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Gustafson B, Britt RD, Eisner M, Narayanan D, Grayson MH. Predictors of recurrent wheezing in late preterm infants. Pediatr Pulmonol 2024; 59:181-188. [PMID: 37921550 DOI: 10.1002/ppul.26739] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Revised: 10/16/2023] [Accepted: 10/18/2023] [Indexed: 11/04/2023]
Abstract
INTRODUCTION Premature infants have an increased risk of respiratory morbidity, including the development of recurrent wheezing. We sought to determine perinatal factors in late preterm infants associated with an increased risk of recurrent wheezing in the first 3 years of life. METHODS A retrospective chart review of infants born between 32 and 36 weeks gestational age at a tertiary hospital from 2013 to 2016 was performed. Infants with any co-morbid medical conditions were excluded. Recurrent wheezing was identified by two or more visit diagnoses for reactive airway disease, wheezing-associated respiratory infection, wheezing, or asthma during the first 3 years of life. Those with recurrent wheezing were compared to matched preterm infants who did not develop wheezing. RESULTS Three hundred and fourteen late preterm infants were included in this study; 210 infants developed recurrent wheezing while 104 did not. Gender, sex, and race were comparable between both groups. Development of wheezing was associated with positive family history of asthma (p = .014), receiving antibiotics during the neonatal period (p < .001), requiring continuous positive airway pressure for <24 h (p = .019), and receiving supplemental oxygen during the newborn period (p = .023). CONCLUSION This study retrospectively identified risk factors associated with development of wheezing in late preterm infants. Prospective studies are needed to determine whether these factors will predict recurrent wheeze in this patient population.
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Affiliation(s)
- Brooke Gustafson
- Division of Pulmonary Medicine, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Rodney D Britt
- Department of Pediatrics, Center for Perinatal Research, The Abigail Wexner Research Institute at Nationwide Children's Hospital, The Ohio State University, Columbus, Ohio, USA
- Department of Pediatrics, The Ohio State University College of Medicine, Columbus, Ohio, USA
| | - Mariah Eisner
- Biostatistics Resource at Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Deepika Narayanan
- Department of Pediatrics, The Ohio State University College of Medicine, Columbus, Ohio, USA
| | - Mitchell H Grayson
- Department of Pediatrics, The Ohio State University College of Medicine, Columbus, Ohio, USA
- Department of Pediatrics, Division of Allergy and Immunology, Nationwide Children's Hospital, Columbus, Ohio, USA
- Center for Clinical and Translational Research, The Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, Ohio, USA
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Chen IL, Huang F, Li SC, Huang HC. Salivary microbiome and asthma risk in children with orofacial defects. Pediatr Pulmonol 2023; 58:2777-2785. [PMID: 37470110 DOI: 10.1002/ppul.26582] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2022] [Revised: 06/14/2023] [Accepted: 06/20/2023] [Indexed: 07/21/2023]
Abstract
BACKGROUND Patients with congenital orofacial defects, cleft lip (CL), cleft palate (CP), and cleft lip and palate (CLP) have continuous exposure of the respiratory system to the microbiome from the oral environment, offering opportunities to develop mucosal immunity in the airway. This two-part study aims to analyze data on asthma occurrence in CL, CP, and CLP infants and the composition of the salivary microbiome, and to evaluate the oral microbiota and its association with the risk of developing childhood asthma. METHODS Patient data from the research database of Chang Gung Memorial Hospital from 2004 to 2015 were retrospectively analyzed by multivariable regression. Diseases diagnoses were defined by ICD codes. Asthma must also meet the criteria for receiving selective β2 agonistic or/and inhaled corticosteroid treatments twice within 1 year. Analysis of the saliva microbiome was performed prospectively from 2016 to 2020 in 10 healthy term infants and 10 CLP infants on postnatal 7th day, 1 month, and 6 months by next-generation sequencing. RESULTS Asthma and nonasthma groups included 988 and 3952 patients, respectively. The incidence of asthma development was higher in patients with CP than in CL and CLP groups (aOR: 5.644, CI: 1.423-22.376). The species composition of the microbiome at 1 and 6 months was significantly different between infants with CLP and healthy infants. CONCLUSION Children with orofacial defects have a higher risk of developing asthma with a possible contribution from oral microbiota in the early months of life.
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Affiliation(s)
- I-Lun Chen
- Department of Pediatrics, College of Medicine, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University, Kaohsiung, Taiwan
- School of Traditional Chinese Medicine, College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Faye Huang
- Department of Plastic Surgery, College of Medicine, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University, Kaohsiung, Taiwan
| | - Sung-Chou Li
- Department of Medical Research, College of Medicine, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University, Kaohsiung, Taiwan
| | - Hsin-Chun Huang
- Department of Pediatrics, College of Medicine, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University, Kaohsiung, Taiwan
- School of Medicine, College of Medicine, Chang Gung University, Taoyuan, Taiwan
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Yu JF, Zhang Y, Liu ZB, Wang J, Bai LP. 3% nebulized hypertonic saline versus normal saline for infants with acute bronchiolitis: A systematic review and meta-analysis of randomized controlled trials. Medicine (Baltimore) 2022; 101:e31270. [PMID: 36316926 PMCID: PMC10662888 DOI: 10.1097/md.0000000000031270] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2022] [Accepted: 09/19/2022] [Indexed: 01/06/2023] Open
Abstract
BACKGROUND This study evaluated the efficacy and safety of 3% nebulized hypertonic saline (NHS) in infants with acute bronchiolitis (AB). METHODS We systematically searched the PUBMED, EMBASE, Cochrane Library, China National Knowledge Infrastructure Database, WANFANG, and VIP databases from inception to June 1, 2022. We included randomized controlled trials comparing NHS with 0.9% saline. Outcomes included the length of hospital stay (LOS), rate of hospitalization (ROH), clinical severity score (CSS), rate of readmission, respiratory distress assessment instrument, and adverse events. RevMan V5.4 software was used for statistical analysis. RESULTS A total of 27 trials involving 3495 infants were included in this study. Compared to normal saline, infants received 3% NHS showed better outcomes in LOS reduction (MD = -0.60, 95% CI [-1.04, -0.17], I2 = 92%, P = .007), ROH decrease (OR = 0.74, 95% CI [0.59, 0.91], I2 = 0%, P = .005), CSS improvement at day 1 (MD = -0.79, 95% CI [-1.23, -0.34], I2 = 74%, P < .001), day 2 (MD = -1.26, 95% CI [-2.02, -0.49], I2 = 91%, P = .001), and day 3 and over (MD = -1.27, 95% CI [-1.92, -0.61], I2 = 79%, P < .001), and respiratory distress assessment instrument enhancement (MD = -0.60, 95% CI [-0.95, -0.26], I2 = 0%, P < .001). No significant adverse events related to 3% NHS were observed. CONCLUSION This study showed that 3% NHS was better than 0.9% normal saline in reducing LOS, decreasing ROH, improving CSS, and in enhancing the severity of respiratory distress. Further studies are needed to validate these findings.
