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Cogen JD, Sanders DB, Slaven JE, Faino AV, Somayaji R, Gibson RL, Hoffman LR, Ren CL. Antibiotic Regimen Changes during Cystic Fibrosis Pediatric Pulmonary Exacerbation Treatment. Ann Am Thorac Soc 2023; 20:1293-1298. [PMID: 37327485 PMCID: PMC10502882 DOI: 10.1513/annalsats.202301-078oc] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2023] [Accepted: 06/16/2023] [Indexed: 06/18/2023] Open
Abstract
Rationale/Objectives: Antibiotic selection for in-hospital treatment of pulmonary exacerbations (PEx) in people with cystic fibrosis (CF) is typically guided by previous respiratory culture results or past PEx antibiotic treatment. In the absence of clinical improvement during PEx treatment, antibiotics are frequently changed in search of a regimen that better alleviates symptoms and restores lung function. The clinical benefits of changing antibiotics during PEx treatment are largely uncharacterized. Methods: This was a retrospective cohort study using the Cystic Fibrosis Foundation Patient Registry Pediatric Health Information System. PEx were included if they occurred in children with CF from 6 to 21 years old who had been treated with intravenous antibiotics between January 1, 2006, and December 31, 2018. PEx with lengths of stay <5 or >21 days or for which treatment was delivered in an intensive care unit were excluded. An antibiotic change was defined as the addition or subtraction of any intravenous antibiotic between Hospital Day 6 and the day before hospital discharge. Inverse probability of treatment weighting was used to adjust for disease severity and indication bias, which might influence a decision to change antibiotics. Results: In all, 4,099 children with CF contributed 18,745 PEx for analysis, of which 8,169 PEx (43.6%) included a change in intravenous antibiotics on or after Hospital Day 6. The mean change in pre- to post-treatment percent predicted forced expiratory volume in 1 second (ppFEV1) was 11.3 (standard error, 0.21) among events in which an intravenous antibiotic change occurred versus 12.2 (0.18) among PEx without an intravenous antibiotic change (P = 0.001). Similarly, the odds of return to ⩾90% of baseline ppFEV1 were less for PEx with antibiotic changes than for those without changes (odds ratio [OR], 0.89 [95% confidence interval (CI), 0.80-0.98]). The odds of returning to ⩾100% of baseline ppFEV1 did not differ between PEx with versus without antibiotic changes (OR, 0.94 [95% CI, 0.86-1.03]). In addition, PEx treated with intravenous antibiotic changes were associated with higher odds of future PEx (OR, 1.17 [95% CI, 1.12-1.22]). Conclusions: In this retrospective study, changing intravenous antibiotics during PEx treatment in children with CF was common and not associated with improved clinical outcomes.
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Affiliation(s)
- Jonathan D Cogen
- Division of Pulmonary and Sleep Medicine, Department of Pediatrics, Seattle Children's Hospital, University of Washington, Seattle, Washington
| | - Don B Sanders
- Division of Pediatric Pulmonology, Allergy and Sleep Medicine, and
| | - James E Slaven
- Department of Biostatistics and Health Data Science, Indiana University School of Medicine, Indianapolis, Indiana
| | - Anna V Faino
- Core for Biostatistics, Epidemiology and Analytics in Research, Seattle Children's Research Institute, Seattle, Washington
| | - Ranjani Somayaji
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada; and
| | - Ron L Gibson
- Division of Pulmonary and Sleep Medicine, Department of Pediatrics, Seattle Children's Hospital, University of Washington, Seattle, Washington
| | - Lucas R Hoffman
- Division of Pulmonary and Sleep Medicine, Department of Pediatrics, Seattle Children's Hospital, University of Washington, Seattle, Washington
| | - Clement L Ren
- Division of Pulmonary and Sleep Medicine, Department of Pediatrics, Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
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Faino AV, Hoffman LR, Gibson RL, Kronman MP, Nichols DP, Rosenfeld M, Cogen JD. Polymicrobial infections and antibiotic treatment patterns for cystic fibrosis pulmonary exacerbations. J Cyst Fibros 2023; 22:630-635. [PMID: 36849332 DOI: 10.1016/j.jcf.2023.02.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2022] [Revised: 01/09/2023] [Accepted: 02/04/2023] [Indexed: 02/27/2023]
Abstract
BACKGROUND No data exist to guide antibiotic selection among people with CF (PwCF) with respiratory cultures positive for multiple CF-related bacteria (polymicrobial infections). This study aimed to describe the number of polymicrobial in-hospital treated pulmonary exacerbations (PEx), to determine the proportion of polymicrobial PEx where antibiotics were prescribed with activity against all bacteria detected (termed complete antibiotic coverage), and to determine clinical and demographic factors associated with complete antibiotic coverage. METHODS Retrospective cohort study using the CF Foundation Patient Registry-Pediatric Health Information System dataset. Children aged 1-21 years with an in-hospital treated PEx from 2006 to 2019 were eligible for inclusion. Bacterial culture positivity was based on any positive respiratory culture in the 12 months prior to a study PEx. RESULTS A total of 4,923 children contributed 27,669 total PEx of which 20,214 were polymicrobial; of these, 68% of PEx had complete antibiotic coverage. In regression modeling, a prior PEx with complete antibiotic coverage for MRSA was associated with a higher likelihood of having complete antibiotic coverage at a subsequent study PEx (OR (95% CI) 3.48 (2.50, 4.83)). CONCLUSIONS The majority of children with CF hospitalized for polymicrobial PEx were prescribed complete antibiotic coverage. Prior PEx treatment with complete antibiotic coverage predicted complete antibiotic coverage at a future PEx for all bacteria studied. Studies are needed comparing outcomes of polymicrobial PEx treated with different antibiotic coverages to optimize PEx antibiotic selection.
