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Ramgopal S, Belanger T, Lorenz D, Lipsett SC, Neuman MI, Liebovitz D, Florin TA. Preferences for Management of Pediatric Pneumonia: A Clinician Survey of Artificially Generated Patient Cases. Pediatr Emerg Care 2024:00006565-990000000-00488. [PMID: 38950412 DOI: 10.1097/pec.0000000000003231] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/03/2024]
Abstract
BACKGROUND It is unknown which factors are associated with chest radiograph (CXR) and antibiotic use for suspected community-acquired pneumonia (CAP) in children. We evaluated factors associated with CXR and antibiotic preferences among clinicians for children with suspected CAP using case scenarios generated through artificial intelligence (AI). METHODS We performed a survey of general pediatric, pediatric emergency medicine, and emergency medicine attending physicians employed by a private physician contractor. Respondents were given 5 unique, AI-generated case scenarios. We used generalized estimating equations to identify factors associated with CXR and antibiotic use. We evaluated the cluster-weighted correlation between clinician suspicion and clinical prediction model risk estimates for CAP using 2 predictive models. RESULTS A total of 172 respondents provided responses to 839 scenarios. Factors associated with CXR acquisition (OR, [95% CI]) included presence of crackles (4.17 [2.19, 7.95]), prior pneumonia (2.38 [1.32, 4.20]), chest pain (1.90 [1.18, 3.05]) and fever (1.82 [1.32, 2.52]). The decision to use antibiotics before knowledge of CXR results included past hospitalization for pneumonia (4.24 [1.88, 9.57]), focal decreased breath sounds (3.86 [1.98, 7.52]), and crackles (3.45 [2.15, 5.53]). After revealing CXR results to clinicians, these results were the sole predictor associated with antibiotic decision-making. Suspicion for CAP correlated with one of 2 prediction models for CAP (Spearman's rho = 0.25). Factors associated with a greater suspicion of pneumonia included prior pneumonia, duration of illness, worsening course of illness, shortness of breath, vomiting, decreased oral intake or urinary output, respiratory distress, head nodding, focal decreased breath sounds, focal rhonchi, fever, and crackles, and lower pulse oximetry. CONCLUSIONS Ordering preferences for CXRs demonstrated similarities and differences with evidence-based risk models for CAP. Clinicians relied heavily on CXR findings to guide antibiotic ordering. These findings can be used within decision support systems to promote evidence-based management practices for pediatric CAP.
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Affiliation(s)
- Sriram Ramgopal
- From the Division of Emergency Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, IL
| | | | - Douglas Lorenz
- Department of Bioinformatics and Biostatistics, University of Louisville, Louisville, KY
| | - Susan C Lipsett
- Department of Pediatrics, Division of Emergency Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA
| | - Mark I Neuman
- Department of Pediatrics, Division of Emergency Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA
| | - David Liebovitz
- Department of General Internal Medicine, Northwestern University Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - Todd A Florin
- From the Division of Emergency Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, IL
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2
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Geanacopoulos AT, Amirault JP, Michelson KA, Monuteaux MC, Lipsett SC, Hirsch AW, Neuman MI. Community-Acquired Pneumonia Diagnosis Following Emergency Department Visits for Respiratory Illness. Clin Pediatr (Phila) 2024:99228241254153. [PMID: 38757645 DOI: 10.1177/00099228241254153] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/18/2024]
Abstract
Community-acquired pneumonia (CAP) is often considered for children presenting to the emergency department (ED) with respiratory symptoms. It is unclear how often children are diagnosed with CAP following an ED visit for respiratory illness. We performed a retrospective case-control study to evaluate 7-day CAP diagnosis among children 3 months to 18 years discharged from the ED with respiratory illness from 2011 to 2021 and who receive care at 4 hospital-affiliated primary care clinics. Logistic regression was performed to assess for predictors of 7-day CAP diagnosis. Seventy-four (0.7%, 95% confidence interval [CI] = 0.6%, 0.9%) of 10 329 children were diagnosed with CAP within 7 days, and fever at the index visit was associated with increased odds of diagnosis (odds ratio [OR] = 3.32, 95% CI = 1.75-6.28). Community-acquired pneumonia diagnosis after discharge from the ED with respiratory illness is rare, even among children who are febrile at time of initial evaluation.
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Affiliation(s)
- Alexandra T Geanacopoulos
- Department of Pediatrics, Harvard Medical School, Boston, MA, USA
- Division of Emergency Medicine, Boston Children's Hospital, Boston, MA, USA
| | - Janine P Amirault
- Department of Pediatrics, Harvard Medical School, Boston, MA, USA
- Division of Emergency Medicine, Boston Children's Hospital, Boston, MA, USA
| | - Kenneth A Michelson
- Division of Emergency Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - Michael C Monuteaux
- Department of Pediatrics, Harvard Medical School, Boston, MA, USA
- Division of Emergency Medicine, Boston Children's Hospital, Boston, MA, USA
| | - Susan C Lipsett
- Department of Pediatrics, Harvard Medical School, Boston, MA, USA
- Division of Emergency Medicine, Boston Children's Hospital, Boston, MA, USA
| | - Alexander W Hirsch
- Department of Pediatrics, Harvard Medical School, Boston, MA, USA
- Division of Emergency Medicine, Boston Children's Hospital, Boston, MA, USA
| | - Mark I Neuman
- Department of Pediatrics, Harvard Medical School, Boston, MA, USA
- Division of Emergency Medicine, Boston Children's Hospital, Boston, MA, USA
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3
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Madden K, Wolf M, Tasker RC, Figueroa J, McCracken C, Hall M, Kamat P. Antipsychotic Drug Prescription in Pediatric Intensive Care Units: A 10-Year U.S. Retrospective Database Study. J Pediatr Intensive Care 2024; 13:46-54. [PMID: 38571986 PMCID: PMC10987219 DOI: 10.1055/s-0041-1736523] [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: 07/10/2021] [Accepted: 08/31/2021] [Indexed: 10/20/2022] Open
Abstract
Delirium recognition during pediatric critical illness may result in the prescription of antipsychotic medication. These medications have unclear efficacy and safety. We sought to describe antipsychotic medication use in pediatric intensive care units (PICUs) contributing to a U.S. national database. This study is an analysis of the Pediatric Health Information System Database between 2008 and 2018, including children admitted to a PICU aged 0 to 18 years, without prior psychiatric diagnoses. Antipsychotics were given in 16,465 (2.3%) of 706,635 PICU admissions at 30 hospitals. Risperidone (39.6%), quetiapine (22.1%), and haloperidol (20.8%) were the most commonly used medications. Median duration of prescription was 4 days (interquartile range: 2-11 days) for atypical antipsychotics, and haloperidol was used a median of 1 day (1-3 days). Trend analysis showed quetiapine use increased over the study period, whereas use of haloperidol and chlorpromazine (typical antipsychotics) decreased ( p < 0.001). Compared with no antipsychotic administration, use of antipsychotics was associated with comorbidities (81 vs. 65%), mechanical ventilation (57 vs. 36%), longer PICU stay (6 vs. 3 days), and higher mortality (5.7 vs. 2.8%) in univariate analyses. In the multivariable model including demographic and clinical factors, antipsychotic prescription was associated with mortality (odds ratio [OR] = 1.09, 95% confidence interval [CI]: 1.02-1.18). Use of atypical antipsychotics increased over the 10-year period, possibly reflecting increased comfort with their use in pediatric patients. Antipsychotics were more common in patients with comorbidities, mechanical ventilation, and longer PICU stay, and associated with higher mortality in an adjusted model which warrants further study.
