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Rickey L, Hall M, Berry JG. Pre- and Post-admission Care for Children Hospitalized With Skin and Soft Tissue Infections. Hosp Pediatr 2024; 14:815-822. [PMID: 39257368 DOI: 10.1542/hpeds.2023-007621] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2023] [Revised: 06/28/2024] [Accepted: 07/03/2024] [Indexed: 09/12/2024]
Abstract
BACKGROUND AND OBJECTIVES Although skin and soft tissue infections (SSTIs) are among the most common indications for pediatric hospitalization, little is known about outpatient care received for SSTI before and after hospitalization. We assessed peri-hospitalization care for SSTI, including antibiotic exposures and their impact on hospital length of stay (LOS). METHODS This is a retrospective cohort study of 1229 SSTI hospitalizations in 2019 from children aged 1-to-18 years enrolled in Medicaid from 10 US states included in the Merative Marketscan Medicaid database. We characterized health service utilization (outpatient visits, laboratory and diagnostic tests, antibiotic exposures) 14 days before and 30 days after hospitalization and evaluated the effects of pre-hospitalization care on hospital LOS with linear regression. RESULTS Only 43.1% of children hospitalized with SSTI had a preceding outpatient visit with a SSTI diagnosis, 69.8% of which also filled prescription for an antibiotic. Median LOS for SSTI admission was 2 days (interquartile range 1-3). Pre-hospitalization visits with a diagnosis of SSTI were associated with a 0.7 day reduction (95% confidence interval: 0.6-0.81) in LOS (P < .001), but pre-hospital antibiotic exposure alone had no effect on LOS. Most children (81.7%) filled antibiotic prescriptions after hospital discharge and 74.5% had post-discharge ambulatory visits. CONCLUSIONS Although most children did not receive pre-admission care for SSTI, those that did had a shorter hospitalization. Further investigation is necessary on how to optimize access and use of outpatient care for SSTI.
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Affiliation(s)
- Lisa Rickey
- Division of General Pediatrics, Department of Pediatrics, Boston Children's Hospital, Boston
- Department of Pediatrics, Harvard Medical School, Boston
| | - Matt Hall
- Children's Hospital Association, Lenexa, Kansas
| | - Jay G Berry
- Division of General Pediatrics, Department of Pediatrics, Boston Children's Hospital, Boston
- Department of Pediatrics, Harvard Medical School, Boston
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Patel P, Foster CE, Stimes G, Lee SR, Wallace SS. Risk Factors for Treatment Failure in Neonates With Skin and Soft Tissue Infection: A Retrospective Cohort Study. Clin Pediatr (Phila) 2024; 63:689-696. [PMID: 37491834 DOI: 10.1177/00099228231189132] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/27/2023]
Abstract
We aimed to describe the frequency of treatment failure and associated risk factors for treatment failure amongst neonates with skin and soft tissue infections (SSTIs). We conducted a retrospective cohort study of neonates 0 to 28 days old with uncomplicated SSTIs presenting to the emergency department of a quaternary care children's hospital from 2009 to 2017. Data were collected via chart review. Skin and soft tissue infections included the following: cellulitis, abscess, mastitis, perirectal SSTI, carbuncle, and furuncle. Of the 202 neonates in the study, most were term, afebrile with mastitis, or perirectal SSTI. Treatment failure occurred in 8% (17/202) of neonates receiving oral antibiotics; 10 of these neonates had perirectal SSTIs and 2 had clindamycin and methicillin-resistant Staphylococcus aureus. Neonates with treatment failure had increased odds of having perirectal SSTIs (odds ratio [OR] = 4.08, 95% confidence interval [CI] = 1.46-11.31). Further studies are needed to identify strategies to prevent treatment failure in neonates with perirectal SSTIs.