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Affiliation(s)
- Anna V Faino
- Core for Biostatistics, Epidemiology and Analytics in Research, Seattle Children's Research Institute, USA.
| | - Lucas R Hoffman
- Division of Pulmonary and Sleep Medicine, Department of Pediatrics, University of Washington, USA
| | - Ronald L Gibson
- Division of Pulmonary and Sleep Medicine, Department of Pediatrics, University of Washington, USA
| | - Matthew P Kronman
- Division of Infectious Diseases, Department of Pediatrics, Seattle Children's Hospital, University of Washington, USA
| | - David P Nichols
- Division of Pulmonary and Sleep Medicine, Department of Pediatrics, University of Washington, USA
| | - Margaret Rosenfeld
- Division of Pulmonary and Sleep Medicine, Department of Pediatrics, University of Washington, USA
| | - Jonathan D Cogen
- Division of Pulmonary and Sleep Medicine, Department of Pediatrics, University of Washington, USA
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Sato J, Mitsutake N, Yamada H, Kitsuregawa M, Goda K. Virtual patient identifier (vPID): Improving patient traceability using anonymized identifiers in Japanese healthcare insurance claims database. Heliyon 2023; 9:e16209. [PMID: 37234615 PMCID: PMC10205637 DOI: 10.1016/j.heliyon.2023.e16209] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Revised: 05/09/2023] [Accepted: 05/10/2023] [Indexed: 05/28/2023] Open
Abstract
Objective Japan's national-level healthcare insurance claims database (NDB) is a collective database that contains the entire information on healthcare services being provided to all citizens. However, existing anonymized identifiers (ID1 and ID2) have a poor capability of tracing patients' claims in the database, hindering longitudinal analyses. This study presents a virtual patient identifier (vPID), which we have developed on top of these existing identifiers, to improve the patient traceability. Methods vPID is a new composite identifier that intensively consolidates ID1 and ID2 co-occurring in an identical claim to allow to collect claims of each patient even though its ID1 or ID2 may change due to life events or clerical errors. We conducted a verification test with prefecture-level datasets of healthcare insurance claims and enrollee history records, which allowed us to compare vPID with the ground truth, in terms of an identifiability score (indicating a capability of distinguishing a patient's claims from another patient's claims) and a traceability score (indicating a capability of collecting claims of an identical patient). Results The verification test has clarified that vPID offers significantly higher traceability scores (0.994, Mie; 0.997, Gifu) than ID1 (0.863, Mie; 0.884, Gifu) and ID2 (0.602, Mie; 0.839, Gifu), and comparable (0.996, Mie) and lower (0.979, Gifu) identifiability scores. Discussion vPID is seemingly useful for a wide spectrum of analytic studies unless they focus on sensitive cases to the design limitation of vPID, such as patients experiencing marriage and job change, simultaneously, and same-sex twin children. Conclusion vPID successfully improves patient traceability, providing an opportunity for longitudinal analyses that used to be practically impossible for NDB. Further exploration is also necessary, in particular, for mitigating identification errors.
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Affiliation(s)
- Jumpei Sato
- Institute of Industrial Science, The University of Tokyo, Meguro-ku, Tokyo, Japan
| | | | - Hiroyuki Yamada
- Institute of Industrial Science, The University of Tokyo, Meguro-ku, Tokyo, Japan
| | - Masaru Kitsuregawa
- Institute of Industrial Science, The University of Tokyo, Meguro-ku, Tokyo, Japan
| | - Kazuo Goda
- Institute of Industrial Science, The University of Tokyo, Meguro-ku, Tokyo, Japan
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Cogen JD, Hall M, Faino AV, Ambroggio L, Blaschke AJ, Brogan TV, Cotter JM, Gibson RL, Grijalva CG, Hersh AL, Lipsett SC, Shah SS, Shapiro DJ, Neuman MI, Gerber JS. Antibiotics and outcomes of CF pulmonary exacerbations in children infected with MRSA and Pseudomonas aeruginosa. J Cyst Fibros 2023; 22:313-319. [PMID: 35945130 PMCID: PMC11315227 DOI: 10.1016/j.jcf.2022.08.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2022] [Revised: 07/29/2022] [Accepted: 08/01/2022] [Indexed: 10/15/2022]
Abstract
BACKGROUND Limited data exist to inform antibiotic selection among people with cystic fibrosis (CF) with airway infection by multiple CF-related microorganisms. This study aimed to determine among children with CF co-infected with methicillin-resistant Staphylococcus aureus (MRSA) and Pseudomonas aeruginosa (Pa) if the addition of anti-MRSA antibiotics to antipseudomonal antibiotic treatment for pulmonary exacerbations (PEx) would be associated with improved clinical outcomes compared with antipseudomonal antibiotics alone. METHODS Retrospective cohort study using data from the CF Foundation Patient Registry-Pediatric Health Information System linked dataset. The odds of returning to baseline lung function and having a subsequent PEx requiring intravenous antibiotics were compared between PEx treated with anti-MRSA and antipseudomonal antibiotics and those treated with antipseudomonal antibiotics alone, adjusting for confounding by indication using inverse probability of treatment weighting. RESULTS 943 children with CF co-infected with MRSA and Pa contributed 2,989 PEx for analysis. Of these, 2,331 (78%) PEx were treated with both anti-MRSA and antipseudomonal antibiotics and 658 (22%) PEx were treated with antipseudomonal antibiotics alone. Compared with PEx treated with antipseudomonal antibiotics alone, the addition of anti-MRSA antibiotics to antipseudomonal antibiotic therapy was not associated with a higher odds of returning to ≥90% or ≥100% of baseline lung function or a lower odds of future PEx requiring intravenous antibiotics. CONCLUSIONS Children with CF co-infected with MRSA and Pa may not benefit from the addition of anti-MRSA antibiotics for PEx treatment. Prospective studies evaluating optimal antibiotic selection strategies for PEx treatment are needed to optimize clinical outcomes following PEx treatment.