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Affiliation(s)
- Kate Madden
- Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital, Boston, Massachusetts, United States
| | - Michael Wolf
- Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia, United States
| | - Robert C. Tasker
- Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital, Boston, Massachusetts, United States
| | - Janet Figueroa
- Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia, United States
| | - Courtney McCracken
- Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia, United States
| | - Matt Hall
- Children's Hospital Association, Lenexa, Kansas, United States
| | - Pradip Kamat
- Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia, United States
- Division of Critical Care, Children's Healthcare of Atlanta at Egleston, Atlanta, Georgia, United States
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4
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Geanacopoulos AT, Neuman MI, Michelson KA. Cost of Pediatric Pneumonia Episodes With or Without Chest Radiography. Hosp Pediatr 2024; 14:146-152. [PMID: 38229532 PMCID: PMC10873478 DOI: 10.1542/hpeds.2023-007506] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2024]
Abstract
BACKGROUND AND OBJECTIVES Despite its routine use, it is unclear whether chest radiograph (CXR) is a cost-effective strategy in the workup of community-acquired pneumonia (CAP) in the pediatric emergency department (ED). We sought to assess the costs of CAP episodes with and without CXR among children discharged from the ED. METHODS This was a retrospective cohort study within the Healthcare Cost and Utilization Project State ED and Inpatient Databases of children aged 3 months to 18 years with CAP discharged from any EDs in 8 states from 2014 to 2019. We evaluated total 28-day costs after ED discharge, including the index visit and subsequent care. Mixed-effects linear regression models adjusted for patient-level variables and illness severity were performed to evaluate the association between CXR and costs. RESULTS We evaluated 225c781 children with CAP, and 86.2% had CXR at the index ED visit. Median costs of the 28-day episodes, index ED visits, and subsequent visits were $314 (interquartile range [IQR] 208-497), $288 (IQR 195-433), and $255 (IQR 133-637), respectively. There was a $33 (95% confidence interval [CI] 22-44) savings over 28-days per patient for those who received a CXR compared with no CXR after adjusting for patient-level variables and illness severity. Costs during subsequent visits ($26 savings, 95% CI 16-36) accounted for the majority of the savings as compared with the index ED visit ($6, 95% CI 3-10). CONCLUSIONS Performance of CXR for CAP diagnosis is associated with lower costs when considering the downstream provision of care among patients who require subsequent health care after initial ED discharge.
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Affiliation(s)
- Alexandra T Geanacopoulos
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
- Division of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts
| | - Mark I Neuman
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
- Division of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts
| | - Kenneth A Michelson
- Division of Emergency Medicine, Ann & Robert Lurie Children's Hospital of Chicago, Chicago, Illinois
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5
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Rees CA, Kuppermann N, Florin TA. Community-Acquired Pneumonia in Children. Pediatr Emerg Care 2023; 39:968-976. [PMID: 38019716 DOI: 10.1097/pec.0000000000003070] [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] [Indexed: 12/01/2023]
Abstract
ABSTRACT Community-acquired pneumonia (CAP) is the most common cause of childhood mortality globally. In the United States, CAP is a leading cause of pediatric hospitalization and antibiotic use and is associated with substantial morbidity. There has been a dramatic shift in microbiological etiologies for CAP in children over time as pneumococcal pneumonia has become less common and viral etiologies have become predominant. There is no commonly agreed on approach to the diagnosis of CAP in children. When indicated, antimicrobial treatment should consist of narrow-spectrum antibiotics. In this article, we will describe the current understanding of the microbiological etiologies, clinical presentation, diagnostic approach, risk factors, treatment, and future directions in the diagnosis and management of pediatric CAP.
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Affiliation(s)
| | - Nathan Kuppermann
- Professor, Departments of Emergency Medicine and Pediatrics, University of California Davis Health, University of California Davis, School of Medicine, Sacramento, CA
| | - Todd A Florin
- Associate Professor, Department of Pediatrics, Northwestern University Feinberg School of Medicine and Division of Emergency Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL
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Ambroggio L, Cotter J, Hall M, Shapiro DJ, Lipsett SC, Hersh AL, Shah SS, Brogan TV, Gerber JS, Williams DJ, Blaschke AJ, Cogen JD, Neuman MI. Management of Pediatric Pneumonia: A Decade After the Pediatric Infectious Diseases Society and Infectious Diseases Society of America Guideline. Clin Infect Dis 2023; 77:1604-1611. [PMID: 37352841 DOI: 10.1093/cid/ciad385] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Revised: 06/09/2023] [Accepted: 06/20/2023] [Indexed: 06/25/2023] Open
Abstract
BACKGROUND Incomplete uptake of guidelines can lead to nonstandardized care, increased expenditures, and adverse clinical outcomes. The objective of this study was to evaluate the impact of the 2011 Pediatric Infectious Diseases Society and Infectious Diseases Society of America (PIDS/IDSA) pediatric community-acquired pneumonia (CAP) guideline that emphasized aminopenicillin use and de-emphasized the use of chest radiographs (CXRs) in certain populations. METHODS This quasi-experimental study queried a national administrative database of children's hospitals to identify children aged 3 months-18 years with CAP who visited 1 of 28 participating hospitals from 2009 to 2021. PIDS/IDSA pediatric CAP guideline recommendations regarding antibiotic therapy, diagnostic testing, and imaging were evaluated. Segmented regression interrupted time series was used to measure guideline-concordant practices with interruptions for guideline publication and the Coronavirus Disease 2019 (COVID-19) pandemic. RESULTS Of 315 384 children with CAP, 71 804 (22.8%) were hospitalized. Among hospitalized children, there was a decrease in blood culture performance (0.5% per quarter) and increase in aminopenicillin prescribing (1.1% per quarter). Among children discharged from the emergency department (ED), there was an increase in aminopenicillin prescription (0.45% per quarter), whereas the rate of obtaining CXRs declined (0.12% per quarter). However, use of CXRs rebounded during the COVID-19 pandemic (increase of 1.56% per quarter). Hospital length of stay, ED revisit rates, and hospital readmission rates remained stable. CONCLUSIONS Guideline publication was associated with an increase of aminopenicillin prescribing. However, rates of diagnostic testing did not materially change, suggesting the need to consider implementation strategies to meaningfully change clinical practice for children with CAP.
