management of infants and children hospitalized for bronchiolitis who show clinical improvement.nnnTRIAL REGISTRATIONnclinicaltrials.gov Identifier: NCT01014910.

Epidemiology of pediatric hospitalizations at general hospitals and freestanding children's hospitals in the United States.

BACKGROUNDnChildren may be hospitalized at general hospitals or freestanding childrens hospitals. Knowledge about how inpatient care differs at these hospitals is important to inform national research and quality efforts.nnnOBJECTIVEnTo describe the volume and characteristics of pediatric hospitalizations at acute care general and freestanding childrens hospitals in the United States.nnnDESIGN, PATIENTS, AND SETTINGnCross-sectional study of hospitalizations in the United States among children <18 years, excluding in-hospital births, using the Healthcare Cost and Utilization Projects 2012 Kids Inpatient Database.nnnMEASUREMENTnWe examined differences between hospitalizations at general and freestanding childrens hospitals, applying weights to generate national estimates. Reasons for hospitalization were categorized using a pediatric grouper, and differences in hospital volumes were assessed for common diagnoses.nnnRESULTSnA total of 1,407,822 (standard deviation 50,456) hospitalizations occurred at general hospitals, representing 71.7% of pediatric hospitalizations. Hospitalizations at general hospitals accounted for 63.6% of hospital days and 50.0% of pediatric inpatient healthcare costs. Median volumes of pediatric hospitalizations, per hospital, were significantly lower at general hospitals than freestanding childrens hospitals for common medical and surgical diagnoses. Although the most common reasons for hospitalization were similar, the most costly conditions differed.nnnCONCLUSIONSnIn 2012, more than 70% of pediatric hospitalizations occurred at general hospitals in the United States. Differences in patterns of care at general hospitals and freestanding childrens hospitals may inform clinical programs, research, and quality improvement efforts. Journal of Hospital Medicine 2016;11:743-749.

Evaluating the Use of Blood Cultures in the Management of Children Hospitalized for Community-Acquired Pneumonia

Background Blood cultures are often recommended for the evaluation of community-acquired pneumonia (CAP). However, institutions vary in their use of blood cultures, and blood cultures have unclear utility in CAP management in hospitalized children. Objective To identify clinical factors associated with obtaining blood cultures in children hospitalized with CAP, and to estimate the association between blood culture obtainment and hospital length of stay (LOS). Methods We performed a multicenter retrospective cohort study of children admitted with a diagnosis of CAP to any of four pediatric hospitals in the United States from January 1, 2011-December 31, 2012. Demographics, medical history, diagnostic testing, and clinical outcomes were abstracted via manual chart review. Multivariable logistic regression evaluated patient and clinical factors for associations with obtaining blood cultures. Propensity score-matched Kaplan-Meier analysis compared patients with and without blood cultures for hospital LOS. Results Six hundred fourteen charts met inclusion criteria; 390 children had blood cultures obtained. Of children with blood cultures, six (1.5%) were positive for a pathogen and nine (2.3%) grew a contaminant. Factors associated with blood culture obtainment included presenting with symptoms of systemic inflammatory response syndrome (OR 1.78, 95% CI 1.10–2.89), receiving intravenous hydration (OR 3.94, 95% CI 3.22–4.83), receiving antibiotics before admission (OR 1.49, 95% CI 1.17–1.89), hospital admission from the ED (OR 1.65, 95% CI 1.05–2.60), and having health insurance (OR 0.42, 95% CI 0.30–0.60). In propensity score-matched analysis, patients with blood cultures had median 0.8 days longer LOS (2.0 vs 1.2 days, P < .0001) without increased odds of readmission (OR 0.94, 95% CI 0.45–1.97) or death (P = .25). Conclusions Obtaining blood cultures in children hospitalized with CAP rarely identifies a causative pathogen and is associated with increased LOS. Our results highlight the need to refine the role of obtaining blood cultures in children hospitalized with CAP.

Question from the clinician: Fever and bacteremia

1. Eric Biondi, MD*n2. Jennifer Murzycki, MD, PhD*n3. Shawn Ralston, MD†n4. Francis Gigliotti, MD*nnn nn1. *Golisano Children’s Hospital at Strong Memorial Hospital, Department of Pediatrics, University of Rochester Medical Center, Rochester, NY.nn2. †Director of Hospital Medicine at Childrens Hospital at Dartmouth, Hanover, NH.nnIs it necessary to monitor blood cultures for a full 48 hours to consider a febrile infant to be free of serious bacterial infection? nnFever that could be due to bacteremia in infants is a common and serious problem faced by pediatricians. Because of their immature immune systems and nonspecific signs, infants are more susceptible to serious bacterial infections (SBIs) than adults. A wide variety of strategies have been developed for the assessment of febrile but well-appearing children younger than age 90 days, known collectively as the “rule out sepsis” evaluation. This clinical presentation is a common reason for infant hospitalization. However, it remains unclear how long blood cultures from this population need to be monitored and how long infants need to be hospitalized. The literature is inconclusive, and there is variability in current practice.nnA review of currently published data did not identify a clear-cut observational period. Randhawa et al suggest a 96-hour observational period, although it was not obvious from this study what type of culture detection system was used or whether the patients were symptomatic. (1) In 2011, Guerti et al demonstrated support for an evaluation period of more than 36 hours. (2) They found that 56% of blood cultures were positive for bacteremia after an incubation time of 24 hours, 89% after 48 hours, and 97% after 72 hours. Another large study by Kumar et al demonstrated similar results. (3) Interestingly, if all coagulase-negative Staphylococcus are removed in these …

Fever and bacteremia.

