Trends in resource utilization for hospitalized children with skin and soft tissue infections

Dalbavancin for the treatment of acute bacterial skin and skin structure infections (ABSSSI) in pediatric patients: a case series

Acute bacterial skin and skin-structure infections (ABSSSI) are a significant cause of morbidity in pediatric patients, requiring timely and effective treatment. Dalbavancin, a long-acting lipoglycopeptide antibiotic recently approved for pediatric use, offers advantages such as excellent bactericidal activity against Gram-positive bacteria (including multidrug-resistant pathogens) and high tissue penetration. We present a case series of pediatric patients with ABSSSI treated with dalbavancin. Five cases were described demonstrating the efficacy of dalbavancin in different clinical scenarios. Patients with complex skin conditions, including cellulitis and deep abscesses, benefited from dalbavancin therapy, achieving significant clinical improvement. Notably, dalbavancin facilitated early discharge, improving quality of life and reducing healthcare costs. These cases highlight the potential of dalbavancin as a valuable treatment option for ABSSSI in pediatric patients, particularly in settings where conventional therapies fail to achieve optimal clinical outcomes or prolonged hospitalization is not feasible. Further research is needed to clarify its role and optimize its use in pediatric patients with ABSSSI.

Real-World Use of Dalbavancin for Treatment of Soft Tissue and Bone Infection in Children: Safe, Effective and Hospital-Time Sparing

Acute bacterial skin and skin structure infections (ABSSSI) and osteoarticular infections compound the burden of morbidity, mortality and prolonged hospitalizations among gram-positive infections. Dalbavancin, a second-generation, intravenous lipoglycopeptide, due to its prolonged half-life, can be a valuable alternative in their treatment when administered as inpatient treatment at the price of an extended hospital stay. Between October 2019 and September 2023, 31 children and adolescents were treated with dalbavancin because of bone and joint infections (n = 12 patients, 39%), ABSSSI (n = 13 patients, 42%), mainly for the limbs, facial cellulitis or complicated ABSSSI (n = 6 patients, 19%), at five Italian pediatric centers. Microbiological study provided gram-positive bacterial isolate in 16 cases, in 11 cases from a positive blood culture; 9 of them were MRSA. Twenty-five patients were initially treated with a different antibiotic therapy: beta-lactam-based in 18 patients (58%), glycopeptide-based in 15 patients (48%) and daptomycin in 6 (19%). The median time that elapsed between admission and start of dalbavancin was 18 days. A total of 61 doses of dalbavancin were administered to the 31 patients: 16 received a single dose while the remaining 15 patients received between two (n = 9) and nine doses. The frequency of administration was weekly in five cases or fortnightly in nine patients. Median length of stay in hospital was 16 days. Median time to discharge after the first dose of dalbavancin was 1 day. Treatment was very well-tolerated: of the 61 administered doses, only four doses, administered to four patients, were associated with an adverse event: drug extravasation during intravenous administration occurred in two patients, with no sequelae; however, in two patients the first administration was stopped soon after infusion start: in one (ID #11), due to headache and vomiting; in another (ID #12) due to a systemic reaction. In both patients, drug infusion was not repeated. None of the remaining 29 patients reported treatment failure (resistant or recurrent disease) or an adverse effect during a median follow-up time of two months. The use of dalbavancin was safe, feasible and also effective in shortening the hospital stay in children and adolescents.

Validation of an Educational Tool for Skin Abscess Incision and Drainage by Delphi and Angoff Methods

BACKGROUND

Bedside incision and drainage (I&D) of skin abscesses is a common medical procedure performed in a variety of medical settings. Yet, there is a paucity of published validated educational tools to teach and assess competency for this procedure.

OBJECTIVE

To validate an educational tool to teach and assess competency for bedside I&D of skin abscesses via the Delphi consensus and Angoff standard setting methods.

DESIGN

Expert consensus on the importance of each procedural step in the educational tool was obtained using the Delphi method, consisting of four rounds of iterative revisions based on input from a panel of experts. The passing cut-off score for a proficient provider was determined using the modified dichotomous Angoff method.

PARTICIPANTS

All participants met the minimum criteria of active involvement in resident education and performance of at least 20 skin abscess I&D's within the past 5 years. Participant specialties included general surgery, emergency medicine, and internal medicine.

MAIN MEASURES

The primary outcome was consensus on procedural steps and errors, defined as an interquartile range ≤ 2 on a 9-point Likert scale. A cut-off score was determined by the average across all respondents for the anticipated number of errors that would be committed by a provider with the level of proficiency defined in the survey. Qualitative input was incorporated into the educational tool.

KEY RESULTS

At the end of four rounds of review via the Delphi process, participants achieved consensus on 93% of items on the clinical checklist and 85% of errors on the assessment checklist. Via the modified dichotomous Angoff method, the determined passing cut-off for competency was 6 out of 22 errors.

CONCLUSION

An educational and evaluation tool for bedside I&D of skin abscesses was validated via the Delphi and Angoff methods.

Acute bacterial skin and skin structure infections in pediatric patients: potential role of dalbavancin

INTRODUCTION

Acute bacterial skin and skin structure infections (ABSSSIs) are a subtype of skin and soft tissue infections (SSTI), usually sustained by Gram-positive bacteria, whose incidence is high among children. ABSSSIs are responsible for a considerable number of hospitalizations. Moreover, as multidrug resistant (MDR) pathogens become widespread, the pediatric category seems burdened with an increased risk of resistance and treatment failure.

AREAS COVERED

To obtain a view on the status of the field, we describe the clinical, epidemiological, and microbiological aspects of ABSSSI in children. Old and new treatment options were critically revised with a focus on the pharmacological characteristics of dalbavancin. Evidence on the use of dalbavancin in children was collected, analyzed, and summarized.

EXPERT OPINION

Many of the therapeutic options available at the moment are characterized by the need for hospitalization or repeated intravenous infusions, safety issues, possible drug-drug interactions, and reduced efficacy on MDRs. Dalbavancin, the first long-acting molecule with strong activity against methicillin-resistant and also many vancomycin-resistant pathogens represents a game changer for adult ABSSSI. In pediatric settings, the available literature is still limited, but a growing body of evidence supports dalbavancin use in children with ABSSSI, demonstrating this drug to be safe and highly efficacious.

The Safety and Efficacy of Dalbavancin and Active Comparator in Pediatric Patients With Acute Bacterial Skin and Skin Structure Infections

BACKGROUND

Acute bacterial skin and skin structure infections (ABSSSIs) are a significant source of morbidity in children. Dalbavancin, approved for the treatment of adults and children with ABSSSI, has a well-established safety profile in adults. We report safety and descriptive efficacy data for the treatment of ABSSSI in children.

METHODS

Children with ABSSSI (birth-<18 years old) or sepsis (<3 months old) known/suspected to be caused by susceptible Gram-positive organisms were enrolled in this phase 3, multicenter, open-label, comparator-controlled study (NCT02814916). Children ≥3 months old were randomized 3:3:1 to receive single-dose dalbavancin, 2-dose dalbavancin, or a comparator antibiotic in 4 age cohorts; those <3 months old received single-dose dalbavancin. Clinical response and microbiologic efficacy were evaluated 48-72 hours and 14, 28 and 54 days posttreatment. Bowel flora testing and audiology were collected in a subset of patients at baseline and day 28. Adverse events (AEs) were collected throughout the study.

RESULTS

Treatment-emergent AEs occurred in 7.2%, 9.0% and 3.3% of patients in dalbavancin single-dose, dalbavancin 2-dose and comparator arms, respectively. Three serious AEs occurred in the dalbavancin single-dose arm; no treatment-related AEs, serious AEs, or AEs leading to study discontinuation were reported. Favorable clinical response at 48-72 hours was documented in 97.4%, 98.6% and 89.7% of patients. Safety and efficacy were comparable across age cohorts. The microbiologic intent-to-treat population had comparable clinical response for all baseline pathogens, including methicillin-resistant Staphylococcus aureus .