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Affiliation(s)
- Jin-Feng Yu
- Department of Pediatric Medicine, Hongqi Hospital Affiliated to Mudanjiang Medical University, Mudanjiang, China
| | - Yan Zhang
- Department of Hematology, Hongqi Hospital Affiliated to Mudanjiang Medical University, Mudanjiang, China
| | - Zhan-Bo Liu
- Department of Computer, Hongqi Hospital Affiliated to Mudanjiang Medical University, Mudanjiang, China
| | - Jing Wang
- Department of Pediatric Medicine, Hongqi Hospital Affiliated to Mudanjiang Medical University, Mudanjiang, China
| | - Li-Ping Bai
- Department of Pediatric Medicine, Hongqi Hospital Affiliated to Mudanjiang Medical University, Mudanjiang, China
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Beigelman A, Srinivasan M, Goss CW, Wang J, Zhou Y, True K, Ahrens E, Burgdorf D, Haslam MD, Boomer J, Bram S, Burnham CAD, Casper TJ, Coverstone AM, Kanchongkittiphon W, Kuklinski C, Storch GA, Wallace MA, Yin-DeClue H, Castro M, Schechtman KB, Bacharier LB. Azithromycin to Prevent Recurrent Wheeze Following Severe Respiratory Syncytial Virus Bronchiolitis. NEJM EVIDENCE 2022; 1:10.1056/evidoa2100069. [PMID: 37621674 PMCID: PMC10448891 DOI: 10.1056/evidoa2100069] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/26/2023]
Abstract
BACKGROUND Early-life severe respiratory syncytial virus (RSV) bronchiolitis is a risk factor for childhood asthma. Because azithromycin may attenuate airway inflammation during RSV bronchiolitis, we evaluated whether it would reduce the occurrence of post-RSV recurrent wheeze. METHODS We prospectively enrolled 200 otherwise healthy 1- to 18-month-old children hospitalized with RSV bronchiolitis in this single-center, double-blind, placebo-controlled study and randomly assigned them to receive oral azithromycin (10 mg/kg daily for 7 days, followed by 5 mg/kg daily for 7 days) or placebo. Randomization was stratified by recent open-label antibiotic use. The primary outcome was the occurrence of recurrent wheeze, defined as a third episode of post-RSV wheeze over the following 2 to 4 years. RESULTS As an indication of the biologic activity of azithromycin, nasal wash interleukin-8 levels, at day 14 after randomization, were lower among azithromycin-treated participants (P<0.01). Despite evidence of biologic activity, azithromycin did not reduce the risk of post-RSV recurrent wheeze (47% in the azithromycin group vs. 36% in the placebo group; adjusted hazard ratio, 1.45; 95% confidence interval [CI], 0.92 to 2.29; P=0.11). Azithromycin also did not modify the risk of recurrent wheeze among participants already receiving other antibiotic treatment at the time of enrollment (hazard ratio, 0.94; 95% CI, 0.43 to 2.07). There was a potential signal among antibiotic-naïve participants who received azithromycin to have an increased risk of recurrent wheeze (hazard ratio, 1.79; 95% CI, 1.03 to 3.1). CONCLUSIONS Azithromycin therapy for 14 days during acute severe RSV bronchiolitis did not reduce recurrent wheeze occurrence over the following 2 to 4 years. Our data suggest no benefit of azithromycin administration with the goal of preventing recurrent wheeze in later life. (Funded by the National Heart, Lung, and Blood Institute; ClinicalTrials.gov number, NCT02911935.).