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Affiliation(s)
- Jonathan D Cogen
- Division of Pulmonary & Sleep Medicine, Department of Pediatrics, Seattle Children's Hospital, University of Washington, Seattle, Washington, United States.
| | - Matthew Hall
- Children's Hospital Association, Lenexa, Kansas, United States
| | - Anna V Faino
- Core for Biostatistics, Epidemiology, and Analytics in Research, Seattle Children's Research Institute, Seattle, Washington, United States
| | - Lilliam Ambroggio
- Sections of Emergency Medicine and Hospital Medicine, Children's Hospital Colorado, Department of Pediatrics, University of Colorado, Denver, Colorado, United States
| | - Anne J Blaschke
- Division of Pediatric Infectious Disease, Department of Pediatrics, School of Medicine, University of Utah, Salt Lake City, Utah, United States
| | - Thomas V Brogan
- Division of Critical Care, Department of Pediatrics, Seattle Children's Hospital, University of Washington, Seattle, Washington, United States
| | - Jillian M Cotter
- Sections of Emergency Medicine and Hospital Medicine, Children's Hospital Colorado, Department of Pediatrics, University of Colorado, Denver, Colorado, United States
| | - Ronald L Gibson
- Division of Pulmonary & Sleep Medicine, Department of Pediatrics, Seattle Children's Hospital, University of Washington, Seattle, Washington, United States
| | - Carlos G Grijalva
- Department of Health Policy, Vanderbilt University School of Medicine, Nashville, Tennessee, United States
| | - Adam L Hersh
- Division of Pediatric Infectious Disease, Department of Pediatrics, School of Medicine, University of Utah, Salt Lake City, Utah, United States
| | - Susan C Lipsett
- Division of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts, United States
| | - Samir S Shah
- Division of Hospital Medicine, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio, Canada
| | - Daniel J Shapiro
- Division of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts, United States
| | - Mark I Neuman
- Division of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts, United States
| | - Jeffrey S Gerber
- Division of Infectious Diseases, Children's Hospital of Philadelphia, Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, United States
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Systemic Corticosteroids in the Management of Pediatric Cystic Fibrosis Pulmonary Exacerbations. Ann Am Thorac Soc 2023; 20:75-82. [PMID: 36044723 DOI: 10.1513/annalsats.202203-201oc] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
Rationale: Pulmonary exacerbation (PEx) events contribute to lung function decline in people with cystic fibrosis (CF). CF Foundation PEx guidelines note that a short course of systemic corticosteroids may offer benefit without contributing to long-term adverse effects. However, insufficient evidence exists to recommend systemic corticosteroids for PEx treatment. Objectives: To determine if systemic corticosteroids for the treatment of in-hospital pediatric PEx are associated with improved clinical outcomes compared with treatment without systemic corticosteroids. Methods: We conducted a retrospective cohort study using the CF Foundation Patient Registry-Pediatric Health Information System linked database. People with CF were included if hospitalized for a PEx between 2006 and 2018 and were 6-21 years of age. Time to next PEx was assessed by Cox proportional hazards regression. Lung function outcomes were assessed by linear mixed-effect modeling and generalized estimating equations. To address confounding by indication, inverse probability treatment weighting was used. Results: A total of 3,471 people with CF contributed 9,787 PEx for analysis. Systemic corticosteroids were used in 15% of all PEx. In our primary analysis, systemic corticosteroids were not associated with better pre- to post-PEx percent predicted forced expiratory volume in 1 second responses (mean difference, -0.36; 95% confidence interval [CI], -1.14, 0.42; P = 0.4) or a higher odds of returning to lung function baseline (odds ratio, 0.97; 95% CI, 0.84-1.12; P = 0.7) but were associated with a reduced chance of future PEx requiring intravenous antibiotics (hazard ratio, 0.91; 95% CI, 0.85-0.96; P = 0.002). When restricting the analysis to one PEx per person, lung function outcomes remained no different among PEx treated with or without systemic corticosteroids, but, in contrast to our primary analysis, the use of systemic corticosteroids was no longer associated with a reduced chance of having a future PEx requiring intravenous antibiotics (hazard ratio, 0.96; 95% CI, 0.86, 1.07; P = 0.42). Conclusions: Systemic corticosteroid treatment for in-hospital pediatric PEx was not associated with improved lung function outcomes. Prospective trials are needed to better evaluate the risks and benefits of systemic corticosteroid use for PEx treatment in children with CF.