CONCLUSION

The safety profile of dalbavancin was consistent in children and adults with ABSSSI. No new safety signals were identified.

Population Pharmacokinetic and Pharmacokinetic/Pharmacodynamic Target Attainment Analyses for Dalbavancin in Pediatric Patients

BACKGROUND

Dalbavancin, approved for the treatment of pediatric and adult patients with acute bacterial skin and skin structure infections, has a terminal half-life of >14 days allowing administration as a single-dose regimen.

METHODS

We developed a population pharmacokinetic (PK) model using 1124 dalbavancin concentrations from 211 pediatric patients, with allometric scaling of clearance and volume parameter exponents fixed at 0.75 and 1, respectively. Serum albumin was included as a covariate on all PK parameters; creatinine clearance or estimated glomerular filtration rate was a covariate on clearance. The final model, qualified by visual predictive checks and bootstrapping, was used to simulate 1000 PK profiles for a range of pediatric age groups. PK/pharmacodynamic target attainment (PTA) was calculated for targets associated with stasis, 1-log kill, and 2-log kill of Staphylococcus aureus (neutropenic murine thigh infection model).

RESULTS

Dalbavancin PK was well characterized by a three-compartment model. No additional significant covariates were identified. Simulations showed that single-dose (30-minute intravenous infusion) regimens of 22.5 mg/kg (patients <6 years) and 18 mg/kg (patients 6 years to <18 years) resulted in PTA ≥94% for minimal inhibitory concentrations ≤2 mg/L and ≤0.5 mg/L for the stasis and 2-log kill targets, respectively. PTA for pediatric patients was similar to adults with exposures within the range for adults administered 1500 mg dalbavancin.

CONCLUSION

Dalbavancin PK in pediatric patients was well characterized by a three-compartment model. Simulations with the final model demonstrated adequate PTA across the entire age range for the approved pediatric dalbavancin doses.

Activity of Tedizolid and Comparator Agents Against Gram-positive Isolates Causing Skin and Skin Structure Infections in Pediatric Patients in United States Hospitals (2015-2019)

BACKGROUND

Tedizolid was approved by the United States Food and Drug Administration to treat acute bacterial skin and skin structure infections in adults in 2014, and in 2020, United States Food and Drug Administration expanded the approval of tedizolid to treat pediatric patients 12 years of age and older. This study assessed the activity of tedizolid and comparator agents against clinical surveillance isolates collected from pediatric patients with skin and skin structure infection in the United States.

METHODS

A total of 2747 gram-positive organisms (1 per patient) were collected in 2015 to 2019 from pediatric (≤17 years old) patients with skin and skin structure infections. The isolates were collected from 33 US medical centers and susceptibility tested against tedizolid and comparators by reference broth microdilution methods. Susceptibility results for main pathogens were stratified by patient age: ≤1 years old (851 isolates), 2 to 5 years old (623), 6 to 12 years old (754) and 13 to 17 years old (519).

RESULTS

Staphylococcus aureus (n = 2163) was the main pathogen recovered from all age groups, followed by β-hemolytic streptococci (n = 460). Tedizolid inhibited all S. aureus , including methicillin-resistant S. aureus (MRSA) isolates (41.0%), regardless of the age group. MRSA rates varied by age group; MRSA was highest among ≤1 years old (45.0%) and lowest in the 13 to 17 years old (32.7%) groups. Linezolid, daptomycin and vancomycin also displayed susceptibility rates of 100% against S. aureus isolates. Clindamycin (81.3%-98.5%), tetracycline (91.6%-97.1%) and trimethoprim-sulfamethoxazole (97.0%-100%) susceptibility rates varied among age groups and methicillin resistance profiles. Overall, tedizolid, linezolid, daptomycin and vancomycin inhibited all gram-positive pathogens in this collection.

CONCLUSIONS

Tedizolid was very active against a large collection of gram-positive pathogens causing skin and skin structure infection in pediatric patients, including MRSA isolates.

Role of Daptomycin in Cutaneous Wound Healing: A Narrative Review

Daptomycin is active against Gram-positive bacteria, including methicillin-resistant Staphylococcus aureus (MRSA) and the on-label indications for its use include complicated skin and skin structure infections (cSSSI). We performed a narrative review of the literature with the aim to evaluate the role of daptomycin in the skin wound healing process, proposing our point of view on the possible association with other molecules that could improve the skin healing process. Daptomycin may improve wound healing in MRSA-infected burns, surgical wounds, and diabetic feet, but further studies in humans with histological examination are needed. In the future, the combination of daptomycin with other molecules with synergistic action, such as vitamin E and derivates, IB-367, RNA III-inhibiting peptide (RIP), and palladium nanoflowers, may help to improve wound healing and overcome forms of antibiotic resistance.

Outpatient management of moderate cellulitis in children using high-dose oral cephalexin

Objectives

To evaluate the effectiveness of a high-dose (HD) oral cephalexin treatment guideline for children with moderate cellulitis treated as outpatients.

Methods

In this retrospective cohort study, we included children who presented to the emergency department (ED) with moderate cellulitis and treated according to the institution’s HD oral cephalexin guideline over a 2-year period. All children had standardized follow-up at a medical day hospital (MDH). Treatment was considered effective in the absence of treatment failure, defined as admission, switch to IV treatment or ED visit within 2 weeks of discharge from the MDH. Safety was ascertained by recording adverse events and severe complications at follow-up.

Results

A total of 123 children were treated as outlined in the guideline, including 117 treated with HD oral cephalexin. The success rate was 89.7% (105/117). Among 12 (10.3%) children who had treatment failure, 10 (8.5%) required admission, 1 (0.9%) received IV antibiotics at the MDH and 1 (0.9%) had a return visit to the ED without admission. No severe complications were reported; four abscesses required drainage and one patient had a rash. The mean number of visits per child at the MDH was 1.6 (SD 1.0).

Conclusions

With a success rate of 89.7%, HD oral cephalexin seems effective and safe for the treatment of children with moderate cellulitis. Its use potentially reduces hospitalization rates for this condition and decreases the need for IV insertion.

Trends and Variation in Length of Stay Among Hospitalized Febrile Infants ≤60 Days Old

OBJECTIVES

Researchers in recent studies suggest that hospitalized febrile infants aged ≤60 days may be safely discharged if bacterial cultures are negative after 24-36 hours of incubation. We aimed to describe trends and variation in length of stay (LOS) for hospitalized febrile infants across children's hospitals.

METHODS

We conducted a multicenter retrospective cohort study of febrile infants aged ≤60 days hospitalized from 2016 to 2019 at 39 hospitals in the Pediatric Health Information System database. We excluded infants with complex chronic conditions, bacterial infections, lower respiratory tract viral infections, and those who required ICU admission. The primary outcomes were trends in LOS overall and for individual hospitals, adjusted for patient demographics and clinical characteristics. We also evaluated the hospital-level association between LOS and 30-day readmissions.

RESULTS

We identified 11 868 eligible febrile infant encounters. The adjusted mean LOS for the study cohort decreased from 44.0 hours in 2016 to 41.9 hours in 2019 (P < .001). There was substantial variation in adjusted mean LOS across children's hospitals, range 33.5-77.9 hours in 2016 and 30.4-100.0 hours in 2019. The change from 2016 to 2019 in adjusted mean LOS across individual hospitals also varied widely (-23.9 to +26.7 hours; median change -1.8 hours, interquartile range: -5.4 to 0.3). There was no association between hospital-level LOS and readmission rates (P = .70).

