Therapeutic approach to bronchiolitis: why pediatricians continue to overprescribe drugs?

Factors Associated with Inhaled Bronchodilator and Oral Corticosteroid Use in Young Children with First Lower Respiratory Tract Infection

OBJECTIVES

To examine factors associated with claims for and potential overuse of inhaled bronchodilators (IBs) and oral corticosteroids (OCSs) for children <2 years old at first lower respiratory tract infections (LRTIs).

STUDY DESIGN

Retrospective cohort study using Colorado All Payer Claims data from 2009 through 2019. Children with asthma were excluded. Primary outcomes were 1) IB and 2) OCS claims within 7 days of index LRTI. Primary predictors were previous IB or OCS claims for each outcome respectively. Covariates included demographics, atopy, family history of asthma, complex chronic conditions, prior inhaled corticosteroid claim, and location of index LRTI. Separate multivariable logistic regression models were used for each outcome.

RESULTS

Of 10 194 eligible children, 1468 (14.4%) had an IB and 741 (7.3%) an OCS claim at or within 7 days of index LRTI. Index LRTIs were most often at outpatient visits (64%). Adjusting for covariates, prior IB prescription was associated with the IB outcome (aOR 1.9; 95% CI 1.3, 2.8), and prior OCS prescription was associated with the OCS outcome (AOR 2.2; 95% CI 1.7, 2.9). Other variables associated with either outcome included age, sex, insurance, location, and atopy. Prior inhaled corticosteroid claim, asthma family history, and complex chronic conditions were not associated with either outcome.

CONCLUSIONS

This study identifies factors that might serve as opportunities for de-implementation strategies for IB and OCS overuse in young children with LRTI.

Different Pediatric Acute Care Settings Influence Bronchiolitis Management: A 10-Year Retrospective Study

Bronchiolitis is the main cause of hospitalization in infants. Diagnosis is clinical, and treatment is based on hydration and oxygen therapy. Nevertheless, unnecessary diagnostic tests and pharmacological treatments are still very common. This retrospective study aimed to evaluate whether the setting of bronchiolitis care influences diagnostic and therapeutic choices. The management of 3201 infants, referred to our Italian Tertiary Care Center for bronchiolitis between 2010 and 2020, was analyzed by comparing children discharged from the pediatric emergency department (PEDd group) undergoing short-stay observation (SSO group) and hospitalization. Antibiotic use in PEDd, SSO, and ward was 59.3% vs. 51.6% vs. 49.7%, respectively (p < 0.001); inhaled salbutamol was mainly administered in PEDd and during SSO (76.1% and 82.2% vs. 38.3% in ward; p < 0.001); the use of corticosteroids was higher during SSO and hospitalization (59.6% and 49.1% vs. 39.0% in PEDd; p < 0.001); inhaled adrenaline was administered mostly in hospitalized infants (53.5% vs. 2.5% in SSO and 0.2% in PEDd; p < 0.001); chest X-ray use in PEDd, SSO, and ward was 30.3% vs. 49.0% vs. 70.5%, respectively (p < 0.001). In a multivariate analysis, undergoing SSO was found to be an independent risk factor for the use of systemic corticosteroid and salbutamol; being discharged at home was found to be a risk factor for antibiotic prescription; undergoing SSO and hospitalization resulted as independent risk factors for the use of CXR. Our study highlights that different pediatric acute care settings could influence the management of bronchiolitis. Factors influencing practice may include a high turnover of PED medical staff, personal reassurance, and parental pressure.

A comparison of individual and ecological indicators of social deprivation and their association with hospital efficiency in the context of infectious diseases in two French general paediatric departments

BACKGROUND

To identify deprivation indicators usable in everyday practice and included in medico-administrative databases, particularly with infectious diseases, which represent the greatest proportion of hospitalizations. Our objective was to compare ecological indicators to individual questionnaires and apply both types to the study of the impact of deprivation on hospital efficiency.

METHODS

We conducted an epidemiological observational prospective multicentre study in two French public hospitals between 20 October 2016 and 20 March 2017. Children hospitalized for one of the four most common infectious diseases were included and their parents were asked to answer the Evaluation of Precarity and Inequalities in Health Examination Centers (EPICES) questionnaire. The ecological indicator French DEPrivation index (FDep) was derived from patients' address, both at the zip code and at a smaller geographical area (IRIS [ilôts de regroupement pour l'information statistique]) level. Correlation and concordance between the three indicators were assessed. The endpoint used to assess the impact on hospital efficiency was the ratio between patients' length of stay (LOS) and the national LOS of their disease-related group.

RESULTS

Data were available for 540 patients with a mean age of 9 mo. A total of 56.1% of patients were considered deprived with EPICES, 50.4% with zip code FDep and 45.7% with IRIS FDep. Concordance between EPICES and either type of FDep was <0.1. There was no increase in LOS compared with national LOS with any of the indicators.