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Affiliation(s)
- Lilliam Ambroggio
- Sections of Emergency Medicine and Hospital Medicine, Children's Hospital Colorado, Department of Pediatrics, University of Colorado, Aurora, Colorado, USA
| | - Jillian Cotter
- Sections of Emergency Medicine and Hospital Medicine, Children's Hospital Colorado, Department of Pediatrics, University of Colorado, Aurora, Colorado, USA
| | - Matthew Hall
- Children's Hospital Association, Lenexa, Kansas, USA
| | - Daniel J Shapiro
- Division of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts, USA
- Departments of Pediatrics and Emergency Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - Susan C Lipsett
- Division of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts, USA
- Departments of Pediatrics and Emergency Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - Adam L Hersh
- Division of Pediatric Infectious Diseases, Department of Pediatrics, School of Medicine, University of Utah, Salt Lake City, Utah, USA
| | - Samir S Shah
- Division of Hospital Medicine, Cincinnati Children's Hospital Medicine Center, Cincinnati, Ohio, USA
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Thomas V Brogan
- Division of Critical Care, Seattle Children's Hospital, Seattle, Washington, USA
- Department of Pediatrics, School of Medicine, University of Washington, Seattle, Washington, USA
| | - Jeffrey S Gerber
- Division of Infectious Diseases, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Derek J Williams
- Division of Hospital Medicine, Department of Pediatrics, Monroe Carell Jr Children's Hospital at Vanderbilt, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - Anne J Blaschke
- Division of Pediatric Infectious Diseases, Department of Pediatrics, School of Medicine, University of Utah, Salt Lake City, Utah, USA
| | - Jonathan D Cogen
- Division of Pulmonary Medicine and Sleep Medicine, Seattle Children's Hospital, University of Washington, Seattle, Washington, USA
| | - Mark I Neuman
- Division of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts, USA
- Departments of Pediatrics and Emergency Medicine, Harvard Medical School, Boston, Massachusetts, USA
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7
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Amirault JP, Porter JJ, Hirsch AW, Lipsett SC, Neuman MI. Diagnosis and Management of Pneumonia in Infants Less Than 90 Days of Age. Hosp Pediatr 2023; 13:694-707. [PMID: 37492932 DOI: 10.1542/hpeds.2022-007062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/27/2023]
Abstract
BACKGROUND Current guidelines and recent studies on pediatric pneumonia pertain to children older than 3 months of age. Little information exists regarding the diagnostic evaluation, management, and outcomes of infants less than 90 days with pneumonia. METHODS We compared infants <90 days of age diagnosed with pneumonia across 38 US children's hospitals from 2016 to 2021 to children 90 days to 5 years of age. We evaluated whether differences exist in patient characteristics, diagnostic testing, antibiotic treatment, and outcomes between young infants and older children. Additionally, we assessed seasonal variability and trends over time in pneumonia diagnoses by age group. RESULTS Among 109 796 children diagnosed with pneumonia, 3128 (2.8%) were <90 days of age. Compared with older children, infants <90 days had more laboratory testing performed (88.6% vs 48.8%, P < .001; median number of laboratory tests 4 [interquartile range: 2-5] vs 0 [interquartile range: 0-3] respectively), with wide variation in testing across hospitals. Chest radiograph utilization did not differ by age group. Infants <90 days were more likely to be hospitalized and require respiratory support than older children. Seasonal variation was observed for pneumonia encounters in both age groups. CONCLUSIONS Infants <90 days with pneumonia were more likely to undergo laboratory testing, be hospitalized, and require respiratory support than children 90 days to 5 years of age. This may reflect inherent differences in the pathophysiology of pneumonia by age, the manner in which pneumonia is diagnosed, or possible overuse of testing in infants.
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Affiliation(s)
- Janine P Amirault
- Division of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts
| | - John J Porter
- Division of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts
| | - Alexander W Hirsch
- Division of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts
| | - Susan C Lipsett
- Division of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts
| | - Mark I Neuman
- Division of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts
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8
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Rixe N, Frisch A, Wang Z, Martin JM, Suresh S, Florin TA, Ramgopal S. The development of a novel natural language processing tool to identify pediatric chest radiograph reports with pneumonia. Front Digit Health 2023; 5:1104604. [PMID: 36910570 PMCID: PMC9992200 DOI: 10.3389/fdgth.2023.1104604] [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: 11/21/2022] [Accepted: 01/16/2023] [Indexed: 02/25/2023] Open
Abstract
Objective Chest radiographs are frequently used to diagnose community-acquired pneumonia (CAP) for children in the acute care setting. Natural language processing (NLP)-based tools may be incorporated into the electronic health record and combined with other clinical data to develop meaningful clinical decision support tools for this common pediatric infection. We sought to develop and internally validate NLP algorithms to identify pediatric chest radiograph (CXR) reports with pneumonia. Materials and methods We performed a retrospective study of encounters for patients from six pediatric hospitals over a 3-year period. We utilized six NLP techniques: word embedding, support vector machines, extreme gradient boosting (XGBoost), light gradient boosting machines Naïve Bayes and logistic regression. We evaluated their performance of each model from a validation sample of 1,350 chest radiographs developed as a stratified random sample of 35% admitted and 65% discharged patients when both using expert consensus and diagnosis codes. Results Of 172,662 encounters in the derivation sample, 15.6% had a discharge diagnosis of pneumonia in a primary or secondary position. The median patient age in the derivation sample was 3.7 years (interquartile range, 1.4-9.5 years). In the validation sample, 185/1350 (13.8%) and 205/1350 (15.3%) were classified as pneumonia by content experts and by diagnosis codes, respectively. Compared to content experts, Naïve Bayes had the highest sensitivity (93.5%) and XGBoost had the highest F1 score (72.4). Compared to a diagnosis code of pneumonia, the highest sensitivity was again with the Naïve Bayes (80.1%), and the highest F1 score was with the support vector machine (53.0%). Conclusion NLP algorithms can accurately identify pediatric pneumonia from radiography reports. Following external validation and implementation into the electronic health record, these algorithms can facilitate clinical decision support and inform large database research.
