Emergency Department Management of Febrile Respiratory Illness in Children

External validation of two clinical prediction models for pediatric pneumonia

OBJECTIVE

To externally validate two prediction models for pediatric radiographic pneumonia.

METHODS

We prospectively evaluated the performance of two prediction models (Pneumonia Risk Score [PRS] and CARPE DIEM models) from a prospective convenience sample of children 90 days - 18 years of age from a pediatric emergency department undergoing chest radiography for suspected pneumonia between January 1, 2022, to December 31st, 2023. We evaluated model performance using the original intercepts and coefficients and evaluated for performance changes when performing recalibration and re-estimation procedures.

RESULTS

We included 202 patients (median age 3 years, IQR 1-6 years), of whom radiographic pneumonia was found in 92 (41.0%). The PRS model had an area under the receiver operator characteristic curve of 0.72 (95% confidence interval [CI] 0.64-0.79), which was higher than the CARPE DIEM (0.59; 95% CI 0.51-0.67) (P<0.01). Using optimal cutpoints, the PRS model showed higher sensitivity (65.2%, 95% CI 54.6-74.9) and specificity (72.7%, 95% CI 63.4-80.8) compared to the CARPE DIEM model (sensitivity 56.5 [95% CI 45.8-66.8]; specificity 60.9 [95% CI 50.2-69.2]). Recalibration and re-estimation of models improved performance, particularly for the CARPE DIEM model, with gains in sensitivity and specificity, and improved calibration.

CONCLUSION

The PRS model demonstrated better performance than the CARPE DIEM model in predicting radiographic pneumonia. Among children with a high rate of pneumonia, these models did not reach a level of performance sufficient to be used independently of clinical judgement. These findings highlight the need for further validation and improvement of models to enhance their utility.

Community-Acquired Pneumonia Diagnosis Following Emergency Department Visits for Respiratory Illness

Community-acquired pneumonia (CAP) is often considered for children presenting to the emergency department (ED) with respiratory symptoms. It is unclear how often children are diagnosed with CAP following an ED visit for respiratory illness. We performed a retrospective case-control study to evaluate 7-day CAP diagnosis among children 3 months to 18 years discharged from the ED with respiratory illness from 2011 to 2021 and who receive care at 4 hospital-affiliated primary care clinics. Logistic regression was performed to assess for predictors of 7-day CAP diagnosis. Seventy-four (0.7%, 95% confidence interval [CI] = 0.6%, 0.9%) of 10 329 children were diagnosed with CAP within 7 days, and fever at the index visit was associated with increased odds of diagnosis (odds ratio [OR] = 3.32, 95% CI = 1.75-6.28). Community-acquired pneumonia diagnosis after discharge from the ED with respiratory illness is rare, even among children who are febrile at time of initial evaluation.

The Importance of Subspecialty Pediatricians to the Health and Wellbeing of the Nation's Children

Through this review of published literature, it is clear that children benefit in measurable ways when they receive care from trained pediatric subspecialists. The improved outcomes provided by pediatric subspecialists supports the care provided in the patient's pediatric medical home and emphasizes the importance of care coordination between all components of the pediatric workforce. The AAP highlights this in a recent policy statement by stating the care provided by pediatric clinicians "encompasses diagnosis and treatment of acute and chronic health disorders; management of serious and life-threatening illnesses; and when appropriate, referral of patients with more complex conditions for medical subspecialty or surgical specialty care" Explicit in this statement is the emphasis on the role of complex care coordination between pediatric specialist and primary care pediatricians and that collaboration and guidance by the pediatrician is central to providing optimal care of patients. ⁶⁵ Improving health outcomes early in life is an important public health strategy for modifying the complications from childhood chronic disease and highlights the role of pediatricians in mitigating the long-term consequences of antecedents of adult disease. ⁶⁶ The recent announcement of the National Academies of Science, Engineering, and Medicine (NASEM)'s plan for a Consensus Study on The Pediatric Subspecialty Workforce and Its Impact on Child Health and Well-being is a related and exciting development, on a national scale. ⁶⁷ In response to shortages and geographic maldistributions of pediatric subspecialists, the NASEM committee intends to assess the impact of current pediatric clinical workforce trends on child health and well-being, in order to develop informed strategies to ensure an adequate, high-quality pediatric workforce, with a robust research portfolio that informs those recommendations. While this large, national initiative will surely lead to a better understanding of and strategies to implement across the pediatric subspecialty workforce, more well-designed studies that specifically measure child outcomes related to access to pediatric subspecialty care, would add meaningfully to the body of pediatric literature and to our national pediatric advocacy initiatives.