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Clinical Outcomes of Antipseudomonal versus Other Antibiotics Among Children with Cystic Fibrosis without Pseudomonas aeruginosa. Ann Am Thorac Soc 2022; 19:1320-1327. [PMID: 35289740 DOI: 10.1513/annalsats.202111-1294oc] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
RATIONALE Antibiotic selection for pulmonary exacerbation (PEx) management in children with CF is typically guided by prior respiratory culture results. While antipseudomonal antibiotics are often used in children with chronic Pseudomonas aeruginosa (Pa) airway infection, no data exist to guide antibiotic selection in children who are culture negative for Pa for ≥1 year. OBJECTIVES To determine among children classified as 1-, 2-, or 3-years Pa-negative if PEx treatment with at least 1 oral and/or intravenous anti-Pa antibiotic is associated with improved clinical outcomes compared to treatment with antibiotics not effective against Pa. METHODS Retrospective cohort study using the linked CF Foundation Patient Registry-Pediatric Health Information System (CFFPR-PHIS) database. We included children 6-21 years old hospitalized between 2008-2018 consistently culture-negative for Pa 1 year prior to a study PEx. Children were classified as 1- or 2-years Pa-negative if their last Pa-positive culture occurred in the 13-24 months or 25-36 months prior to a study PEx, respectively, with all subsequent cultures negative for Pa. Children classified as 3-years Pa-negative had no Pa-positive cultures in the 36 months prior to a study PEx. Inverse probability of treatment weighted linear or logistic regression models were used to compare clinical outcomes (pre- to post-PEx forced expiratory volume in one second, odds of returning to ≥90% of baseline lung function, and odds of having a future PEx) between anti-Pa and non-anti-Pa antibiotic strategies. RESULTS Among all children included in the linked dataset, 1,290 children with 2,347 PEx were eligible for analysis. Among all study PEx, 530, 326, and 1,491 PEx were classified as 1-, 2-, or 3-years Pa-negative, respectively, and anti-Pa antibiotics were administered in 79%, 67%, and 66% of all PEx classified as 1-, 2-, or 3-years Pa-negative, respectively. For all Pa-negative groups, when compared to non-anti-Pa antibiotic regimens, anti-Pa antibiotic treatment was not associated with greater improvement in any studied clinical outcomes. CONCLUSIONS Despite its common use, including antibiotics effective against Pa may provide no additional benefit for PEx treatment among children who are Pa-negative for at least 1 year prior. Prospective trials are warranted to directly test this hypothesis.
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Virgin FW, Thurm C, Sanders DB, Freeman AJ, Cogen J, Gamel B, Sawicki G, Fink AK. Prevalence, variability, and predictors of sinus surgery in pediatric patients with cystic fibrosis. Pediatr Pulmonol 2021; 56:4029-4038. [PMID: 34648689 DOI: 10.1002/ppul.25669] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Revised: 08/21/2021] [Accepted: 09/04/2021] [Indexed: 11/07/2022]
Abstract
INTRODUCTION Chronic rhinosinusitis is common among individuals with cystic fibrosis (CF) and has an impact on quality of life. Sinus surgery is a treatment option, but minimal literature exists regarding prevalence and indications. METHODS Using the linked CF Foundation Patient Registry (CFFPR) - Pediatric Health Information Systems (PHIS) database, we investigated variability in receipt of surgery, predictors of surgery, and time to first surgery. We included individuals less than 18 receiving care between 2006 and 2015 at a CF Foundation care program that is also a PHIS-participating-hospital. We used logistic regression to examine predictors of receipt of surgery and a Kaplan-Meier curve to examine time to first surgery among those born 2005-2007. RESULTS There were 11,545 children and adolescents and 2156 (18.7%) received at least one surgery. Variation in number of surgeries was observed across hospitals (median: 63 [IQR, 33-110]). There was an inconsistent pattern between receipt of surgery and markers of disease severity; those receiving surgery having increased odds of treatment use and pulmonary exacerbations and decreased odds of lower lung function and body mass index. Among the cohort of young children, 159 (14%) had at least one surgery with a median age at first surgery of 5.6 (IQR, 3.9-7.0). CONCLUSIONS The use of sinus surgery is frequent, but variable, among children and adolescents. Clinical factors are associated with receipt of surgery, but further understanding is needed on other factors that impact variability in use. Our study indicates the need for additional evaluation of the management of CF-related CRS and indications for surgery.