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Affiliation(s)
- Purva Patel
- Divisions of Pediatric Hospital Medicine, Texas Children's Hospital, Baylor College of Medicine, Houston, TX, USA
| | - Catherine E Foster
- Departments of Infectious Diseases and Pediatrics, Texas Children's Hospital, Baylor College of Medicine, Houston, TX, USA
| | - Grant Stimes
- Departments of Infectious Diseases and Pediatrics, Texas Children's Hospital, Baylor College of Medicine, Houston, TX, USA
- Department of Pharmacy, Texas Children's Hospital, Baylor College of Medicine, Houston, TX, USA
| | - Su Rin Lee
- Divisions of Pediatric Hospital Medicine, Texas Children's Hospital, Baylor College of Medicine, Houston, TX, USA
- Department of Pharmacy, Texas Children's Hospital, Baylor College of Medicine, Houston, TX, USA
| | - Sowdhamini S Wallace
- Divisions of Pediatric Hospital Medicine, Texas Children's Hospital, Baylor College of Medicine, Houston, TX, USA
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McCulloh RJ, Kerns E, Flores R, Cane R, El Feghaly RE, Marin JR, Markham JL, Newland JG, Wang ME, Garber M. A National Quality Improvement Collaborative to Improve Antibiotic Use in Pediatric Infections. Pediatrics 2024; 153:e2023062246. [PMID: 38682258 DOI: 10.1542/peds.2023-062246] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/03/2023] [Indexed: 05/01/2024] Open
Abstract
BACKGROUND Nearly 25% of antibiotics prescribed to children are inappropriate or unnecessary, subjecting patients to avoidable adverse medication effects and cost. METHODS We conducted a quality improvement initiative across 118 hospitals participating in the American Academy of Pediatrics Value in Inpatient Pediatrics Network 2020 to 2022. We aimed to increase the proportion of children receiving appropriate: (1) empirical, (2) definitive, and (3) duration of antibiotic therapy for community-acquired pneumonia, skin and soft tissue infections, and urinary tract infections to ≥85% by Jan 1, 2022. Sites reviewed encounters of children >60 days old evaluated in the emergency department or hospital. Interventions included monthly audit with feedback, educational webinars, peer coaching, order sets, and a mobile app containing site-specific, antibiogram-based treatment recommendations. Sites submitted 18 months of baseline, 2-months washout, and 10 months intervention data. We performed interrupted time series (analyses for each measure. RESULTS Sites reviewed 43 916 encounters (30 799 preintervention, 13 117 post). Overall median [interquartile range] adherence to empirical, definitive, and duration of antibiotic therapy was 67% [65% to 70%]; 74% [72% to 75%] and 61% [58% to 65%], respectively at baseline and was 72% [71% to 72%]; 79% [79% to 80%] and 71% [69% to 73%], respectively, during the intervention period. Interrupted time series revealed a 13% (95% confidence interval: 1% to 26%) intercept change at intervention for empirical therapy and a 1.1% (95% confidence interval: 0.4% to 1.9%) monthly increase in adherence per month for antibiotic duration above baseline rates. Balancing measures of care escalation and revisit or readmission did not increase. CONCLUSIONS This multisite collaborative increased appropriate antibiotic use for community-acquired pneumonia, skin and soft tissue infections, and urinary tract infection among diverse hospitals.
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Affiliation(s)
- Russell J McCulloh
- Department of Pediatrics, University of Nebraska Medical Center, Omaha, Nebraska
- Divisions of Pediatric Hospital Medicine
| | - Ellen Kerns
- Department of Pediatrics, University of Nebraska Medical Center, Omaha, Nebraska
- Care Transformation, Children's Nebraska, Omaha, Nebraska
| | - Ricky Flores
- Care Transformation, Children's Nebraska, Omaha, Nebraska
| | - Rachel Cane
- Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Rana E El Feghaly
- Divisions of Infectious Diseases
- Department of Pediatrics, University of Missouri Kansas City, Kansas City, Missouri
| | - Jennifer R Marin
- Division of Pediatric Emergency Medicine, Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Jessica L Markham
- Pediatric Hospital Medicine, Department of Pediatrics, Children's Mercy Kansas City, Kansas City, Missouri
- Department of Pediatrics, University of Missouri Kansas City, Kansas City, Missouri
| | - Jason G Newland
- Department of Pediatrics, Washington University School of Medicine, Division of Pediatric Infectious Diseases, St Louis, Missouri
| | - Marie E Wang
- Department of Pediatrics, Stanford University School of Medicine, Palo Alto, California
| | - Matthew Garber
- Department of Pediatrics, University of Florida College of Medicine, Jacksonville, Florida
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De Rose DU, Pugnaloni F, Martini L, Bersani I, Ronchetti MP, Diociaiuti A, El Hachem M, Dotta A, Auriti C. Staphylococcal Infections and Neonatal Skin: Data from Literature and Suggestions for the Clinical Management from Four Challenging Patients. Antibiotics (Basel) 2023; 12:632. [PMID: 37106994 PMCID: PMC10135205 DOI: 10.3390/antibiotics12040632] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Revised: 03/16/2023] [Accepted: 03/21/2023] [Indexed: 04/29/2023] Open
Abstract
Staphylococcal infections in neonates might be associated with skin blistering since early antibiotic therapy has been shown to limit infection spread and positively influence outcomes; therefore, neonatologists should be aware of these conditions. This review examines the recent literature on the management of Staphylococcal infections that involve neonatal skin, discussing the most appropriate clinical approach to four cases of neonatal blistering diseases with Staphylococcal infections: a case of Staphylococcal bullous impetigo, a case of Staphylococcal scalded skin syndrome (SSSS), a case of epidermolysis bullosa with overlapping Staphylococcal infection, and a case of burns with overlapping Staphylococcal infection. In treating Staphylococcal infections involving skin in neonates, the presence or absence of systemic symptoms should be considered. In the lack of evidence-based guidelines in this age category, treatment should be individualized according to several factors including the extension of the disease or further skin comorbidities (such as skin fragility), with a multidisciplinary approach.