Factors Associated With Clinician Self-Reported Resource Use in Acute Care and Ambulatory Pediatrics

The objective of this study is to determine predictors of resource use among pediatric providers for common respiratory illnesses. We surveyed pediatric primary care, emergency department (ED)/urgent care (UC), and hospital medicine providers at a free-standing children's hospital system. Five clinical vignettes assessed factors affecting resource use for upper respiratory infections, bronchiolitis, and pneumonia, including provider-type, practice location, tolerance to uncertainty, and medical decision-making behaviors. The response rate was 75.3% (168/223). The ED/UC and primary care providers had higher vignette scores, indicating higher resource use, compared with inpatient providers; advanced practice providers (APPs) had higher vignette scores compared with physicians. In multivariate analysis, being an ED/UC provider, an APP, and greater concern for bad outcomes were associated with higher vignette scores. Overall, provider type and location of practice may predict resource use for children with respiratory illnesses. Interventions targeted at test-maximizing providers may improve quality of care and reduce resource burden.

Impact of Viral Radiographic Features on Antibiotic Treatment for Pediatric Pneumonia

BACKGROUND/OBJECTIVES

Chest radiograph (CXR) is routinely performed among children with suspected pneumonia, though it is not clear how specific radiographic findings impact antibiotic treatment for pneumonia. We evaluated the impact of viral radiographic features on antibiotic treatment among children undergoing pneumonia evaluation in the emergency department (ED).

METHODS

Children presenting to a pediatric ED who underwent a CXR for pneumonia evaluation were prospectively enrolled. Prior to CXR performance, physicians indicated their level of suspicion for pneumonia. The CXR report was reviewed to assess for the presence of viral features (peribronchial cuffing, perihilar markings, and interstitial infiltrate) as well as radiographic features suggestive of pneumonia (consolidation, infiltrate, and opacity). The relationship between viral radiographic features and antibiotic treatment was assessed based on the level of clinical suspicion for pneumonia prior to CXR.

RESULTS

Patients with normal CXRs (n = 400) and viral features alone (n = 370) were managed similarly, with 8.0% and 8.6% of patients receiving antibiotic treatment, respectively (P = .75). Compared with children with radiographic pneumonia (n = 174), patients with concurrent viral features and radiographic pneumonia (n = 177) were treated with antibiotics less frequently (86.2% vs 54.3%, P < .001). Among children with isolated viral features on CXR, antibiotic treatment rates were correlated with pre-CXR level of suspicion for pneumonia.

CONCLUSIONS

Among children with suspected pneumonia, the presence of viral features alone on CXR is not associated with increased rates of antibiotic use. Among children with radiographic pneumonia, the addition of viral features on CXR is associated with lower rates of antibiotic use, as compared to children with radiographic pneumonia alone.

Guideline Adherence in Diagnostic Testing and Treatment of Community-Acquired Pneumonia in Children

OBJECTIVES

The objective of this study was to determine emergency department (ED) physician adherence with the 2011 Pediatric Infectious Diseases Society (PIDS) and Infectious Diseases Society of America (IDSA) guidelines for outpatient management of children with mild-to-moderate community-acquired pneumonia (CAP).

METHODS

A cross-sectional survey of physicians on the American Academy of Pediatrics Section on Emergency Medicine Survey listserv was conducted. We evaluated ED physicians' reported adherence with the PIDS/IDSA guidelines through presentation of 4 clinical vignettes representing mild-to-moderate CAP of presumed viral (preschool-aged child), bacterial (preschool and school-aged child), and atypical bacterial (school-aged child) etiology.