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Affiliation(s)
- Avraham Beigelman
- Division of Allergy and Pulmonary Medicine, Department of Pediatrics, Washington University School of Medicine, St. Louis
- Kipper Institute of Allergy and Immunology, Schneider Children's Medical Center of Israel and the Tel Aviv University, Petach Tikvah, Israel
| | - Mythili Srinivasan
- Division of Hospitalist Medicine, Department of Pediatrics, Washington University School of Medicine, St. Louis
| | - Charles W Goss
- Division of Biostatistics, Washington University School of Medicine, St. Louis
| | - Jinli Wang
- Division of Biostatistics, Washington University School of Medicine, St. Louis
| | - Yanjiao Zhou
- Department of Medicine, University of Connecticut School of Medicine, Farmington, CT
| | - Kelly True
- Division of Allergy and Pulmonary Medicine, Department of Pediatrics, Washington University School of Medicine, St. Louis
| | - Elizabeth Ahrens
- Division of Allergy and Pulmonary Medicine, Department of Pediatrics, Washington University School of Medicine, St. Louis
| | - Dana Burgdorf
- Division of Allergy and Pulmonary Medicine, Department of Pediatrics, Washington University School of Medicine, St. Louis
| | | | - Jonathan Boomer
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Kansas Medical Center, Kansas City, KS
| | - Sarah Bram
- Division of Hospitalist Medicine, Department of Pediatrics, Washington University School of Medicine, St. Louis
| | - Carey-Ann D Burnham
- Department of Pathology and Immunology, Washington University School of Medicine, St. Louis
| | | | - Andrea M Coverstone
- Division of Allergy and Pulmonary Medicine, Department of Pediatrics, Washington University School of Medicine, St. Louis
| | | | - Cadence Kuklinski
- Division of Allergy and Pulmonary Medicine, Department of Pediatrics, Washington University School of Medicine, St. Louis
| | - Gregory A Storch
- Division of Pediatric Infectious Disease, Department of Pediatrics, Washington University School of Medicine, St. Louis
| | - Meghan A Wallace
- Department of Pathology and Immunology, Washington University School of Medicine, St. Louis
| | - Huiqing Yin-DeClue
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Kansas Medical Center, Kansas City, KS
| | - Mario Castro
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Kansas Medical Center, Kansas City, KS
| | | | - Leonard B Bacharier
- Department of Pediatrics, Monroe Carell Jr Children's Hospital at Vanderbilt University Medical Center, Nashville
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Duong QA, Pittet LF, Curtis N, Zimmermann P. Antibiotic exposure and adverse long-term health outcomes in children: a systematic review and meta-analysis. J Infect 2022; 85:213-300. [PMID: 35021114 DOI: 10.1016/j.jinf.2022.01.005] [Citation(s) in RCA: 39] [Impact Index Per Article: 19.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Accepted: 01/04/2022] [Indexed: 12/15/2022]
Abstract
BACKGROUND Antibiotics are among the most commonly used drugs in children. In addition to inducing antibiotic resistance, antibiotic exposure has been associated with long-term adverse health outcomes. METHODS A systematic search using PRISMA Guidelines to identify original studies reporting associations between antibiotic exposure and long-term adverse health outcomes in children. Overall pooled estimates of the odds ratios (ORs) were obtained using fixed or random-effects models. RESULTS We identified 160 observational studies investigating 21 outcomes in 22,103,129 children. Antibiotic exposure was associated with an increased risk of atopic dermatitis (OR 1.40, 95% confidence interval (CI) 1.30-1.52, p<0.01), allergic symptoms (OR 1.93, 95%CI 1.66-2.26, p<0.01), food allergies (OR 1.35, 95%CI 1.20-1.52, p<0.01), allergic rhinoconjunctivitis (OR 1.66, 95%CI 1.51-1.83, p<0.01), wheezing (OR 1.81, 95%CI 1.65-1.97, p<0.01), asthma (OR 1.96, 95%CI 1.76-2.17, p<0.01), increased weight gain or overweight (OR 1.18, 95%CI 1.11-1.26, p<0.01), obesity (OR 1.21, 95%CI 1.05-1.40, p<0.01), juvenile idiopathic arthritis (OR 1.74, 95%CI 1.21-2.52, p<0.01), psoriasis (OR 1.75, 95%CI 1.44-2.11, p<0.01), autism spectrum disorders (OR 1.19, 95%CI 1.04-1.36, p=0.01) and neurodevelopment disorders (OR 1.29, 95%CI 1.09-1.53, p<0.01). Dose-response effects and stronger effects with broad-spectrum antibiotic were often reported. Antibiotic exposure was not associated with an altered risk of allergic sensitisation, infantile colic, abdominal pain, inflammatory bowel disease, celiac disease, type 1 diabetes, fluorosis, and attention deficit hyperactivity disorder. CONCLUSION Although a causal association cannot be determined from these studies, the results support the meticulous application of sound antibiotic stewardship to avoid potential adverse long-term health outcomes.
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Affiliation(s)
- Quynh Anh Duong
- Faculty of Science and Medicine, University of Fribourg, Fribourg, Switzerland
| | - Laure F Pittet
- Department of Paediatrics, The University of Melbourne, Parkville, Australia; Infectious Diseases Research Group, Murdoch Children's Research Institute, Parkville, Australia; Infectious Diseases Unit, The Royal Children's Hospital Melbourne, Parkville, Australia; Unit of Pediatric Infectious Diseases, Department of Pediatrics, Gynecology & Obstetrics, University Hospitals of Geneva and Faculty of Medicine, Geneva, Switzerland
| | - Nigel Curtis
- Department of Paediatrics, The University of Melbourne, Parkville, Australia; Infectious Diseases Research Group, Murdoch Children's Research Institute, Parkville, Australia; Infectious Diseases Unit, The Royal Children's Hospital Melbourne, Parkville, Australia
| | - Petra Zimmermann
- Faculty of Science and Medicine, University of Fribourg, Fribourg, Switzerland; Infectious Diseases Research Group, Murdoch Children's Research Institute, Parkville, Australia; Department of Paediatrics, Fribourg Hospital HFR, Fribourg, Switzerland.