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Affiliation(s)
- Nancy Rixe
- Division of Pediatric Emergency Medicine, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States
| | - Adam Frisch
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States
| | - Zhendong Wang
- School of Computing and Information, University of Pittsburgh, Pittsburgh, PA, United States
| | - Judith M Martin
- Division of General Academic Pediatrics, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States
| | - Srinivasan Suresh
- Division of Pediatric Emergency Medicine, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States.,Division of Health Informatics, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States
| | - Todd A Florin
- Division of Emergency Medicine, Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL, United States
| | - Sriram Ramgopal
- Division of Emergency Medicine, Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL, United States
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9
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Cotter JM, Hall M, Shah SS, Molloy MJ, Markham JL, Aronson PL, Stephens JR, Steiner MJ, McCoy E, Collins M, Tchou MJ. Variation in bacterial pneumonia diagnoses and outcomes among children hospitalized with lower respiratory tract infections. J Hosp Med 2022; 17:872-879. [PMID: 35946482 DOI: 10.1002/jhm.12940] [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] [Received: 03/23/2022] [Revised: 07/14/2022] [Accepted: 07/18/2022] [Indexed: 11/08/2022]
Abstract
BACKGROUND Current diagnostics do not permit reliable differentiation of bacterial from viral causes of lower respiratory tract infection (LRTI), which may lead to over-treatment with antibiotics for possible bacterial community-acquired pneumonia (CAP). OBJECTIVES We sought to describe variation in the diagnosis and treatment of bacterial CAP among children hospitalized with LRTIs and determine the association between CAP diagnosis and outcomes. DESIGN, SETTING AND PARTICIPANTS This multicenter cross-sectional study included children hospitalized between 2017 and 2019 with LRTIs at 42 children's hospitals. MAIN OUTCOME AND METHODS We calculated the proportion of children with LRTIs who were diagnosed with and treated for bacterial CAP. After adjusting for confounders, hospitals were grouped into high, moderate, and low CAP diagnosis groups. Multivariable regression was used to examine the association between high and low CAP diagnosis groups and outcomes. RESULTS We identified 66,581 patients hospitalized with LRTIs and observed substantial variation across hospitals in the proportion diagnosed with and treated for bacterial CAP (median 27%, range 12%-42%). Compared with low CAP diagnosing hospitals, high diagnosing hospitals had higher rates of CAP-related revisits (0.6% [95% confidence interval: 0.5, 0.7] vs. 0.4% [0.4, 0.5], p = .04), chest radiographs (58% [53, 62] vs. 46% [41, 51], p = .02), and blood tests (43% [33, 53] vs. 26% [19, 35], p = .046). There were no significant differences in length of stay, all-cause revisits or readmissions, CAP-related readmissions, or costs. CONCLUSION There was wide variation across hospitals in the proportion of children with LRTIs who were treated for bacterial CAP. The lack of meaningful differences in clinical outcomes among hospitals suggests that some institutions may over-diagnose and overtreat bacterial CAP.
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Affiliation(s)
- Jillian M Cotter
- Department of Pediatrics, Section of Hospital Medicine, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Matt Hall
- Children's Hospital Association, Lenexa, Kansas, USA
| | - Samir S Shah
- Department of Pediatrics, Cincinnati Children's Hospital Medical Center and the University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Matthew J Molloy
- Department of Pediatrics, Cincinnati Children's Hospital Medical Center and the University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Jessica L Markham
- Department of Pediatrics, Children's Mercy Kansas City, University of Missouri Kansas City, Kansas City, Missouri, USA
| | - Paul L Aronson
- Departments of Pediatrics and Emergency Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - John R Stephens
- Department of Pediatrics, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
- Department of Medicine, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
| | - Michael J Steiner
- Department of Pediatrics, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
| | - Elisha McCoy
- Department of Pediatrics and Medicine, Le Bonheur Children's Hospital, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Megan Collins
- Department of Pediatrics, Children's Mercy Kansas City, University of Missouri Kansas City, Kansas City, Missouri, USA
| | - Michael J Tchou
- Department of Pediatrics, Section of Hospital Medicine, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colorado, USA
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10
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Walsh PS, Schnadower D, Zhang Y, Ramgopal S, Shah SS, Wilson PM. Assessment of Temporal Patterns and Patient Factors Associated With Oseltamivir Administration in Children Hospitalized With Influenza, 2007-2020. JAMA Netw Open 2022; 5:e2233027. [PMID: 36149655 PMCID: PMC9508650 DOI: 10.1001/jamanetworkopen.2022.33027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
IMPORTANCE Oseltamivir therapy is recommended for all pediatric inpatients with influenza, particularly those with high-risk conditions, although data regarding its uptake and benefits are limited. OBJECTIVE To describe temporal patterns and independent patient factors associated with the use of oseltamivir and explore patterns in resource use and patient outcomes among children hospitalized with influenza. DESIGN, SETTING, AND PARTICIPANTS This multicenter retrospective cross-sectional study was conducted at 36 tertiary pediatric hospitals participating in the Pediatric Health Information System in the US. A total of 70 473 children younger than 18 years who were hospitalized with influenza between October 1, 2007, and March 31, 2020, were included. EXPOSURES Hospitalization with a diagnosis of influenza. MAIN OUTCOMES AND MEASURES The primary outcome was the use of oseltamivir, which was described by influenza season and by hospital. Patient factors associated with oseltamivir use were assessed using multivariable mixed-effects logistic regression models. Secondary outcomes were resource use (including antibiotic medications, chest radiography, supplemental oxygen, positive pressure ventilation, central venous catheter, and intensive care unit [ICU]) and patient outcomes (length of stay, late ICU transfer, 7-day hospital readmission, use of extracorporeal membrane oxygenation, and in-hospital mortality), which were described as percentages per influenza season. RESULTS Among 70 473 children hospitalized with influenza, the median (IQR) age was 3.65 (1.05-8.26) years; 30 750 patients (43.6%) were female, and 39 715 (56.4%) were male. Overall, 16 559 patients (23.5%) were Black, 36 184 (51.3%) were White, 14 133 (20.1%) were of other races (including 694 American Indian or Alaska Native [1.0%], 2216 Asian [3.0%], 372 Native Hawaiian or Pacific Islander [0.5%], and 10 850 other races [15.4%]), and 3597 (5.1%) were of unknown race. A total of 47 071 patients (66.8%) received oseltamivir, increasing from a low of 20.2% in the 2007-2008 influenza season to a high of 77.9% in the 2017-2018 season. Use by hospital ranged from 43.2% to 79.7% over the entire study period and from 56.5% to 90.1% in final influenza season studied (2019-2020). Factors associated with increased oseltamivir use included the presence of a complex chronic condition (odds ratio [OR], 1.42; 95% CI, 1.36-1.47), a history of asthma (OR, 1.31; 95% CI, 1.23-1.38), and early severe illness (OR, 1.19; 95% CI, 1.13-1.25). Children younger than 2 years (OR, 0.81; 95% CI, 0.77-0.85) and children aged 2 to 5 years (OR, 0.83; 95% CI, 0.79-0.88) had lower odds of receiving oseltamivir. From the beginning (2007-2008) to the end (2019-2020) of the study period, the use of antibiotic medications (from 74.4% to 60.1%) and chest radiography (from 59.2% to 51.7%) decreased, whereas the use of oxygen (from 33.6% to 29.3%), positive pressure ventilation (from 10.8% to 7.9%), and central venous catheters (from 2.5% to 1.0%) did not meaningfully change. Patient outcomes, including length of stay (median [IQR], 3 [2-5] days for all seasons), readmissions within 7 days (from 4.0% to 3.4%), use of extracorporeal membrane oxygenation (from 0.5% to 0.5%), and in-hospital mortality (from 1.1% to 0.8%), were stable from the beginning to the end of the study period. CONCLUSIONS AND RELEVANCE In this cross-sectional study of children hospitalized with influenza, the use of oseltamivir increased over time, particularly among patients with high-risk conditions, but with wide institutional variation. Patient outcomes remained largely unchanged. Further work is needed to evaluate the impact of oseltamivir therapy in this population.
