Variation in Care and Clinical Outcomes in Children Hospitalized With Orbital Cellulitis

Association of empiric antibiotic selection and clinical outcomes in hospitalised children with severe orbital infections: a retrospective cohort study

OBJECTIVE

To determine the association of initial empiric antibiotic regimens with clinical outcomes in hospitalised children with severe orbital infections.

DESIGN

Multi-centre observational cohort study using data from 2009 to 2018 clinical records.

SETTING

Canadian children's hospitals (7) and community hospitals (3).

PATIENTS

Children between 2 months and 18 years hospitalised for >24 hours with severe orbital infections.

INTERVENTIONS

Empiric intravenous antibiotic regimen in the first 24 hours of hospitalisation.

MAIN OUTCOME MEASURES

Length of hospital stay and surgical intervention using multivariable median regression and multivariate logistic regression, with adjustment for covariates.

RESULTS

Of 1421 patients, 60.0% were male and the median age was 5.5 years (IQR 2.4-9.9). Median length of stay was 86.4 hours (IQR 56.9-137.5) and 180 (12.7%) received surgical intervention. Patients receiving broad-spectrum empiric antibiotics had an increased median length of stay, ranging from an additional 13.8 hours (third generation cephalosporin and anaerobic coverage) to 19.5 hours (third generation cephalosporin, staphylococcal and anaerobic coverage). No antibiotic regimen was associated with a change in the odds of surgical intervention. These findings remained unchanged in sensitivity analyses restricted to more severely ill patients. There was a twofold increase in the percentage of patients receiving the broadest empiric antibiotic regimens containing both staphylococcal and anaerobic coverage from 17.8% in 2009 to 40.3% in 2018.

CONCLUSIONS

Empiric use of broad-spectrum antibiotics with staphylococci and anaerobic coverage was associated with longer length of stay and similar rates of surgery in children with orbital infections. There is an urgent need for comparative effectiveness studies of various antibiotic regimes.

Bugs Behind the Bulging Eyeball: Microbiology and Antibiotic Management in Orbital Cellulitis With or Without Subperiosteal Abscess

The objective of this study is to describe causative pathogens and current antibiotic management among hospitalized children with orbital cellulitis. This retrospective study, performed at a tertiary care children's health system, included patients up to 18 years old who presented with radiographic evidence of orbital cellulitis from 2012 to 2019. Of the 298 patients included in the study, 103 had surgery and an intraoperative culture obtained. A pathogen was recovered in 86 cultures (83.5%). The most common pathogens were Streptococcus anginosus group (26.2%), Streptococcus pyogenes (11.7%), methicillin-susceptible Staphylococcus aureus (10.7%), and Streptococcus pneumoniae (9.7%). Only 8/194 (4.1%) blood cultures returned positive. Median duration of intravenous antibiotics was 4 days and median total duration was 17 days. The most common empiric regimen prescribed was ceftriaxone and clindamycin (64.1%). Despite low incidence of methicillin-resistant S aureus, empiric antibiotics often consisted of 2 antibiotics to ensure coverage for this bacterium.

Progression of Subperiosteal Orbital Abscess after Clinical Resolution on Intravenous Antibiotics and Steroids

We present a case of a 7-year-old boy who was presented with a small medial subperiosteal orbital abscess (SPOA) and trace superior phlegmon and who was initially treated with intravenous (IV) antibiotics, corticosteroids, and observation. After clinical resolution and discharge, the patient returned with superior migration of his abscess requiring surgical drainage. Potential factors leading to readmission are discussed, including the anti-inflammatory and immunosuppressant effects of steroids, and presence of early surgical indictors such as bony dehiscence and proptosis. This case highlights the need for careful consideration of initial imaging and presence of a non-medial phlegmon prior to initiation of steroids.

Microbial patterns and culture utility in orbital cellulitis

PURPOSE

To determine the prevalence and types of pathogens found in children with orbital cellulitis and to evaluate the utility of nonoperative cultures.

METHODS

This was a retrospective cohort study of children with imaging-confirmed orbital cellulitis over a period of 8 years. Outcomes included prevalence and types of organisms, polymicrobial infection, mixed aerobic-anaerobic infection, effect of age, and culture utility.

RESULTS

Of 220 children with orbital cellulitis, 112 (51%) had cultures taken; 69 (31%) had surgical intervention. Culture sources for the 112 children with cultures included blood (57 patients [51%]), sinus (53 [47%]), orbit (42 [38%]), brain (6 [5%]), and skin/conjunctiva/lacrimal sac (6 [5%]). Streptococcus anginosus group strains grew in cultures from 19 children (17%); methicillin-sensitive Staphylococcus aureus (MSSA), in 15 (13%); Streptococcus pyogenes, in 12 (11%); methicillin-resistant Staphylococcus aureus (MRSA), in 6 (5%); anaerobic/facultative gram negative rods, in 8 (7%); anaerobic Gram-positive cocci, other Viridans group streptococci, and Streptococci pneumoniae, in 3 (3%) each; and normal respiratory/skin flora, in 23 (21%). Polymicrobial infection (P = 0.08) and anaerobic organisms (P = 0.58) did not differ by age (range, 0.1-16.8 years). In all 220 (100%) children, nonoperative cultures were either not obtained (108 [49%]), not helpful in avoiding surgery (69 [31%]), showed no growth (39 [18%]), or grew an organism that did not change management from empiric therapy (4 [2%]).