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Affiliation(s)
| | - Flaminia Pugnaloni
- Neonatal Intensive Care Unit, “Bambino Gesù” Children’s Hospital IRCCS, 00165 Rome, Italy
| | - Ludovica Martini
- Neonatal Intensive Care Unit, “Bambino Gesù” Children’s Hospital IRCCS, 00165 Rome, Italy
| | - Iliana Bersani
- Neonatal Intensive Care Unit, “Bambino Gesù” Children’s Hospital IRCCS, 00165 Rome, Italy
| | - Maria Paola Ronchetti
- Neonatal Intensive Care Unit, “Bambino Gesù” Children’s Hospital IRCCS, 00165 Rome, Italy
| | - Andrea Diociaiuti
- Dermatology Unit and Genodermatosis Unit, “Bambino Gesù” Children’s Hospital IRCCS, 00165 Rome, Italy
| | - May El Hachem
- Dermatology Unit and Genodermatosis Unit, “Bambino Gesù” Children’s Hospital IRCCS, 00165 Rome, Italy
| | - Andrea Dotta
- Neonatal Intensive Care Unit, “Bambino Gesù” Children’s Hospital IRCCS, 00165 Rome, Italy
| | - Cinzia Auriti
- Neonatal Intensive Care Unit, “Bambino Gesù” Children’s Hospital IRCCS, 00165 Rome, Italy
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Neubauer HC, Hall M, Lopez MA, Cruz AT, Queen MA, Foradori DM, Aronson PL, Markham JL, Nead JA, Hester GZ, McCulloh RJ, Wallace SS. Antibiotic Regimens and Associated Outcomes in Children Hospitalized With Staphylococcal Scalded Skin Syndrome. J Hosp Med 2021; 16:149-155. [PMID: 33617441 PMCID: PMC7929614 DOI: 10.12788/jhm.3529] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Accepted: 09/01/2020] [Indexed: 11/20/2022]
Abstract
BACKGROUND Controversy exists regarding the optimal antibiotic regimen for use in hospitalized children with staphylococcal scalded skin syndrome (SSSS). Various regimens may confer toxin suppression and/or additional coverage for methicillin-susceptible Staphylococcus aureus (MSSA) or methicillin-resistant S aureus (MRSA). OBJECTIVES To describe antibiotic regimens in hospitalized children with SSSS and examine the association between antistaphylococcal antibiotic regimens and patient outcomes. DESIGN/METHODS Retrospective cohort study of children hospitalized with SSSS using the Pediatric Health Information System database (2011-2016). Children who received clindamycin monotherapy, clindamycin plus MSSA coverage (eg, nafcillin), or clindamycin plus MRSA coverage (eg, vancomycin) were included. The primary outcome was hospital length of stay (LOS); secondary outcomes were treatment failure and cost. Generalized linear mixed-effects models were used to compare outcomes among antibiotic groups. RESULTS Of 1,259 children included, 828 children received the most common antistaphylococcal antibiotic regimens: clindamycin monotherapy (47%), clindamycin plus MSSA coverage (33%), and clindamycin plus MRSA coverage (20%). Children receiving clindamycin plus MRSA coverage had higher illness severity (44%) compared with clindamycin monotherapy (28%) and clindamycin plus MSSA (32%) (P =.001). In adjusted analyses, LOS and treatment failure did not differ among the 3 regimens (P =.42 and P =.26, respectively). Cost was significantly lower for children receiving clindamycin monotherapy and highest in those receiving clindamycin plus MRSA coverage (mean, $4,839 vs $5,348, respectively; P <.001). CONCLUSIONS In children with SSSS, the addition of MSSA or MRSA coverage to clindamycin monotherapy was associated with increased cost and no incremental difference in clinical outcomes.