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Affiliation(s)
- Frank W Virgin
- Department of Otolaryngology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Cary Thurm
- Children's Hospital Association, Lenexa, Kansas, USA
| | - Don B Sanders
- Pediatric Pulmonology, Indiana University, Indianapolis, Indiana, USA
| | - Alvin J Freeman
- Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Jonathan Cogen
- Department of Pulmonary Medicine, Seattle Children's Hospital, Seattle, Washington, USA
| | - Breck Gamel
- Children's Medical Center, Dallas, Texas, USA
| | - Greg Sawicki
- Division of Pulmonary Medicine, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Aliza K Fink
- Cystic Fibrosis Foundation, Bethesda, Maryland, USA
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Association of Inhaled Antibiotics in Addition to Standard Intravenous Therapy and Outcomes of Pediatric Inpatient Pulmonary Exacerbations. Ann Am Thorac Soc 2021; 17:1590-1598. [PMID: 32726564 DOI: 10.1513/annalsats.202002-179oc] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
Rationale: Considerable morbidity and disease progression in people with cystic fibrosis (CF) result from pulmonary exacerbations (PExs). PEx guidelines note insufficient evidence to recommend for or against the concomitant use of inhaled and intravenous antibiotics.Objectives: We hypothesize that the addition of inhaled antibiotics for PEx therapy is associated with improvements in lung function and a longer time to next PEx compared with standard intravenous antibiotics alone.Methods: We performed a retrospective cohort study using the CF Foundation Patient Registry-Pediatric Health Information System linked dataset. People with CF were included if they were hospitalized for PEx between 2006 and 2016 and 6 to 21 years of age. Lung function outcomes were assessed by linear mixed effect modeling and generalized estimating equations. The time to next PEx was assessed by Cox proportional hazards regression. To estimate independent causal effects while accounting for indication bias and other confounders, inverse probabilities of treatment weights were calculated based on covariates believed to influence the likelihood of inhaled antibiotic use during PEx treatment.Results: A total of 3,253 children and adolescents contributed 9,040 PEx events for analysis. Inhaled antibiotics were used in 23% of PEx events but were not associated with better pre- to post-PEx percent predicted forced expiratory volume in 1 second responses (mean difference, -1.11%; 95% confidence interval [CI], -1.83 to -0.38; P = 0.003), higher odds of returning to lung function baseline (odds ratio, 0.94; 95% CI, 0.82 to 1.07; P = 0.34), or longer time to next PEx (hazard ratio, 1.05; 95% CI, 0.99 to 1.12; P = 0.098).Conclusions: The addition of inhaled antibiotics to standard intravenous antibiotic PEx treatment was not associated with improved lung function outcomes or a longer time to next PEx.
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Effect of Concomitant Azithromycin and Tobramycin Use on Cystic Fibrosis Pulmonary Exacerbation Treatment. Ann Am Thorac Soc 2021; 18:266-272. [PMID: 32810412 DOI: 10.1513/annalsats.202002-176oc] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Rationale: Pulmonary exacerbations (PExs) are associated with significant morbidity in people with cystic fibrosis (CF). Severe PExs are treated with intravenous antibiotics, including tobramycin. CF care guidelines recommend continuing chronic maintenance medications during PEx treatment. Azithromycin (AZM) is one of the most widely prescribed chronic medications for CF in the United States. Recent evidence has identified a potential antagonistic relationship between AZM and tobramycin.Objectives: To determine whether, among PEx treated with intravenous tobramycin, concomitant AZM use is associated with worse clinical outcomes.Methods: Retrospective cohort study using the CF Foundation Patient Registry-Pediatric Health Information System (CFFPR-PHIS)-linked dataset. People with CF age 6-21 years were included if they were hospitalized between 2006 and 2016 for a PEx. Inverse probability of treatment weighing was used to minimize the effects of confounders, including indication bias. Associations of concomitant treatment with AZM and lung function outcomes were determined using linear mixed-effect models and generalized estimating equations. Cox proportional hazard regression models were used to evaluate associations with time to next PEx.Results: Among the 10,660 people with CF included in the CFFPR-PHIS-linked dataset, 2,294 children and adolescents with 5,022 PExs that had intravenous tobramycin use were identified. A little less than half (n = 2,247; 45%) of all PExs were treated concomitantly with AZM and intravenous tobramycin. AZM use both at the most recent outpatient clinic encounter and during PEx treatment in combination with intravenous tobramycin was associated with a significantly lower absolute improvement in percentage-predicted forced expiratory volume in 1 second (ppFEV1) (-0.93%; 95% confidence interval [CI], -1.78 to -0.07; P = 0.033), a lesser odds of returning to 90% or more of baseline ppFEV1 (odds ratio, 0.79; 95% CI, 0.68-0.93; P = 0.003), and a shorter time to next PEx requiring intravenous antibiotics (hazard ratio, 1.22; 95% CI, 1.14-1.31; P < 0.001) compared with intravenous tobramycin use without concomitant AZM.Conclusions: Concomitant AZM and intravenous tobramycin use for in-hospital PEx treatment was associated with poorer clinical outcomes than treatment with intravenous tobramycin without AZM. These results support the hypothesis that an antagonistic relationship between these two medications might exist.