CONCLUSIONS

While many organisms may be cultured from children with orbital cellulitis, Streptococcus and MSSA were the most common in our study cohort. MRSA is uncommon, so initial empiric coverage is not necessary. Rates of polymicrobial and anaerobic infection were similar across ages. Our results indicate that nonoperative cultures are not indicated in the initial medical management of orbital cellulitis; in our cohort, they neither resulted in treatment changes nor helped avoid surgery.

Variation in the Management of Hospitalized Children With Orbital Cellulitis Over 10 Years

OBJECTIVES

No previous study has examined the management of hospitalized children with orbital cellulitis at both children's and community hospitals across multiple sites in Canada. We describe variation and trends over time in diagnostic testing and imaging, adjunctive agents, empiric antibiotics, and surgical intervention in children hospitalized with orbital cellulitis.

PATIENTS AND METHODS

Multicenter cohort study of 1579 children aged 2 months to 18 years with orbital cellulitis infections admitted to 10 hospitals from 2009 to 2018. We assessed hospital-level variation in the use of diagnostic tests, imaging, antibiotics, adjunctive agents, surgical intervention, and clinical outcomes using X2, Mann-Whitney U, and Kruskal-Wallis tests. The association between clinical management and length of stay was evaluated with median regression analysis with hospital as a fixed effect.

RESULTS

There were significant differences between children's hospitals in usage of C-reactive protein tests (P < .001), computed tomography scans (P = .004), MRI scans (P = .003), intranasal decongestants (P < .001), intranasal corticosteroids (P < .001), intranasal saline spray (P < .001), and systemic corticosteroids (P < .001). Children's hospital patients had significantly longer length of hospital stay compared with community hospitals (P = .001). After adjustment, diagnostic testing, imaging, and subspecialty consults were associated with longer median length of hospital stay at children's hospitals. From 2009 to 2018, C-reactive protein test usage increased from 28.8% to 73.5% (P < .001), whereas erythrocyte sedimentation rate decreased from 31.5% to 14.1% (P < .001).

CONCLUSIONS

There was significant variation in diagnostic test usage and treatments, and increases in test usage and medical intervention rates over time despite minimal changes in surgical interventions and length of stay.

The Role of Steroids for Pediatric Orbital Cellulitis - Review of the Controversy

Orbital cellulitis in the pediatric population is treated primarily with antibiotic therapy. This leaves the inflammatory component unchecked. Corticosteroid therapy has been used to accelerate recovery and decrease the long-term morbidity in other infectious conditions. Its use has also been proposed for pediatric orbital cellulitis. The aim of this manuscript is to conduct a literature review to summarize existing evidence and understand ongoing controversies. Overall, prior investigations on corticosteroid therapy for pediatric orbital cellulitis are limited by their study design and sample sizes. One of the most discussed potential benefits is that adjuvant steroid therapy for pediatric orbital cellulitis is associated with shorter hospitalization without major infectious complications. However, decreased hospitalization length is an imperfect metric, especially without standardized criteria for hospital discharge. Future studies are warranted to better guide the use of adjuvant steroid therapy and to optimize its potential in the management of pediatric orbital cellulitis.

Factors Associated with Surgery and Imaging Characteristics in Severe Orbital Infections

OBJECTIVES

To evaluate risk factors associated with surgical intervention and subperiosteal/orbital abscess in hospitalized children with severe orbital infections.

STUDY DESIGN

We conducted a multicenter cohort study of children 2 months to 18 years hospitalized with periorbital or orbital cellulitis from 2009 to 2018 at 10 hospitals in Canada. Clinical details were extracted, and patients were categorized as undergoing surgical or medical-only management. Primary outcome was surgical intervention and the main secondary outcome was clinically important imaging. Logistic regression was used to identify predictors.

RESULTS

Of 1579 patients entered, median age was 5.4 years, 409 (25.9%) had an orbital/subperiosteal abscess, and 189 (12.0%) underwent surgery. In the adjusted analysis, the risk of surgical intervention was associated with older age (age 9 to <14: aOR 3.9, 95% CI 2.3-6.6; and age 14 to ≤18 years: aOR 7.0, 95% CI 3.4-14.1), elevated C-reactive protein >120 mg/L (aOR 2.8, 95% CI 1.3-5.9), elevated white blood cell count of 12-20 000/μL (aOR 1.7, 95% CI 1.1-2.6), proptosis (aOR 2.6, 95% CI 1.7-4.0), and subperiosteal/orbital abscess (aOR 5.3, 95% CI 3.6-7.9). There was no association with antibiotic use before hospital admission, sex, presence of a chronic disease, temperature greater than 38.0°C, and eye swollen shut. Complications were identified in 4.7% of patients, including vision loss (0.6%), intracranial extension (1.6%), and meningitis (0.8%).