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Association of infant antibiotic exposure and risk of childhood asthma: A meta-analysis. World Allergy Organ J 2021; 14:100607. [PMID: 34934469 DOI: 10.1016/j.waojou.2021.100607] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2021] [Revised: 10/15/2021] [Accepted: 10/25/2021] [Indexed: 01/01/2023] Open
Abstract
Background Infant antibiotic exposure may be associated with childhood asthma development. Objective To examine and detail this association considering potential confounders. Study design PubMed, EMBASE, Web of Science, and the Cochrane Library were searched for publications from January 2011 to March 2021. Eligible studies were independently reviewed to extract data and assess quality. Random effect model was used to pool odds ratio (OR) and corresponding 95% confidence intervals (CIs). Results A total of 52 studies were included. The association of infant antibiotic exposure and childhood asthma was statistically significant for overall analysis (OR, 1.37; 95% CI, 1.29-1.45) and for studies that addressed reverse causation (RC) and confounding by indication (CbI) (1.19; 95% CI, 1.11-1.28). Significance remained after stratification by adjustment for maternal antibiotic exposure, medical consultation, sex, smoke exposure, parental allergy, birth weight, and delivery mode. In detailed analyses, macrolides (OR, 1.56; 95% CI, 1.31-1.86), antibiotic course≥5 (OR, 1.79; 95% CI, 1.36-2.36), exposure within 1 week of birth (OR, 1.82; 95% CI, 1.34-2.47), asthma developed among 1-3 years (OR, 1.84; 95% CI, 1.63-2.08), short time lag between exposure and asthma onset (OR, 2.05; 95% CI, 1.91-2.20), persistent asthma (OR, 2.61; 95% CI, 1.49-4.59), and atopic asthma (OR, 2.14; 95% CI, 1.58-2.90) showed higher pooled estimates. Conclusion Infant antibiotic exposure is associated with increased risk of childhood asthma considering confounding, and the association varied with different settings of exposure and outcomes. This highlights the need for prevention of asthma after early antibiotic exposure. Heterogeneity among studies called for caution when interpretation.
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Tramper‐Stranders G, Ambrożej D, Arcolaci A, Atanaskovic‐Markovic M, Boccabella C, Bonini M, Karavelia A, Mingomataj E, O' Mahony L, Sokolowska M, Untersmayr E, Feleszko W. Dangerous liaisons: Bacteria, antimicrobial therapies, and allergic diseases. Allergy 2021; 76:3276-3291. [PMID: 34390006 DOI: 10.1111/all.15046] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2021] [Accepted: 07/31/2021] [Indexed: 12/15/2022]
Abstract
Microbiota composition and associated metabolic activities are essential for the education and development of a healthy immune system. Microbial dysbiosis, caused by risk factors such as diet, birth mode, or early infant antimicrobial therapy, is associated with the inception of allergic diseases. In turn, allergic diseases increase the risk for irrational use of antimicrobial therapy. Microbial therapies, such as probiotics, have been studied in the prevention and treatment of allergic diseases, but evidence remains limited due to studies with high heterogeneity, strain-dependent effectiveness, and variable outcome measures. In this review, we sketch the relation of microbiota with allergic diseases, the overuse and rationale for the use of antimicrobial agents in allergic diseases, and current knowledge concerning the use of bacterial products in allergic diseases. We urgently recommend 1) limiting antibiotic therapy in pregnancy and early childhood as a method contributing to the reduction of the allergy epidemic in children and 2) restricting antibiotic therapy in exacerbations and chronic treatment of allergic diseases, mainly concerning asthma and atopic dermatitis. Future research should be aimed at antibiotic stewardship implementation strategies and biomarker-guided therapy, discerning those patients that might benefit from antibiotic therapy.
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Affiliation(s)
- Gerdien Tramper‐Stranders
- Department of Pediatrics Franciscus Gasthuis & Vlietland Rotterdam the Netherlands
- Department of Neonatology Erasmus Medical CenterSophia Children's Hospital Rotterdam the Netherlands
| | - Dominika Ambrożej
- Department of Pediatric Pneumonology and Allergy Medical University of Warsaw Warsaw Poland
- Doctoral School Medical University of Warsaw Warsaw Poland
| | - Alessandra Arcolaci
- Immunology Unit University of Verona and General Hospital Borgo Roma Hospital Verona Italy
| | | | - Cristina Boccabella
- Department of Cardiovascular and Thoracic Sciences Università Cattolica del Sacro CuoreFondazione Policlinico Universitario A. Gemelli – IRCCS Rome Italy
| | - Matteo Bonini
- Department of Cardiovascular and Thoracic Sciences Università Cattolica del Sacro CuoreFondazione Policlinico Universitario A. Gemelli – IRCCS Rome Italy
- National Heart and Lung Institute (NHLI) Imperial College London London UK
| | - Aspasia Karavelia
- Department of Ear‐Nose‐Throat surgery General Hospital of Kozani Kozani Greece
| | - Ervin Mingomataj
- Department of Allergology & Clinical Immunology ‘Mother Theresa’ School of Medicine Tirana Albania
| | - Liam O' Mahony
- Departments of Medicine and Microbiology APC Microbiome IrelandNational University of Ireland Cork Ireland
| | - Milena Sokolowska
- Swiss Institute of Allergy and Asthma Research (SIAF) University of Zurich Zurich Switzerland
| | - Eva Untersmayr
- Institute of Pathophysiology and Allergy Research Center for Pathophysiology, Infectiology and Immunology Medical University of Vienna Vienna Austria
| | - Wojciech Feleszko
- Department of Pediatric Pneumonology and Allergy Medical University of Warsaw Warsaw Poland
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Early Life Factors Associated with Preschool Wheezing in Preterm Infants. CHILDREN-BASEL 2021; 8:children8090732. [PMID: 34572164 PMCID: PMC8468763 DOI: 10.3390/children8090732] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/23/2021] [Revised: 08/23/2021] [Accepted: 08/25/2021] [Indexed: 11/17/2022]
Abstract
Advanced neonatal care has increased the survival of neonates born prematurely, and prematurity is a well-known risk factor for asthma/wheezing disorders. Thus, this prospective study aimed to determine the early life factors associated with preschool wheezing in premature neonates. Preterm neonates born between 2012 and 2017 were recruited, excluding those with bacterial infection within 7 days of life, maternal sepsis, and maternal chorioamnionitis. Birth and admission history, comorbidities, and maternal history were documented. Respiratory problems were followed-up at the neonatal outpatient department. Patients were divided into wheezing and non-wheezing groups. Data were analyzed using the Mann-Whitney test and Fisher's exact test, and multivariable logistic regression was used to define the risk factors of preschool wheezing/asthma. A total of 125 preterm infants were enrolled, including 19 in the wheezing group and 106 in the non-wheezing group. Patients in the wheezing group had longer duration of intubation (p = 0.025), higher rates for exclusive breast milk feeding (p = 0.012), and higher re-hospitalization rates for respiratory tract infections (p < 0.001), especially for respiratory syncytial virus (RSV) bronchiolitis (p = 0.045). The incidence of allergic rhinitis was also higher in the wheezing group (p = 0.005). After multivariable logistic regression, allergic rhinitis and re-hospitalization for respiratory tract infections were two significant risk factors for preschool wheezing/asthma in premature neonates. Close follow-up of premature infants at high risk for asthma susceptibility is recommended.