RESULTS

Of 120 respondents with analyzable data (31.4% response rate), use of chest radiograph (CXR) was nonadherent to the guidelines in greater than 50% of respondents for each of the 4 vignettes. Pediatric emergency medicine fellowship training was independently associated with increased CXR use in all vignettes, except for school-aged children with bacterial CAP. Guideline-recommended amoxicillin was selected to treat bacterial CAP by 91.7% of the respondents for preschool-aged children and by 75.8% for school-aged children. Macrolide monotherapy for atypical CAP was appropriately selected by 88.2% and was associated with obtaining a CXR (adjusted odds ratio, 3.9 [95% confidence interval, 1.4-11.1]). Guideline-adherent antibiotic use for all vignettes was independently associated with congruence between respondent's presumed diagnosis and the vignette's intended etiologic diagnosis.

CONCLUSIONS

Reported ED CXR use in the management of outpatient CAP was often nonadherent to the PIDS/IDSA guidelines. Most respondents were adherent to the guidelines in their use of antibiotics. Strategies to increase diagnostic test accuracy are needed to improve adherence and reduce variation in care.

Shortness of breath in children at the emergency department: Variability in management in Europe

OBJECTIVE

Our aim was to describe variability in resource use and hospitalization in children presenting with shortness of breath to different European Emergency Departments (EDs) and to explore possible explanations for variability.

DESIGN

The TrIAGE project, a prospective observational study based on electronic health record data.

PATIENTS AND SETTING

Consecutive paediatric emergency department visits for shortness of breath in five European hospitals in four countries (Austria, Netherlands, Portugal, United Kingdom) during a study period of 9-36 months (2012-2014).

MAIN OUTCOME MEASURES

We assessed diversity between EDs regarding resource use (diagnostic tests, therapy) and hospital admission using multivariable logistic regression analyses adjusting for potential confounding variables.

RESULTS

In total, 13,552 children were included. Of those, 7,379 were categorized as immediate/very urgent, ranging from 13-80% in the participating hospitals. Laboratory tests and X-rays were performed in 8-33% of the cases and 21-61% was treated with inhalation medication. Admission rates varied between 8-47% and PICU admission rates varied between 0.1-9%. Patient characteristics and markers of disease severity (age, sex, comorbidity, urgency, vital signs) could explain part of the observed variability in resource use and hospitalization. However, after adjusting for these characteristics, we still observed substantial variability between settings.

CONCLUSION

European EDs differ substantially regarding the resource use and hospitalization in children with shortness of breath, even when adjusting for patient characteristics. Possible explanations for this variability might be unmeasured patient characteristics such as underlying disease, differences in guideline use and adherence or different local practice patterns.

The influence of chest X-ray results on antibiotic prescription for childhood pneumonia in the emergency department

The aim of this study is to evaluate the influence of chest X-ray (CXR) results on antibiotic prescription in children suspected of lower respiratory tract infections (RTI) in the emergency department (ED). We performed a secondary analysis of a stepped-wedge, cluster randomized trial of children aged 1 month to 5 years with fever and cough/dyspnoea in 8 EDs in the Netherlands (2016-2018), including a 1-week follow-up. We analysed the observational data of the pre-intervention period, using multivariable logistic regression to evaluate the influence of CXR result on antibiotic prescription. We included 597 children (median age 17 months [IQR 9-30, 61% male). CXR was performed in 109/597 (18%) of children (range across hospitals 9 to 50%); 52/109 (48%) showed focal infiltrates. Children who underwent CXR were more likely to receive antibiotics, also when adjusted for clinical signs and symptoms, hospital and CXR result (OR 7.25 [95% CI 2.48-21.2]). Abnormalities on CXR were not significantly associated with antibiotic prescription.Conclusion: Performance of CXR was independently associated with more antibiotic prescription, regardless of its results. The limited influence of CXR results on antibiotic prescription highlights the inferior role of CXR on treatment decisions for suspected lower RTI in the ED. What is Known: • Chest X-ray (CXR) has a high inter-observer variability and cannot distinguish between bacterial or viral pneumonia. • Current guidelines recommend against routine use of CXR in children with uncomplicated respiratory tract infections (RTIs) in the outpatient setting. What is New: • CXR is still frequently performed in non-complex children suspected of lower RTIs in the emergency department • CXR performance was independently associated with more antibiotic prescriptions, regardless of its results, highlighting the inferior role of chest X-rays in treatment decisions.

Age, Period and Cohort Analysis of Rates of Emergency Department Visits Due to Pneumonia in Taiwan, 1998-2012

Background

Emergency room (ER) physicians need to face clinically suspected pneumonia patients in the front line of medical care and must do to give major medical interventions if patients show severity in pneumonia.