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Cogen JD, Faino AV, Onchiri F, Hoffman LR, Kronman MP, Nichols DP, Rosenfeld M, Gibson RL. Association Between Number of Intravenous Antipseudomonal Antibiotics and Clinical Outcomes of Pediatric Cystic Fibrosis Pulmonary Exacerbations. Clin Infect Dis 2021; 73:1589-1596. [PMID: 34100912 DOI: 10.1093/cid/ciab525] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Pulmonary exacerbations (PEx) in people with cystic fibrosis (PwCF) are associated with significant morbidity. While standard PEx treatment for PwCF with Pseudomonas aeruginosa infection includes two IV antipseudomonal antibiotics, little evidence exists to recommend this approach. This study aimed to compare clinical outcomes of single versus double antipseudomonal antibiotic use for PEx treatment. METHODS Retrospective cohort study using the linked CF Foundation Patient Registry-Pediatric Health Information System dataset. PwCF were included if hospitalized between 2007-2018 and 6-21 years of age. Regression modeling accounting for repeated measures was used to compare lung function outcomes between single versus double IV antipseudomonal antibiotic regimens using propensity-score weighting to adjust for relevant confounding factors. RESULTS Among 10,660 PwCF in the dataset, we analyzed 2,578 PEx from 1,080 PwCF, of which 455 and 2,123 PEx were treated with 1 versus 2 IV antipseudomonal antibiotics, respectively. We identified no significant differences between PEx treated with 1 versus 2 IV antipseudomonal antibiotics either in change between pre- and post-PEx percent predicted forced expiratory volume in one second (ppFEV1) (-0.84%, [95% CI -2.25, 0.56]; p=0.24), odds of returning to ≥90% of baseline ppFEV1 within 3 months following PEx (Odds Ratio 0.83, [95% CI 0.61, 1.13]; p=0.24) or time to next PEx requiring IV antibiotics (Hazard Ratio 1.04, [95% CI 0.87, 1.24]; p=0.69). CONCLUSION Use of 2 IV antipseudomonal antibiotics for PEx treatment in young PwCF was not associated with greater improvements in measured respiratory and clinical outcomes compared to treatment with 1 IV antipseudomonal antibiotic.
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Affiliation(s)
- Jonathan D Cogen
- Division of Pulmonary & Sleep Medicine, Department of Pediatrics, Seattle Children's Hospital, University of Washington, Seattle, WA, USA
| | - Anna V Faino
- Children's Core for Biostatistics, Epidemiology and Analytics in Research, Seattle Children's Research Institute, Seattle, WA, USA
| | - Frankline Onchiri
- Children's Core for Biostatistics, Epidemiology and Analytics in Research, Seattle Children's Research Institute, Seattle, WA, USA
| | - Lucas R Hoffman
- Division of Pulmonary & Sleep Medicine, Department of Pediatrics, Seattle Children's Hospital, University of Washington, Seattle, WA, USA
| | - Matthew P Kronman
- Division of Infectious Diseases, Department of Pediatrics, University of Washington, Seattle, WA, USA
| | - David P Nichols
- Division of Pulmonary & Sleep Medicine, Department of Pediatrics, Seattle Children's Hospital, University of Washington, Seattle, WA, USA
| | - Margaret Rosenfeld
- Division of Pulmonary & Sleep Medicine, Department of Pediatrics, Seattle Children's Hospital, University of Washington, Seattle, WA, USA
| | - Ronald L Gibson
- Division of Pulmonary & Sleep Medicine, Department of Pediatrics, Seattle Children's Hospital, University of Washington, Seattle, WA, USA
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Griffiths R, Schlüter DK, Akbari A, Cosgriff R, Tucker D, Taylor-Robinson D. Identifying children with Cystic Fibrosis in population-scale routinely collected data in Wales: A Retrospective Review. Int J Popul Data Sci 2020; 5:1346. [PMID: 33644411 PMCID: PMC7898022 DOI: 10.23889/ijpds.v5i1.1346] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
INTRODUCTION The challenges in identifying a cohort of people with a rare condition can be addressed by routinely collected, population-scale electronic health record (EHR) data, which provide large volumes of data at a national level. This paper describes the challenges of accurately identifying a cohort of children with Cystic Fibrosis (CF) using EHR and their validation against the UK CF Registry. OBJECTIVES To establish a proof of principle and provide insight into the merits of linked data in CF research; to identify the benefits of access to multiple data sources, in particular the UK CF Registry data, and to demonstrate the opportunity it represents as a resource for future CF research. METHODS Three EHR data sources were used to identify children with CF born in Wales between 1st January 1998 and 31st August 2015 within the Secure Anonymised Information Linkage (SAIL) Databank. The UK CF Registry was later acquired by SAIL and linked to the EHR cohort to validate the cases and explore the reasons for misclassifications. RESULTS We identified 352 children with CF in the three EHR data sources. This was greater than expected based on historical incidence rates in Wales. Subsequent validation using the UK CF Registry found that 257 (73%) of these were true cases. Approximately 98.7% (156/158) of individuals identified as CF cases in all three EHR data sources were confirmed as true cases; but this was only the case for 19.8% (20/101) of all those identified in just a single data source. CONCLUSION Identifying health conditions in EHR data can be challenging, so data quality assurance and validation is important or the merit of the research is undermined. This retrospective review identifies some of the challenges in identifying CF cases and demonstrates the benefits of linking cases across multiple data sources to improve quality.