CONCLUSIONS

In children hospitalized with severe orbital infections, older age, elevated C-reactive protein, elevated white blood cell count, proptosis, and subperiosteal/orbital abscess were predictors of surgical intervention.

Management of intraorbital infections in the pediatric emergency department

Intraorbital infections may lead to severe complications, necessitating rapid diagnosis and intervention. The decision process regarding the need for emergent imaging and possible surgical intervention is unclear in the literature. This retrospective cohort study included two major pediatric emergency departments in Israel between 2010 and 2020. Patients arriving at the emergency department with an admission diagnosis of intraorbital infection and at least one high-risk symptom for orbital involvement were included in the study. The main outcome measures were the computerized tomography (CT) timing and results, whether the case was managed surgically or conservatively and whether the patient returned to the same hospital with significant complications. Ninety-five patients were included; 70 underwent a CT scan in the first 24 h, and of those 21 were managed surgically; 16 were treated based on clinical findings alone, with no imaging performed. When comparing groups based on management, we found no significant differences based on presenting symptoms, duration of complaints, or severity of CT findings. However, having three or more high-risk presenting symptoms was associated with a greater likelihood of surgical intervention (multivariate logistic regression p = 0.069, odds ratio 1.73, 95% confidence interval 0.96-3.11; one-way ANOVA and Fisher's exact test p < 0.05).

CONCLUSION

The decision to treat intraorbital infections at our institutions appears to be based on clinical impression of disease severity rather than radiologic findings. This suggests a need for further interdisciplinary studies to clarify optimal management.

WHAT IS KNOWN

• Orbital c ellulitis is associated with significant potential complications, necessitating rapid diagnosis and treatment. • Present literature provides insufficiently clear guidance on emergency department management.

WHAT IS NEW

• Consideration of all relevant factors (clinical features, laboratory findings, timing of imaging, and conservative vs. surgical management) in a single retrospective cohort. • Our findings suggest that decision-making in practice may be guided by clinical impression rather than imaging.

Epidemiology and Management of Orbital Cellulitis in Children

BACKGROUND

The epidemiology of orbital cellulitis likely has evolved due to the emergence of methicillin-resistant Staphylococcus aureus (MRSA) and the adoption of pneumococcal conjugate vaccination. In the absence of published guidelines, management is highly variable. We characterized epidemiology and management over an 11-year period.

METHODS

A retrospective cohort study of children 0 to 21 years of age with orbital cellulitis +/- subperiosteal orbital abscess hospitalized at a large quaternary children's hospital from January 2008 to June 2018. We reviewed charts for demographic characteristics, clinical features, management, and outcomes. Using multivariable logistic regression, we evaluated predictors of surgical intervention and assessed whether corticosteroid use or antibiotic duration was related to clinical outcomes.

RESULTS

Among 220 patients, methicillin-susceptible S. aureus was the most common organism (26.3%), with MRSA found in only 5.0%. Rates of vancomycin use fluctuated annually from 40.9% to 84.6%. Surgery was performed in 39.5% of the patients. Corticosteroids, used in 70 patients (32.1%), were unrelated to treatment failure (n = 9), defined as persistent signs and symptoms or initial clinical improvement followed by worsening (P = .137). The median antibiotic duration was 17 days (interquartile range 14-26). After controlling for age, gender, proptosis, eye pain with movement, eyelid swelling, neutrophil count, and corticosteroid use, treatment failure was not significantly associated with receipt of ≥ 3 weeks of antibiotic therapy (8/84, 9.5%) compared with > 2 but < 3 weeks (0/51, 0.0%) or ≤ 2 weeks (1/85, 1.2%) (adjusted odds ratio = 5.83 for ≥ 3 vs ≤2 weeks; 95% confidence interval: 0.58, 59.0).

CONCLUSIONS

Although MRSA was rare, empiric vancomycin use was high. Treatment failure was uncommon in patients who received ≤ 2 weeks of therapy, suggesting that shorter durations are adequate in some patients.

Association Between Corticosteroids and Outcomes in Children Hospitalized With Orbital Cellulitis

OBJECTIVES

To examine the association between systemic corticosteroid use and outcomes for children hospitalized with orbital cellulitis at US children's hospitals.

METHODS

We conducted a multicenter observational study using administrative data from the Pediatric Health Information System database from 2007 to 2019. Children between the ages of 2 months and 18 years with International Classification of Diseases, Ninth Revision, Clinical Modification or 10th Revision, Clinical Modification discharge diagnostic codes of orbital cellulitis were included. The primary exposure was receipt of systemic corticosteroids on the day of hospital admission. The primary outcome was hospital length of stay, and secondary outcomes included surgical intervention, ICU admissions, revisits, and health care costs. We used generalized logit model with inverse probability weighting logistic regression to adjust for demographic factors and assess for differences in clinical outcomes reported.