Methods

The data of pneumonia-related ER visit rates were categorized based on the International Classification of Disease (ICD) Codes (480–486) between 1998 and 2012. We use an age-period-cohort (APC) model to separate the pneumonia-related ER visit rates to identify the effects of age, time period, and cohort for a total of 1,813,588 patients.

Results

The age effect showed high risk for pediatric and elder populations. There is a significant increasing period effect, which increased from 1998 to 2012. The cohort effect tended to show an oscillation from 1913 to 1988 and the reverse in a recent cohort. Furthermore, the visit rate of pneumonia showed an increase from 1998 to 2012 for both genders.

Conclusion

Age is a risk factor for pneumonia-related ER visits, especially for children and adolescents and older patients. Period and cohort effects were also found to increase the pneumonia visit rates. An APC model used to provide an advance clue for trend of pneumonia-related ER visit rates diversified.

Cepheid Xpert® Flu/RSV and Seegene Allplex™ RP1 show high diagnostic agreement for the detection of influenza A/B and respiratory syncytial viruses in clinical practice

Background

Molecular assays based on reverse transcription‐polymerase chain reaction (RT‐PCR) provide reliable results for the detection of respiratory pathogens, although diagnostic agreement varies. This study determined the agreement between the RT‐PCR assays (Xpert^® Flu/RSV vs Allplex^™ RP1) in detecting influenza A, influenza B, and respiratory syncytial viruses (RSVs) in clinical practice.

Methods

We retrospectively identified 914 patient encounters where testing with both Xpert^® Flu/RSV and Allplex^™ RP1 was undertaken between October 2015 and September 2019 in seven hospitals across New South Wales, Australia. The diagnostic agreement of the two assays was evaluated using positive percent agreement, negative percent agreement, and prevalence and bias‐adjusted kappa.

Results

The positive percent agreement was 95.1% for influenza A, 87.5% for influenza B, and 77.8% for RSV. The negative percent agreement was 99.4% for influenza A, 99.9% for influenza B, and 100% for RSV. The prevalence and bias‐adjusted kappa was 0.98 for influenza A, 0.99 for influenza B, and 0.97 for RSV. In a sensitivity analysis, the positive percent agreement values were significantly higher during the non‐influenza season than the influenza season for influenza B and RSV.

Conclusions

The Xpert^® Flu/RSV and Allplex^™ RP1 demonstrated a high diagnostic agreement for all three viruses assessed. The seasonal variation in the positive percent agreement of the two assays for influenza B and RSV may have been due to lower numbers assessed, variability in the virology of infections outside the peak season, or changes in the physiology of the infected host in different seasons.

Antibiotic Prescribing for Viral Respiratory Infections in the Pediatric Emergency Department and Urgent Care

BACKGROUND

Viral acute respiratory tract infections (vARTI) are a frequent source of inappropriate antibiotic prescribing. We describe the prevalence of antibiotic prescribing for vARTI in the pediatric emergency department (ED) and urgent care (UC) within a health system, and identify factors associated with overall and broad-spectrum antibiotic prescribing.

METHODS

Retrospective chart review within a single pediatric referral health system. Visits of patients, 3 months- 17 years old, with a discharge diagnosis of a vARTI from 2010 to 2015. Data collected included specific vARTI diagnosis, site type (ED or UC), provider type [pediatric emergency medicine subspecialist or physicians, nurse practitioners, physician assistants (non-PEM)] and discharge antibiotics. Odds ratios and 95% confidence intervals (CI) were calculated where appropriate.

RESULTS

There were 132,458 eligible visits, mean age 4.1 ± 4.3 years. Fifty-three percent were treated in an ED. Advanced practice providers, a term encompassing nurse practitioners and physician assistants, were the most common provider type (47.7%); 16.5% of patients were treated by a pediatric emergency medicine subspecialist. Antibiotics were prescribed for 3.8% (95% CI: 3.72-3.92) of children with vARTI; 25.4% (95% CI: 24.2-26.6) of these were broad-spectrum, most commonly first-generation cephalosporins (11%; 95% CI 10.2-11.9). Patients treated in an ED or by a non-PEM and those receiving chest radiograph (CXR) received antibiotics most frequently. Prescribing rates varied by specific vARTI diagnosis.