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Affiliation(s)
- Patrick S. Walsh
- Department of Pediatrics, Section of Pediatric Emergency Medicine, Medical College of Wisconsin, Milwaukee
| | - David Schnadower
- Division of Emergency Medicine, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Yin Zhang
- Division of Biostatistics and Epidemiology, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
| | - Sriram Ramgopal
- Ann and Robert H. Lurie Children’s Hospital of Chicago, Division of Emergency Medicine, Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Samir S. Shah
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
- Division of Hospital Medicine, Cincinnati Children’s Hospital Medicine Center, Cincinnati, Ohio
| | - Paria M. Wilson
- Division of Emergency Medicine, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
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11
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Shapiro DJ, Thurm CW, Hall M, Lipsett SC, Hersh AL, Ambroggio L, Shah SS, Brogan TV, Gerber JS, Grijalva CG, Blaschke AJ, Cogen JD, Neuman MI. Respiratory virus testing and clinical outcomes among children hospitalized with pneumonia. J Hosp Med 2022; 17:693-701. [PMID: 35747928 DOI: 10.1002/jhm.12902] [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] [Received: 11/18/2021] [Revised: 05/11/2022] [Accepted: 05/26/2022] [Indexed: 11/10/2022]
Abstract
BACKGROUND Despite the increased availability of diagnostic tests for respiratory viruses, their clinical utility for children with community-acquired pneumonia (CAP) remains uncertain. OBJECTIVE To identify patterns of respiratory virus testing across children's hospitals prior to the COVID-19 pandemic and to determine whether hospital-level rates of viral testing were associated with clinical outcomes. DESIGN, SETTING, AND PARTICIPANTS Multicenter retrospective cohort study of children hospitalized for CAP at 19 children's hospitals in the United States from 2010-2019. MAIN OUTCOMES AND MEASURES Using a novel method to identify the performance of viral testing, we assessed time trends in the use of viral tests, both overall and stratified by testing method. Adjusted proportions of encounters with viral testing were compared across hospitals and were correlated with length of stay, antibiotic and oseltamivir use, and performance of ancillary laboratory testing. RESULTS There were 46,038 hospitalizations for non-severe CAP among children without complex chronic conditions. The proportion with viral testing increased from 38.8% to 44.2% during the study period (p < .001). Molecular testing increased (27.2% to 40.0%, p < .001) and antigen testing decreased (33.2% to 7.8%, p < .001). Hospital-specific adjusted proportions of testing ranged from 10.0% to 83.5% and were not associated with length of stay, antibiotic use, or antiviral use. Hospitals that performed more viral testing did not have lower rates of ancillary laboratory testing. CONCLUSIONS Viral testing practices varied widely across children's hospitals and were not associated with clinically important process or outcome measures. Viral testing may not influence clinical management for many children hospitalized with CAP.
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Affiliation(s)
- Daniel J Shapiro
- Division of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Cary W Thurm
- Children's Hospital Association, Lenexa, Kansas, USA
| | - Matthew Hall
- Children's Hospital Association, Lenexa, Kansas, USA
| | - Susan C Lipsett
- Division of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts, USA
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, USA
| | - Adam L Hersh
- Department of Pediatrics, Division of Pediatric Infectious Diseases, School of Medicine, University of Utah, Salt Lake City, Utah, USA
| | - Lilliam Ambroggio
- Department of Pediatrics, Sections of Emergency Medicine and Hospital Medicine, Children's Hospital Colorado, University of Colorado, Denver, Colorado, USA
| | - Samir S Shah
- Division of Hospital Medicine, Cincinnati Children's Hospital Medicine Center, Cincinnati, Ohio, USA
- Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, Ohio, USA
| | - Thomas V Brogan
- Division of Critical Care, Seattle Children's Hospital, Seattle, Washington, USA
- Department of Pediatrics, School of Medicine, University of Washington, Seattle, Washington, USA
| | - Jeffrey S Gerber
- Division of Infectious Diseases, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Carlos G Grijalva
- Department of Health Policy, Division of Pharmacoepidemiology, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - Anne J Blaschke
- Department of Pediatrics, Division of Pediatric Infectious Diseases, School of Medicine, University of Utah, Salt Lake City, Utah, USA
| | - Jonathan D Cogen
- Division of Pulmonary Medicine and Sleep Medicine, Seattle Children's Hospital, Seattle, Washington, USA
| | - Mark I Neuman
- Division of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts, USA
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, USA
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12
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Ramgopal S, Lorenz D, Ambroggio L, Navanandan N, Cotter JM, Florin TA. Identifying Potentially Unnecessary Hospitalizations in Children With Pneumonia. Hosp Pediatr 2022; 12:788-806. [PMID: 36000331 DOI: 10.1542/hpeds.2022-006608] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
OBJECTIVE To characterize the outcomes of children with community acquired pneumonia (CAP) across 41 United States hospitals and evaluate factors associated with potentially unnecessary admissions. METHODS We performed a cross-sectional study of patients with CAP from 41 United States pediatric hospitals and evaluated clinical outcomes using a composite ordinal severity outcome: mild-discharged (discharged from the emergency department), mild-admitted (hospitalized without other interventions), moderate (provision of intravenous fluids, supplemental oxygen, broadening of antibiotics, complicated pneumonia, and presumed sepsis) or severe (ICU, positive-pressure ventilation, vasoactive infusion, chest drainage, extracorporeal membrane oxygenation, severe sepsis, or death). Our primary outcome was potentially unnecessary admissions (ie, mild-admitted). Among mild-discharged and mild-admitted patients, we constructed a generalized linear mixed model for mild-admitted severity and assessed the role of fixed (demographics and clinical testing) and random effects (institution) on this outcome. RESULTS Of 125 180 children, 68.3% were classified as mild-discharged, 6.6% as mild-admitted, 20.6% as moderate and 4.5% as severe. Among admitted patients (n = 39 692), 8321 (21%) were in the mild-admitted group, with substantial variability in this group across hospitals (median 19.1%, interquartile range 12.8%-28.4%). In generalized linear mixed models comparing mild-admitted and mild-discharge severity groups, hospital had the greatest contribution to model variability compared to all other variables. CONCLUSIONS One in 5 hospitalized children with CAP do not receive significant interventions. Among patients with mild disease, institutional variation is the most important contributor to predict potentially unnecessary admissions. Improved prognostic tools are needed to reduce potentially unnecessary hospitalization of children with CAP.
