Transcript peytonmanning.stvincent.org

“Litz” Blitz 2013
Top Articles in Pediatric Hospital Medicine
Benjamin D. Bauer, MD, FAAP
June 1st, 2013
A review of recent literature impacting the practice of pediatric medicine
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Disclosure Statement
• Benjamin D. Bauer:
–Has no relevant financial relationships to
disclose.
–Has no conflicts of interest to resolve.
• This presentation will not involve discussion
of unapproved, off-label, or experimental
interventions or medications.
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Strategy & Criteria for Article Selection:
• Reviewed literature from the past 18 months:
– Pediatrics, Hospital Pediatrics, JAMApeds, JAMA, NEJM<,
Archives of Pediatrics & Adolescent Med, Journal of
Pediatrics, Pediatric Infectious Disease, Journal of
Hospital Medicine, Pediatric Emergence Care
• Selection based on general interest and
potential to impact practice of pediatric hospital
medicine
• General guidelines of the 3 R’s:
– Recent, Relevant and Reputable.
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Strategy & Criteria for Article Selection:
• Final selection of
articles, also considered
‘clinical grouping’ based
on areas of interest to
pediatric hospitalists
• Here are the clinical
topics that will be
covered in today’s talk:
1. Febrile Neonate / SBI
2. Fluid management
3. Failure to Thrive
4. Gastroesophageal
Reflux
5. Hyperbilirubinemia
6. Bronchiolitis
7. Pneumonia
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Disclaimer:
• Literature presented was chosen based
general interest of the presenter
• No claim made regarding whether these are the
most well-designed studies on a given topic
• The literature discussed should be critically and
individually reviewed before change in practice
is implemented
• Feel free to throw rotten fruit… but kindly wait
until the end of the presentation
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The Febrile Infant
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Background
• Serious Bacterial Infection (SBI) evaluation
remains a challenge
• SBI Rates as high as 10-12% <3mo of age
– UTI accounts for majority of SBI
– Bacteremia and meningitis are less common
• Risk stratification strategies have been
developed; remain controversial
• Even those suggesting less invasive strategies
push for LP prior to starting antibiotics
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Background / Study Objective
• Rochester Criteria for Febrile Infants:
– Infant appears well
– Infant has been previously healthy
– No evidence of skin, bone, joint or ear infection
– Labs: WBC 5K – 15K; Bands < 1,500;
< 10 WBCs in U/A; No pus in stool
– When ALL criteria met; NPV for SBI is 98.9%
• Study Aim: Necessity of performing routine LP in
well appearing 30-90 day old febrile infant with U/A
suggestive of UTI
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Study Methods
• Retrospective Study
• Tertiary care children’s hospital ED; 200 pt/day
• 4 year period; October 2001 – August 2005
• Identified all febrile infants 30-90 days of life:
– underwent full sepsis work-up: LP for culture,
blood culture, urine culture and urinalysis.
• Exclusion Criteria: Premature (<35wk), chronic
conditions, pre-culture antibiotics, or localizing
infection on presentation
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Results:
N = 392
30-90 day febrile infants
full sepsis evaluation
1 + Culture
52 patients
2 + Cultures
7 patients
3 + Cultures
1 patient
Urine only
46 patients
Blood
Urine
Urine & Blood
5 patients
Blood,
Urine
Urine,
CSF, Blood
Blood
&Urine
CSF
&
patient
1 Patient
Blood only
5 patients
CSF
&&
Blood
Blood
CSF
22patients
patients
•Highlights:
• 392 patients included
• 61% male (241/392)
• Mean age 56 days
• Overall Rates of Infection:
•SBI: 60/392 (15.3%)
•UTI: 52/392 (13.3%)
•Sepsis: 13/392 (3.3%)
•Meningitis: 4/392 (1%)
• Only 1 patient with both
abnormal U/A and Meningitis
CSF only
1 patients
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Results
• 1 patient with both abnormal U/A and meningitis
• 71 day old female:
– Urinalysis:
– WBC:
– Cultures:
– Clinical:
LE+, Nitrite+, 4WBCs/HPF
2.9 x 109
E. coli (Blood, Urine and CSF)
38.5◦C, irritable, lethargic, mottled
• NOT Low Risk by Rochester: Based on signs/sx
would have undergone full sepsis work up
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Patients with meningitis
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Results
• Of the 388 infants without meningitis:
– 56 (14%) had an abnormal U/A
– 51 (13%) had a culture positive UTI
• Negative Predictive Value (NPV):
– 98.2% NPV
– 100% NPV, if Rochester ‘low risk’ criteria are met
• Does not change the overall NPV of the
Rochester criteria, but does potentially add to
discussion regarding risk of meningitis
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Study Limitations
• May not generalize: Tertiary Care ED vs.. outpatient
• Small sample size: Decreases power to identify
the potential case of meningitis in this population
• Retrospective design: Impossible to confirm that
all “NON-low risk” infants actually underwent full
septic work-up.