1. Eric Biondi, MD*n2. Jennifer Murzycki, MD, PhD*n3. Shawn Ralston, MD†n4. Francis Gigliotti, MD*nnn nn1. *Golisano Children’s Hospital at Strong Memorial Hospital, Department of Pediatrics, University of Rochester Medical Center, Rochester, NY.nn2. †Director of Hospital Medicine at Childrens Hospital at Dartmouth, Hanover, NH.nnIs it necessary to monitor blood cultures for a full 48 hours to consider a febrile infant to be free of serious bacterial infection? nnFever that could be due to bacteremia in infants is a common and serious problem faced by pediatricians. Because of their immature immune systems and nonspecific signs, infants are more susceptible to serious bacterial infections (SBIs) than adults. A wide variety of strategies have been developed for the assessment of febrile but well-appearing children younger than age 90 days, known collectively as the “rule out sepsis” evaluation. This clinical presentation is a common reason for infant hospitalization. However, it remains unclear how long blood cultures from this population need to be monitored and how long infants need to be hospitalized. The literature is inconclusive, and there is variability in current practice.nnA review of currently published data did not identify a clear-cut observational period. Randhawa et al suggest a 96-hour observational period, although it was not obvious from this study what type of culture detection system was used or whether the patients were symptomatic. (1) In 2011, Guerti et al demonstrated support for an evaluation period of more than 36 hours. (2) They found that 56% of blood cultures were positive for bacteremia after an incubation time of 24 hours, 89% after 48 hours, and 97% after 72 hours. Another large study by Kumar et al demonstrated similar results. (3) Interestingly, if all coagulase-negative Staphylococcus are removed in these …

Antibiotic Prescribing Patterns Across the Continuum of Care for Children Hospitalized With Community-Acquired Pneumonia:

Objectives The aim of this study was to describe the variation in antibiotic prescribing practices for uncomplicated community-acquired pneumonia across the continuum of care for hospitalized pediatric patients to better inform future efforts at standardizing antibiotic therapy throughout a single hospitalization. Methods This is a retrospective cohort study involving 4 hospitals caring for children aged 3 months to 18 years, hospitalized between January 1, 2011, and December 31, 2012, with diagnosis of uncomplicated pneumonia and without complex chronic medical conditions. Data collected include antibiotics prescribed before hospitalization, at the emergency department (ED) encounter, during hospitalization, and at hospital discharge. Results Six hundred nine children met inclusion criteria, with a mean age of 5.3 years and median length of stay of 2 days. Emergency department providers prescribed narrow-spectrum therapy 27% of the time, whereas discharging providers prescribed narrow-spectrum therapy 56% of the time. Third- and fourth-generation cephalosporins were less often prescribed in the preadmission setting and at discharge but were more often prescribed in the ED and inpatient setting. There was an association between inpatient prescription of broad-spectrum antibiotics when a blood culture was obtained, when broad-spectrum antibiotics were prescribed in the ED, and with increasing length of stay. Conclusion Broad-spectrum antibiotic therapy for community-acquired pneumonia, especially third- and fourth-generation cephalosporins, often originates in the ED. When initiated in this setting, it is likely to be continued in the inpatient setting.

Question From the Clinician

1. Eric Biondi, MD*n2. Jennifer Murzycki, MD, PhD*n3. Shawn Ralston, MD†n4. Francis Gigliotti, MD*nnn nn1. *Golisano Children’s Hospital at Strong Memorial Hospital, Department of Pediatrics, University of Rochester Medical Center, Rochester, NY.nn2. †Director of Hospital Medicine at Childrens Hospital at Dartmouth, Hanover, NH.nnIs it necessary to monitor blood cultures for a full 48 hours to consider a febrile infant to be free of serious bacterial infection? nnFever that could be due to bacteremia in infants is a common and serious problem faced by pediatricians. Because of their immature immune systems and nonspecific signs, infants are more susceptible to serious bacterial infections (SBIs) than adults. A wide variety of strategies have been developed for the assessment of febrile but well-appearing children younger than age 90 days, known collectively as the “rule out sepsis” evaluation. This clinical presentation is a common reason for infant hospitalization. However, it remains unclear how long blood cultures from this population need to be monitored and how long infants need to be hospitalized. The literature is inconclusive, and there is variability in current practice.nnA review of currently published data did not identify a clear-cut observational period. Randhawa et al suggest a 96-hour observational period, although it was not obvious from this study what type of culture detection system was used or whether the patients were symptomatic. (1) In 2011, Guerti et al demonstrated support for an evaluation period of more than 36 hours. (2) They found that 56% of blood cultures were positive for bacteremia after an incubation time of 24 hours, 89% after 48 hours, and 97% after 72 hours. Another large study by Kumar et al demonstrated similar results. (3) Interestingly, if all coagulase-negative Staphylococcus are removed in these …