RESULTS

Of the 5832 patients hospitalized with orbital cellulitis, 330 (5.7%) were in the corticosteroid group and 5502 (94.3%) were in the noncorticosteroid group. Patients in the corticosteroid group were older, had more severe illness, and received broad spectrum antibiotics. In adjusted analyses, corticosteroid exposure was not associated with differences in length of hospital stay, need for surgical intervention, ICU admissions, emergency department revisits, 30-day hospital readmissions, or hospital costs. Restricting the analysis to only those patients who received broad spectrum antibiotics did not change the findings.

CONCLUSIONS

Early use of systemic corticosteroids in hospitalized children with orbital cellulitis is not associated with improved clinical outcomes. Use of corticosteroids in hospitalized children with orbital cellulitis should be discouraged outside of clinical trials.

Prediction across healthcare settings: a case study in predicting emergency department disposition

Several approaches exist today for developing predictive models across multiple clinical sites, yet there is a lack of comparative data on their performance, especially within the context of EHR-based prediction models. We set out to provide a framework for prediction across healthcare settings. As a case study, we examined an ED disposition prediction model across three geographically and demographically diverse sites. We conducted a 1-year retrospective study, including all visits in which the outcome was either discharge-to-home or hospitalization. Four modeling approaches were compared: a ready-made model trained at one site and validated at other sites, a centralized uniform model incorporating data from all sites, multiple site-specific models, and a hybrid approach of a ready-made model re-calibrated using site-specific data. Predictions were performed using XGBoost. The study included 288,962 visits with an overall admission rate of 16.8% (7.9–26.9%). Some risk factors for admission were prominent across all sites (e.g., high-acuity triage emergency severity index score, high prior admissions rate), while others were prominent at only some sites (multiple lab tests ordered at the pediatric sites, early use of ECG at the adult site). The XGBoost model achieved its best performance using the uniform and site-specific approaches (AUC = 0.9–0.93), followed by the calibrated-model approach (AUC = 0.87–0.92), and the ready-made approach (AUC = 0.62–0.85). Our results show that site-specific customization is a key driver of predictive model performance.

Evaluation and Medical Management of the Pediatric Patient With Orbital Cellulitis/Abscess: A Systematic Review

BACKGROUND AND OBJECTIVES

Pediatric orbital cellulitis/abscess (OCA) can lead to vision loss, intracranial extension of infection, or cavernous thrombosis if not treated promptly. No widely recognized guidelines exist for the medical management of OCA. The objective of this review was to summarize existing evidence regarding the role of inflammatory markers in distinguishing disease severity and need for surgery; the role of imaging in OCA evaluation; and the microbiology of OCA over the past 2 decades.

METHODS

This review was reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Searches were performed in MEDLINE (Ovid), Web of Science Core Collection, Scopus, CINAHL (EBSCO), and Cochrane Central Register of Controlled Trials (CENTRAL), most recently on February 9, 2021.

RESULTS

A total of 63 studies were included. Most were descriptive and assessed to have poor quality with high risk of bias. The existing publications evaluating inflammatory markers in the diagnosis of OCA have inconsistent results. Computed tomography imaging remains the modality of choice for evaluating orbital infection. The most common organisms recovered from intraoperative cultures are Streptococcus species (Streptococcus anginosus group, group A Streptococcus, and pneumococcus) and Staphylococcus aureus. Methicillin-resistant S aureus in culture-positive cases had a median prevalence of 3% (interquartile range, 0%-13%).

CONCLUSION

This systematic review summarizes existing literature concerning inflammatory markers, imaging, and microbiology for OCA evaluation and management. High-quality evidence is still needed to define the optimal medical management of OCA.

Corticosteroids for Acute Orbital Cellulitis

OBJECTIVES

Standard treatment of children hospitalized for acute orbital cellulitis includes systemic antibiotics. Recent data from single-center studies suggest the addition of systemic corticosteroids may hasten clinical improvement and reduce hospital length of stay (LOS). We investigate the potential relationship between corticosteroid exposure and duration of hospitalization for pediatric orbital cellulitis.

METHODS

Using Pediatric Health Information System registry data from 51 children's facilities, we performed a retrospective cohort study of children hospitalized for orbital cellulitis <18 years of age from 2007 to 2018. The primary study outcome was hospital LOS. Secondary outcomes included frequency of surgical interventions, PICU admission, and 30-day related-cause readmission.

RESULTS

Of the 5645 children included for study, 1347 (24%) were prescribed corticosteroids within 2 days of admission. Corticosteroid prescription was not associated with LOS in analyses adjusted for age; presence of meningitis, abscess, or vision issues; and operative episode and PICU admission within 2 days (e ^β = 1.01, 95% confidence interval [CI]: 0.97-1.06). Corticosteroid exposure was associated with operative episodes after 2 days of hospitalization (odds ratio = 2.05, 95% CI: 1.29-3.27) and 30-day readmission (odds ratio = 2.40, 95% CI: 1.52-3.78) among patients with a primary diagnosis of orbital cellulitis.