• Underestimates downstream impact: Does not
acknowledge difficulty for those making decisions
regarding management, if LP not done at antibiotic
initiation.
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Clinical Bottom Line
• Study confirms findings of others:
– Combined UTI and meningitis is uncommon in
infants <90 days of age ( 0% – 0.3%)
• Routine LPs may not be necessary in infants
30-90 days of life, if otherwise low-risk based
on Rochester criteria
• If any uncertainty, or patient not well appearing
then an LP MUST BE DONE prior to starting
antibiotics
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In search of the 24 hour discharge…
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Background
• The management of the febrile infant is
evolving
• Still common for infants with fever and no clear
source to remain in hospital receiving empiric
treatment for 48hrs while culture results
mature
• Some institutions have used available evidence
to push the LOS envelope for these patients…
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Evidence Based Care Process Model
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Study Objectives
• To determine if bacterial cultures in young
infants would produce results in <36 hours
• With enough reliability to allow for discharge of
otherwise healthy infants earlier than the
standard 48 hour observation period
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Methods
• Retrospective chart review
• Oct 2007 – Feb 2011 (3 yrs 4 months)
• All positive culture results (Blood, Urine, CSF)
• Drawn on infants 0 – 90 days of age during the
evaluation of SBI in ED or as inpatient
• Exclusion: Any indwelling lines, shunts, catheters;
any cultures drawn while in ICU setting;
significant underlying condition; repeat cultures
taken from same patient during same stay
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Results
• 283 patients with positive cultures
• 2092 Blood cultures were drawn
– 38% (38/101) of blood cultures = true pathogens
– Mean time to detection (TTD) 13.3 hours (vs.. 25 hrs)
• 2283 Urine cultures were drawn
– 58% (111/192) of urine cultures = true pathogens
– Mean TTD 21 hours (vs.. 26.7 hrs)
• 1159 CSF cultures were drawn
– 50% (7/14) of CSF cultures = true pathogens
– Mean TTD 28.9 hours (vs.. 57.7 hrs)
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Time To Detection of Bacterial Cultures
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Bottom Line
• This article adds to existing data about
management of febrile neonate
– Already excellent data to help with risk
stratification (Rochester criteria…)
– Those infants admitted to the hospital as ‘Low
Risk’ have SBI rates in range of 1-3%
• In the appropriate clinical and social context
– May consider discontinue antibiotics therapy at
36 hours
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Fluids Management
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Background
• Hospital acquired hyponatremia is common
• Neurologic morbidity and death have been
documented as a result of iatrogenic
hyponatremia
• Has raised questions regarding 50yr standard
of using Holliday-Segar recommendations for
calculating parenteral maintenance fluids
• Growing evidence emerging that the use of
isotonic fluids may decrease risk
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Study Objectives
• Fully blinded, randomized controlled trial
• Determine whether isotonic solution
administered as maintenance IV fluids
decrease the risk of hyponatremia when
compared to hypotonic fluids
• Population: euvolemic pediatric patients in the
acute post-operative period, with non-emergent
reasons for surgery; requiring MIVF for 48hrs
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Study Methods
• IRB approved, Blinded, RCT
• Tertiary care children’s hospital, Canada