CONCLUSIONS

Individual and ecological indicators do not measure the same aspects of deprivation. The decision to use one or the other must be carefully weighed when studying the impact of deprivation on the healthcare system.

Les β2-agonistes pour la bronchiolite virale

Question

Au mois de février, un bébé de 9 mois est amené à ma clinique d’urgence rurale après un épisode de 2 jours de toux et de congestion, et de 1 jour de difficultés respiratoires. Une auscultation des poumons révèle des sons diffus, de faibles sibilances et des crépitants. En tenant compte de l’âge du bébé, de la symptomatologie et de la saison hivernale, le diagnostic probable est une bronchiolite. Les β2-agonistes inhalés sont-ils un traitement approprié pour un tel patient?

Réponse

Il n’est pas indiqué d’utiliser des β2-agonistes inhalés chez les enfants de 2 ans et moins souffrant de bronchiolite. La sibilance fait le plus souvent partie des critères diagnostiques d’une bronchiolite, qui est une infection virale des voies respiratoires inférieures chez les jeunes enfants. Au contraire de l’asthme, la bronchiolite ne compte pas parmi ses symptômes la contraction des muscles lisses du poumon. Le traitement de la bronchiolite exige des soins de soutien, et il n’a pas été démontré que les interventions pharmacologiques, comme les β2-agonistes, les corticostéroïdes et les antibiotiques, raccourcissaient la durée de la maladie, diminuaient sa gravité ou réduisaient les taux d’hospitalisation. Il pourrait y avoir un sous-groupe de nourrissons souffrant de bronchiolite qui répondraient à un traitement aux β2-agonistes; toutefois, ce groupe n’a pas encore été entièrement défini dans la littérature jusqu’ici.

[Not Available]

Question

A 9-month-old baby presented to my rural emergency department with 2 days of cough and congestion and 1 day of breathing difficulties in the month of February. An auscultation examination of the lungs indicated there were scattered, faint wheezes and coarse sounds. Based on the baby’s age, symptomatology, and the winter season, the likely diagnosis was bronchiolitis. Are inhaled β₂-agonists an appropriate treatment for this patient?

Answer

The use of inhaled β₂-agonists in children younger than 2 years of age with bronchiolitis is not indicated. Wheezing is most commonly part of the diagnosis of bronchiolitis, a lower respiratory viral infection in young children. Unlike with asthma, smooth muscle constriction in the lungs is not a symptom of bronchiolitis. Treatment of bronchiolitis requires supportive care, but pharmaceutical interventions such as β₂-agonists, steroids, and antibiotics have not been shown to decrease length of illness, illness severity, or hospitalization rates. There may be a subgroup of infants with bronchiolitis who respond to β₂-agonists treatment; however, this group has not been fully identified in the literature to date.

Acute bronchiolitis in Switzerland - Current management and comparison over the last two decades

BACKGROUND

Although international guidelines and Cochrane reviews emphasize that therapies do not alter the natural course of acute viral bronchiolitis (AVB), they are still prescribed frequently. This survey evaluated self-reported management of AVB by Swiss pediatricians in 2019 and compared it with previous surveys.

METHODS

We performed a cross-sectional online survey of all board-certified pediatricians in Switzerland in November 2019 and compared the reported use of therapies with that reported in the 2001 and 2006 surveys. We used multivariable ordered logistic regression to assess factors associated with reported prescription of bronchodilators, corticosteroids, antibiotics, and physiotherapy.

RESULTS

Among 1618 contacted board-certified pediatricians, 884 returned the questionnaires (55% response rate). After exclusions were applied, 679 were included in the final analysis. Pediatricians working in primary care reported using therapeutics more frequently than those working in a hospital setting, either always or sometimes: bronchodilators 53% versus 38%, corticosteroids 37% versus 23%, and antibiotics 39% versus 22%. The opposite occurred with physiotherapy: 53% reported prescribing it in hospital and 44% in primary care. There was an overall decrease in the prescription of therapeutics and interventions for AVB from 2001 to 2019. The proportion who reported "always" prescribing corticosteroids decreased from 71% to 2% in primary care, and of those "always" prescribing bronchodilators from 55% to 1% in hospitals.

CONCLUSION

Although we observed a significant decrease since 2001, more effort is required to reduce the use of unnecessary therapies in children with AVB.

Management of Hospitalized Respiratory Syncytial Virus Bronchiolitis in the Pediatric Ward in Spain: Assessing the Impact of a New Clinical Practice Protocol

BACKGROUND

Bronchiolitis caused by the respiratory syncytial virus (RSV) is the main reason for hospitalization in infants. Supportive care is the mainstay of treatment, and tests are restricted to a few indications. During 2015, our hospital bronchiolitis protocol (2015 HBP) was updated according to the latest practice guidelines.