CONCLUSIONS

Patients discharged from the pediatric ED or UC with vARTI receive inappropriate antibiotics at a lower rate than reported in other community settings; however, they frequently receive broad-spectrum agents.

Antibiotic Prescribing for Children in United States Emergency Departments: 2009-2014

: media-1vid110.1542/5972296744001PEDS-VA_2018-1056Video Abstract OBJECTIVES: To characterize and compare ambulatory antibiotic prescribing for children in US pediatric and nonpediatric emergency departments (EDs).

METHODS

A cross-sectional retrospective study of patients aged 0 to 17 years discharged from EDs in the United States was conducted by using the 2009-2014 National Hospital Ambulatory Medical Care Survey ED data. We estimated the proportion of ED visits resulting in antibiotic prescriptions, stratified by antibiotic spectrum, class, diagnosis, and ED type ("pediatric" defined as >75% of visits by patients aged 0-17 years, versus "nonpediatric"). Multivariable logistic regression was used to determine factors independently associated with first-line, guideline-concordant prescribing for acute otitis media, pharyngitis, and sinusitis.

RESULTS

In 2009-2014, of the 29 million mean annual ED visits by children, 14% (95% confidence interval [CI]: 10%-20%) occurred at pediatric EDs. Antibiotics overall were prescribed more frequently in nonpediatric than pediatric ED visits (24% vs 20%, P < .01). Antibiotic prescribing frequencies were stable over time. Of all antibiotics prescribed, 44% (95% CI: 42%-45%) were broad spectrum, and 32% (95% CI: 30%-34%, 2.1 million per year) were generally not indicated. Compared with pediatric EDs, nonpediatric EDs had a higher frequency of prescribing macrolides (18% vs 8%, P < .0001) and a lower frequency of first-line, guideline-concordant prescribing for the respiratory conditions studied (77% vs 87%, P < .001).

CONCLUSIONS

Children are prescribed almost 7 million antibiotic prescriptions in EDs annually, primarily in nonpediatric EDs. Pediatric antibiotic stewardship efforts should expand to nonpediatric EDs nationwide, particularly regarding avoidance of antibiotic prescribing for conditions for which antibiotics are not indicated, reducing macrolide prescriptions, and increasing first-line, guideline-concordant prescribing.

Antibiotic Use in Febrile Children Presenting to the Emergency Department: A Systematic Review

Introduction: While fever is the main complaint among pediatric emergency services and high antibiotic prescription are observed, only a few studies have been published addressing this subject. Therefore this systematic review aims to summarize antibiotic prescriptions in febrile children at the ED and assess its determinants. Methods: We extracted studies published from 2000 to 2017 on antibiotic use in febrile children at the ED from different databases. Author, year, and country of publishing, study design, inclusion criteria, primary outcome, age, and number of children included in the study was extracted. To compare the risk-of-bias all articles were assessed using the MINORS criteria. For the final quality assessment we additionally used the sample size and the primary outcome. Results: We included 26 studies reporting on antibiotic prescription and 28 intervention studies on the effect on antibiotic prescription. In all 54 studies antibiotic prescriptions in the ED varied from 15 to 90.5%, pending on study populations and diagnosis. Respiratory tract infections were mostly studied. Pediatric emergency physicians prescribed significantly less antibiotics then general emergency physicians. Most frequent reported interventions to reduce antibiotics are delayed antibiotic prescription in acute otitis media, viral testing and guidelines. Conclusion: Evidence on antibiotic prescriptions in children with fever presenting to the ED remains inconclusive. Delayed antibiotic prescription in acute otitis media and guidelines for fever and respiratory infections can effectively reduce antibiotic prescription in the ED. The large heterogeneity of type of studies and included populations limits strict conclusions, such a gap in knowledge on the determining factors that influence antibiotic prescription in febrile children presenting to the ED remains.