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Srinivasan M, Bacharier LB, Goss CW, Zhou Y, Boomer J, Bram S, Burgdorf D, Burnham CA, Casper T, Castro M, Coverstone A, Haslam M, Kanchongkittiphon W, Kuklinski C, Lian Q, Schechtman K, Storch GA, True K, Wallace MA, Yin-DeClue H, Ahrens E, Wang J, Beigelman A. The azithromycin to prevent wheezing following severe RSV bronchiolitis-II clinical trial: Rationale, study design, methods, and characteristics of study population. Contemp Clin Trials Commun 2021; 22:100798. [PMID: 34189338 PMCID: PMC8219746 DOI: 10.1016/j.conctc.2021.100798] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2020] [Revised: 04/30/2021] [Accepted: 06/03/2021] [Indexed: 02/02/2023] Open
Abstract
Severe respiratory syncytial virus (RSV) bronchiolitis in early life is a significant risk factor for future recurrent wheeze (RW) and asthma. The goal of the Azithromycin to Prevent Wheezing following severe RSV bronchiolitis II (APW-RSV II) clinical trial is to evaluate if azithromycin treatment in infants hospitalized with RSV bronchiolitis reduces the occurrence of RW during the preschool years. The APW-RSV II clinical trial is a double-blind, placebo-controlled, parallel-group, randomized trial, including otherwise healthy participants, ages 30 days-18 months, who are hospitalized due to RSV bronchiolitis. The study includes an active randomized treatment phase with azithromycin or placebo for 2 weeks, and an observational phase of 18-48 months. Two hundred participants were enrolled during three consecutive RSV seasons beginning in the fall of 2016 and were randomized to receive oral azithromycin 10 mg/kg/day for 7 days followed by 5 mg/kg/day for an additional 7 days, or matched placebo. The study hypothesis is that in infants hospitalized with RSV bronchiolitis, the addition of azithromycin therapy to routine bronchiolitis care would reduce the likelihood of developing post-RSV recurrent wheeze (≥3 episodes). The primary clinical outcome is the occurrence of a third episode of wheezing, which is evaluated every other month by phone questionnaires and during yearly in-person visits. A secondary objective of the APW-RSV II clinical trial is to examine how azithromycin therapy changes the upper airway microbiome composition, and to determine if these changes are related to the occurrence of post-RSV RW. Microbiome composition is characterized in nasal wash samples obtained before and after the study treatments. This clinical trial may identify the first effective intervention applied during severe RSV bronchiolitis to reduce the risk of post-RSV RW and ultimately asthma.
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Key Words
- AE, Adverse events
- AESI, AEs of Special Interest
- APW, Azithromycin to Prevent Wheezing
- AZM, Azithromycin
- Asthma
- Azithromycin
- DSMB, Data safety and monitoring board
- ED, Emergency department
- ICS, Inhaled corticosteroids
- IL, Interleukin
- IRB, Institutional review board
- LRTI, Lower respiratory tract infection
- MMP-9, Matrix metallopeptidase-9
- Microbiome
- NHLBI, National Heart, Lung, and Blood Institute
- PC, Phone call
- RBEL, RSV Bronchiolitis in Early Life
- RSV, Respiratory syncytial virus
- RW, Recurrent wheezing
- RZ, Randomization
- Recurrent wheezing
- Respiratory syncytial virus (RSV) bronchiolitis
- SAE, serious adverse events
- SLCH, Saint Louis Children's Hospital
- V, visit
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Affiliation(s)
- Mythili Srinivasan
- Division of Hospitalist Medicine, Department of Pediatrics, Washington University School of Medicine, 660 S. Euclid Ave, St. Louis, MO, 63110, USA
| | - Leonard B Bacharier
- Division of Allergy, Immunology and Pulmonary Medicine, Department of Pediatrics, Washington University School of Medicine, 660 S. Euclid Ave, St. Louis, MO, 63110, USA
| | - Charles W Goss
- Division of Biostatistics, Washington University School of Medicine, 660 S. Euclid Ave, St. Louis, MO, 63110, USA
| | - Yanjiao Zhou
- Department of Medicine, University of Connecticut School of Medicine, Farmington, CT, USA
| | - Jonathan Boomer
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Washington University School of Medicine, 660 S. Euclid Ave, St. Louis, MO, 63110, USA
| | - Sarah Bram
- Division of Hospitalist Medicine, Department of Pediatrics, Washington University School of Medicine, 660 S. Euclid Ave, St. Louis, MO, 63110, USA
| | - Dana Burgdorf
- Division of Allergy, Immunology and Pulmonary Medicine, Department of Pediatrics, Washington University School of Medicine, 660 S. Euclid Ave, St. Louis, MO, 63110, USA
| | - Carey-Ann Burnham
- Department of Pathology and Immunology, Washington University School of Medicine, 660 S. Euclid Ave, St. Louis, MO, 63110, CAB, USA
| | - Timothy Casper
- Division of Hospitalist Medicine, Department of Pediatrics, Washington University School of Medicine, 660 S. Euclid Ave, St. Louis, MO, 63110, USA
| | - Mario Castro
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Washington University School of Medicine, 660 S. Euclid Ave, St. Louis, MO, 63110, USA
| | - Andrea Coverstone
- Division of Allergy, Immunology and Pulmonary Medicine, Department of Pediatrics, Washington University School of Medicine, 660 S. Euclid Ave, St. Louis, MO, 63110, USA
| | - Matthew Haslam
- Division of Allergy, Immunology and Pulmonary Medicine, Department of Pediatrics, Washington University School of Medicine, 660 S. Euclid Ave, St. Louis, MO, 63110, USA