CONCLUSIONS

The LOS for hospitalized febrile infants decreased marginally between 2016 and 2019, although overall LOS and change in LOS varied substantially across children's hospitals. Continued quality improvement efforts are needed to reduce LOS for hospitalized febrile infants.

National Trends of Acute Osteomyelitis and Peripherally Inserted Central Catheters in Children

OBJECTIVES

Although a growing body of evidence suggests that early transition to oral antimicrobial therapy is equally efficacious to prolonged intravenous antibiotics for treatment of acute pediatric osteomyelitis, little is known about the pediatric trends in peripherally inserted central catheter (PICC) placements. Using a national database, we examined incidence rates of pediatric hospitalizations for acute osteomyelitis in the United States from 2007 through 2016, as well as the trends in PICC placement, length of stay (LOS), and cost associated with these hospitalizations.

METHODS

This was a retrospective, serial cross-sectional study of the National Inpatient Sample database from 2007 through 2016. Patients ≤18 years of age with acute osteomyelitis were identified by using appropriate diagnostic codes. Outcomes measured included PICC placement rate, LOS, and inflation-adjusted hospitalization costs. Weighted analysis was reported, and a hierarchical regression model was used to analyze predictors.

RESULTS

The annual incidence of acute osteomyelitis increased from 1.0 to 1.8 per 100 000 children from 2007 to 08 to 2015 to 16 (P < .0001), whereas PICC placement rates decreased from 58.8% to 5.9% (P < .0001). Overall, changes in LOS and inflation-adjusted hospital costs were not statistically significant. PICC placements and sepsis were important predictors of increased LOS and hospital costs.

CONCLUSIONS

Although PICC placement rates for acute osteomyelitis significantly decreased in the face of increased incidence of acute osteomyelitis in children, LOS and hospital costs for all hospitalizations remained stable. However, patients receiving PICC placements had longer LOS. Further studies are needed to explore the long-term outcomes of reduced PICC use.

Utility of Inflammatory Markers in Hospitalized Children With Skin Erythema

BACKGROUND

There is overlap in the clinical presentations of superficial skin infections (eg, cellulitis) and deeper infections (eg, osteomyelitis). Inflammatory markers are frequently obtained in hospitalized patients with cellulitis. However, it is unknown whether inflammatory markers discriminate between superficial and deeper infections.

METHODS

We performed a retrospective review of children hospitalized with erythema on the skin and diagnoses of cellulitis, bursitis, myositis, osteomyelitis, and/or tenosynovitis. Patients were grouped into superficial infection (cellulitis and bursitis) and deeper infection (myositis, tenosynovitis, osteomyelitis). We compared C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) values between the two groups and constructed receiver operating characteristic curves to determine optimal cutoff values.

RESULTS

Among 168 children hospitalized with skin erythema, 122 patients had superficial and 46 patients had deeper infections. Mean CRP and ESR were significantly higher in patients with deeper infections (CRP: 8.3 [±9.6] mg/dL versus 2.8 [±3.5] mg/dL; P < .001; ESR: 48.3 [±28.6] mm/h versus 21.8 [±16.0] mm/h; P < .001). Neither WBC nor fever was significantly different between groups. CRP ≥2 mg/dL and ESR ≥30 mm/h were associated with deeper infections (CRP: odds ratio: 4.77; 95% confidence interval: 2.24-10.15; ESR: odds ratio: 7.93; 95% confidence interval: 3.46-17.67). When CRP and ESR were below these cutoffs, the negative predictive value was 89%.

CONCLUSIONS

Among patients presenting with skin erythema, CRP ≥2 mg/dL and ESR ≥30 mm/hr were significantly associated with deeper infection, whereas values below these cutoffs were reassuring against deeper infection. Future study of inflammatory markers in skin and soft tissue infections may help develop tailored testing strategies.

Understanding Pediatric Drug Lag Time: Review of Selected Drug Package Inserts

The wait for a pharmaceutical drug to become approved by the FDA for pediatrics lasts approximately 8 years longer than that for adults. One of the reasons given is the concern that simultaneous pediatric and adult trials may affect licensing in adults. We reviewed drug package inserts obtained from the FDA database for 5 selected agents for the years prior to and after being FDA approved for pediatric use. There were no new contraindications, warnings, or adverse events identified during pediatric clinical trials that would have put adult licensure at risk if approval was obtained in parallel for pediatric populations. The few changes in the package inserts in those years were due to ongoing adult clinical trials and post-marking experience in adults. The concern that pediatric trials might affect adult licensure does not appear to be justifiable.

Does Point-of-Care Ultrasound Affect Outcomes in Pediatric Patients with Skin and Soft Tissue Infections?

OBJECTIVE

There is increasing evidence for the use of point-of-care ultrasound (POCUS) in pediatric patients with skin and soft tissue infections (SSTI), but there is a lack of sufficient data on its impact on SSTI outcomes. The objective of this study was to determine whether POCUS use is associated with fewer complications after discharge from the pediatric emergency department.

METHODS

This was a prospective cohort study in patients presenting to the emergency department with SSTI between the ages of 2 months and 19 years old. Adverse outcomes included hospitalization after discharge, change in antibiotics, subsequent procedures, or reevaluation by a medical professional. Outcome information was obtained 1 week later. Descriptive statistics and χ² tests were used.

RESULTS

Of 456 patients screened, 250 were enrolled. POCUS was performed on 113 (45%) patients. The median age was 5 years, with more females in the non-POCUS group compared with the POCUS group (58% vs. 52%). Cellulitis without abscess was more commonly diagnosed in the POCUS group than in the non-POCUS group (26% vs 14%, P = 0.02.) The patients in the non-POCUS group were more likely to undergo incision and drainage than those in the POCUS group (62% vs 45%, P = 0.008). Overall, a greater number of patients in the POCUS group did not undergo any procedure (45% vs 27%, P = 0.003). The outcomes at 1 week did not differ significantly between the two groups.

CONCLUSIONS

POCUS use may lead to fewer procedures, but it does not lead to significantly better outcomes. Large randomized controlled trials are needed to confirm or refute our findings.

Cellulitis in children: a retrospective single centre study from Australia

AIM

To characterise the epidemiology, clinical features and treatment of paediatric cellulitis.

METHODS

A retrospective study of children presenting to a paediatric tertiary hospital in Western Australia, Australia in 2018. All inpatient records from 1 January to 31 December 2018 and emergency department presentations from 1 July to 31 December 2018 were screened for inclusion.

RESULTS

302 episodes of cellulitis were included comprising 206 (68.2%) admitted children and 96 (31.8%) non-admitted children. The median age was 5 years (IQR 2-9), 40 (13.2%) were Aboriginal and 180 (59.6%) boys. The extremities were the most commonly affected body site among admitted and non-admitted patients. There was a greater proportion of facial cellulitis in admitted patients (27.2%) compared with non-admitted patients (5.2%, p<0.01). Wound swab was the most frequent microbiological investigation (133/302, 44.0%), yielding positive cultures in the majority of those tested (109/133, 82.0%). The most frequent organisms identified were Staphylococcus aureus (94/109, 86.2%) (methicillin-susceptible S. aureus (60/94, 63.8%), methicillin-resistant S. aureus) and Streptococcus pyogenes (22/109, 20.2%) with 14 identifying both S. aureus and S. pyogenes. Intravenous flucloxacillin was the preferred antibiotic (154/199, 77.4%), with median intravenous duration 2 days (IQR 2-3), oral 6 days (IQR 5-7) and total 8 days (IQR 7-10).

CONCLUSIONS

Cellulitis is a common reason for presentation to a tertiary paediatric hospital. We confirm a high prevalence of extremity cellulitis and demonstrate that children with facial cellulitis often require admission. Cellulitis disproportionately affected Aboriginal children and children below 5 years. Prevention of cellulitis involves early recognition and treatment of skin infections such as impetigo and scabies.