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Affiliation(s)
- Sriram Ramgopal
- Division of Emergency Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Douglas Lorenz
- Department of Bioinformatics and Biostatistics, University of Louisville, Louisville, Kentucky
| | - Lilliam Ambroggio
- Section of Pediatric Emergency Medicine and
- Section of Pediatric Hospital Medicine, Children's Hospital Colorado, Department of Pediatrics, University of Colorado, Aurora, Colorado
| | | | - Jillian M Cotter
- Section of Pediatric Hospital Medicine, Children's Hospital Colorado, Department of Pediatrics, University of Colorado, Aurora, Colorado
| | - Todd A Florin
- Division of Emergency Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois
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13
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Cotter JM, Florin TA, Moss A, Suresh K, Ramgopal S, Navanandan N, Shah SS, Ruddy R, Ambroggio L. Factors Associated With Antibiotic Use for Children Hospitalized With Pneumonia. Pediatrics 2022; 150:188468. [PMID: 35775330 PMCID: PMC9727820 DOI: 10.1542/peds.2021-054677] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/23/2022] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Antibiotics are frequently used for community-acquired pneumonia (CAP), although viral etiologies predominate. We sought to determine factors associated with antibiotic use among children hospitalized with suspected CAP. METHODS We conducted a prospective cohort study of children who presented to the emergency department (ED) and were hospitalized for suspected CAP. We estimated risk factors associated with receipt of ≥1 dose of inpatient antibiotics and a full treatment course using multivariable Poisson regression with an interaction term between chest radiograph (CXR) findings and ED antibiotic use. We performed a subgroup analysis of children with nonradiographic CAP. RESULTS Among 477 children, 60% received inpatient antibiotics and 53% received a full course. Factors associated with inpatient antibiotics included antibiotic receipt in the ED (relative risk 4.33 [95% confidence interval, 2.63-7.13]), fever (1.66 [1.22-2.27]), and use of supplemental oxygen (1.29 [1.11-1.50]). Children with radiographic CAP and equivocal CXRs had an increased risk of inpatient antibiotics compared with those with normal CXRs, but the increased risk was modest when antibiotics were given in the ED. Factors associated with a full course were similar. Among patients with nonradiographic CAP, 29% received inpatient antibiotics, 21% received a full course, and ED antibiotics increased the risk of inpatient antibiotics. CONCLUSIONS Inpatient antibiotic utilization was associated with ED antibiotic decisions, CXR findings, and clinical factors. Nearly one-third of children with nonradiographic CAP received antibiotics, highlighting the need to reduce likely overuse. Antibiotic decisions in the ED were strongly associated with decisions in the inpatient setting, representing a modifiable target for future interventions.
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Affiliation(s)
- Jillian M. Cotter
- Section of Hospital Medicine, Children’s Hospital Colorado, Department of Pediatrics, University of Colorado, Aurora, CO
| | - Todd A. Florin
- Division of Pediatric Emergency Medicine, Ann and Robert H. Lurie Children’s Hospital of Chicago & Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Angela Moss
- Adult and Child Consortium for Health Outcomes Research and Delivery Science, University of Colorado, Aurora, CO
| | - Krithika Suresh
- Adult and Child Consortium for Health Outcomes Research and Delivery Science, University of Colorado, Aurora, CO,Department of Biostatistics and Informatics, Colorado School of Public Health, University of Colorado, Aurora, CO
| | - Sriram Ramgopal
- Division of Pediatric Emergency Medicine, Ann and Robert H. Lurie Children’s Hospital of Chicago & Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Nidhya Navanandan
- Section of Emergency Medicine, Children’s Hospital Colorado, Department of Pediatrics, University of Colorado, Aurora, CO
| | - Samir S. Shah
- Cincinnati Children’s Hospital Medical Center and the University of Cincinnati College of Medicine, Cincinnati, OH
| | - Richard Ruddy
- Cincinnati Children’s Hospital Medical Center and the University of Cincinnati College of Medicine, Cincinnati, OH
| | - Lilliam Ambroggio
- Section of Hospital Medicine, Children’s Hospital Colorado, Department of Pediatrics, University of Colorado, Aurora, CO,Section of Emergency Medicine, Children’s Hospital Colorado, Department of Pediatrics, University of Colorado, Aurora, CO
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14
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Ramgopal S, Lorenz D, Navanandan N, Cotter JM, Shah SS, Ruddy RM, Ambroggio L, Florin TA. Validation of Prediction Models for Pneumonia Among Children in the Emergency Department. Pediatrics 2022; 150:e2021055641. [PMID: 35748157 PMCID: PMC11127179 DOI: 10.1542/peds.2021-055641] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/12/2022] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Several prediction models have been reported to identify patients with radiographic pneumonia, but none have been validated or broadly implemented into practice. We evaluated 5 prediction models for radiographic pneumonia in children. METHODS We evaluated 5 previously published prediction models for radiographic pneumonia (Neuman, Oostenbrink, Lynch, Mahabee-Gittens, and Lipsett) using data from a single-center prospective study of patients 3 months to 18 years with signs of lower respiratory tract infection. Our outcome was radiographic pneumonia. We compared each model's area under the receiver operating characteristic curve (AUROC) and evaluated their diagnostic accuracy at statistically-derived cutpoints. RESULTS Radiographic pneumonia was identified in 253 (22.2%) of 1142 patients. When using model coefficients derived from the study dataset, AUROC ranged from 0.58 (95% confidence interval, 0.52-0.64) to 0.79 (95% confidence interval, 0.75-0.82). When using coefficients derived from original study models, 2 studies demonstrated an AUROC >0.70 (Neuman and Lipsett); this increased to 3 after deriving regression coefficients from the study cohort (Neuman, Lipsett, and Oostenbrink). Two models required historical and clinical data (Neuman and Lipsett), and the third additionally required C-reactive protein (Oostenbrink). At a statistically derived cutpoint of predicted risk from each model, sensitivity ranged from 51.2% to 70.4%, specificity 49.9% to 87.5%, positive predictive value 16.1% to 54.4%, and negative predictive value 83.9% to 90.7%. CONCLUSIONS Prediction models for radiographic pneumonia had varying performance. The 3 models with higher performance may facilitate clinical management by predicting the risk of radiographic pneumonia among children with lower respiratory tract infection.