CONCLUSIONS

In this database query, we were not able to detect a reduction in LOS associated with corticosteroid exposure during hospitalization for orbital cellulitis. Corticosteroid prescription was associated with PICU admission and operative episodes after 2 days of hospitalization. Before the adoption of routine corticosteroid use, prospective, randomized control trials are needed.

Changes in the Management of Severe Orbital Infections Over Seventeen Years

OBJECTIVES

Periorbital and orbital cellulitis are common but serious infections in children. Management of these infections varies because of an absence of clinical guidelines, but it is unclear if management within institutions has changed over time. We compared the management and outcomes of children hospitalized with periorbital and orbital cellulitis in 2 eras.

METHODS

Data were extracted from records of children hospitalized at a tertiary care children's hospital with periorbital or orbital cellulitis from 2000 to 2005 and 2012 to 2016. Patient demographics, cross-sectional imaging, antibiotic and corticosteroid use, length of stay, and surgical rates were collected. Data from the eras were compared by using descriptive statistics, t tests, Mann-Whitney U tests, Fisher's exact tests, and χ² tests.

RESULTS

There were 318 children included, 143 from 2000 to 2005 and 175 from 2012 to 2016. Compared with the first era, in the second era there were increased rates of MRI (5% vs 11%, P = .04), although rates of computed tomography scan use remained unchanged (60% vs 65%); increased number (1 vs 3, P < .01) and spectrum of antibiotics; increased use of intranasal corticosteroids (3% vs 49%, P < .01); and subspecialty consultation (89% vs 99%, P = .01). There were no differences in length of stay, readmission, or surgical rates between eras.

CONCLUSIONS

There has been considerable change in the management of hospitalized children with severe orbital infections at our institution, including the rates of MRI, number and spectrum of antibiotics used, use of adjunctive agents, and increased subspecialty involvement with no observed impact on clinical outcomes. Future research is needed to rationalize antimicrobial therapy and reduce low-value health care.

Corticosteroids for periorbital and orbital cellulitis

BACKGROUND

Periorbital and orbital cellulitis are infections of the tissue anterior and posterior to the orbital septum, respectively, and can be difficult to differentiate clinically. Periorbital cellulitis can also progress to become orbital cellulitis. Orbital cellulitis has a relatively high incidence in children and adults, and potentially serious consequences including vision loss, meningitis, and death. Complications occur in part due to inflammatory swelling from the infection creating a compartment syndrome within the bony orbit, leading to elevated ocular pressure and compression of vasculature and the optic nerve. Corticosteroids are used in other infections to reduce this inflammation and edema, but they can lead to immune suppression and worsening infection.

OBJECTIVES

To assess the effectiveness and safety of adjunctive corticosteroids for periorbital and orbital cellulitis, and to assess their effectiveness and safety in children and in adults separately.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (which contains the Cochrane Eyes and Vision Trials Register) (2020, Issue 3); Ovid MEDLINE; Embase.com; PubMed; Latin American and Caribbean Health Sciences Literature Database (LILACS); ClinicalTrials.gov, and the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP). We did not use any date or language restrictions in the electronic search for trials. We last searched the electronic databases on 2 March 2020.

SELECTION CRITERIA

We included studies of participants diagnosed with periorbital or orbital cellulitis. We excluded studies that focused exclusively on participants who were undergoing elective endoscopic surgery, including management of infections postsurgery as well as studies conducted solely on trauma patients. Randomized and quasi-randomized controlled trials were eligible for inclusion. Any study that administered corticosteroids was eligible regardless of type of steroid, route of administration, length of therapy, or timing of treatment. Comparators could include placebo, another corticosteroid, no treatment control, or another intervention.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures recommended by Cochrane.

MAIN RESULTS

The search yielded 7998 records, of which 13 were selected for full-text screening. We identified one trial for inclusion. No other eligible ongoing or completed trials were identified. The included study compared the use of corticosteroids in addition to antibiotics to the use of antibiotics alone for the treatment of orbital cellulitis. The study included a total of 21 participants aged 10 years and older, of which 14 participants were randomized to corticosteroids and antibiotics and 7 participants to antibiotics alone. Participants randomized to corticosteroids and antibiotics received adjunctive corticosteroids after initial antibiotic response (mean 5.13 days), at an initial dose of 1.5 mg/kg for three days followed by 1 mg/kg for another three days before being tapered over a one- to two-week period. We assessed the included study as having an unclear risk of bias for allocation concealment, masking (blinding), selective outcome reporting, and other sources of bias. Risk of bias from sequence generation and incomplete outcome data were low. The certainty of evidence for all outcomes was very low, downgraded for risk of bias (-1) and imprecision (-2). Length of hospital stay was compared between the group receiving antibiotics alone compared to the group receiving antibiotics and corticosteroids (mean difference (MD) 4.30, 95% confidence interval (CI) -0.48 to 9.08; 21 participants). There was no observed difference in duration of antibiotics between treatment groups (MD 3.00, 95% CI -0.48 to 6.48; 21 participants). Likewise, preservation of visual acuity at 12 weeks of follow-up between group was also assessed (RR 1.00, 95% CI 0.82 to 1.22; 21 participants). Pain scores were compared between groups on day 3 (MD -0.20, 95% CI -1.02 to 0.62; 22 eyes) along with the need for surgical intervention (RR 1.00, 95% CI 0.11 to 9.23; 21 participants). Exposure keratopathy was reported in five participants who received corticosteroids and antibiotics and three participants who received antibiotic alone (RR 1.20, 95% CI 0.40 to 3.63; 21 participants). No major complications of orbital cellulitis were seen in either the intervention or the control group. No side effects of corticosteroids were reported, although it is unclear which side effects were assessed.