Disparities in the use of antineoplastic immunotherapy in pediatric malignant adrenal tumors

Dinutuximab is a costly life-prolonging immunotherapy for high-risk neuroblastoma. We used a large pediatric inpatient database to analyze the use of antineoplastic immunotherapy in patients with malignant adrenal tumors 1 year after Food and Drug Administration approval of dinutuximab for high-risk neuroblastoma. On multivariate modeling, children of Black race (odds ratio [OR] 0.62, P = .04; referent non-Black) and the lowest ZIP code income quartile (OR 0.74, P = .03; referent wealthier 3 quartiles) were significantly less like to receive antineoplastic immunotherapy. These results suggest substantial disparities in the distribution of a vital therapy in children with advanced cancer.

Inpatient Observation After Transition From Intravenous to Oral Antibiotics

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.

Necrotizing soft tissue infection of both ear lobules occurring concomitantly in a set of twins following non-aseptic ear piercing: a case report

Background

Necrotizing soft tissue infection of the ear following ear piercing is a very rare condition. It is easily misdiagnosed leading to reconstructive morbidities and mortality in neonates. High clinical suspicion is important for early diagnosis. Our knowledge, this is the first case reported in the literature in this unique initial presentation. We hope to heighten the awareness of necrotizing soft tissue infection of the ear following ear piercing to ensure early aggressive intervention.

Case presentation

We report a set of 19-day-old female twin neonates who developed bilateral ear sores following ear piercing in a primary healthcentre without adherence to surgical asepsis. Examination findings showed features consistent with necrotizing soft tissue infections of the ears. They were successfully managed with antibiotics and wound care.

Conclusion

Necrotizing soft tissue infections is a very rare complication of neonatal ear piercing. It may occur following suboptimal aseptic procedure and a high index of suspicion is necessary to make this diagnosis to ensure early intervention and to forestall the potential reconstructive morbidities and mortality associated with late recognition. Adherence to basic aseptic surgical principles is the key to prevention of necrotizing soft tissue infections.

Point-of-Care Ultrasound for the Pediatric Hospitalist's Practice

Point-of-care ultrasound (POCUS) has the potential to provide real-time valuable information that could alter diagnosis, treatment, and management practices in pediatric hospital medicine. We review the existing pediatric POCUS literature to identify potential clinical applications within the scope of pediatric hospital medicine. Diagnostic point-of-care applications most relevant to the pediatric hospitalist include lung ultrasound for pneumothorax, pleural effusion, pneumonia, and bronchiolitis; cardiac ultrasound for global cardiac function and hydration status; renal or bladder ultrasound for nephrolithiasis, hydronephrosis, and bladder volumes; soft tissue ultrasound for differentiating cellulitis from abscess; and procedural-guidance applications, including line placement, lumbar puncture, and abscess incision and drainage. We discuss POCUS applications with reviews of major pathologic findings, research gaps, the integration of POCUS into practice, and barriers to implementation.

Efficacy and safety of intravenous ceftriaxone at home versus intravenous flucloxacillin in hospital for children with cellulitis (CHOICE): a single-centre, open-label, randomised, controlled, non-inferiority trial

BACKGROUND

Outpatient parenteral antimicrobial therapy in children is common despite no evidence of its efficacy or safety from clinical trials. We aimed to compare the efficacy and safety of intravenous antibiotic therapy at home with that of standard treatment in hospital for children with moderate to severe cellulitis.

METHODS

The Cellulitis at Home or Inpatient in Children from the Emergency Department (CHOICE) trial was a randomised, controlled, non-inferiority trial in children aged 6 months to 18 years who presented to the emergency department at The Royal Children's Hospital (Melbourne, VIC, Australia) with uncomplicated moderate to severe cellulitis. Participants were randomly assigned to receive either intravenous ceftriaxone (50 mg/kg once daily) at home or intravenous flucloxacillin (50 mg/kg every 6 h) in hospital with web-based randomisation, stratified by age and periorbital cellulitis. The primary outcome was treatment failure, which was defined as no clinical improvement or occurrence of an adverse event, resulting in a change in empiric antibiotics within 48 h of the first dose. Secondary outcomes included adverse events and acquisition of antibiotic-resistant bacteria. Outcomes were assessed in all randomised participants with outcome data (intention-to-treat population) and in all individuals who received treatment as allocated and did not have any major protocol violations (per-protocol population). For home treatment to be non-inferior to hospital treatment, the difference between groups in the proportion of children with treatment failure in the intention-to-treat population had to be less than 15%. This trial is registered with ClinicalTrials.gov, number NCT02334124.

FINDINGS

Between Jan 9, 2015, and June 15, 2017, we screened 1135 children for eligibility, of whom 190 were randomly assigned to receive ceftriaxone at home (n=95) or flucloxacillin in hospital (n=95). The intention-to-treat analysis comprised 188 children (93 in the home group and 95 in the hospital group) because two children in the home group were found to be ineligible after randomisation and were excluded. Treatment failure occurred in two (2%) children in the home group and in seven (7%) children in the hospital group (risk difference -5·2%, 95% CI -11·3 to 0·8, p=0·088). In the per-protocol analysis, treatment failure occurred in one (1%) of 89 children in the home group and in seven (8%) of 91 children in the hospital group (-6·5%, -12·4 to -0·7). Fewer children treated at home than in hospital had an adverse event (two [2%] vs ten [11%]; p=0·048). There was no difference between groups in rates of nasal acquisition of meticillin-resistant Staphylococcus aureus or gastrointestinal acquisition of extended-spectrum β-lactamase-producing bacteria or Clostridium difficile after 3 months.

INTERPRETATION

Home treatment with intravenous ceftriaxone is not inferior to treatment in hospital with intravenous flucloxacillin for children with cellulitis. The standard of care for the intravenous treatment of uncomplicated cellulitis in children should be home or outpatient care when feasible.

FUNDING

The Royal Children's Hospital Foundation and Murdoch Children's Research Institute.

Managing Skin and Soft Tissue Infections in the Emergency Department Observation Unit

BACKGROUND

Skin and soft tissue infections (SSTIs) are a common reason for presentation to the emergency department (ED) and account for 3% of ED visits. Patients with a diagnosis of cellulitis requiring intravenous (IV) antibiotics have traditionally been admitted to the hospital. In our institution, these patients are placed in the ED Observation Unit (EDOU) for IV antibiotics.

OBJECTIVES

The purpose of this study is to determine if 3 doses of IV antibiotics are adequate to document clinical improvement in children with uncomplicated SSTI.

METHODS

A prospective cohort study of children aged 3 months to 18 years with uncomplicated SSTI admitted (2009-2013) to the EDOU at a children's hospital for IV antibiotics was conducted.

RESULTS

One hundred six patients (mean age, 68 months) were enrolled; 57% were boys, 53% of patients had cellulitis only and 47% had cellulitis with drained abscesses. There was a significant decrease in pain scores and size of cellulitis from arrival to discharge (P < 0.001 and P < 0.001, respectively). Eighty-three percent of patients were discharged after 3 to 4 doses of antibiotics, and 17% were admitted. The location of the wound, presence of systemic symptoms, and prior use of oral antibiotics did not predict admission in our study.

CONCLUSIONS

The EDOU is a reasonable alternative to inpatient admission in the management of patients with uncomplicated SSTI requiring IV antibiotics.

Development and Validation of a Cellulitis Risk Score: The Melbourne ASSET Score

: media-1vid110.1542/5972298232001PEDS-VA_2018-1420Video Abstract BACKGROUND: The evidence is unclear about the optimal route of treatment for children with cellulitis, specifically how to assess the risk of moderate-to-severe cellulitis requiring intravenous (IV) antibiotics. We aimed to derive and validate a cellulitis risk assessment scoring system to guide providers as to which patients require IV antibiotics.