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Affiliation(s)
- R Griffiths
- Swansea University Medical School, Swansea University
- Health Data Research UK
| | - DK Schlüter
- Department of Public Health and Policy, University of Liverpool, Liverpool L69 7ZX
| | - A Akbari
- Swansea University Medical School, Swansea University
- Health Data Research UK
- Administrative Data Research Wales
| | - R Cosgriff
- Cystic Fibrosis Trust, One Aldgate, London EC3N 1R
| | - D Tucker
- Public Health Wales, Capital Quarter 2, Tyndall Street, Cardiff. CF10 4BZ\break † Joint First Authors
| | - D Taylor-Robinson
- Department of Public Health and Policy, University of Liverpool, Liverpool L69 7ZX
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Barletta P, Ortiz MT, Abreu AR, Salathe M, Chediak AD. Sleep, Obstructive Sleep Apnea, and Chronic Alveolar Hypoventilation in Cystic Fibrosis: Role of Noninvasive Ventilation During Sleep. CURRENT PULMONOLOGY REPORTS 2020. [DOI: 10.1007/s13665-020-00252-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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13
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Cogen JD, Kahl BC, Maples H, McColley SA, Roberts JA, Winthrop KL, Morris AM, Holmes A, Flume PA, VanDevanter DR, Waters V, Muhlebach MS, Elborn JS, Saiman L, Bell SC. Finding the relevance of antimicrobial stewardship for cystic fibrosis. J Cyst Fibros 2020; 19:511-520. [PMID: 32122785 DOI: 10.1016/j.jcf.2020.02.012] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2020] [Revised: 01/29/2020] [Accepted: 02/12/2020] [Indexed: 12/15/2022]
Abstract
Antimicrobials have undoubtedly improved the lives of people with CF, but important antimicrobial-related toxicities and the emergence of antimicrobial-resistant bacteria associated with their use must be considered. Antimicrobial stewardship (AMS) is advocated across the spectrum of healthcare to promote the appropriate use of antimicrobials to preserve their current effectiveness and to optimise treatment, and it is clear that AMS strategies are applicable to and can benefit both non-CF and CF populations. This perspective explores the definition and components of an AMS program, the current evidence for AMS, and the reasons why AMS is a challenging concept in the provision of CF care. We also discuss the elements of CF care which align with AMS programs and principles and propose research priorities for AMS in CF.
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Affiliation(s)
- Jonathan D Cogen
- Division of Pulmonary & Sleep Medicine, Department of Pediatrics, University of Washington, Seattle, WA, USA.
| | - Barbara C Kahl
- Institute of Medical Microbiology, University Hospital Münster, Münster, Germany
| | - Holly Maples
- Department of Pharmacy Practice, University of Arkansas for Medical Sciences and Arkansas Children's Hospital, Little Rock, AR, USA
| | - Susanna A McColley
- Division of Pulmonary and Sleep Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, and Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Jason A Roberts
- University of Queensland Centre for Clinical Research and School of Pharmacy, The University of Queensland, Departments of Pharmacy and Intensive Care Medicine, Royal Brisbane and Women's Hospital, Brisbane, Australia; Division of Anaesthesiology, Critical Care, Emergency and Pain Medicine, Nîmes University Hospital, University of Montpelier, Nîmes France
| | - Kevin L Winthrop
- Oregon Health and Science University School of Medicine and Public Health, Portland, Oregon, USA
| | - Andrew M Morris
- Division of Infectious Diseases, Department of Medicine, Sinai Health, University Health Network, and University of Toronto, Toronto, Canada
| | - Alison Holmes
- National Institute for Health Research (NIHR) Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Imperial College London, Hammersmith Campus, London, UK
| | | | - Donald R VanDevanter
- Department of Pediatrics, Case Western Reserve University School of Medicine, Cleveland OH, USA
| | - Valerie Waters
- Division of Infectious Diseases, Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Marianne S Muhlebach
- Department of Pediatrics, Division Pulmonology, University of North Carolina at Chapel Hill, NC, USA
| | - J Stuart Elborn
- Centre for Experimental Medicine, School of Medicine, Dentistry and Biomedical Sciences, Queen's University Belfast, Belfast, UK
| | - Lisa Saiman
- Columbia University Irving Medical Center and New York-Presbyterian Hospital, New York, NY, USA
| | - Scott C Bell
- Department of Thoracic Medicine, The Prince Charles Hospital, and QIMR Berghofer Medical Research Institute, Brisbane, QLD, Australia
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McMahon AW, Cooper WO, Brown JS, Carleton B, Doshi-Velez F, Kohane I, Goldman JL, Hoffman MA, Kamaleswaran R, Sakiyama M, Sekine S, Sturkenboom MCJM, Turner MA, Califf RM. Big Data in the Assessment of Pediatric Medication Safety. Pediatrics 2020; 145:peds.2019-0562. [PMID: 31937606 DOI: 10.1542/peds.2019-0562] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/13/2019] [Indexed: 11/24/2022] Open
Abstract
Big data (BD) in pediatric medication safety research provides many opportunities to improve the safety and health of children. The number of pediatric medication and device trials has increased in part because of the past 20 years of US legislation requiring and incentivizing study of the effects of medical products in children (Food and Drug Administration Modernization Act of 1997, Pediatric Rule in 1998, Best Pharmaceuticals for Children Act of 2002, and Pediatric Research Equity Act of 2003). There are some limitations of traditional approaches to studying medication safety in children. Randomized clinical trials within the regulatory context may not enroll patients who are representative of the general pediatric population, provide the power to detect rare safety signals, or provide long-term safety data. BD sources may have these capabilities. In recent years, medical records have become digitized, and cell phones and personal devices have proliferated. In this process, the field of biomedical science has progressively used BD from those records coupled with other data sources, both digital and traditional. Additionally, large distributed databases that include pediatric-specific outcome variables are available. A workshop entitled "Advancing the Development of Pediatric Therapeutics: Application of 'Big Data' to Pediatric Safety Studies" held September 18 to 19, 2017, in Silver Spring, Maryland, formed the basis of many of the ideas outlined in this article, which are intended to identify key examples, critical issues, and future directions in this early phase of an anticipated dramatic change in the availability and use of BD.