AUTHORS' CONCLUSIONS

There is insufficient evidence to draw conclusions about the use of corticosteroids in the treatment of periorbital and orbital cellulitis. Since there is significant variation in how corticosteroids are used in clinical practice, additional high-quality evidence from randomized controlled trials is needed to inform decision making. Future studies should explore the effects of corticosteroids in children and adults separately, and evaluate different dosing and timing of corticosteroid therapy.

Readmissions Following Hospitalization for Infection in Children With or Without Medical Complexity

OBJECTIVE

To describe the prevalence and characteristics of infection-related readmissions in children and to identify opportunities for readmission reduction and estimate associated cost savings.

STUDY DESIGN

Retrospective analysis of 380,067 nationally representative index hospitalizations for children using the 2014 Nationwide Readmissions Database. We compared 30-day, all-cause unplanned readmissions and costs across 22 infection categories. We used the Inpatient Essentials database to measure hospital-level readmission rates and to establish readmission benchmarks for individual infections. We then estimated the number of readmissions avoided and costs saved if hospitals achieved the 10th percentile of hospitals' readmission rates (ie, readmission benchmark). All analyses were stratified by the presence/absence of a complex chronic condition (CCC).

RESULTS

The overall 30-day readmission rate was 4.9%. Readmission rates varied substantially across infections and by presence/absence of a CCC (CCC: range, 0%-21.6%; no CCC: range, 1.5%-8.6%). Approximately 42.6% of readmissions (n = 3,576) for children with a CCC and 54.7% of readmissions (n = 5,507) for children without a CCC could have been potentially avoided if hospitals achieved infection-specific benchmark readmission rates, which could result in an estimated savings of $70.8 million and $44.5 million, respectively. Bronchiolitis, pneumonia, and upper respiratory tract infections were among infections with the greatest number of potentially avoidable readmissions and cost savings for children with and without a CCC.

CONCLUSION

Readmissions following hospitalizations for infection in children vary significantly by infection type. To improve hospital resource use for infections, future preventative measures may prioritize children with complex chronic conditions and those with specific diagnoses (eg, respiratory illnesses).

Opportunities for Stewardship in the Transition From Intravenous to Enteral Antibiotics in Hospitalized Pediatric Patients

BACKGROUND/OBJECTIVE

Pediatric patients hospitalized with bacterial infections often receive intravenous (IV) antibiotics. Early transition to enteral antibiotics can reduce hospital duration, cost, and complications. We aimed to identify opportunities to transition from IV to enteral antibiotics, describe variation of transition among hospitals, and evaluate feasibility of novel stewardship metrics.

METHODS

This multisite retrospective cohort study used the Pediatric Health Information System to identify pediatric patients hospitalized with pneumonia, neck infection, orbital infection, urinary tract infection (UTI), osteomyelitis, septic arthritis, or skin and soft tissue infection (SSTI) between 2017 and 2018. Opportunity days were defined as days on which patients received both IV antibiotics and enteral medications, suggesting enteral tolerance. Percent opportunity was defined as opportunity days divided by days on any antibiotics. Both outcomes excluded IV antibiotics that have no alternative oral formulation. We evaluated outcomes per infection and antibiotic and assessed across-hospital variation.

RESULTS

We identified 88,522 aggregate opportunity days in 100,103 hospitalizations. On 57% of the antibiotic days, there was an opportunity to switch patients to enteral therapy, with greatest opportunity days in SSTI, neck infection, and pneumonia encounters, and with clindamycin, ceftriaxone, and ampicillin-sulbactam. Percent opportunity varied by infection (73% in septic arthritis to 40% in pneumonia). There was significant across-hospital variation in percent opportunity for all infections.

CONCLUSION

This multicenter study demonstrated the potential opportunity to transition from IV to enteral therapy in over half of antibiotic days. Opportunity varied by infection, antibiotic, and hospital. Across-hospital variation demonstrated likely missed opportunities for earlier transition and the need to define optimal transition times. Stewardship efforts promoting earlier transition for highly bioavailable antibiotics could reduce healthcare utilization and promote high-value care. We identified feasible stewardship metrics.