METHODS

This was a prospective cohort study of children presenting to the emergency department aged 6 months to 18 years diagnosed with cellulitis from January 2014 to August 2017. Patients were divided into 2 groups based on route of antibiotics at 24 hours (the predetermined gold standard). Demographics and clinical features were compared. Clinicians were surveyed about which features they used to decide whether to start IV antibiotics. Combinations of differentiating features were plotted on receiver operating characteristic curves.

RESULTS

There were 285 children in the derivation cohort used to create the Melbourne Area, Systemic features, Swelling, Eye, Tenderness (ASSET) Score, which has a maximum score of 7. The area under the curve was 0.86 (95% confidence interval 0.83-0.91). Using a cutoff score of 4 to start IV antibiotics yielded the highest correct classification of 80% of patients (sensitivity 60%; specificity 93%). This score was validated in 251 children and maintained a robust area under the curve of 0.83 (95% confidence interval 0.78-0.89).

CONCLUSIONS

The Melbourne ASSET Score was derived and validated for cellulitis in children to guide clinicians regarding when to start IV antibiotics. Although intended for widespread use, if limitations exist in other settings, it is designed to allow for refinement and is amenable to local impact analysis.

Variation in Antibiotic Selection and Clinical Outcomes in Infants <60 Days Hospitalized With Skin and Soft Tissue Infections

OBJECTIVES

To describe variation in empirical antibiotic selection in infants <60 days old who are hospitalized with skin and soft-tissue infections (SSTIs) and to determine associations with outcomes, including length of stay (LOS), 30-day returns (emergency department revisit or readmission), and standardized cost.

METHODS

Using the Pediatric Health Information System, we conducted a retrospective study of infants hospitalized with SSTI from 2009 to 2014. We analyzed empirical antibiotic selection in the first 2 days of hospitalization and categorized antibiotics as those typically administered for (1) staphylococcal infection, (2) neonatal sepsis, or (3) combination therapy (staphylococcal infection and neonatal sepsis). We examined the association of antibiotic selection and outcomes using generalized linear mixed-effects models.

RESULTS

A total of 1319 infants across 36 hospitals were included; the median age was 30 days (interquartile range [IQR]: 17-42 days). We observed substantial variation in empirical antibiotic choice, with 134 unique combinations observed before categorization. The most frequently used antibiotics included staphylococcal therapy (50.0% [IQR: 39.2-58.1]) and combination therapy (45.4% [IQR: 36.0-56.0]). Returns occurred in 9.2% of infants. Compared with administration of staphylococcal antibiotics, use of combination therapy was associated with increased LOS (adjusted rate ratio: 1.35; 95% confidence interval: 1.17-1.53) and cost (adjusted rate ratio: 1.39; 95% confidence interval: 1.21-1.58), but not with 30-day returns.

CONCLUSIONS

Infants who are hospitalized with SSTI experience wide variation in empirical antibiotic selection. Combination therapy was associated with increased LOS and cost, with no difference in returns. Our findings reveal the need to identify treatment strategies that can be used to optimize resource use for infants with SSTI.

Comparison of Ultrasound Guidance vs. Clinical Assessment Alone for Management of Pediatric Skin and Soft Tissue Infections

BACKGROUND

Point-of-care ultrasound (POCUS) can potentially help distinguish cellulitis from abscess, which can appear very similar on physical examination but necessitate different treatment approaches.

OBJECTIVE

To compare POCUS guidance vs. clinical assessment alone on the management of pediatric skin and soft tissue infections (SSTI) in the emergency department (ED) setting.

METHODS

Children ages 6 months to 18 years presenting to participating EDs with SSTIs ≥ 1 cm were eligible. All treatment decisions, including use of POCUS, were at the discretion of the treating clinicians. Patients were divided into those managed with POCUS guidance (POCUS group) and those managed using clinical assessment alone (non-POCUS group). Primary outcome was clinical treatment failure at 7-10 days (unscheduled ED return visit or admission, procedural intervention, change in antibiotics therapy). Secondary outcomes were ED length of stay, discharge rate, use of alternative imaging, and need for procedural sedation. POCUS utility and impact on management decisions were also assessed by treating clinicians.

RESULTS

In total, 321 subjects (327 lesions) were analyzed, of which 299 (93%) had completed follow-up. There was no significant difference between the POCUS and non-POCUS groups in any of the primary or secondary outcomes. Management plan was changed in the POCUS group in 22.9% of cases (13.8% from medical to surgical, 9.1% from surgical to medical). Clinicians reported increased benefit of POCUS in cases of higher clinical uncertainty.

CONCLUSIONS

Use of POCUS was not associated with decreased ED treatment failure rate or process outcomes in pediatric SSTI patients. However, POCUS changed the management plan in approximately one in four cases.

Prospective observational study to assess the need for postoperative antibiotics following surgical incision and drainage of skin and soft tissue abscess in pediatric patients

BACKGROUND

Post-operative antibiotics are often utilized for skin and soft tissue infection (SSTI) requiring surgical incision and drainage (I&D). We propose that antibiotics are unnecessary following I&D.

METHODS

Patients aged 3months to 6years with SSTI of the buttocks, groin, thigh, and/or labia requiring I&D were prospectively enrolled. The primary outcome was the proportion of patients requiring re-drainage and/or antibiotics for SSTI recurrence, within 30days. Follow-up consisted of a 30-day phone call, with optional 2-week office visit, combined with chart review for patients lost to follow-up. A one-sample binomial proportion with 95% confidence interval (CI) was used to examine non-inferiority for rate of treatment success, using previously published success rates for patients receiving antibiotics post-operatively (95.9%, with a 7% margin of equivalence).

RESULTS

A total of 92 patients were enrolled. All patients received pre-operative antibiotics. There was one treatment failure (success rate 0.989, CI 0.941-0.999). The recurrence rate was noninferior to previously-published data for patients receiving postoperative antibiotics (p<0.001). Subgroup analysis of patients who completed 30-day follow-up yielded a success rate of 0.973, CI 0.858-0.999 and evidence of non-inferiority (p=0.04).

CONCLUSIONS

Post-operative management excluding antibiotics should be considered for patients who undergo I&D for SSTI.

LEVEL OF EVIDENCE

Level II (prospective cohort study with <80% follow-up).

Pediatric Cellulitis: A Red-Hot Concern

Cellulitis and other skin and soft tissue infections are a common reason for children to seek care, both in the primary care setting and the emergency department. Cellulitis is a common skin and soft-tissue infection that is usually caused by streptococci bacteria or, less commonly, Staphylococcus aureus. Most children recover quickly from cellulitis, but a small subset will require hospitalization. Practitioners need to be skilled in the diagnosis and treatment of cellulitis, including recognition of the need for inpatient treatment. However, diagnosis of cellulitis, and exclusion of complicated or other more serious infections, can be challenging. Management of these infections has also been highly variable, resulting in some difficulty identifying the ideal treatment regimen. The goal is to use the antibiotic with the narrowest spectrum for the shortest duration necessary to provide clinical improvement. Research to identify the best treatment for pediatric cellulitis will be important moving forward. [Pediatr Ann. 2017;46(7):e265-e269.].

Daptomycin for Complicated Skin Infections: A Randomized Trial

BACKGROUND

Complicated skin and skin structure infections (cSSSI) are common in children. Due to safety and resistance issues with recommended agents, new treatment options would be advantageous.