OBJECTIVE

The objective of this study was to assess implementation of the 2015 HBP and the clinical outcome of children aged ≤ 24 months with RSV bronchiolitis admitted to a pediatric ward.

METHODS

We compared the use of treatments and tests, hospital length of stay (LOS), and oxygen requirements before implementation of the 2015 HBP (2014-2015 and 2015-2016 seasons) and after implementation (2016-2017 and 2017-2018 seasons).

RESULTS

The study population comprised 251 children (44.90%) in the first period and 308 (55.10%) in the second (median age 99 days, interquartile range 44-233). After implementation of the 2015 HBP, a statistically significant reduction was found in the percentage of patients undergoing the following treatments or diagnostic tests: salbutamol, from 57.77 to 31.17% (p < 0.001); epinephrine, from 61.75 to 1.30% (p < 0.001); 3% hypertonic saline, from 70.12 to 6.82% (p < 0.001); antibiotics, from 33.07 to 23.05% (p = 0.008); and chest X-ray, from 43.82 to 31.17% (p = 0.001). No statistically significant reductions were observed in the use of corticosteroids and blood tests. Hospital LOS and oxygen requirements were similar in each period.

CONCLUSIONS

Appropriate implementation of the 2015 HBP in the pediatric ward improves the use of medication and chest X-ray without modifying clinical outcomes. However, further efforts are needed to reduce the use of salbutamol, corticosteroids, and blood tests.

An outbreak of RSV infections in a neonatology clinic during the RSV-season

BACKGROUND

Respiratory syncytial virus (RSV) is the predominant cause of lower respiratory tract infections (LRTI) in infancy. Preterm infants with bronchopulmonary dysplasia (BPD) are at the highest risk of severe RSV-LRTI. This is a retrospective study that analyses a nosocomial outbreak of RSV infections in the Neonatology clinic of the University Hospital of Obstetrics and Gynecology, Sofia, 2019.

METHODS

Two groups of infants without contact between them were diagnosed with RSV-infection: 14 infants were treated in the Department for healthy newborns - Group 1, and 7 preterm infants were treated in the Neonatal Intensive Care Unit (NICU) - Group 2. The detection of RSV was performed using Real-Time PCR in nasal/throat swabs.

RESULTS

Respiratory symptoms occurred 2-5 days after discharge in 14 of 148 healthy term infants born February 5 to 18, 2019; 12 babies were re-hospitalized with LRTI and recovered in a few days. RSV-PCR was positive in 6 infants, while in the others, RSV etiology was suggested, due to similar symptoms and contact between them. The first NICU patient with RSV-LRTI was one of the 26 gestational weeks (GW) twins, who had severe BPD. The other twin was always discharged home without LRTI-symptoms. In the period February 19 to March 15, 2019, 26 premature babies born at 26-34 GW, were tested for RSV (33 nasal/throat swabs). They received a first or subsequent palivizumab injection. We identified 11 positive samples in 7 of the babies. Despite the clinical recovery, the second RSV-PCR remained positive in 4 babies. Six of the 7 NICU patients had symptoms of LRTI, and two of them needed mechanical ventilation. Six babies were discharged home after stabilization, one was transferred to the Pediatric department for further treatment of BPD and later discharged too.

CONCLUSIONS

This was the most serious outbreak of RSV infections in neonates since the RSV-PCR diagnostic in Bulgaria was introduced. The course of RSV-LRTI was severe in extremely preterm patients with underlying BPD. So, routine in-hospital RSV-prophylaxis with palivizumab should be considered for infants at the highest risk.

Impact of Guidelines Publication on Acute Bronchiolitis Management: 10-Year Experience from a Tertiary Care Center in Italy

Bronchiolitis is the most common lower respiratory tract infection in infants. According to evidence-based guidelines, diagnosis is clinical, there is no need for routine use of laboratory or instrumental tests and therapy is primarily supportive, based on oxygen and adequate fluid supplementation. Nevertheless, unnecessary diagnostic tests and pharmacological treatments are still very common. The aim of this retrospective cohort study was to evaluate how the management of bronchiolitis has changed in the last ten years in a Tertiary Care Center in Italy, assessing adherence to national guidelines. Considering the publication of the Italian inter-society consensus document in 2014, we compared patients admitted in the prior four epidemic seasons with patients admitted in the latter six epidemic seasons. The comparison between the two groups showed a significant reduction in the prescription of systemic corticosteroids (58.9% vs. 41.8%, p < 0.001), nebulized epinephrine (73.8% vs. 38.3%, p < 0.001) and antibiotics (59.5% vs. 42.3%, p < 0.001), together with a drastic decrease in the use of chest X-ray (92.2% vs. 54.4%, p < 0.001). On the contrary, the use of inhaled salbutamol remained substantially stable over time (39.4% vs. 37.6%, p = 0.505). Despite the encouraging results, further efforts are needed to limit the prescription of ineffective therapies like antibiotics and inhaled salbutamol.