Variations in Sedated Echocardiography and Association With Repeat Echocardiography in Nonrefractory Kawasaki Disease

OBJECTIVES

Echocardiography performed under sedation allows for better coronary artery visualization in children with Kawasaki disease. We sought to describe hospital-level variability in the percentage of sedated echocardiography (SE) among children with nonrefractory Kawasaki disease (NRKD) and then test its association with repeat echocardiography, length of stay (LOS), and costs.

METHODS

We identified children in the Pediatric Health Information System <36 months of age hospitalized with NRKD from March 2010 to February 2017. Hospital-level percentage of SE was the primary outcome. Secondary outcomes were repeat echocardiography during the same hospitalization, LOS, and costs. We used χ² and Wilcoxon rank tests to compare differences in repeat echocardiography between SE and nonsedated echocardiography. Pearson correlation was used to test associations between SE and repeat echocardiography, LOS, and costs.

RESULTS

There were 2887 NRKD hospitalizations from 40 children's hospitals. Initial SE varied from 0.0% to 87.0% (median 5.9%; interquartile range 1.4%-21.1%). Of initial echocardiographies, 22.4% were sedated and 10.1% of all hospitalizations had a repeat echocardiography. Use of SE at the hospital level was associated with a lower likelihood for repeat echocardiography (r = -0.32; 95% confidence interval -0.58 to -0.01; P = .042). Absolute risk reduction was 3.5% and the number needed to sedate was 29. Initial SE was not associated with LOS or hospital-level costs but was associated with increased patient-level costs.

CONCLUSIONS

Significant variation exists in the use of SE for children <36 months of age with NRKD at children's hospitals. Our results suggest that determination of SE should not be driven by concern for repeat echocardiography or LOS considerations.

Variation in Early Inflammatory Marker Testing for Infection-Related Hospitalizations in Children

BACKGROUND AND OBJECTIVES

Inflammatory marker testing in children has been identified as a potential area of overuse. We sought to describe variation in early inflammatory marker (C-reactive protein and erythrocyte sedimentation rate) testing for infection-related hospitalizations across children's hospitals and to determine its association with length of stay (LOS), 30-day readmission rate, and cost.

METHODS

We conducted a cross-sectional study of children aged 0 to 17 years with infection-related hospitalizations using the Pediatric Health Information System. After adjusting for patient characteristics, we examined rates of inflammatory marker testing (C-reactive protein or erythrocyte sedimentation rate) during the first 2 days of hospitalization. We used k-means clustering to assign each hospital to 1 of 3 groups on the basis of similarities in adjusted diagnostic testing rates across 12 infectious conditions. Multivariable regression was used to examine the association between hospital testing group and outcomes.

RESULTS

We included 55 771 hospitalizations from 48 hospitals. In 7945 (14.3%), there was inflammatory marker testing in the first 2 days of hospitalization. We observed wide variation in inflammatory marker testing rates across hospitals and infections. Group A hospitals tended to perform more tests than group B or C hospitals (37.4% vs 18.0% vs 10.4%; P < .001) and had the longest adjusted LOS (3.2 vs 2.9 vs 2.8 days; P = .01). There was no significant difference in adjusted 30-day readmission rates or costs.

CONCLUSIONS

Inflammatory marker testing varied widely across hospitals. Hospitals with higher inflammatory testing for one infection tend to test more frequently for other infections and have longer LOS, suggesting opportunities for diagnostic stewardship.

Variation in Care and Clinical Outcomes Among Infants Hospitalized With Hyperbilirubinemia

OBJECTIVES

To assess hospital-level variation in laboratory testing and intravenous fluid (IVF) use and examine the association between these interventions and hospitalization outcomes among infants admitted with neonatal hyperbilirubinemia.

METHODS

We performed a retrospective multicenter study of infants aged 2 to 7 days hospitalized with a primary diagnosis of hyperbilirubinemia from December 1, 2016, to June 30, 2018, using the Pediatric Health Information System. Hospital-level variation in laboratory and IVF use was evaluated after adjusting for clinical and demographic factors and associated with hospital-level outcomes by using Pearson correlation.

RESULTS

We identified 4396 infants hospitalized with hyperbilirubinemia. In addition to bilirubin level, the most frequently ordered laboratories were direct antiglobulin testing (45.7%), reticulocyte count (39.7%), complete blood cell counts (43.7%), ABO blood type (33.4%), and electrolyte panels (12.9%). IVFs were given to 26.3% of children. Extensive variation in laboratory testing and IVF administration was observed across hospitals (all P < .001). Increased use of laboratory testing but not IVFs was associated with a longer length of stay (P = .007 and .162, respectively). Neither supplementary laboratory use nor IVF use was associated with either readmissions or emergency department revisits.