METHODS

Multicenter, evaluator-blinded clinical trial. Patients 1 to 17 years old with cSSSI caused by Gram-positive pathogens were randomized 2:1 to intravenous daptomycin or standard-of-care (SOC) treatment for ≤14 days. Daptomycin was administered once daily with dosing by patient age: 12 to 17 years, 5 mg/kg; 7 to 11 years, 7 mg/kg; 2 to 6 years, 9 mg/kg; 12 to 23 months, 10 mg/kg. The primary objective was to evaluate daptomycin safety. The secondary objective was to assess the efficacy of daptomycin compared with SOC. The intent-to-treat (ITT) population consisted of all randomized patients with any dose of study drug.

RESULTS

The ITT population comprised 257 daptomycin and 132 SOC patients (primarily clindamycin or vancomycin); 35% had confirmed methicillin-resistant Staphylococcus aureus. The most common adverse events were diarrhea (7% daptomycin, 5% SOC) and increased creatine phosphokinase (6% daptomycin, 5% SOC). The proportions of safety population patients with treatment-related adverse events were similar between the daptomycin (14%) and SOC (17%) groups. Clinical success rates (blinded evaluator-assessed complete/partial resolution of cSSSI signs and symptoms 7-14 days after end-of-treatment) in the ITT population were also similar for the daptomycin (91%) and SOC groups.

CONCLUSIONS

Once-daily daptomycin was well tolerated, with safety and efficacy comparable to SOC in children/adolescents with cSSSI caused by Gram-positive pathogens, including community-acquired methicillin-resistant S aureus.

Using quality improvement methods to change surgical practice: a case example of pediatric soft-tissue abscesses

BACKGROUND

Surgical treatments of soft-tissue abscesses (STAs) include packing and ring drain (RD) and straight drain (SD) placement. Potential benefits of SDs include a single incision, less scarring, and no need for a follow-up appointment. We used a multidisciplinary quality improvement (QI) process to promote surgeon adoption of an STA drainage technique to improve efficiency and quality of care.

SUBJECTS AND METHODS

Outcome measures included the proportion of STAs drained using SDs, the number of postoperative clinic visits, the proportion of patients requiring follow-up with a pediatric surgeon and other providers, and the postoperative complication rate, defined as need for an additional drainage procedure.

RESULTS

After beginning the QI initiative, the proportion of STAs drained by SDs increased from 23% to 78% (P < .00001) and the proportion of patients requiring a surgical follow-up clinic appointment decreased from 71% to 32% (P < .00001). The mean number of surgical clinic visits per patient decreased from 0.79 to 0.39 visits per patient (P < .00001). Complication rates were similar between drain types (RD: 2.4%; SD: 1.7%; P = .57). This QI initiative produced a rapid sustained shift in surgeon practice with increased use of SDs, decreased number of follow-up visits, and no increase in complications.

Deep tissue biopsy vs. superficial swab culture, including microbial loading determination, in the microbiological assessment of Skin and Soft Tissue Infections (SSTIs)

Thirty-two patients affected by SSTIs including DFIs were enrolled between 2013 and 2014. Superficial swab was obtained before and after cleansing with sterile saline, and after ultrasonic debridement; deep tissue biopsy was obtained from ulcer base. Samples were diluted with 1 mL of saline, serial 10-fold dilutions to 10^-6 were made and 50 μL of each dilution was plated onto appropriate media. Bacteria were identified by Vitek II system. Microbial load was expressed as CFU/mL. Statistical analysis was performed by χ2. Incidence of Gram positives was higher than Gram negatives (S. aureus and P. aeruginosa being the most frequent); concordance (same bacteria isolated before and after debridement) never exceeded 60%. Ultrasonic debridement significantly reduced bacterial load or even suppressed bacterial growth. While reliability of superficial swab is poor for microbiological diagnosis of SSTIs, swabbing after ultrasonic debridement and biopsy of the ulcer base may be equally reliable.

Point-of-Care Ultrasonography for the Diagnosis of Pediatric Soft Tissue Infection

OBJECTIVES

To determine the test characteristics of point-of-care ultrasonography for the identification of a drainable abscess and to compare the test characteristics of ultrasonography with physical examination. In addition, we sought to measure the extent to which ultrasonography impacts clinical management of children with skin and soft tissue infections (SSTIs).

STUDY DESIGN

We performed a prospective study of children with SSTIs evaluated in a pediatric emergency department. Treating physicians recorded their initial impression of whether a drainable abscess was present based on physical examination. Another physician, blinded to the treating physician's assessment, performed an ultrasound study and conveyed their interpretation and recommendations to the treating physician. Any management change was recorded. An abscess was defined as a lesion from which purulent fluid was expressed during a drainage procedure in the emergency department or during the 2- to 5-day follow-up period. We defined a change in management as correct when the ultrasound diagnosis was discordant from physical examination and matched the ultimate lesion classification.

RESULTS

Of 151 SSTIs evaluated among 148 patients, the sensitivity and specificity of point-of-care ultrasonography for the presence of abscess were 96% (95% CI 90%-99%) and 87% (74%-95%), respectively. The sensitivity and specificity of physical examination for the presence of abscess were 84% (75%-90%) and 60% (44%-73%), respectively. For every 4 ultrasound examinations performed, there was 1 correct change in management.

CONCLUSIONS

Point-of-care ultrasonography demonstrates excellent test characteristics for the identification of skin abscess and has superior test characteristics compared with physical examination alone.

Risk Factors Associated With Abscess Formation in Children 5 Years of Age and Younger

From 1997 to 2009, hospitalization rates have doubled for pediatric patients with soft tissue abscesses requiring incision and drainage. Despite this increasing national burden, few studies have been conducted to identify the risk factors associated with abscess formation. Our study evaluates a collection of physiological and lifestyle parameters that may serve as risk factors for abscess formation among pediatric patients 5 years of age or younger. Our results indicate family history and age 2 years and younger are associated with higher risk of abscess formation. Furthermore, methicillin-resistant Staphylococcus aureus and methicillin-susceptible Staphylococcus aureus were prevalent pathogens associated with abscess in our study group. Pediatricians may employ these novel parameters to educate parents and/or guardians of high-risk groups on preventing abscess formation to alleviate the burden of incision & dragining requiring abscess on health care costs.

Failure of Emergency Department Observation Unit Treatment for Skin and Soft Tissue Infections

BACKGROUND

The effectiveness of observation unit (OU) management of skin and soft tissue infections (SSTI) has not been fully evaluated.

OBJECTIVE

This study was performed to determine the rate and risk factors.

METHODS

Retrospective cohort study of children ages 2 months to 18 years admitted to the OU for an SSTI between 2007 and 2010 from a pediatric emergency department (ED). Failure of OU therapy was defined as subsequent inpatient ward admission, re-admission after discharge from OU, initial or repeat incision and drainage after OU admission, or change in antibiotic therapy. Demographic, clinical, and lesion characteristics were collected. Comparative analyses were conducted to determine factors associated with OU failure; prolonged OU admission, defined as length of stay ≥ 36 h was evaluated.

RESULTS

One hundred ninety-two (63.2%) of 304 subjects with SSTI were eligible; mean age was 6.2 ± 5.3 years, and 52% were male. Fever (≥38°C) in the ED was present for 77 (40%). Most lesions were skin abscesses (53%) and were located on the lower extremity (36%) and buttock/genitourinary (21%). OU treatment failure occurred in 22% (95% confidence interval [CI] 16.5-28.3), primarily due to inpatient admission. Fever on ED presentation was significantly associated with OU failure (odds ratio 2.02; 95% CI 1.02-4.02). Demographics, body site, presence of abscess, and methicillin-resistant Staphylococcus aureus were not associated with OU failure. Prolonged OU admission occurred in 18 subjects (9.4%).

CONCLUSION

SSTI can be successfully treated in the OU, though febrile children with SSTI are at risk for OU treatment failure and should be considered for inpatient admission.