International Practice Patterns of Antibiotic Therapy and Laboratory Testing in Bronchiolitis

BACKGROUND AND OBJECTIVES

International patterns of antibiotic use and laboratory testing in bronchiolitis in emergency departments are unknown. Our objective is to evaluate variation in the use of antibiotics and nonindicated tests in infants with bronchiolitis in 38 emergency departments in Pediatric Emergency Research Networks in Canada, the United States, Australia and New Zealand, the United Kingdom and Ireland, and Spain and Portugal. We hypothesized there would be significant variation, adjusted for patient characteristics.

METHODS

We analyzed a retrospective cohort study of previously healthy infants aged 2 to 12 months with bronchiolitis. Variables examined included network, poor feeding, dehydration, nasal flaring, chest retractions, apnea, saturation, respiratory rate, fever, and suspected bacterial infection. Outcomes included systemic antibiotic administration and urine, blood, or viral testing or chest radiography (CXR).

RESULTS

In total, 180 of 2359 (7.6%) infants received antibiotics, ranging from 3.5% in the United Kingdom and Ireland to 11.1% in the United States. CXR (adjusted odds ratio [aOR] 2.3; 95% confidence interval 1.6-3.2), apnea (aOR 2.2; 1.1-3.5), and fever (aOR 2.4; 1.7-3.4) were associated with antibiotic use, which did not vary across networks (P = .15). In total, 768 of 2359 infants (32.6%) had ≥1 nonindicated test, ranging from 12.7% in the United Kingdom and Ireland to 50% in Spain and Portugal. Compared to the United Kingdom and Ireland, the aOR (confidence interval) results for testing were Canada 5.75 (2.24-14.76), United States 4.14 (1.70-10.10), Australia and New Zealand 2.25 (0.86-5.74), and Spain and Portugal 3.96 (0.96-16.36). Testing varied across networks (P < .0001) and was associated with suspected bacterial infections (aOR 2.12; 1.30-2.39) and most respiratory distress parameters. Viral testing (591 of 768 [77%]) and CXR (507 of 768 [66%]) were obtained most frequently.

CONCLUSIONS

The rate of antibiotic use in bronchiolitis was low across networks and was associated with CXR, fever, and apnea. Nonindicated testing was common outside of the United Kingdom and Ireland and varied across networks irrespective of patient characteristics.

Association of Pediatric Inpatient Socioeconomic Status With Hospital Efficiency and Financial Balance

IMPORTANCE

In health care systems in which hospital reimbursement is based on a national mean length of stay (LOS), disadvantaged patients with an increased LOS may be a source of inefficiency. This implication has been reported in adult patients, but pediatric data have been scarce.

OBJECTIVE

To examine the association of patient socioeconomic status with hospital efficiency and financial balance in pediatrics.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study obtained data from the French national hospital discharge database covering a 3-year period, from January 1, 2012, to December 31, 2014. Statistical analyses were performed between June 2016 and December 2018. All inpatient stays in hospital pediatric wards in mainland France by children older than 28 days or younger than 18 years (n = 4 121 187) were included. Admissions with coding errors or missing values for social disadvantage and/or cost calculations were excluded.

EXPOSURE

Social disadvantage was estimated with an ecological indicator, the FDep, available at the patient's postcode of residence and divided into national quintiles.

MAIN OUTCOMES AND MEASURES

Efficiency was assessed through the variations in patient LOS compared with different national mean LOS (for pediatric patients, pediatric patients with a similar condition, and pediatric patients with a similar condition and severity level). Hospital financial balance was assessed at the admission level through the ratio of production costs to revenues and at the hospital level through the difference between aggregated revenues and production costs. Multivariate regression models examined the association between these indicators and socioeconomic status.

RESULTS

A total of 4 121 187 admissions were included (2 336 540 [56.7%] male; mean [SD] age, 7.4 [5.8] years). In all, 1 561 219 patients (37.9%) were in the 2 most disadvantaged quintiles. Patient LOS was shorter than the national mean LOS (mean [SD], 1.73 [4.21] days) for patients in the least disadvantaged quintile and longer for those in the more disadvantaged quintile (mean [SD], 1.67 [4.33] days vs 1.82 [4.14] days). This difference was higher for diagnosis related groups that included both adult and pediatric patients (mean [SD], 1.46 [4.22] days vs 1.61 [4.13] days) compared with those dedicated to pediatric patients (2.22 [4.13] days vs 2.12 [4.53] days). Patients in the most disadvantaged quintile were associated with a 3.2% increase in LOS (odds ratio, 1.0322; 95% CI, 1.0302-1.0341) compared with the national mean LOS. Social disadvantage was also associated with a significant increase in financial deficit for hospitals with 20% to 60% of patients in the 2 most disadvantaged quintiles (estimate: -€146 389; 95% CI, -€279 566 to -€13 213).