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Affiliation(s)
- Sriram Ramgopal
- Division of Emergency Medicine, Department of Pediatrics, Ann & Robert H. Lurie Children’s Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Douglas Lorenz
- Department of Bioinformatics and Biostatistics, University of Louisville, Louisville, Kentucky
| | - Nidhya Navanandan
- Sections of Emergency Medicine, Children’s Hospital Colorado, University of Colorado, Aurora, Colorado
- Department of Pediatrics, Children’s Hospital Colorado, University of Colorado, Aurora, Colorado
| | - Jillian M. Cotter
- Pediatric Hospital Medicine, Department of Pediatrics, Children’s Hospital Colorado, University of Colorado, Aurora, Colorado
- Department of Pediatrics, Children’s Hospital Colorado, University of Colorado, Aurora, Colorado
| | - Samir S. Shah
- Divisions of Hospital Medicine, Cincinnati Children’s Hospital Medical Center and University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Richard M. Ruddy
- Emergency Medicine, Cincinnati Children’s Hospital Medical Center and University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Lilliam Ambroggio
- Sections of Emergency Medicine, Children’s Hospital Colorado, University of Colorado, Aurora, Colorado
- Pediatric Hospital Medicine, Department of Pediatrics, Children’s Hospital Colorado, University of Colorado, Aurora, Colorado
- Department of Pediatrics, Children’s Hospital Colorado, University of Colorado, Aurora, Colorado
| | - Todd A. Florin
- Division of Emergency Medicine, Department of Pediatrics, Ann & Robert H. Lurie Children’s Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois
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15
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Geanacopoulos AT, Lipsett SC, Hirsch AW, Monuteaux MC, Neuman MI. Impact of Viral Radiographic Features on Antibiotic Treatment for Pediatric Pneumonia. J Pediatric Infect Dis Soc 2022; 11:207-213. [PMID: 35020928 DOI: 10.1093/jpids/piab132] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2021] [Accepted: 12/14/2021] [Indexed: 11/12/2022]
Abstract
BACKGROUND/OBJECTIVES Chest radiograph (CXR) is routinely performed among children with suspected pneumonia, though it is not clear how specific radiographic findings impact antibiotic treatment for pneumonia. We evaluated the impact of viral radiographic features on antibiotic treatment among children undergoing pneumonia evaluation in the emergency department (ED). METHODS Children presenting to a pediatric ED who underwent a CXR for pneumonia evaluation were prospectively enrolled. Prior to CXR performance, physicians indicated their level of suspicion for pneumonia. The CXR report was reviewed to assess for the presence of viral features (peribronchial cuffing, perihilar markings, and interstitial infiltrate) as well as radiographic features suggestive of pneumonia (consolidation, infiltrate, and opacity). The relationship between viral radiographic features and antibiotic treatment was assessed based on the level of clinical suspicion for pneumonia prior to CXR. RESULTS Patients with normal CXRs (n = 400) and viral features alone (n = 370) were managed similarly, with 8.0% and 8.6% of patients receiving antibiotic treatment, respectively (P = .75). Compared with children with radiographic pneumonia (n = 174), patients with concurrent viral features and radiographic pneumonia (n = 177) were treated with antibiotics less frequently (86.2% vs 54.3%, P < .001). Among children with isolated viral features on CXR, antibiotic treatment rates were correlated with pre-CXR level of suspicion for pneumonia. CONCLUSIONS Among children with suspected pneumonia, the presence of viral features alone on CXR is not associated with increased rates of antibiotic use. Among children with radiographic pneumonia, the addition of viral features on CXR is associated with lower rates of antibiotic use, as compared to children with radiographic pneumonia alone.
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Affiliation(s)
- Alexandra T Geanacopoulos
- Department of Pediatrics, Boston Children's Hospital, Boston, Massachusetts, USA.,Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, USA.,Division of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Susan C Lipsett
- Department of Pediatrics, Boston Children's Hospital, Boston, Massachusetts, USA.,Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, USA.,Division of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Alexander W Hirsch
- Department of Pediatrics, Boston Children's Hospital, Boston, Massachusetts, USA.,Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, USA.,Division of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Michael C Monuteaux
- Department of Pediatrics, Boston Children's Hospital, Boston, Massachusetts, USA.,Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, USA.,Division of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Mark I Neuman
- Department of Pediatrics, Boston Children's Hospital, Boston, Massachusetts, USA.,Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, USA.,Division of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts, USA
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16
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Emergency department diagnosis and management of constipation in the United States, 2006–2017. Am J Emerg Med 2022; 54:91-96. [DOI: 10.1016/j.ajem.2022.01.065] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2021] [Revised: 01/22/2022] [Accepted: 01/27/2022] [Indexed: 11/30/2022] Open
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17
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Ramgopal S, Ambroggio L, Lorenz D, Shah SS, Ruddy RM, Florin TA. A Prediction Model for Pediatric Radiographic Pneumonia. Pediatrics 2022; 149:183721. [PMID: 34845493 PMCID: PMC9647527 DOI: 10.1542/peds.2021-051405] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/28/2021] [Indexed: 01/03/2023] Open
Abstract
BACKGROUND Chest radiographs (CXRs) are frequently used in the diagnosis of community-acquired pneumonia (CAP). We sought to construct a predictive model for radiographic CAP based on clinical features to decrease CXR use. METHODS We performed a single-center prospective study of patients 3 months to 18 years of age with signs of lower respiratory infection who received a CXR for suspicion of CAP. We used penalized multivariable logistic regression to develop a full model and bootstrapped backward selection models to develop a parsimonious reduced model. We evaluated model performance at different thresholds of predicted risk. RESULTS Radiographic CAP was identified in 253 (22.2%) of 1142 patients. In multivariable analysis, increasing age, prolonged fever duration, tachypnea, and focal decreased breath sounds were positively associated with CAP. Rhinorrhea and wheezing were negatively associated with CAP. The bootstrapped reduced model retained 3 variables: age, fever duration, and decreased breath sounds. The area under the receiver operating characteristic for the reduced model was 0.80 (95% confidence interval: 0.77-0.84). Of 229 children with a predicted risk of <4%, 13 (5.7%) had radiographic CAP (sensitivity of 94.9% at a 4% risk threshold). Conversely, of 229 children with a predicted risk of >39%, 140 (61.1%) had CAP (specificity of 90% at a 39% risk threshold). CONCLUSIONS A predictive model including age, fever duration, and decreased breath sounds has excellent discrimination for radiographic CAP. After external validation, this model may facilitate decisions around CXR or antibiotic use in CAP.
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Affiliation(s)
- Sriram Ramgopal
- Division of Emergency Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Department of Pediatrics, Feinberg School of Medicine, Northwestern University, Chicago, Illinois,Address correspondence to Sriram Ramgopal, MD, Division of Pediatric Emergency Medicine, Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago, 225 E Chicago Ave, Box 62, Chicago, IL 60611. E-mail:
| | - Lilliam Ambroggio
- Department of Pediatrics, University of Colorado and Sections of Emergency Medicine and Hospital Medicine, Children's Hospital Colorado, Aurora, Colorado
| | - Douglas Lorenz
- Department of Bioinformatics and Biostatistics, University of Louisville, Louisville, Kentucky
| | | | - Richard M. Ruddy
- Emergency Medicine, Cincinnati Children’s Hospital Medical Center and College of Medicine, University of Cincinnati, Cincinnati, Ohio
| | - Todd A. Florin
- Division of Emergency Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Department of Pediatrics, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
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18
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Abstract
BACKGROUND The diagnosis of pneumonia in children is challenging, given the wide overlap of many of the symptoms and physical examination findings with other common respiratory illnesses. We sought to derive and validate the novel Pneumonia Risk Score (PRS), a clinical tool utilizing signs and symptoms available to clinicians to determine a child's risk of radiographic pneumonia. METHODS We prospectively enrolled children 3 months to 18 years in whom a chest radiograph (CXR) was obtained in the emergency department to evaluate for pneumonia. Before CXR, we collected information regarding symptoms, physical examination findings, and the physician-estimated probability of radiographic pneumonia. Logistic regression was used to predict the presence of radiographic pneumonia, and the PRS was validated in a distinct cohort of children with suspected pneumonia. RESULTS Among 1181 children included in the study, 206 (17%) had radiographic pneumonia. The PRS included age in years, triage oxygen saturation, presence of fever, presence of rales, and presence of wheeze. The area under the curve (AUC) of the PRS was 0.71 (95% confidence interval [CI]: 0.68-0.75), while the AUC of clinician judgment was 0.61 (95% CI: 0.56-0.66) (P < 0.001). Among 2132 children included in the validation cohort, the PRS demonstrated an AUC of 0.69 (95% CI: 0.65-0.73). CONCLUSIONS In children with suspected pneumonia, the PRS is superior to clinician judgment in predicting the presence of radiographic pneumonia. Use of the PRS may help efforts to support the judicious use of antibiotics and chest radiography among children with suspected pneumonia.