Rapid Tests for Influenza, Respiratory Syncytial Virus, and Other Respiratory Viruses: A Systematic Review and Meta-analysis

Rapid diagnosis of respiratory virus infections contributes to patient care. This systematic review evaluates the diagnostic accuracy of rapid tests for the detection of respiratory viruses. We searched Medline and EMBASE for studies evaluating these tests against polymerase chain reaction as the reference standard. Of 179 studies included, 134 evaluated rapid tests for influenza viruses, 32 for respiratory syncytial virus (RSV), and 13 for other respiratory viruses. We used the bivariate random effects model for quantitative meta-analysis of the results. Most tests detected only influenza viruses or RSV. Summary sensitivity and specificity estimates of tests for influenza were 61.1% and 98.9%. For RSV, summary sensitivity was 75.3%, and specificity, 98.7%. We assessed the quality of studies using the Quality Assessment of Diagnostic Accuracy Studies (QUADAS-2) checklist. Because of incomplete reporting, the risk of bias was often unclear. Despite their intended use at the point of care, 26.3% of tests were evaluated in a laboratory setting. Although newly developed tests seem more sensitive, high-quality evaluations of these tests are lacking.

Reliability of Examination Findings in Suspected Community-Acquired Pneumonia

BACKGROUND

The authors of national guidelines emphasize the use of history and examination findings to diagnose community-acquired pneumonia (CAP) in outpatient children. Little is known about the interrater reliability of the physical examination in children with suspected CAP.

METHODS

This was a prospective cohort study of children with suspected CAP presenting to a pediatric emergency department from July 2013 to May 2016. Children aged 3 months to 18 years with lower respiratory signs or symptoms who received a chest radiograph were included. We excluded children hospitalized ≤14 days before the study visit and those with a chronic medical condition or aspiration. Two clinicians performed independent examinations and completed identical forms reporting examination findings. Interrater reliability for each finding was reported by using Fleiss' kappa (κ) for categorical variables and intraclass correlation coefficient (ICC) for continuous variables.

RESULTS

No examination finding had substantial agreement (κ/ICC > 0.8). Two findings (retractions, wheezing) had moderate to substantial agreement (κ/ICC = 0.6-0.8). Nine findings (abdominal pain, pleuritic pain, nasal flaring, skin color, overall impression, cool extremities, tachypnea, respiratory rate, and crackles/rales) had fair to moderate agreement (κ/ICC = 0.4-0.6). Eight findings (capillary refill time, cough, rhonchi, head bobbing, behavior, grunting, general appearance, and decreased breath sounds) had poor to fair reliability (κ/ICC = 0-0.4). Only 3 examination findings had acceptable agreement, with the lower 95% confidence limit >0.4: wheezing, retractions, and respiratory rate.

CONCLUSIONS

In this study, we found fair to moderate reliability of many findings used to diagnose CAP. Only 3 findings had acceptable levels of reliability. These findings must be considered in the clinical management and research of pediatric CAP.

Predictors for under-prescribing antibiotics in children with respiratory infections requiring antibiotics

BACKGROUND/OBJECTIVE

Previous studies showed variability in the use of diagnostic and therapeutic resources for children with febrile acute respiratory tract infections (ARTI), including antibiotics. Unnecessary antibiotic use has important public and individual health outcomes, but missed antibiotic prescribing also has important consequences. We sought to determine factors associated with antibiotic prescribing in pediatric ARTI, specifically those with pneumonia.

METHODS

We assessed national trends in the evaluation and treatment of ARTI for pediatric emergency department (ED) patients by analyzing the National Hospital Ambulatory Medical Care Survey from 2002 to 2013. We identified ED patients aged ≤18 with a reason for visit of ARTI, and created 4 diagnostic categories: pneumonia, ARTI where antibiotics are typically indicated, ARTI where antibiotics are typically not indicated, and "other" diagnoses. Our primary outcome was factors associated with the administration or prescription of antibiotics. A multivariate logistic regression model was fit to identify risk factors for underuse of antibiotics when they were indicated.

RESULTS

We analyzed 6461 visits, of which 10.2% of the population had a final diagnosis of pneumonia and 86% received antibiotics. 41.5% of patients were diagnosed with an ARTI requiring antibiotics, of which 53.8% received antibiotics. 26.6% were diagnosed with ARTI not requiring antibiotics, of which 36.0% received antibiotics. Black race was a predictor for the underuse of antibiotics in ARTIs that require antibiotics (OR: 0.72; 95% CI: 0.58-0.90).

CONCLUSIONS

For pediatric patients presenting to the ED with pneumonia and ARTI requiring antibiotics, we found that black race was an independent predictor of antibiotic underuse.