CONCLUSIONS AND RELEVANCE

Patient socioeconomic status appears to be statistically significantly associated with an increase in LOS and cost in French hospitals with pediatric departments. This finding suggests that initiating reform in hospital payment methods may improve resource allocation efficiency and equity in access to pediatric care.

The Problematic 2014 American Academy of Pediatrics Bronchiolitis Guidelines

The 2014 American Academy of Pediatrics bronchiolitis guidelines do not adequately serve the needs and clinical realities of front-line clinicians caring for undifferentiated wheezing infants and children. This article describes the clinical challenges of evaluating and managing a heterogeneous disease syndrome presenting as undifferentiated patients to the emergency department. Although the 2014 American Academy of Pediatrics bronchiolitis guidelines and the multiple international guidelines that they closely mirror have made a good faith attempt to provide clinicians with the best evidence-based recommendations possible, they have all failed to address practical, front-line clinical challenges. The therapeutic nihilism of the guidelines and the dissonance between many of the recommendations and frontline realities have had wide-ranging consequences. Nevertheless, newer evidence of therapeutic options is emerging and forecasts hope for more therapeutically optimistic recommendations with the next revision of the guidelines.

Physician Compliance With Bronchiolitis Guidelines in Pediatric Emergency Departments

An online survey was administered through the American Academy of Pediatrics (AAP) Section of Emergency Medicine Survey Listserv in Fall, 2017. Overall compliance was measured as never using chest X-rays, viral testing, bronchodilators, or systemic steroids. Practice compliance was measured as never using those modalities in a clinical vignette. Chi-square tests assessed differences in compliance between modalities. t tests assessed differences on agreement with each AAP statement. Multivariate logistic regression determined factors associated with overall compliance. Response rate was 47%. A third (35%) agreed with all 7 AAP statements. There was less compliance with ordering a bronchodilator compared with chest X-ray, viral testing, or systemic steroid. There was no association between compliance and either knowledge or agreement with the guideline. Physicians with institutional bronchiolitis guidelines were more likely to be practice compliant. Few physicians were compliant with the AAP bronchiolitis guideline, with bronchodilator misuse being most pronounced. Institutional bronchiolitis guidelines were associated with physician compliance.

Assessing physical and respiratory distress in children with bronchiolitis admitted to a community hospital emergency department: A retrospective chart review

Introduction

Bronchiolitis is a leading cause of infant hospitalization with wide variation in its diagnosis and management, especially in smaller community hospitals. The objective of this study is to describe children admitted to a community-based hospital emergency department (ED) for bronchiolitis and explore alternate assessments of illness severity.

Methods

A retrospective chart review (January to September 2014) of 100 children, < 2 years old and meeting International Classification of Diseases 10 for bronchiolitis. Outcomes included demographics, symptoms, and interventions. In addition, the Respiratory Distress Assessment Instrument (RDAI) score was calculated using documented assessments of wheezing and retractions. Descriptive and comparative statistics were completed with p < 0.05 considered significant.

Results

The mean (standard deviation) age 10.6 (8.4) months, n = 41 females. Sixty-seven percent had a chest X-ray (CXR), 17% oral antibiotics, 65% bronchodilators, and 19% oral steroids; 19% were admitted in hospital. There was a significant difference in RDAI score between those given oral antibiotics (mean (95% CI), 6.35 (4.96–7.75)) versus not (4.70 (4.20–5.20)), p = 0.01. Those who received a CXR had a significantly higher oxygen flowrate (1.4 (0.6–2.1) litres per minute (lpm)) and worse physical appearance (tri-pod position, head bobbing) versus those who did not (0.15 (–0.05 to 0.35) lpm), p = 0.002 and p = 0.04, respectively.

Conclusions

A large number of children admitted to a community-based ED for bronchiolitis received unnecessary CXR and medications. Assessing physical and respiratory distress may be more effective at determining illness severity compared with radiological or laboratory testing. Local clinical practice guidelines may aid in optimal management of bronchiolitis for community-based EDs.

Impact of social deprivation on length of stay for common infectious diseases in two French university-affiliated general pediatric departments

BACKGROUND

Adult deprived patients consume more healthcare resources than others, particularly in terms of increased length of stay (LOS) and costs. Very few pediatric studies have focused on LOS, although the effect of deprivation could be greater in children due to the vulnerability of this population. Our objective was to compare LOS between deprived and nondeprived children hospitalized for acute infectious diseases in two university-affiliated pediatric departments located in a low-income area of northern Paris.