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Affiliation(s)
- Hannah C Neubauer
- Section of Pediatric Hospital Medicine, Department of Pediatrics, Baylor College of Medicine, Houston, Texas
- Corresponding Author: Hannah C Neubauer, MD; ; Telephone: 832-824-0671
| | - Matthew Hall
- Children’s Hospital Association, Lenexa, Kansas, Children’s Mercy Kansas City, Kansas City, Missouri
| | - Michelle A Lopez
- Section of Pediatric Hospital Medicine, Department of Pediatrics, Baylor College of Medicine, Houston, Texas
| | - Andrea T Cruz
- Sections of Pediatric Emergency Medicine and Pediatric Infectious Diseases, Department of Pediatrics, Baylor College of Medicine, Houston, Texas
| | - Mary Ann Queen
- Division of Pediatric Hospital Medicine, Department of Pediatrics, Children’s Mercy Kansas City, Kansas City, Missouri
| | - Dana M Foradori
- Department of Pediatric Hospital Medicine, Cleveland Clinic Children’s Hospital, Cleveland, Ohio
| | - Paul L Aronson
- Departments of Pediatrics and of Emergency Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Jessica L Markham
- Division of Pediatric Hospital Medicine, Department of Pediatrics, Children’s Mercy Kansas City, Kansas City, Missouri
| | - Jennifer A Nead
- Department of Pediatrics, SUNY Upstate Medical University, Syracuse, New York
| | | | - Russell J McCulloh
- Department of Pediatrics, University of Nebraska Medical Center and Children’s Hospital & Medical Center, Omaha, Nebraska
| | - Sowdhamini S Wallace
- Section of Pediatric Hospital Medicine, Department of Pediatrics, Baylor College of Medicine, Houston, Texas
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Stromberg TL, Robison AD, Kruger JF, Bentley JP, Schwenk HT. Inpatient Observation After Transition From Intravenous to Oral Antibiotics. Hosp Pediatr 2020; 10:591-599. [PMID: 32532795 DOI: 10.1542/hpeds.2020-0047] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
OBJECTIVES Children hospitalized with infections are commonly transitioned from intravenous (IV) to enteral (per os [PO]) antibiotics before discharge, after which they may be observed in the hospital to ensure tolerance of PO therapy and continued clinical improvement. We sought to describe the frequency and predictors of in-hospital observation after transition from IV to PO antibiotics in children admitted for skin and soft tissue infections (SSTIs). METHODS We conducted a retrospective cohort study of children with SSTIs discharged between January 1, 2016, and June 30, 2018, using the Pediatric Health Information System database. Children were classified as observed if hospitalized ≥1 day after transitioning from IV to PO antibiotics. We calculated the proportion of observed patients and used logistic regression with random intercepts to identify predictors of in-hospital observation. RESULTS Overall, 15% (558 of 3704) of hospitalizations for SSTIs included observation for ≥1 hospital day after the transition from IV to PO antibiotics. The proportion of children observed differed significantly between hospitals (range of 4%-27%; P < .001). Observation after transition to PO antibiotics was less common in older children (adjusted odds ratio [aOR] = 0.69; 95% confidence interval [CI] 0.52-0.90; P = .045). Children initially prescribed vancomycin (aOR = 1.36; 95% CI 1.03-1.79; P = .032) or with infections located on the neck (aOR = 1.72; 95% CI 1.32-2.24; P < .001) were more likely to be observed. CONCLUSIONS Children hospitalized for SSTIs are frequently observed after transitioning from IV to PO antibiotics, and there is substantial variability in the observation rate between hospitals. Specific factors predict in-hospital observation and should be investigated as part of future studies aimed at improving the care of children hospitalized with SSTIs.
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Affiliation(s)
| | | | - Jenna F Kruger
- Lucile Packard Children's Hospital Stanford, Stanford, California; and
| | - Jason P Bentley
- Quantitative Sciences Unit, Division of Biomedical Informatics Research, Department of Medicine and
| | - Hayden T Schwenk
- Lucile Packard Children's Hospital Stanford, Stanford, California; and.,Division of Infectious Diseases, Department of Pediatrics, Stanford Medicine, Stanford University, Stanford, California
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