| | - Watcharoot Kanchongkittiphon
- Division of Allergy, Immunology and Pulmonary Medicine, Department of Pediatrics, Washington University School of Medicine, 660 S. Euclid Ave, St. Louis, MO, 63110, USA
| | - Cadence Kuklinski
- Division of Allergy, Immunology and Pulmonary Medicine, Department of Pediatrics, Washington University School of Medicine, 660 S. Euclid Ave, St. Louis, MO, 63110, USA
| | - Qinghua Lian
- Division of Biostatistics, Washington University School of Medicine, 660 S. Euclid Ave, St. Louis, MO, 63110, USA
| | - Kenneth Schechtman
- Division of Biostatistics, Washington University School of Medicine, 660 S. Euclid Ave, St. Louis, MO, 63110, USA
| | - Gregory A Storch
- Division of Pediatric Infectious Disease, Department of Pediatrics, Washington University School of Medicine, 660 S. Euclid Ave, St. Louis, MO, 63110, USA
| | - Kelly True
- Division of Allergy, Immunology and Pulmonary Medicine, Department of Pediatrics, Washington University School of Medicine, 660 S. Euclid Ave, St. Louis, MO, 63110, USA
| | - Meghan A Wallace
- Department of Pathology and Immunology, Washington University School of Medicine, 660 S. Euclid Ave, St. Louis, MO, 63110, CAB, USA
| | - Huiqing Yin-DeClue
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Washington University School of Medicine, 660 S. Euclid Ave, St. Louis, MO, 63110, USA
| | - Elizabeth Ahrens
- Division of Allergy, Immunology and Pulmonary Medicine, Department of Pediatrics, Washington University School of Medicine, 660 S. Euclid Ave, St. Louis, MO, 63110, USA
| | - Jinli Wang
- Division of Biostatistics, Washington University School of Medicine, 660 S. Euclid Ave, St. Louis, MO, 63110, USA
| | - Avraham Beigelman
- Division of Allergy, Immunology and Pulmonary Medicine, Department of Pediatrics, Washington University School of Medicine, 660 S. Euclid Ave, St. Louis, MO, 63110, USA
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10
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The effects of antibiotic exposure on asthma in children with atopic dermatitis. Sci Rep 2021; 11:8526. [PMID: 33875744 PMCID: PMC8055669 DOI: 10.1038/s41598-021-87981-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2020] [Accepted: 03/15/2021] [Indexed: 11/18/2022] Open
Abstract
Early-life antibiotic use is associated with allergic diseases. The risk factors for the progression from atopic dermatitis (AD) to asthma or allergic rhinitis are still unknown. We aimed to investigate the association between exposure to different antibiotics and the risk of new-onset asthma in children with AD. By using the Longitudinal Health Insurance Database 2005, we selected AD patients less than 6 years old identified by ICD-9-CM code 691.8. The case group was defined as those having new-onset asthma, and the control group was defined as those without an asthma history. Information on antibiotic exposure in the 5 years prior to the index date was collected from drug prescription records. We estimated the adjusted odds ratio by using conditional logistic regression, adjusted for age, sex, index year, other potential risk factors and antibiotics. Antibiotic exposure was associated with the development of asthma in patients with AD (aOR = 3.68, 95% CI 2.13–6.36), particularly for patients less than 5 years old (aOR = 4.14, 95% CI 2.24–7.64) (p for trend < 0.001), even though lower cumulative antibiotic defined daily doses (DDDs) were associated with new-onset asthma occurrence. Antibiotic exposure, especially macrolide exposure, is associated with an increased risk of asthma in patients with AD.
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11
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Buendía JA, Patiño DG. Costs of Respiratory Syncytial Virus Hospitalizations in Colombia. PHARMACOECONOMICS - OPEN 2021; 5:71-76. [PMID: 32418086 PMCID: PMC7895874 DOI: 10.1007/s41669-020-00218-7] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
BACKGROUND Several clinical practice guidelines exist for the management of respiratory syncytial virus (RSV) infection, but the use and overuse of medications and medical tests with insufficient evidence of effectiveness remains substantial. OBJECTIVE This study aimed to evaluate the medical costs associated with bronchiolitis hospitalizations caused by RSV infection among infants aged < 2 years in Colombia. METHODS This was a prevalence-based cost-of-illness multicentric study performed from the societal perspective during 2016-2017. A case was defined as a laboratory-confirmed RSV infection with hospitalization. All costs and use of resources were collected directly from medical invoices and health records. RESULTS This study included 193 patients with a diagnosis of RSV. The average hospital stay duration was 5.55 days. The major contributors to hospitalization costs were room costs (31.5%), drugs (21.8%), and indirect costs (14.9%). Medications with the highest costs were nebulization with a hypertonic solution and systemic antibiotics. In total, 96% of β-lactam antibiotics, 90% of bronchodilators, and 86% of corticosteroids and epinephrine were classified as inappropriate. CONCLUSION RSV infection in Colombia places a high economic burden on the health system. Generating comprehensive data on healthcare resource use and costs associated with RSV will help to provide valuable information for the development of cost-effectiveness models and to guide RSV-prevention strategies.