METHODS

We performed a prospective observational multicenter study in two university-affiliated hospitals, Hôpital Robert-Debré and Hôpital Jean-Verdier. All the patients under 15 years of age admitted to the general pediatric department for pneumonia, bronchiolitis, gastroenteritis, or pyelonephritis between 20 October 2016 and 20 March 2017 were included. Deprivation was assessed with an individual questionnaire and score (EPICES). Endpoints included length of stay, costs, and readmission rates at 15 days in each quintile of deprivation. Multivariate regression assessed the association between deprivation and each endpoint.

RESULTS

A total of 556 patients were included in the study and 540 were analyzed. Sixty percent were boys and the mean age was 9 months±18. Bronchiolitis was the most frequent diagnosis (67.8%). Fifty-six percent of patients were considered to be deprived based on the EPICES questionnaire. Mean LOS was 4.6±3.5 days and we found no significant difference in LOS between the different deprivation quintiles (P=0.83). Multivariate regression did not show an association between LOS and deprivation.

CONCLUSION

There was no difference between deprived and nondeprived patients in terms of LOS. Deprivation may therefore impact hospitals in other ways such as admission rates. The impact of deprivation during hospitalization for chronic diseases should also be investigated.

Medication use in infants admitted with bronchiolitis

BACKGROUND

There are no medications known that improve the outcome of infants with bronchiolitis. Studies have shown the management of bronchiolitis to be varied.

OBJECTIVES

To describe medication use at the seven study hospitals from a recent multi-centre randomised controlled trial on hydration in bronchiolitis (comparative rehydration in bronchiolitis [CRIB]).

METHODS

A retrospective analysis of extant data of infants between 2 months (corrected for prematurity) and 12 months of age admitted with bronchiolitis identified through the CRIB trial. CRIB study records, medical records, pathology and radiology databases were used to collect data using a standardised form and entered in a single site database. Medications investigated included salbutamol, adrenaline, steroids, ipratropium bromide, normal saline, hypertonic saline, steroids and antibiotics.

RESULTS

There were 3456 infants available for analysis, of which 42.0% received at least one medication during hospitalisation. Medication use varied by site between 27.0 and 48.7%. The most frequently used medication was salbutamol (25.5%). Medication use in general, and salbutamol use in particular, increased by 8.2 and 9.3%, respectively, per month after 4 months of age; from 22.9 and 3.6% at 4 months to 81.4 and 68.8% at 11 months. In infants admitted to the intensive care unit (ICU) compared with those not admitted to ICU 81.6 and 39.5%, respectively, received medication at one point during the hospital stay.

CONCLUSIONS

Medication was used for infants with bronchiolitis frequently and variably in Australia and New Zealand. Medication use increased with age. Better strategies for translating evidence into practice are needed.

Systematic review of instruments aimed at evaluating the severity of bronchiolitis

OBJECTIVE

No recent studies have performed a systematic review of all available instruments aimed at evaluating the severity of bronchiolitis. The objective of the present study was to perform a systematic review of instruments aimed at evaluating the severity of bronchiolitis and to evaluate their measurement properties.

METHODS

A systematic search of the literature was performed in order to identify studies in which an instrument for evaluating the severity of bronchiolitis was described. Instruments were evaluated based on their reliability, validity, utility, endorsement frequency, restrictions in range, comprehension, and lack of ambiguity.

RESULTS

A total of 77 articles, describing a total of 32 different instruments were included in the review. The number of items included in the instruments ranged from 2 to 26. Upon analyzing their content, respiratory rate turned out to be the most frequently used item (in 26/32, 81.3% of the instruments), followed by wheezing (in 25/32, 78.1% of the instruments). In 18 (56.3%) instruments, there was a report of at least one of their measurement properties, mainly reliability and utility. Taking into consideration the information contained in the instruments, as well as their measurement properties, one was considered to be the best one available.

CONCLUSIONS

Among the 32 instruments aimed at evaluating the severity of bronchiolitis that were identified and systematically examined, one was considered to be the best one available. However, there is an urgent need to develop better instruments and to validate them in a more comprehensive and proper way.

Overtreatment of asymptomatic bacteriuria: a qualitative study

BACKGROUND

Overtreatment of asymptomatic bacteriuria (ASB) is widespread and may result in antibiotic side-effects, excess costs to the healthcare system, and may potentially trigger antimicrobial resistance. According to international management guidelines, ASB is not an indication for antibiotic treatment (with few exceptions).

AIM

To determine reasons for using antibiotics to treat ASB in the absence of a treatment indication.

METHODS

A qualitative study was conducted at a tertiary care hospital in Switzerland during 2011. We interviewed 21 internal medicine residents and attending physicians selected by purposive sampling, using a semi-structured questionnaire. Responses were analysed in an inductive thematic content approach using dedicated software (MAXQDA(®)).