CONCLUSIONS

Substantial variation exists among hospitals in the management of infants with hyperbilirubinemia. With our results, we suggest that additional testing outside of bilirubin measurement may unnecessarily increase resource use for infants hospitalized with hyperbilirubinemia.

Care and outcomes of Canadian children hospitalised with periorbital and orbital cellulitis: protocol for a multicentre, retrospective cohort study

INTRODUCTION

Skin and soft tissue infections of the eye can be classified based on anatomic location as either anterior to the orbital septum (ie, periorbital cellulitis) or posterior to the orbital septum (ie, orbital cellulitis). These two conditions are often considered together in hospitalised children as clinical differentiation is difficult, especially in young children. Prior studies have identified variation in management of hospitalised children with orbital cellulitis; however, they have been limited either as single centre studies or by the use of administrative data which lacks clinical details important for interpreting variation in care. We aim to describe the care and outcomes of Canadian children hospitalised with periorbital and orbital cellulitis.

METHOD AND ANALYSIS

This is a multisite retrospective cohort study including previously healthy children aged 2 months to 18 years admitted to hospital with periorbital or orbital cellulitis from 2009 to 2018. Clinical data from medical records from multiple Canadian hospitals will be collected, including community and academic centres. Demographic characteristics and study outcomes will be summarised using descriptive statistics, including diagnostic testing, antibiotic therapy, adjunctive therapy, surgical intervention and clinical outcomes. Variation will be described and evaluated using χ² test or Kruskal-Wallis test. Generalised linear mixed models will be used to identify predictors of surgical intervention and longer length of stay.

ETHICS AND DISSEMINATION

Approval of the study by the Research Ethics Board at each participating site has been obtained prior to data extraction. Study results will be disseminated by presentations at national and international meetings and by publications in high impact open access journals. By identifying important differences in management and outcomes by each hospital, the results will identify areas where care can be improved, practice standardised, unnecessary diagnostic imaging reduced, pharmacotherapy rationalised and where trials are needed.

Applying Pharmacodynamics and Antimicrobial Stewardship to Pediatric Preseptal and Orbital Cellulitis

Orbital and preseptal cellulitis are most commonly caused by organisms that originate in the upper respiratory tract or from the skin. There is significant variation in antibiotics used, but ampicillin-sulbactam, ceftriaxone, metronidazole, clindamycin, amoxicillin, amoxicillin-clavulanate, cefuroxime, and vancomycin are often used in the treatment of these infections. The choice of antibiotic, however, is only one consideration. It is also important that antibiotics are dosed to optimize their pharmacodynamic target attainment. Like other serious infections, therapy can be transitioned from initial intravenous therapy to an oral regimen when there are clear signs of clinical and laboratory improvement. The total duration of therapy for these infections have also been decreasing in recent years with durations of approximately 2 weeks becoming more common, even for orbital or subperiosteal infections. Antimicrobial stewardship programs can work closely with providers who manage these infections to create pathways, choose optimal antibiotics and dosage, transition from intravenous to oral therapy, and provide shortest effective durations.

Feasible Strategies for Sustaining Guideline Adherence: Cross-sectional Analysis of a National Collaborative

Health care providers' adherence to guidelines declines over time, and feasible strategies for sustaining adherence have not yet been identified. We assessed the long-term feasibility of various strategies for sustaining guideline adherence and described factors influencing their use. We conducted a cross-sectional survey (N = 104) of physician leaders who participated in a national collaborative to improve care of infants with suspected sepsis. Data were collected on long-term use of strategies to promote guideline adherence (use, perceived effectiveness, and barriers to use). Sixty (58%) participants from diverse hospital settings responded. There were significant declines in use of quality improvement and educational strategies, largely driven by lack of time or staff resources and competing priorities. Electronic strategies (eg, order sets) and hospital policies or guidelines were feasible to continue long-term after the collaborative ended and were perceived as effective. Clinicians and healthcare leaders should consider prioritizing these strategies in their efforts to improve care and outcomes for children in hospital settings.

Microbiology of Pediatric Orbital Cellulitis and Trends in Methicillin-Resistant Staphylococcus aureus Cases

We reviewed medical records of children with orbital cellulitis with positive cultures at a tertiary institution from 2005 to 2018 to identify microbiology trends and features associated with methicillin-resistant Staphylococcus aureus (MRSA) cases. Cultures obtained from the orbits (n = 33), sinuses (n = 31), and dural cavities (n = 4) had yields of 66.7%, 61.3%, and 75%, respectively, compared with 17.6% of blood cultures (n = 69). Fifty-five patients had positive culture results. Staphylococcus aureus was the most common pathogen isolated (n = 19), followed by Streptococcus species, most commonly Streptococcus anginosus (n = 8). The most frequently prescribed antibiotic combination regimen was ampicillin-sulbactam followed by amoxicillin-clavulanate. There were 8 cases of MRSA. MRSA was associated with an age of presentation <1 year old (P = .034). Other clinical features were similar between MRSA and non-MRSA cases. In infants and neonates, or those with epidemiologic risk factors, MRSA should also be considered.