Corticosteroid Therapy During Acute Bronchiolitis in Patients Who Later Develop Asthma

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.

UPDATE - 2022 Italian guidelines on the management of bronchiolitis in infants

Bronchiolitis is an acute respiratory illness that is the leading cause of hospitalization in young children. This document aims to update the consensus document published in 2014 to provide guidance on the current best practices for managing bronchiolitis in infants. The document addresses care in both hospitals and primary care. The diagnosis of bronchiolitis is based on the clinical history and physical examination. The mainstays of management are largely supportive, consisting of fluid management and respiratory support. Evidence suggests no benefit with the use of salbutamol, glucocorticosteroids and antibiotics with potential risk of harm. Because of the lack of effective treatment, the reduction of morbidity must rely on preventive measures. De-implementation of non-evidence-based interventions is a major goal, and educational interventions for clinicians should be carried out to promote high-value care of infants with bronchiolitis. Well-prepared implementation strategies to standardize care and improve the quality of care are needed to promote adherence to guidelines and discourage non-evidence-based attitudes. In parallel, parents' education will help reduce patient pressure and contribute to inappropriate prescriptions. Infants with pre-existing risk factors (i.e., prematurity, bronchopulmonary dysplasia, congenital heart diseases, immunodeficiency, neuromuscular diseases, cystic fibrosis, Down syndrome) present a significant risk of severe bronchiolitis and should be carefully assessed. This revised document, based on international and national scientific evidence, reinforces the current recommendations and integrates the recent advances for optimal care and prevention of acute bronchiolitis.

Knowledge translation in Western Australia tertiary paediatric emergency department: An audit cycle of effectiveness of guideline dissemination on bronchiolitis management

AIM

Bronchiolitis is the commonest cause of hospitalisation for infants. Evidence-based Australasian bronchiolitis guideline was developed and introduced in 2017. This audit was to determine if the knowledge translation process of the updated local tertiary hospital bronchiolitis guideline (based on the Australasian guideline) reduced unnecessary interventions.

METHODS

A retrospective chart review of infants with bronchiolitis diagnosis during the pre-guideline (1 July to 31 August 2015) and post-guideline (1 July to 31 August 2017) period, with the primary outcome of the number/proportion of unnecessary interventions.

RESULTS

Presentations between 1 July to 31 August 2015 (n = 465) were compared with 2017 (n = 343). There was no difference in undertaking chest X-ray (24 (5.2%) vs. 17 (5.0%), odds ratio (OR) 0.98 (95% confidence interval (CI) 0.71-1.35), P = 0.911), salbutamol (23 (4.9%) vs. 10 (2.9%), OR 0.86 (95% CI 0.65-1.13), P = 0.279), glucocorticoids (2 (0.4%) vs. 5 (1.5%), OR 1.89 (95% CI 0.83-4.31), p = 0.129), antibiotics (11 (2.4%) vs. 5 (1.5%), OR 0.86 (95% CI 0.65-1.15), P = 0.307) or nasopharyngeal aspirate (172 (37%) vs. 124 (36.2%), OR 1.00 (95% CI 0.87-1.67), P = 0.937) in hospital. Adrenaline was not administered in both years. There was reduced hospital admissions (303 (65.2%) vs. 192 (56.0%), OR 0.82 (95% CI 0.71-0.95), P = 0.008) with no difference in paediatric intensive care unit admissions (10 (2.2%) vs. 8 (2.3%), OR 1.04 (95% CI 0.65-1.67), P = 0.863).

CONCLUSION

The dissemination process of the updated local hospital bronchiolitis guideline did not show any statistically significant reduction of unnecessary interventions in the hospital. Further studies are required to determine the effective process to instigate changes in health services.

Antibiotic Prescription in Young Children With Respiratory Syncytial Virus-Associated Respiratory Failure and Associated Outcomes

OBJECTIVES

To describe antibiotic prescribing practices during the first 2 days of mechanical ventilation among previously healthy young children with respiratory syncytial virus-associated lower respiratory tract infection and evaluate associations between the prescription of antibiotics at onset of mechanical ventilation with clinical outcomes.

DESIGN

Retrospective cohort study.

SETTING

Forty-six children's hospitals in the United States.