FINDINGS

In the 21 interviews, the following thematic rationales for antibiotic overtreatment of ASB were reported (in order of reporting frequency): (i) treating laboratory findings without taking the clinical picture into account (N = 17); (ii) psychological factors such as anxiety, overcautiousness, or anticipated positive impact on patient outcomes (N = 13); (iii) external pressors such as institutional culture, peer pressure, patient expectation, and excessive workload that interferes with proper decision-making (N = 9); (iv) difficulty with interpreting clinical signs and symptoms (N = 8).

CONCLUSION

In this qualitative study we identified both physician-centred factors (e.g. overcautiousness) and external pressors (e.g. excessive workload) as motivators for prescribing unnecessary antibiotics. Also, we interpreted the frequently cited practice of treating asymptomatic patients based on laboratory findings alone as lack of awareness of evidence-based best practices.

Utilisation and off-label prescriptions of respiratory drugs in children

Respiratory drugs are widely used in children to treat labeled and non-labeled indications but only some data are available quantifying comprehensively off-label usage. Thus, we aim to analyse drug utilisation and off-label prescribing of respiratory drugs focusing on age- and indication-related off-label use. Patients aged ≤18 years documented in the Bavarian Association of Statutory Health Insurance Physicians database (approx. 2 million children) between 2004 and 2008 were included in our study. Annual period prevalence rates (PPRs) per 10,000 children and the proportion of age- and indication-related off-label prescriptions were calculated and stratified by age and gender. Within the study period, highest PPRs were found for the fixed combination of clenbuterol/ambroxol (between 374–575 per 10,000 children) and the inhaled short acting beta-2-agonist salbutamol (between 378–527 per 10,000 children). Highest relative PPR increase was found for oral salbutamol (approx. 39-fold) whereas the most distinct decrease was found for oral long-acting beta-2-agonist clenbuterol (−97%). Compound classes most frequently involved in off-label prescribing were inhaled bronchodilative compounds (91,402; 37.3%) and oral beta-2-agonists (26,850; 22.5%). The highest absolute number of off-label prescriptions were found for inhaled salbutamol (n = 67,084; 42.0%) and oral clenbuterol/ambroxol (fixed combination, n = 18,897; 20.7%). Off-label prescribing due to indication was of much greater relevance than age-related off-label use. Most frequently, bronchodilative compounds were used off-label to treat respiratory tract infections. Highest off-label prescription rates were found in the youngest patients without relevant gender-related differences. Off-label prescribing of respiratory drugs is common especially in young children. Bronchodilative drugs were most frequently used off-label for treating acute bronchitis or upper respiratory tract infections underlining the essential need for a more rational prescribing in this area.

Overuse of bronchodilators and steroids in bronchiolitis of different severity: bronchiolitis-study of variability, appropriateness, and adequacy

BACKGROUND

In the management of acute bronchiolitis there is a generalised use of treatments that have not been shown to be useful or efficacious in clinical studies. The objective of this study was to determine the appropriateness in the treatment of acute bronchiolitis of different severity within different clinical care settings.

METHODS

This is a cross-sectional, descriptive study of 5647 cases of acute bronchiolitis in 91 Spanish hospitals and primary care centres. We classified the appropriateness of the treatments according to the recommendations of a consensus conference.

RESULTS

There was an inappropriate use of treatments in 58.3% of the cases during the acute phase and in 45.4% during the maintenance phase. There was a generalised use of inhaled beta 2 agonists, regardless of the severity of the patients (hospitalised patients 69.3%, emergency care 63.2% and ambulatory 64.1%). Adrenaline was used in 30.1% of hospitalised cases and in 80.2% of intensive care patients. Systemic corticosteroids were not only used in one-third of hospitalised patients but also in 25.8% of ambulatory cases.

CONCLUSIONS

In acute bronchiolitis in Spain there is a wide use of treatments that are not recommended by the available clinical practice guidelines. Beta 2 agonist bronchodilators and corticosteroids are widely used and maintained, regardless of the severity of the patients.

Hypotonic solution decreases serum sodium in infants with moderate bronchiolitis

AIM

To investigate the influence of hypotonic parenteral hydration on serum and urinary sodium and osmolality in infants with moderate bronchiolitis.

METHODS

We studied 36 infants (mean age 3.7 ± 2.3 months), with a diagnosis of moderate bronchiolitis admitted to a paediatric emergency unit in São Paulo, Brazil. Patients received a standard parenteral hypotonic solution, according to Holliday and Segar, during the first 24 h, due to respiratory distress. The disease was monitored by a respiratory severity score (RDAI-Respiratory Distress Assessment Instrument), respiratory rate and oxygen saturation. Serum and urinary sodium and osmolality were monitored at admission, 24 and 48 h after admission.