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Affiliation(s)
- Jefferson Antonio Buendía
- Department of Pharmacology and Toxicology, Research Group in Pharmacology and Toxicology (INFARTO), Centro de Información y Estudio de Medicamentos y Tóxicos (CIEMTO), Faculty of Medicine, Universidad de Antioquia, Carrera 51D #62-29, Medellín, Colombia
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12
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Chang Q, Liu S, Chen Z, Zu B, Zhang H. Association between air pollutants and outpatient and emergency hospital visits for childhood asthma in Shenyang city of China. INTERNATIONAL JOURNAL OF BIOMETEOROLOGY 2020; 64:1539-1548. [PMID: 32388688 DOI: 10.1007/s00484-020-01934-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/23/2019] [Accepted: 04/30/2020] [Indexed: 06/11/2023]
Abstract
Effects of air pollution on asthma vary in different study areas, and long-term time series research on the effects of air pollution on asthma outpatients and emergency hospital visits has not been conducted in Northeast China. We assessed the impact of air pollutants on the risk of asthma outpatients and emergency hospital visits in Shenyang, China. A distributed lag non-linear model with a Poisson regression was used to assess the short-term effects of air pollutants on asthma outpatient and emergency hospital visits between January 1, 2013 and December 31, 2017. Confounding factors were adjusted using natural cubic splines. Ozone (O3), carbon monoxide (CO), and suspended particulates < 10 μm in aerodynamic diameter (PM10) were positively associated with the number of asthma hospital visits. The largest cumulative effects of O3, CO, and PM10 on hospital visits were on lag day 2 (RR = 1.163, 95% CI 1.051-1.287) for 0-5-year-old childhood asthma, on lag day 3 (RR = 1.386, 95% CI 1.136-1.69) for asthma in winter, and on lag day 10 (RR = 1.148, 95% CI 0.942-1.399) for female asthma, respectively. The cumulative effect of air pollution represented by the air quality index (AQI) was largest on lag day 10 for 0-5-year-old childhood asthma with an increase of 28.6% (95% CI 6.5-55.4) hospital visits every IQR increment of the AQI. CO, O3, and PM10 were the main air pollutants in Shenyang city. Children with bronchitis asthma were more vulnerable to air pollution during the cold season.
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Affiliation(s)
- Qing Chang
- Clinical Research Center, Shengjing Hospital of China Medical University, Huaxiang Road, No. 39, Tiexi District, Shenyang, China
| | - Shu Liu
- Department of Atmospheric Environment Monitoring Office, Environmental Monitoring Experiment Center of Liaoning Province, Shuang Road, No. 30 A3, Hunnan District, Shenyang, China
| | - Zongjiao Chen
- Department of Atmospheric Environment Monitoring Office, Environmental Monitoring Experiment Center of Liaoning Province, Shuang Road, No. 30 A3, Hunnan District, Shenyang, China
| | - Biao Zu
- Department of Atmospheric Environment Monitoring Office, Environmental Monitoring Experiment Center of Liaoning Province, Shuang Road, No. 30 A3, Hunnan District, Shenyang, China
| | - Hehua Zhang
- Clinical Research Center, Shengjing Hospital of China Medical University, Huaxiang Road, No. 39, Tiexi District, Shenyang, China.
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13
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First-Year Antibiotics Exposure in Relation to Childhood Asthma, Allergies, and Airway Illnesses. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:ijerph17165700. [PMID: 32784540 PMCID: PMC7460111 DOI: 10.3390/ijerph17165700] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Revised: 07/05/2020] [Accepted: 07/27/2020] [Indexed: 12/13/2022]
Abstract
Background: Associations of early antibiotics exposures with childhood asthma, allergies, and airway illnesses are debated. Objectives: We aimed to investigate associations of first-year antibiotics exposure with childhood asthma, allergies, and airway illnesses. Methods: A cross-sectional study was conducted among preschoolers in Shanghai, China during 2011–2012. A questionnaire regarding household environment and lifestyles and childhood health outcomes was reported by the child’s parents. Results: In total, 13,335 questionnaires (response rate: 85.3%) were analyzed and 3049 (24.1%) children had first-year antibiotics exposure. In the multivariate logistic regression analyses, first-year antibiotics exposure had significant associations with the higher odds of lifetime-ever pneumonia (adjusted OR, 95% CI: 2.15, 1.95–2.37), croup (1.46, 1.24–1.73), wheeze (1.44, 1.30–1.60), asthma (1.38, 1.19–1.61), food allergy (1.29, 1.13–1.46), and allergic rhinitis (1.23, 1.07–1.41), and as well as current (one year before the survey) common cold (≥3 times) (1.38, 1.25–1.52), dry cough (1.27, 1.13–1.42), atopic dermatitis (1.25, 1.09–1.43), wheeze (1.23, 1.10–1.38), and rhinitis symptoms (1.15, 1.04–1.26). These associations were different in children with different individual characteristics (age, sex, family history of atopy, and district) and other early exposures (breastfeeding, home decoration, pet-keeping, and environmental tobacco smoke). Conclusions: Our results indicate that first-year antibiotics exposure could be a strong risk factor for childhood pneumonia, asthma, allergies, and their related symptoms. The individual characteristics and other early exposures may modify effects of early antibiotic exposure on childhood allergies and airway illnesses.