• Randomly assigned to receive base parenteral
maintenance solution (PMS) of either 0.45%
saline (hypotonic) or 0.9% saline (isotonic)
– Dextrose (D5) present in both
– Potassium added according treating MD request
• 6mo – 16yrs; euvolemic; within 6hrs of nonemergent surgery; likely to need MIVF >24hrs
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Study methods / Outcome measures
• Plasma sodium, Urine sodium/potassium and
ADH measured every 12 hours
• Intervention was started immediately post-op
and continued for maximum of 48hrs
• Primary Outcome: Hyponatremia; ≤ 134mmol/L
• Secondary Outcomes: Severe hyponatremia (≤
129mmol/L), hypernatremia (≥ 146mmol/L),
plasma ADH levels, adverse events, and patients
who changed fluids during study (reason)
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Results
• 3/2008 – 12/2009
• 728 patients screened
• 427 eligible
• 258 were enrolled
• 128 randomized to
isotonic fluid
• 130 randomized to
hypotonic fluid
18 lacked
data
14 lacked
data
• 4 patents from each group
withdrew during study
• 32 patients lacked data
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• Baseline characteristics
between groups is similar
• 77 of 258 (29.8%) admitted
to ICU postoperatively
• No differences in baseline
sodium or fluid intake
• Only 16 (6%) had pre-op
sodium levels ordered
• Median time to starting fluid
intervention was 22minutes
post operatively (6hrs max)
• Most common surgery:
Orthopedic, General,
Urologic
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Results: Primary Outcome
• Primary Outcomes: Risk of hyponatremia was
higher in the hypotonic fluid group:
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Results: Secondary Outcomes
• Plasma ADH levels on POD#1 elevated in both
groups, but no difference (P= .208)
• Subgroup analysis showed PICU patients at NO
higher risk after adjusting for fluid type (P= .105)
• 15 pts changed to open-label isotonic fluids
– 12 (9.2%) vs.. 3 (2.3%); P = .036
(Hypotonic)
(Isotonic)
• with ‘Hyponatremia’ most common cited reason
– 1 (0.8%)
(Hypotonic)
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vs.. 7(5.4%); P = .033
(Isotonic)
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Study Limitations
• Well-designed, blinded, randomized trial
• May Not Generalize: Did not include patients
requiring emergency surgeries; did not include
non-surgical patients
• Baseline Comparison Data: Most patients in
study did not have ‘baseline’ lab values prior
to enrollment
• Missing Data: Not all patients included in study
had all planned samples drawn.
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Clinical Bottom Line
• Risk of hyponatremia is significantly higher in
post-op patients receiving hypotonic fluids
• Relative risk reduction of 44% with isotonic fluid
• NNT to prevent 1 case of hyponatremia = 6
• Isotonic fluid use does not appear to increase
adverse events or lead to hypernatremia
• Current standard of post-operative fluid
management should be re-evaluated…
– Isotonic fluid may be safer!
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Failure to Thrive
Background
• Failure to Thrive (FTT) is common
– As many as 10% of general pediatric patients
• Outpatient management of failure to thrive “is
fraught with difficulties because trying to organize
a cohesive approach… is logistically challenging.”
• Often assumed that admission may be the more
efficient approach, with goal of coordinating
multiple resources needed to diagnose and treat
• FTT: Up to 5% of all admissions for children less
than 2 years of age
Background
• Heavy resource utilization for these patients:
– Labs, imaging, speech, nutrition, social work,
and subspecialist consultation
• Limited access to many of these resources
during the weekend; even at large tertiary
referral centers
• Is the weekend the best time to admit these
patients to the hospital?