PATIENTS

Children less than 2 years old discharged between 2012 and 2016 with an International Classification of Diseases diagnosis of respiratory syncytial virus-associated lower respiratory tract infection, no identified comorbid conditions, and receipt of mechanical ventilation.

INTERVENTIONS

Antibiotic prescription during the first 2 days of mechanical ventilation.

MEASUREMENTS AND MAIN RESULTS

We compared duration of mechanical ventilation and hospital length of stay between children prescribed antibiotics on both of the first 2 days of mechanical ventilation and children not prescribed antibiotics during the first 2 days of mechanical ventilation. We included 2,107 PICU children with respiratory syncytial virus-associated lower respiratory tract infection (60% male, median age of 1 mo [interquartile range, 1-4 mo]). The overall proportion of antibiotic prescription on both of the first 2 days of mechanical ventilation was 82%, decreasing over the study period (p = 0.004) and varying from 36% to 100% across centers. In the bivariate analysis, antibiotic prescription was associated with a shorter duration of mechanical ventilation (6 d [4-9 d] vs 8 d [6-11 d]; p < 0.001) and a shorter hospital length of stay (11 d [8-16 d] vs 13 d [10-18 d]; p < 0.001). After adjustment for center, demographics, and vasoactive medication prescription, antibiotic prescription was associated with a 1.21-day shorter duration of mechanical ventilation and a 2.07-day shorter length of stay. Ultimately, 95% of children were prescribed antibiotics sometime during hospitalization, but timing, duration, and antibiotic choice varied markedly.

CONCLUSIONS

Although highly variable across centers and decreasing over time, the practice of instituting antibiotics after intubation in young children with respiratory syncytial virus-associated lower respiratory tract infection was associated with a shortened clinical course after adjustment for the limited available covariates. A prudent approach to identify and optimally treat bacterial coinfection is needed.

Periostin levels in children without respiratory disease

BACKGROUND

Periostin is a protein that serves as a downstream marker of the T-helper type 2 (Th2) cell response. It may serve to identify drug-responsive inflammatory phenotypes, particularly in children with asthma and possibly bronchiolitis. There are no published levels of periostin in healthy children <2 years of age, limiting interpretation of periostin levels in disease. We sought to explore the range of periostin levels of children <2 years without significant confounding illnesses.

METHODS

Children undergoing clinically indicated phlebotomy or having a peripheral intravenous catheter inserted prior to general anesthesia or procedural sedation were enrolled. A 0.5 mL sample of blood was collected and frozen at -70°C. After thawing, periostin was measured with a Luminex assay (R&D Systems, Minneapolis, MN). Medical record review and/or parental interview elicited potential variables associated with periostin. Association was evaluated using Mann-Whitney rank sum test, Kruskal-Wallis ANOVA, and Spearman correlation as appropriate.

RESULTS

Among 43 children (23 male, 20 female, age range 9-15.7 months), periostin levels were inversely correlated to age (r = -0.438, P = 0.003). Periostin levels also differed significantly between children <12mo (734.0 [576.6-906.5] ng/mL), 12-18mo (645.1 [363.8-538.2] ng/mL) and >18mo (416.4 [363.8-538.15] ng/mL) (P < 0.001).

CONCLUSION

In our sample of relatively healthy patients <2 years old, periostin levels were inversely correlated with age and not dependent on other studied variables. However, further work is needed to establish normal periostin values in young children.

Improving Evidence Based Bronchiolitis Care

Bronchiolitis is the number one cause of hospitalization in infants during the first year of life. Clinical guidelines recommend primarily supportive care and discourage use of pharmacotherapies and diagnostics. However, there continues to be widespread use of non-recommended therapies and variation in the use of therapeutic interventions among hospitals in the United States. Here we review evidence-based management of this common disease in order to optimize resource utilization, decrease healthcare costs, and decrease unnecessary hospitalization. Current evidence does not support the routine use of chest radiographs, viral testing or laboratory evaluation in children with bronchiolitis. In addition, routine administration of bronchodilators, including albuterol and nebulized epinephrine, corticosteroids and hypertonic saline are not recommended for infants and children with bronchiolitis. Intravenous or nasogastric hydration and nutritional support, supplemental oxygen, and respiratory support are recommended. Standardization of bronchiolitis care with evidence based institutional clinical pathways spanning ED to inpatient care can help optimize resource utilization while simultaneously improving care of bronchiolitis and reducing hospital length of stays and costs.