Causes and risk factors for 30-day unplanned readmissions after pediatric spinal deformity surgery

STUDY DESIGN

Retrospective review of a prospective cohort.

OBJECTIVE

To determine the incidence, risk factors, and causes for 30-day unplanned readmission after pediatric spinal deformity surgery.

SUMMARY OF BACKGROUND DATA

The government has targeted 30-day readmissions as a quality of care measure. However, few studies have analyzed readmission in pediatric cohorts.

METHODS

A multicenter registry designed to collect pediatric surgical outcomes was queried for patients undergoing spinal deformity surgery in 2012. Patients were divided into groups of those with and without an unplanned readmission within 30 days postoperatively. Univariate and multivariate logistic regression analyses were used to compare the cohorts, and to identify variables associated with readmission.

RESULTS

In total, 75 of 1890 pediatric patients undergoing spinal fusion for deformity had an unplanned 30-day readmission (3.96%). Readmissions were highest in the neuromuscular group (6.83%) and lowest in the idiopathic (2.66%) and infantile (1.31%) cohorts, (P < 0.01). The top reasons for readmission included wound complications (73.3%) and gastrointestinal disturbances (13.3%). In the univariate analysis, increasing surgical complexity, particularly fusions to the pelvis and isolated anterior spinal fusions, as well as increasing medical comorbidity burden were each associated with readmission (P < 0.05 for each). In the subsequent multivariate analysis, isolated anterior spinal fusions (odds ratio, 7.65; 95% confidence interval, 1.32-44.3) structural pulmonary abnormalities (odds ratio, 2.53; 95% confidence interval, 1.22-5.23) and an American Society of Anesthesiologists class of 3 or 4 (odds ratio, 2.18; 95% confidence interval, 1.07-4.47) were independently associated with readmission.

CONCLUSION

The overall rate of 30-day unplanned readmissions after pediatric deformity surgery was low, but not insignificant. Surgeons should consider discharge optimization in the at-risk patient cohorts defined here, and should focus on wound complications and gastrointestinal disturbances to minimize readmissions. Quality reporting metrics should incorporate these risk factors to avoid unduly penalizing surgeons who take on complex cases.

LEVEL OF EVIDENCE

3.

Increasing utilization of pediatric epilepsy surgery in the United States between 1997 and 2009

OBJECTIVE

To examine national trends of pediatric epilepsy surgery usage in the United States between 1997 and 2009.

METHODS

We performed a serial cross-sectional study of pediatric epilepsy surgery using triennial data from the Kids' Inpatient Database from 1997 to 2009. The rates of epilepsy surgery for lobectomies, partial lobectomies, and hemispherectomies in each study year were calculated based on the number of prevalent epilepsy cases in the corresponding year. The age-race-sex adjusted rates of surgeries were also estimated. Mann-Kendall trend test was used to test for changes in the rates of surgeries over time. Multivariable regression analysis was also performed to estimate the effect of time, age, race, and sex on the annual incidence of epilepsy surgery.

RESULTS

The rates of pediatric epilepsy surgery increased significantly from 0.85 epilepsy surgeries per 1,000 children with epilepsy in 1997 to 1.44 epilepsy surgeries per 1,000 children with epilepsy in 2009. An increment in the rates of epilepsy surgeries was noted across all age groups, in boys and girls, all races, and all payer types. The rate of increase was lowest in blacks and in children with public insurance. The overall number of surgical cases for each study year was lower than 35% of children who were expected to have surgery, based on the estimates from the Connecticut Study of Epilepsy.

SIGNIFICANCE

In contrast to adults, pediatric epilepsy surgery numbers have increased significantly in the past decade. However, epilepsy surgery remains an underutilized treatment for children with epilepsy. In addition, black children and those with public insurance continue to face disparities in the receipt of epilepsy surgery.

Trends in hospitalizations and resource utilization for pediatric pertussis

BACKGROUND AND OBJECTIVE

Pertussis is a serious and preventable childhood illness often necessitating hospitalization. The objective was to describe national trends in pediatric pertussis hospitalizations and resource utilization and factors associated with increased length of stay (LOS).

METHODS

This was a cross-sectional analysis of the 1997 to 2009 Healthcare Cost and Utilization Project Kids' Inpatient Databases. We examined pediatric hospitalizations of children (0-18 years) with a diagnosis of pertussis. Primary outcomes were hospitalizations, LOS, and charges. Weighted linear regression was used to evaluate trends in resource utilization. Multivariate logistic regression was used to determine factors associated with prolonged LOS.

RESULTS

Infants 0 to 6 months old accounted for nearly 90% of pediatric pertussis hospitalizations. Hospitalizations in public payers increased from 50% in 1997 to 67.4% in 2009 (P < .01). Among children with complex chronic conditions (CCCs), pertussis hospitalizations increased from 9.4% in 1997 to 16.8% in 2009 (P < .01). Mean LOS for pediatric pertussis hospitalizations decreased from 5.40 days in 1997 to 5.28 days in 2009 (P < .01), whereas those for children with CCCs increased from 8.86 days in 1997 to 9.25 days in 2009 (P < .01). Mean adjusted charges for pediatric pertussis hospitalizations rose from $14 520 in 1997 to $22 278 in 2009 (P < .01). For all study years, neonates and children with CCCs had greater odds of prolonged LOS.

CONCLUSIONS

Young infants and publicly insured patients account for a disproportionate number of pertussis-related hospitalizations. Patients with CCCs are increasingly contributing to hospitalizations and resource utilization attributable to pertussis. As new vaccine recommendations are implemented, targeted interventions are warranted to increase preventive efforts in these vulnerable populations.

Increasing hospital charges for adolescent idiopathic scoliosis in the United States

STUDY DESIGN

Retrospective cohort study.

OBJECTIVE

To determine the trends and causes for increases in hospital charges in adolescent idiopathic scoliosis (AIS) fusions.

SUMMARY OF BACKGROUND DATA

Trends in utilization rates, surgical procedure types, and hospital charges for AIS fusions have not been well investigated.

METHODS

We used International Classification of Diseases, Ninth Revision, billing codes to identify 29,594 AIS fusion cases from the National Inpatient Service (NIS) database between 2001 and 2011. Data were trended over time, and contrasted against other common procedures. To identify specific drivers of charges, we queried our own hospital's billing system, and averaged charges from 40 cases (10 cases for each of 4 yr studied). Dollar amounts were adjusted for inflation to 2011 dollars.

RESULTS

Utilization rates for AIS fusions have remained constant, whereas utilization of adult spinal fusions increased by 64% (P = 0.0004). Utilization of anterior thoracic fusions decreased by 80% (P < 0.0001). Mean hospital charges for AIS spinal fusions increased from $72,780 in 2001 to $155,278 in 2011 (113% increase), averaging 11.3% annually (P < 0.0001), with charges for adult spinal procedures increasing at a similar rate (13.4% annually, P < 0.0001). Charges for the other nonspine conditions increased to a lesser degree (range of 4.5%-6% annually, P < 0.001 for each). At our institution, spinal implant charges increased 27.6% annually, whereas surgeon charges decreased 0.5% annually, and all other charges increased only 5.2% annually. Over time, our surgeon used greater numbers of pedicle screws, and greater numbers of implants per surgery and per level fused (P < 0.05 for each). Implant charges were 28% of the total hospital bill in 2003, rising to 53% in 2012.

CONCLUSION

Although utilization rates for AIS fusions have remained constant over time, hospital charges have increased substantively, and there has been a shift toward performing posterior only surgical procedures. This corresponds to the widespread adoption of pedicle screw-based constructs. Spinal implants may be the primary driver of increased charges. Strategies directed toward implant cost savings may thus have the largest impact.

LEVEL OF EVIDENCE

4.