Study Objectives
•To evaluate whether weekend
admission of Failure to Thrive:
1. Affects the length of stay (LOS)
2. Affects the overall cost of the admission
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Methods
• PHIS database
– Administrative data from 43 free-standing
children’s hospitals
• Inclusion Criteria:
– 2003-2011 (9 years of data)
– All Children <2 years with primary admit
diagnosis of Failure to Thrive
• Data: Demographics, LOS, day of admit,
diagnoses, procedures, tests, charges/costs
Results
• 23,332 patients met inclusion criteria
• Median age: 7.5 months
– 43.8 % (10,222) less than 6 months of age
• Weekend admissions STAYED LONGER
– LOS increased by 1.93 days (IRR: 1.20 [95% CI
1.18-1.22]
• Weekend admissions COST MORE
– Mean cost increase of $2785 per admission
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FTT on Weekends: Cost More, Stay Longer
Results
Limitations:
• PHIS database limitations
• Used surrogate data to make assumptions
about how ‘sick’ patients were
• Institutional bias in financial reporting is
possible
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Author Bottom Line
•Acknowledging that some of the weekend
admissions had medical issues requiring
immediate inpatient attention…
•If HALF of the weekend admissions over the
study period were simply converted to Monday
admissions:
– total savings in health care dollars would be in
excess of $500,000 per year
– or > $3.5 Million over the study period
Gastroesophageal Reflux
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Background
• Diagnosis and management of GERD remains
challenging for families and pediatricians
• From 1999 to 2004, 7-fold increase in use of
prescription medication in infants with GERD
• Growing evidence that acid reducing
medications are NO BETTER than placebo in
treating symptoms of GERD
• Growing concern regarding safety of these
agents in both adults and children
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Mechanism for increased infection Risk?
• Gastric Acid is a known non-selective barrier to
infection
• Most pathogens will not survive at pH < 4 (normal
gastric acidity)
• Suppression of acid production may allow bacterial
colonization and overgrowth (including pathogenic
organisms)
• PPIs & H2 Blockers may also directly inhibit
leukocyte activity; thereby blunt immune response
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Objectives & Methods
• Review of literature
• Evaluate potential serious adverse effects
associated with acid-suppressing medications
in the pediatric population
• PubMed Search: English Language, 0-18 yrs
• Limited to original placebo controlled studies
OR studies with comparison to non-acid
suppression which specifically evaluated
adverse events as part of study
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Results
• 14 studies met inclusion criteria
• 6 NICU studies
• 5 PICU studies
• 3 Non-Critical Care Population Studies
• Both H2 Blockers and PPIs represented
• Associate adverse events primarily ‘infectious’
in nature
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14 Studies Reviewed
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NICU Population
• Necrotizing Enterocolitis (NEC): 2 Studies
1. Retrospective Case-Control Study of H2-blockers:
• 787 infants with NEC
• Use of H2-Blocker increased risk of NEC
–
OR: 1.71 [95% CI: 1.34-2.19], P<.001
2. Prospective Multicenter Observation, ranitidine
• 274 infants; 91 got ranitidine, 183 did not
• Increased risk of infection; Sepsis and pneumonia
–
OR 5.5 [95% CI: 2.9-10.4], P<.001
• Increased risk of NEC
–
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OR 6.6 [95% CI: 1.7-25], P=.003
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NICU Population
• Infection Risk: 4 Additional Studies
1. H2 Blockers & Blood Infections:
• Prospective Study: 376 infants, 42 bacteremia
• H2 Blocker increased risk: OR 2.9; P=.008
2. Nosocomial Bacterial Infections:
• Prospective Study: 1504 infants, 127 infections
• H2 Blockers incr. risk: OR 7.3 [95% CI 3.9-13.6]
3. Late Onset Sepsis:
• Retrospective review: 569 infants; 74 sepsis
• Sepsis pts more likely to have received ranitidine
–
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OR 6.99 [95% CI: 3.78-12.94], P<.0001
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PICU Population
• 4 Studies: Ventilator-Associated Pneumonia
(VAP) and Acid Suppressor medication
• 2 Studies found association:
– Prospective Study: 595 ventilated patients
•34 VAP episodes; univariate analysis showed
association with H2 blockers
•47% of VAP patients had received H2 blockers
vs. 24% of Non-VAP patients; P=.006
– Prospective Study: 40 patients; 8/40 with VAP
•63% of VAP patients had received H2 blockers
vs. 22% of Non-VAP patients; P=.025
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Non-Critical Care Population
• PNEUMONIA: 2 Studies
1. Canani et al: Prospective multicenter cohort
• 4 - 36 mo of age; GERD diagnoses by pH monitor &
esophageal biopsy
• H2-Blocker or PPI for 2 month course
• 11% of 91 developed pneumonia vs. 2% of healthy
controls (P<.05)
2. Orenstein et al: Randomized controlled trial
• Lansoprazole vs. placebo for GERD in infants
• Serious Adverse event in 12% of 81 infants in PPI
vs. 2% of 81 patients in placebo; PNA most
common
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Non-Critical Care Population
• Gastrointestinal Infections: 2 Studies
1. Canani et al: Prospective multicenter cohort
• 4 - 36 mo of age; GERD diagnoses by pH monitor &
esophageal biopsy
• 91 patients; H2-Blocker or PPI for 2 month course
• 47% those patient developed acute gastroenteritis
vs. 20% of healthy controls
–
OR: 3.58 [95% CI 1.87-6.85] P=.001
2. Turco et al: Retrospective study: PPI and C.Diff
• Higher rates of C.diff associated disease (CDAD)
–
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OR: 4.52 [95% CI: 1.4-14.4)
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What’s in a Name?