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Affiliation(s)
- Ann W McMahon
- Office of Pediatric Therapeutics, US Food and Drug Administration, Rockville, Maryland;
| | - William O Cooper
- Departments of Pediatrics and Health Policy, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Jeffrey S Brown
- Population Medicine, Harvard Medical School and Harvard Pilgrim Healthcare Insititute, Boston, Massachusetts
| | - Bruce Carleton
- Division of Translational Therapeutics, Department of Pediatrics, Faculty of Medicine, University of British Columbia, Vancouver, Canada
| | - Finale Doshi-Velez
- Paulson School of Engineering and Applied Sciences, Harvard University, Boston, Massachusetts
| | - Isaac Kohane
- Departments of Biomedical Informatics, Pediatrics, and
| | - Jennifer L Goldman
- Divisions of Pediatric Infectious Diseases and Clinical Parmacology, Department of Pediatrics, and
| | - Mark A Hoffman
- Departments of Biomedical Informatics, Pediatrics, and Emergency Medicine, School of Medicine, Emory University, Atlanta, Georgia
| | | | - Michiyo Sakiyama
- Office of New Drug IV, Pharmaceuticals and Medical Devices Agency, Tokyo, Japan.,Department of Epidemiology, Julius Center Research Program Cardiovascular Edpidemiology, Utrecht University Medical Center, Utrecht, Netherlands
| | - Shohko Sekine
- Institute of Translational Medicine, University of Liverpool, Liverpool, United Kingdom; and
| | - Miriam C J M Sturkenboom
- Division of Cardiology, Department of Internal Medicine, School of Medicine, Center for Health Science, Duke Clinical Research Institute, Duke University, Durham, North Carolina
| | - Mark A Turner
- Institute of Translational Medicine, University of Liverpool, Liverpool, United Kingdom; and
| | - Robert M Califf
- Division of Cardiology, Department of Internal Medicine, School of Medicine, Center for Health Science, Duke Clinical Research Institute, Duke University, Durham, North Carolina
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Cogen JD, Faino AV, Onchiri F, Hall M, Fink AK. Evaluation of hospitalization data for the CFFPR-PHIS linked data set. Pediatr Pulmonol 2020; 55:30-32. [PMID: 31544363 DOI: 10.1002/ppul.24527] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2019] [Accepted: 09/06/2019] [Indexed: 11/11/2022]
Affiliation(s)
- Jonathan D Cogen
- Department of Pediatrics, Division of Pulmonary and Sleep Medicine, University of Washington, Seattle, Washington
| | - Anna V Faino
- Core for Biomedical Statistics, Center for Clinical and Translational Research, Seattle Children's Research Institute, Seattle, Washington
| | - Frankline Onchiri
- Core for Biomedical Statistics, Center for Clinical and Translational Research, Seattle Children's Research Institute, Seattle, Washington
| | - Matt Hall
- Children's Hospital Association, Lenexa, Kansas
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16
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Cunningham S. Microbiological outliers in cystic fibrosis: resolving uncertainty. THE LANCET RESPIRATORY MEDICINE 2019; 7:995-997. [PMID: 31727594 DOI: 10.1016/s2213-2600(19)30405-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/15/2019] [Accepted: 10/17/2019] [Indexed: 11/25/2022]
Affiliation(s)
- Steve Cunningham
- Professor of Paediatric Respiratory Medicine, Centre for Inflammation Research, University of Edinburgh, Edinburgh, EH9 1LF, UK.
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17
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The use of antimicrobial susceptibility testing in pediatric cystic fibrosis pulmonary exacerbations. J Cyst Fibros 2019; 18:851-856. [PMID: 31147301 DOI: 10.1016/j.jcf.2019.05.012] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2019] [Revised: 05/14/2019] [Accepted: 05/17/2019] [Indexed: 10/26/2022]
Abstract
BACKGROUND Although antimicrobial susceptibility testing (AST) frequently guides cystic fibrosis (CF) pulmonary exacerbation (PEx) management, its clinical utility is unclear. This study examined associations between AST and antimicrobial switching during PEx treatment and time and occurrence of next PEx as treatment outcomes. METHODS This retrospective cohort study utilized Pediatric Health Information System data. Children and adolescents aged 1-18 years admitted for a PEx from 2011 to 2016 were studied. Antimicrobial switching was defined as any intra-admission change in intravenous (IV), oral, and/or inhaled antimicrobials. Time to next PEx was defined as the time between index PEx hospital discharge and subsequent hospital admission requiring IV antimicrobials. Odds of antimicrobial switching ≥5 days after treatment initiation were determined by generalized linear mixed models, and associations between AST and time to next PEx were studied using Kaplan-Meier curves and Cox proportional hazards regression. RESULTS AST occurred in 2518 (39%) of 6451 PEx at 36 hospitals and was associated with increased odds of antimicrobial switching (OR 1.33, 95% CI 1.16-1.52; p = 0.001) and increased hazard of future PEx (HR 1.32, 95% CI 1.16-1.50; p < 0.001). However, antimicrobial switching was not associated with a longer time to next PEx. CONCLUSIONS AST was associated with both increased probability of antimicrobial regimen change and increased PEx hazard. There was no evidence that antimicrobial regimen change was associated with clinical benefit as assessed by time to next PEx. However, these results indicate residual indication bias remained after adjustment for available disease covariates. Additional studies of the clinical value of AST are warranted.
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