Antibiotic prescribing practices in a multicenter cohort of patients hospitalized for acute bacterial skin and skin structure infection

OBJECTIVE

Hospitalizations for acute bacterial skin and skin structure infection (ABSSSI) are common. Optimizing antibiotic use for ABSSSIs requires an understanding of current management. The objective of this study was to evaluate antibiotic prescribing practices and factors affecting prescribing in a diverse group of hospitals.

DESIGN

Multicenter, retrospective cohort study.

SETTING

Seven community and academic hospitals.

METHODS

Children and adults hospitalized between June 2010 and May 2012 for cellulitis, wound infection, or cutaneous abscess were eligible. The primary endpoint was a composite of 2 prescribing practices representing potentially avoidable antibiotic exposure: (1) use of antibiotics with a broad spectrum of activity against gram-negative bacteria or (2) treatment duration greater than 10 days.

RESULTS

A total of 533 cases were included: 320 with nonpurulent cellulitis, 44 with wound infection or purulent cellulitis, and 169 with abscess. Of 492 cases with complete prescribing data, the primary endpoint occurred in 394 (80%) cases and varied significantly across hospitals (64%-97%; P < .001). By logistic regression, independent predictors of the primary endpoint included wound infection or purulent cellulitis (odds ratio [OR], 5.12 [95% confidence interval (CI)], 1.46-17.88), head or neck involvement (OR, 2.83 [95% CI, 1.17-6.82]), adult cases (OR, 2.20 [95% CI, 1.18-4.11]), and admission to a community hospital (OR, 1.90 [95% CI, 1.05-3.44]).

CONCLUSIONS

Among patients hospitalized for ABSSSI, use of antibiotics with broad gram-negative activity or treatment courses longer than 10 days were common. There may be substantial opportunity to reduce antibiotic exposure through shorter courses of therapy targeting gram-positive bacteria.

Clinical characteristics and antibiotic utilization in pediatric patients hospitalized with acute bacterial skin and skin structure infection

BACKGROUND

Hospitalizations for acute bacterial skin and skin structure infection (ABSSSI) in children are increasingly frequent, but little is known about antibiotic utilization. In adults, recent studies suggest substantial opportunity to reduce broad-spectrum antibiotic use and shorten therapy. We sought to determine whether similar opportunity exists in children.

METHODS

This was a planned secondary analysis of a pediatric cohort taken from a multicenter, retrospective cohort of patients hospitalized for ABSSSI between June 1, 2010, and May 31, 2012. The prespecified primary endpoint was a composite of 2 prescribing practices: (1) use of antibiotics with broad Gram-negative activity or (2) treatment duration >10 days.

RESULTS

One-hundred and two patients ≤ 18 years old were included: 43 had non-purulent cellulitis, 19 had wound infection or purulent cellulitis and 40 had cutaneous abscess. The median age was 5 years (range 45 days to 18 years). Clindamycin was the most frequently prescribed antibiotic during hospitalization (67% of cases) and at discharge (66% of cases). The median duration of therapy was 11 days (interquartile range 10-12) and was similar for all 3 types of ABSSSI. The primary endpoint occurred in 67% of cases, including broad Gram-negative therapy in 25% and treatment duration >10 days in 61%. By multivariate logistic regression, admission through an emergency department and management by a medical (vs. surgical) service were independently associated with the primary endpoint.

CONCLUSIONS

Children hospitalized for ABSSSI are frequently exposed to antibiotics with broad Gram-negative activity or treated longer than 10 days suggesting opportunity to reduce antibiotic use.

Treatment of skin and soft tissue infections in a pediatric observation unit

OBJECTIVES

To report the success rate of observation unit (OU) treatment of pediatric skin and soft tissue infections (SSTIs) and to see if we could identify variables at the time of initial evaluation that predicted successful OU treatment.

METHODS

A retrospective review of children less than 18 years of age admitted for SSTI treatment to our OU from the emergency department between January 2003 and June 2009.

RESULTS

On records review, 853 patients matched eligibility criteria; median age was 5.2 years (interquartile range = 2.5-9 years). Of the 853 patients, 597 (70.0%) met the primary outcome criteria of successful OU discharge within 26 hours. Secondary analysis revealed that 82% of the patients achieved successful discharge from the OU within 48 hours. Although some laboratory variables demonstrated statistical association with success, none achieved a combination of high sensitivity and specificity to predict OU failure. OU success rates varied by location. Dental and face infections and those of the extremities or multiple sites demonstrated OU success rates higher than 65%, while infection of the groin, buttocks, trunk, or neck had success rates between 24% (neck) and 60% (groin). In multivariate analysis, only 3 variables remained significant. Unfavorable location was most strongly associated with OU failure, followed by C-reactive protein > 4 and then by erythrocyte sedimentation rate > 20.

CONCLUSIONS

Our findings suggest that successful OU treatment is possible in a large group of patients needing hospitalization for SSTIs. Consideration of infection location may assist the emergency department clinician in determining the most appropriate unit for admission.

Cutaneous bacterial infections caused by Staphylococcus aureus and Streptococcus pyogenes in infants and children

Acute bacterial skin and skin structure infections (SSSIs) are among the most common bacterial infections in children. The medical burden of SSSIs, particularly abscesses, has increased nationwide since the emergence of community-acquired methicillin-resistant Staphylococcus aureus. SSSIs represent a wide spectrum of disease severity. Prompt recognition, timely institution of appropriate therapy, and judicious antimicrobial use optimize patient outcomes. For abscesses, incision and drainage are paramount and might avoid the need for antibiotic treatment in uncomplicated cases. If indicated, empiric antimicrobial therapy should target Streptococcus pyogenes for nonpurulent SSSIs, such as uncomplicated cellulitis, and S aureus for purulent SSSIs such as abscesses.

Factors associated with high resource utilization in pediatric skin and soft tissue infection hospitalizations

OBJECTIVE

To describe factors associated with prolonged lengths of stay (LOS) and increased charges for pediatric skin and soft tissue infection (SSTI) hospitalizations.

METHODS

This study was a cross-sectional analysis of pediatric SSTI hospital discharges in 2009 within the Healthcare Cost and Utilization Project Kids' Inpatient Database. Outcomes were prolonged LOS (>75th percentile) and increased hospital charges (>75th percentile). Multivariate logistic regression controlling for patient and hospital level factors was conducted for 2009 data to assess associations among variables.

RESULTS

The 75th percentile for LOS was 3 days. Infants had higher odds of prolonged LOS than other age groups (<1 year: 1; 1-4 years: 0.70 [95% confidence interval (CI): 0.64-0.76]; 5-12 years: 0.69 [95% CI: 0.63-0.76]; 13-18 years: 1.01 [95% CI: 0.91-1.10]), as did all minority groups compared with white subjects (black subjects: 1.23 [95% CI: 1.09-1.38]; Hispanic subjects: 1.33 [95% CI: 1.20-1.47]; and other races: 1.30 [95% CI: 1.12-1.50]). Public payers compared with private payers (odds ratio: 1.17 [95% CI: 1.10-1.26]) also had increased odds of prolonged LOS. The 75th percentile for charges was $14 317. The adolescent-aged category had higher odds of charges >75th percentile compared with the age category <1 year (odds ratio: 1.54 [95% CI: 1.36-1.74]). All racial/ethnic minorities had higher odds of charges >75th percentile compared with white subjects (black subjects: 1.38 [95% CI: 1.17-1.62]; Hispanic subjects: 1.90 [95% CI: 1.59-2.26]; and other races: 1.26 [95% CI: 1.06-1.50]).

CONCLUSIONS

Vulnerable populations, including infants, racial/ethnic minorities, and publicly insured children, had higher odds of increased resource utilization during hospitalizations for SSTIs. The findings of this study provide potential targets for future preventive and public health interventions.