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Bottom Line: First, Do No Harm
• With the Exception of endoscopically confirmed
erosive esophagitis, Acid blocking medications
have NOT been shown to be of benefit in young
infants with GERD symptoms
• Conservative therapies, while more difficult and
time consuming do have some evidence behind
them (decreased volumes, thickening feeds)
• CHOOSING WISELY: “Don’t treat GER in infants
routinely with acid suppression therapy.”
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Hyperbilirubinemia
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Background
• Jaundice in newborns is incredibly common
• Indirect bilirubin is a neurotoxin that can cause
both acute and irreversible injury to the brain
• Phototherapy is the cornerstone of effective
treatment of hyperbilirubinemia in newborns;
safe & effective
• Evidence based guidelines published by the
AAP in 2004 and updated in 2011 Technical
report
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Background: Efficacy of Phototherapy
• Efficacy of Phototherapy in reducing Total Serum
Bilirubin (TsB) levels depends on 4 factors:
– Wavelength of light emitted from source (nm)
– Intensity of light (Spectral Irradiance - µw/cm²/nm)
– Surface area exposed to light
– Duration of exposure to light
• AAP has defined ‘Optimal Phototherapy’ as:
– Visible Blue light (460-490nm),
– Delivered at ≥ 30 µw/cm²/nm (Intensive Phototherapy)
– To the largest possible body surface area
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Background: Dose-Response Curve
• Established dose-response data allowed AAP to
set 30 µw/cm²/nm as definition of “intensive
phototherapy”
• Previous Studies suggest “Saturation Point”
above which additional intensity provides no
further benefit in terms of rate of TsB drop
• Old data based on equipment with ‘Minimum
distances to baby’ based on concern for
thermal injury
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Objectives
• To use newer LED technology to investigate
Dose-Response curve for hyperbilirubinemia
• To see if increasing intensity (spectral
irradiance) of phototherapy is associated with
increase rate of drop of TsB in patient
• To see if increasing intensity (spectral
irradiance) of phototherapy is associated with a
‘saturation point’
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Methods
• Prospective, randomized treatment trial
• NICU in Denmark; July 2009 – December 2010
• Inclusion Criteria: Healthy Neonates, >33wks ,
uncomplicated hyperbilirubinemia, open
bassinet.
• Exclusion Criteria: Known hemolytic disease,
patients requiring exchange transfusion,
patients with Total Bili rise > 0.5mg/dl/hr,
<24hrs of age at time of initiation of photothx
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Methods
• Equipment Used:
– NATUS, neoBLUE LED bank system
– ‘High’ setting only
• Randomized to 1 of 4 phototherapy regimens:
– Based on distance to mattress in 3.5”
increments: 8”, 11.5”, 15”, 18.5”
– Avg to baby: 5”, 8.5” , 1 2”, 15.5”
• Babies received continuous phototherapy x 24h
• Diapers & goggles only, out to feed 30m Q 3h
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Results: 151 infants
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Bottom Line
• As intensity of light increases, the rate of TsBdrop increases.