RESULTS

All respiratory parameters improved during hospitalisation. Serum sodium and osmolality dropped after 24 h (136.8 ± 2.8 and 135.8 ± 2.6 mEq/L, p = 0.031; 283.4 ± 4.1 and 281.6 ± 3.9 mOsm/kg, p = 0.004 respectively) as well as urinary osmolality (486.8 ± 243.4 mOsm/kg and 355.7 ± 205.0 mOsm/kg, p < 0.001) when compared to admission.

CONCLUSION

This study reinforces the occurrence of hyponatraemia in bronchiolitis even in patients with moderate disease and highlights the risk of serum sodium drop caused by hypotonic parenteral hydration.

Dosing variability in prescriptions of acetaminophen to children: comparisons between pediatricians, family physicians and otolaryngologists

BACKGROUND

To estimate the extents of dosing variability in prescriptions of acetaminophen to children among pediatricians, family physicians and otolaryngologists.

METHODS

The acetaminophen prescriptions in the systematic sampling datasets from the National Health Insurance Research Database in Taiwan were analyzed. The distribution of dosages was measured and expressed in terms of coefficient of variation (CV). The analyses were stratified by patient's age, prescriber's specialty and preparation form.

RESULTS

From 13,868 prescribed items of acetaminophen in 2009, liquids accounted only for 11.1% (n = 1544). More than half (56.9%) of liquids were prescribed by pediatricians. The median dose (83.3 mg, n = 1683) of acetaminophen prescriptions in infants is around half of that in preschool children (166.7 mg, n = 3921), one-third in children (250.0 mg, n = 4926) and one-sixth in adolescents (500.0 mg, n = 3338). In infants, the prescriptions by pediatricians had the highest CV (86.7%), followed by family physicians (82.3%) and otolaryngologists (70.3%). The patterns were similar in preschool children and children, but the difference of CV among specialties narrowed down with the patient's age.

CONCLUSIONS

In acetaminophen prescriptions to children, pediatricians had a wider variability of dosages and a higher ratio of liquid preparations than family physicians and otolaryngologists. Further investigations can be undertaken to estimate the accuracy of dosing variability as an indicator of prescribing quality. Besides, child-suitable drug preparations should be promoted to ensure patient safety.

Management of acute bronchiolitis in emergency wards in Spain: variability and appropriateness analysis (aBREVIADo Project)

Most patients with acute bronchiolitis have a mild course and only require outpatient care. However, some of them have to go to emergency departments, because they have respiratory distress or feeding problems. There, they frequently receive diagnostic and therapeutic procedures. We want to know the variability and appropriateness of these procedures. A cross-sectional study (October 2007 to March 2008) was carried out on 2,430 diagnosed cases of bronchiolitis in hospital emergency departments, which required no hospitalization. An analysis of the appropriateness of the treatments was made in 2,032 cases gathered in ten departments with at least 100 cases, using as criterion the recommendations of a consensus conference. We estimated the adjusted percentages of each department. Most of the bronchiolitis were mild, in spite that they underwent multiple diagnostic and therapeutic procedures. In the acute phase, different treatments were used: inhaled beta 2 agonists (61.4%), antipyretics (17.1%), oral steroids (11.3%), and nebulized adrenaline (9.3%). In the maintenance phase, the most common treatments were: inhaled beta 2 agonists (50.5%), oral steroids (17%), oral beta 2 agonists (14.9%), and antibiotics (6.1%). The 64% of the treatments used in the acute phase and the 55.9% in the maintenance phase were considered inappropriate in the appropriateness analysis; a great heterogeneity among centers was found.

CONCLUSIONS

There are discrepancies between clinical practice and evidence-based management of bronchiolitis in Spanish emergency departments. Inappropriate treatments were used in more than half of patients. The wide variation between centers shows the influence of local prescribing habits and reveals the scope for improvement.

The diagnostic value of apolipoprotein E in pediatric patients with invasive bacterial infections

OBJECTIVE

To evaluate the potential diagnostic value of apolipoprotein E (ApoE) measurements in pediatric patients with invasive bacterial infections.

DESIGN AND METHOD

A total of 185 pediatric patients were enrolled in this study, including 94 patients with confirmable infections and 91 patients without confirmable infections. Serum and cerebrospinal fluid (CSF) ApoE levels were measured by immunoturbidimetry. The diagnostic values of ApoE were evaluated by the receiver operating curve (ROC) method.

RESULTS

ApoE levels in CSF were significantly increased in patients with bacterial meningitis, and serum ApoE was markedly elevated in patients with sepsis or with bacterial meningitis compared with patients with other infections and uninfected children. The optimal ApoE cutoff value for CSF was >1.7 mg/L with 85% sensitivity and 100% specificity and was >42 mg/L in serum with 80% sensitivity and 93% specificity.

CONCLUSION

ApoE detection provided a novel diagnostic marker for invasive bacterial infections in pediatric patients.