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Pediatric Hospital Medicine Top 10 Articles Elena Aragona Jamie Librizzi.

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Presentation on theme: "Pediatric Hospital Medicine Top 10 Articles Elena Aragona Jamie Librizzi."— Presentation transcript:

1 Pediatric Hospital Medicine Top 10 Articles Elena Aragona Jamie Librizzi

2 Objectives Summarize important evidence-based literature relating to pediatric hospital medicine Appraise key PHM articles as they relate to clinical practice

3 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

4 P: In infants presenting with ALTE I/C: are there any factors O: that increase risk of subsequent event?

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6 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 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…

7 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

8 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

9 P: In children presenting pleocytosis I/C: Is there a clinical score to identify children with high risk for O: Bacterial Meningitis

10 JAMA

11 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)

12 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 /=1 risk factor had sensitivity 92.3%

13 Blood Cultures 20mo M with L thigh cellulitis – Failed outpt therapy; plan to admit on clindamycin Blood culture?

14 P: In patients with asthma, bronchiolitis, pneumonia, SSTI I: does obtaining blood culture C: versus no blood culture O: affect outcomes?

15 Do We Need This Blood Culture? Kavita Parikh, Aisha Barber Davis, Padmaja Pavuluri Hospital Pediatrics 2014; 4; 78 DOI: /hpeds

16 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)

17 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

18 SBI Rule Out in Infant 3 wk M with fever – Well appearing, labs reassuring – Admitted on IV antibiotics

19 P: Neonates <1 mo admitted w/fever for IV antibiotics I: Discharge at 36h C: Discharge at 48 hour O: No missed/untreated SBI

20 Time to Detection of Bacterial Cultures in Infants Aged 0-90 days Rianna C. Evans and Brian Fine Hospital Pediatrics 2013;3;97 DOI: /hpeds

21 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 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

22 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 hours, then q24h – CSF cultures Goal gram stain within 1 hour First time to check culture: hours, then q24h – Urine cultures First read at hours, then daily – Can call at night and ask someone to check if still neg

23 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

24 UTI Length of Treatment in Infant 3mo F with fever found to have UTI – Admitted on Ceftriaxone

25 P: Infants admitted with UTI I: Transition to oral antibiotics after 3d C: versus longer IV therapy O: Treatment failure

26 Length of Intravenous Antibiotic Therapy and Treatment Failure in Infants with Urinary Tract Infections Patrick W. Brady, Patrick J. Conway and Anthony Goudie Pediatrics 2010; 126; 196 DOI: /peds

27 Length of IV Abx Therapy in Infants with UTI Objective: – To assess short ( =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

28 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

29 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

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

31 P: In patients with osteomyelitis does I: Early transition to PO Abx C: Versus prolonged IV therapy O: Affect clinical outcomes?

32 Prolonged Intravenous Therapy Versus Early Transition to Oral Antimicrobial Therapy for Acute Osteomyelitis in Children Theoklis Zaoutis, et al. Pediatrics 2009; 123;636 DOI: /peds

33 Prolonged Intravenous Therapy Versus Early Transition to Oral Antimicrobial Therapy for Acute Osteomyelitis in Children Theoklis Zaoutis, et al. Pediatrics 2009; 123;636 DOI: /peds

34 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 at 29 free-standing children’s hospitals Results: – 1 o outcome: Tx failure (readmission w/in 6m) – 2 o outcome: Readmit w/in 6m for line complication, adverse drug rxn, C. Diff, agranulocytosis

35 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) 1 o outcome – 5% for prolonged IV group; 4% PO group – No significant association btw Tx failure and mode Abx therapy 2 o 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)

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

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

39 Are there risks associated with empiric acid suppression treatment of infants and children suspected of having GERD Erica Y. Chung and Jeremy Yardley Hospital Pediatrics 2013;3;16 DOI: /hpeds

40 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

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42 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

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

44 P: In infants with bronchiolitis I: Is testing for serious bacterial infection C: Compared to not testing O: Indicated?

45 Risk of serious bacterial infection in young febrile infants with RSV infections Levine D, et al. Pediatrics 2004; 113; DOI: /peds

46 Serious Bacterial Infections in Infants with RSV Methods: Multi-center prospective, cross-sectional study ( ) – 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)

47 Table 3. SBI by RSV Status

48 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 ) 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 )

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

50 P: In infants presenting for evaluation I/C: What history/PE/labs are associated O: With HSV infection

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52 HSV Methods: Retrospective case study of HSV over 22y ( ) 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

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54 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

55 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?

56 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?

57 Narrow vs broad spectrum antimicrobial therapy for children hospitalized with PNA Williams DJ, et al.* Pediatrics 2013; 132;e DOI: /peds * Kavita Parikh, CNMC

58 Narrow vs Broad Spectrum Abx Tx for PNA Methods: Retrospective cohort study; 42 children’s hospitals btw (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: – 1 o outcome: LOS – 2 o outcome: PICU, 14d readmission, costs

59 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)

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61 Runners Up… Biondi et al. Treatment of Mycoplasma Pneumonia: A Systematic Review. Pediatrics, 2014; 113; 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): Mussman et al. Suctioning and Length of Stay in Infants Hospitalized with Bronchiolitis. JAMA Pediatrics, 2013; 167(5): Fernandes et al. Glucocorticoids for Acute Viral Bronchiolitis in Infants and Young Children. Cochrane Database Syst Rev. 2013; 6: CD Salo et al. Childhood Urinary Tract Infections as a Cause of Chronic Kidney Disease. Pediatrics. 2011; 128(5): 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):

62 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


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