• While not specifically studied in this article, it is
reasonable to assume that, if TsBili decreases
faster, LOS will decrease.
• With NEOblue LED unit a distance of 5”
produces spectral irradiance of up to 55
µw/cm²/nm
– Which should drop TsB by 50% in 24hrs
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Bronchiolitis
• What fun thing should we try this year?
• How can we tell which kids are going to crump?
– Could this help us plan for shorter stays and
earlier discharges?
• Hospitalist “Hands Across America”
– Can we impact change? Yes we can!
– And no body does it better
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Suctioning & LOS in Bronchiolitis:
Background
• The mainstay of bronchiolitis therapy is
supportive
• Suctioning management and its efficacy is
largely unstudied
• Nasal suction provides a temporary relief of
symptoms
• Pharmacologic treatment of nasal obstruction
has not been shown to have significant impact
on outcomes*
Objectives
• To determine if repeated nasopharyngeal
suctioning (“deep suction”) produces worse
outcomes (“is harmful”) when compared to
noninvasive suctioning
• To determine if frequent suctioning improves
clinical outcomes
Methods
• Retrospective cohort study:
– Cincinnati Children’s (CCHMC) & Satellite Facility
– 2 - 12 month-old infants hospitalized with
bronchiolitis; January 2010 – April 2011
– Exclusion: < 2mo old; ICU admit; tracheostomy
• Charts reviewed for:
– Suction Device type
– Time lapses in suctioning (>4hrs)
• Primary Outcome Measure: Length of Stay (LOS)
Results: 740 infants in Device Type cohort
• Multivariable
analysis:
LOS = 0.6 days
longer in >60%
group vs..
None group
P = <.001
Results: 695 in Suctioning Frequency cohort
• Multivariable
analysis:
LOS = 1.02 days
longer in
> 3 lapses group
vs..
0 lapses group
P = <.001
Limitations
• Device Type Cohort: ‘Confounding by Indication’
– Nurses and RTs may have chosen deep
suctioning for patients who were ‘sicker’
– “Confounding by indication for deep suctioning
may be a source of systematic error… results
should be interpreted with caution in this
context.”
– A prospective study that randomizes suction
device type is needed
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Bottom line
• Nasopharyngeal suctioning may have negative
impact on outcomes & may prolong LOS
• Scheduled, non-invasive nasal suctioning may
have a positive impact on length of stay
• Idea for your next study!
Trying to predict who is going to crump?
May be the only study that matters…
• It’s not for lack of trying… but so far, we all
know the truth: Nothing that we do clinically
seems to change outcomes or LOS
• As we look for ways to safely impact LOS and
outcomes in bronchiolitis, One question does
become very important…
Which of these little boogers is going to crump
and need to go to the ICU?
Objective & Methods
• To identify risk factors associated with
progression to need for CPAP and/or intubation
for children with bronchiolitis
• Prospective, multicenter cohort study
– 16 centers: Multicenter Airway Research
Collaboration (MARC)
• 2007-2010: 3 consecutive winter seasons
• Inclusion: <2 yrs admitted with bronchiolitis
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Results
• 2207 children enrolled in study
– 379/2207 (17%) enrolled in the ICU
• Of 379 ICU patients, 161 (42%) required CPAP
and/or intubation
• RSV A/B accounted for 73% of detected
pathogens
– Viral etiology was not an overall predictor of
progression to intubation*
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Independent Predictors of CPAP/ETT
• 4 History Predictors:
– Age: < 6mos at presentation
– Birth weight: < 7 lbs (3.18kg)
– Maternal smoking during pregnancy
– Breathing difficulties < 1 day prior to ED visit
• 4 Clinical Predictors:
– Apnea
– Severe retractions
– Oxygen saturation < 85%
– Inadequate oral intake
Independent Risk Factors: By the Numbers
Characteristic
Age (months)
Detail
Odds Ratio
95% CI
<2
4.29
1.66 – 11.53
2 – 5.9
2.61
1.16 – 6.10
<5
1.70
1.01 – 2.52
≥5-<7
1.68
1.03 – 2.68
YES
1.38
1.05 – 1.91
< 1 day
1.58
1.15 – 2.09
YES
4.78
2.57 -8.50
Retractions
Severe
11.14
2.40 – 33.19
Oxygen Saturation, RA
<85%
3.28
2.02 – 4.82
Inadequate
2.51
1.34 – 4.26
Birth Wt (pounds)
Smoked in Pregnancy
Onset Breathing Difficulty
Apnea
Oral Intake
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Bottom Line
• Smoking is bad!