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14
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Solé D, Matsumoto F, Wandalsen GF. Azithromycin in acute bronchiolitis. J Bras Pneumol 2020; 46:e20200285. [PMID: 32638841 PMCID: PMC7572294 DOI: 10.36416/1806-3756/e20200285] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Affiliation(s)
- Dirceu Solé
- Departamento de Pediatria, Escola Paulista de Medicina, Universidade Federal de São Paulo, São Paulo, SP, Brazil
| | - Fausto Matsumoto
- Departamento de Pediatria, Escola Paulista de Medicina, Universidade Federal de São Paulo, São Paulo, SP, Brazil
| | - Gustavo Falbo Wandalsen
- Departamento de Pediatria, Escola Paulista de Medicina, Universidade Federal de São Paulo, São Paulo, SP, Brazil
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15
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Zhang J, Zhu Z, Zuo X, Pan H, Gu Y, Yuan Y, Wang G, Wang S, Zheng R, Liu Z, Wang F, Zheng J. The role of NTHi colonization and infection in the pathogenesis of neutrophilic asthma. Respir Res 2020; 21:170. [PMID: 32620122 PMCID: PMC7333292 DOI: 10.1186/s12931-020-01438-5] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2019] [Accepted: 06/30/2020] [Indexed: 12/15/2022] Open
Abstract
Asthma is a complex heterogeneous disease. The neutrophilic subtypes of asthma are described as persistent, more severe and corticosteroid-resistant, with higher hospitalization and mortality rates, which seriously affect the lives of asthmatic patients. With the development of high-throughput sequencing technology, an increasing amount of evidence has shown that lower airway microbiome dysbiosis contributes to the exacerbation of asthma, especially neutrophilic asthma. Nontypeable Haemophilus influenzae is normally found in the upper respiratory tract of healthy adults and is one of the most common strains in the lower respiratory tract of neutrophilic asthma patients, in whom its presence is related to the occurrence of corticosteroid resistance. To understand the pathogenic mechanism by which nontypeable Haemophilus influenzae colonization leads to the progression of neutrophilic asthma, we reviewed the previous literature on nontypeable Haemophilus influenzae colonization and subsequent aggravation of neutrophilic asthma and corticosteroid resistance. We discussed nontypeable Haemophilus influenzae as a potential therapeutic target to prevent the progression of neutrophilic asthma.
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Affiliation(s)
- Jing Zhang
- Department of Intensive Care Unit, First Hospital of Jilin University, Changchun, 130021, China.,Department of Pathogen Biology, College of Basic Medical Sciences, Jilin University, Changchun, 130021, China
| | - Zhenxing Zhu
- Department of Hematology and Oncology, China-Japan Union Hospital of Jilin University, Changchun, 130033, China
| | - Xu Zuo
- Department of Pathogen Biology, College of Basic Medical Sciences, Jilin University, Changchun, 130021, China
| | - He Pan
- Department of Pathogen Biology, College of Basic Medical Sciences, Jilin University, Changchun, 130021, China
| | - Yinuo Gu
- Department of Pathogen Biology, College of Basic Medical Sciences, Jilin University, Changchun, 130021, China
| | - Yuze Yuan
- Department of Pathogen Biology, College of Basic Medical Sciences, Jilin University, Changchun, 130021, China
| | - Guoqiang Wang
- Department of Pathogen Biology, College of Basic Medical Sciences, Jilin University, Changchun, 130021, China
| | - Shiji Wang
- Department of Intensive Care Unit, First Hospital of Jilin University, Changchun, 130021, China
| | - Ruipeng Zheng
- Department of Pathogen Biology, College of Basic Medical Sciences, Jilin University, Changchun, 130021, China.,Department of Interventional Therapy, First Hospital of Jilin University, Changchun, 130021, China
| | - Zhongmin Liu
- Department of Intensive Care Unit, First Hospital of Jilin University, Changchun, 130021, China
| | - Fang Wang
- Department of Pathogen Biology, College of Basic Medical Sciences, Jilin University, Changchun, 130021, China
| | - Jingtong Zheng
- Department of Pathogen Biology, College of Basic Medical Sciences, Jilin University, Changchun, 130021, China. .,Key Laboratory of Zoonosis, Ministry of Education, College of Veterinary Medicine, Jilin University, Changchun, 130062, China.
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16
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Affiliation(s)
- Matti Korppi
- Tampere Center for Child Health Research University of Tampere and Tampere University Hospital Tampere Finland
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17
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Lopez AA, Aslanova R, Bridger N, Chafe R. Antibiotic Use for Inpatient Bronchiolitis: Did National Guidelines Impact Practice at a Pediatric Hospital? Hosp Pediatr 2020; 10:147-152. [PMID: 31953374 DOI: 10.1542/hpeds.2019-0230] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
BACKGROUND AND OBJECTIVES Bronchiolitis is a common lower respiratory tract infection that affects infants and young children. Because of variability in physician practice, inpatient management varies among pediatricians. In 2014, the Canadian Pediatric Society published national guidelines aimed at standardizing the inpatient management of this illness, which included recommending against the need for antibiotics for most patients. The study objective was to evaluate antibiotic prescription and supportive investigations for inpatient management of bronchiolitis before and after the publication of national guidelines. METHODS This study was a single-center retrospective chart review of inpatients with bronchiolitis. We included healthy children 1 to 24 months of age who were admitted from November 2011 to October 2016. Those admitted before December 2014 were analyzed in the preguidelines cohort; the remaining, in the postguidelines cohort. The main outcome was antibiotic prescription. The secondary outcome was the frequency of chest radiographs, nasopharyngeal swabs, and blood cultures. RESULTS A total of 131 patients were included in the first cohort; 71, in the second cohort. The rates of antibiotic initiation were almost equal in both cohorts (∼44%; P = .98). More antibiotics were discontinued during hospitalization in the second cohort compared with the first cohort (10% vs 20%; P = .001). Significantly fewer patients were discharged with antibiotics in the second cohort (31% vs 16%; P = .02). CONCLUSIONS Our study revealed a reduction in antibiotic use after the release of national guidelines, illustrating that antibiotic prescribing practices can change. However, there is still a pressing need for local initiatives to continue to reduce the unnecessary use of antibiotics within the pediatric setting.
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Affiliation(s)
| | - Rana Aslanova
- Memorial University of Newfoundland, St. John's, Newfoundland and Labrador, Canada
| | - Natalie Bridger
- Memorial University of Newfoundland, St. John's, Newfoundland and Labrador, Canada
| | - Roger Chafe
- Memorial University of Newfoundland, St. John's, Newfoundland and Labrador, Canada
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