• There are historical and clinical risk factors that
can be used to predict possible progression of
disease and need for ICU
• How can these be used?
– As teaching tools for clinicians
– As components of evidence-based care process
models used to shorten LOS and decrease
hospital admissions…
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Knowing the risk data CAN impact care
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Yes We Can!
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A glimmer of hope…
Percentage Change in Resource
Utilization by Year
80
70
Bronchodilators
(p<0.01)
60
Chest Radiography (p=NS)
50
RSV Testing (p=NS)
40
30
Steroids (p=NS)
20
10
Chest Physiotherapy
(p<0.01)
0
2007
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2008
2009
2010
87
And if anybody can do it…
Pneumonia
Objectives & Methods
• Describe variability in resource utilization for children
hospitalized with Community-Acquired Pneumonia
(CAP)
• Retrospective Cohort study using PHIS database
• July 2005 – June 2010 (5 years of study data)
• Children 1 – 18 years of age, with “non-severe CAP”
– ( ± effusion or empyema )
• Primary Exposure of Interest: Hospital-Level initial
resource utilization on DAY 1
• Measured Outcomes: LOS, Readmission Rates
Results
• 43,819 Children Hospitalized with CAP
• After exclusion criteria applied: 21,213 patients
• Median Age: 3yrs – 72% were between 1-5 yrs
– 22% were 6-12 yrs
– 5% were 13-18 yrs
• LOS: 2 days (IQR: 1-3 days)
– 25% of <12 yr olds hospitalized > 3 days
– 25% of 13-18 yr olds hospitalized > 4 days
• Readmission Rate: Overall 2.3% (higher in 13-18yr)
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Results: Substantial Variation in Resource
Utilization seen at the Hospital Level
Results: Variation in antibiotic use
Hospital - level variation in empiric antibiotic therapy among children with CAP.
Each column on the x-axis represents data from one hospital.
Institutions that performed more diagnostic
testing had longer LOS
Bottom Line
•The more you do… The longer they stay
•Earlier discharge DID NOT correlate
with increased 14 day readmission
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Macrolide combination therapy in CAP
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Objective & Methods
• Determine the effectiveness of β-lactam
monotherapy when compared with β-lactam
PLUS macrolide in pts hospitalized with CAP
• Retrospective Cohort Study Using PHIS
• January 2006 – December 2008 (3 years)
• Children 1 – 18 yrs; with non-severe CAP
• Primary Exposure of Interest: Empiric antibiotic
• Outcome Measures: LOS, 14-day Readmissions
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Results
• 37,461 patients eligible based on ICD-9 coding
• After Exclusion Criteria applied:
– 20,743 patients included
– 76% received β-lactam monotherapy
– 24% received β-lactam PLUS macrolide
• Variability across sites:
– Combination tx ranged from 17% - 48%
• LOS: Median length of stay for cohort: 2 days
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Results
• In the adjusted analysis:
– Average LOS for patients receiving combination
therapy was 20% less than monotherapy
– When age was factored in older children saw
largest drop in LOS
•6-11 yr old saw 25% reduction in LOS
•12-18yr old saw 31% reduction in LOS
– 1-5 year olds saw no benefit in LOS reduction
• No significant decrease in readmissions seen
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Bottom Line
• 5-18 yo CAP inpatients may benefit from addition
of macrolide therapy to standard empiric βlactam therapy (AMPICILLIN!)
• Findings of are in concordance with 2011 IDSA
guidelines, which make macrolide a ‘combination
option’ for patients in whom atypical organisms
“are a significant consideration”
– Namely, school age children and adolescents
• Randomized clinical trials are needed.
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Thank You!
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