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19
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Shapiro DJ, Hall M, Lipsett SC, Hersh AL, Ambroggio L, Shah SS, Brogan TV, Gerber JS, Williams DJ, Grijalva CG, Blaschke AJ, Neuman MI. Short- Versus Prolonged-Duration Antibiotics for Outpatient Pneumonia in Children. J Pediatr 2021; 234:205-211.e1. [PMID: 33745996 DOI: 10.1016/j.jpeds.2021.03.017] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2020] [Revised: 02/15/2021] [Accepted: 03/11/2021] [Indexed: 12/13/2022]
Abstract
OBJECTIVE To identify practice patterns in the duration of prescribed antibiotics for the treatment of ambulatory children with community-acquired pneumonia (CAP) and to compare the frequency of adverse clinical outcomes between children prescribed short-vs prolonged-duration antibiotics. STUDY DESIGN We performed a retrospective cohort study from 2010-2016 using the IBM Watson MarketScan Medicaid Database, a claims database of publicly insured patients from 11 states. We included children 1-18 years old with outpatient CAP who filled a prescription for oral antibiotics (n = 121 846 encounters). We used multivariable logistic regression to determine associations between the duration of prescribed antibiotics (5-9 days vs 10-14 days) and subsequent hospitalizations, new antibiotic prescriptions, and acute care visits. Outcomes were measured during the 14 days following the end of the dispensed antibiotic course. RESULTS The most commonly prescribed duration of antibiotics was 10 days (82.8% of prescriptions), and 10.5% of patients received short-duration therapy. During the follow-up period, 0.2% of patients were hospitalized, 6.2% filled a new antibiotic prescription, and 5.1% had an acute care visit. Compared with the prolonged-duration group, the aORs for hospitalization, new antibiotic prescriptions, and acute care visits in the short-duration group were 1.16 (95% CI 0.80-1.66), 0.93 (95% CI 0.85-1.01), and 1.06 (95% CI 0.98-1.15), respectively. CONCLUSIONS Most children treated for CAP as outpatients are prescribed at least 10 days of antibiotic therapy. Among pediatric outpatients with CAP, no significant differences were found in rates of adverse clinical outcomes between patients prescribed short-vs prolonged-duration antibiotics.
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Affiliation(s)
- Daniel J Shapiro
- Division of Emergency Medicine, Boston Children's Hospital, Boston, MA.
| | | | - Susan C Lipsett
- Division of Emergency Medicine, Boston Children's Hospital, Boston, MA; Department of Pediatrics, Harvard Medical School, Boston, MA
| | - Adam L Hersh
- Division of Pediatric Infectious Diseases, Department of Pediatrics, School of Medicine, University of Utah, Salt Lake City, UT
| | - Lilliam Ambroggio
- Sections of Emergency Medicine and Hospital Medicine, Children's Hospital Colorado, Department of Pediatrics, University of Colorado, Denver, CO
| | - Samir S Shah
- Division of Hospital Medicine, Cincinnati Children's Hospital Medicine Center, Cincinnati, OH; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Thomas V Brogan
- Division of Critical Care, Seattle Children's Hospital, Seattle, WA; Department of Pediatrics, School of Medicine, University of Washington, Seattle, WA
| | - Jeffrey S Gerber
- Division of Infectious Diseases, Children's Hospital of Philadelphia, Philadelphia, PA; Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Derek J Williams
- Division of Hospital Medicine, Department of Pediatrics, Monroe Carell Jr. Children's Hospital at Vanderbilt, Vanderbilt University School of Medicine, Nashville, TN
| | - Carlos G Grijalva
- Department of Health Policy, Vanderbilt University School of Medicine, Nashville, TN
| | - Anne J Blaschke
- Sections of Emergency Medicine and Hospital Medicine, Children's Hospital Colorado, Department of Pediatrics, University of Colorado, Denver, CO
| | - Mark I Neuman
- Division of Emergency Medicine, Boston Children's Hospital, Boston, MA; Department of Pediatrics, Harvard Medical School, Boston, MA
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Poutanen R, Virta T, Heikkilä P, Pauniaho S, Csonka P, Korppi M, Renko M, Palmu S. National Current Care Guidelines for paediatric lower respiratory tract infections reduced the use of chest radiographs but local variations were observed. Acta Paediatr 2021; 110:1594-1600. [PMID: 33247995 DOI: 10.1111/apa.15692] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2020] [Revised: 11/18/2020] [Accepted: 11/24/2020] [Indexed: 11/29/2022]
Abstract
AIM Our aim was to evaluate the impact of the 2014 Finnish Current Care Guidelines for paediatric lower respiratory tract infections (LRTIs), particularly on taking of chest radiographs. METHODS This study used official national data and regional (Pirkanmaa) data on children aged 0-16 years who underwent chest radiographs in 2011 and 2015. We also collected data for LRTI diagnoses from local registers, including prescribed antibiotics and taking of chest radiographs. The local cohort comprised children aged 0-15 who presented to the primary care emergency room or to the hospital emergency department (Tampere university hospital) in November-December 2012-2015. RESULTS Chest radiographs for Finnish children aged 0-16 fell from 2011 to 2015: by 15.9% nationally and by 16.9% in Pirkanmaa. When asylum seekers with chest radiographs for tuberculosis screening were excluded, the estimated national reduction was 29.9%. In the local cohort, chest radiographs increased from 82 to 139 (69.5%) between 2012/2013 and 2014/2015 as the occurrence of community-acquired pneumonia (CAP) increased. However, the proportion of patients with CAP who had chest radiograph taken tended to decrease from 84.6% to 71.3% (p = 0.078). CONCLUSION Decreases in national and regional chest imaging trends were observed after the 2014 guidance for children`s LRTI was introduced.
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Affiliation(s)
- Roope Poutanen
- Centre for Child Health Research Tampere University and Department of PediatricsTampere University Hospital Tampere Finland
- Faculty of Medicine and Health Technology Tampere University Tampere Finland
| | - Tuija Virta
- Faculty of Medicine and Health Technology Tampere University Tampere Finland
| | - Paula Heikkilä
- Centre for Child Health Research Tampere University and Department of PediatricsTampere University Hospital Tampere Finland
- Faculty of Medicine and Health Technology Tampere University Tampere Finland
| | - Satu‐Liisa Pauniaho
- Centre for Child Health Research Tampere University and Department of PediatricsTampere University Hospital Tampere Finland
| | - Peter Csonka
- Centre for Child Health Research Tampere University and Department of PediatricsTampere University Hospital Tampere Finland
- Terveystalo Healthcare Tampere Finland
| | - Matti Korppi
- Centre for Child Health Research Tampere University and Department of PediatricsTampere University Hospital Tampere Finland
- Faculty of Medicine and Health Technology Tampere University Tampere Finland
| | - Marjo Renko
- Department of Paediatrics Kuopio University HospitalUniversity of Eastern Finland Kuopio Finland
| | - Sauli Palmu
- Centre for Child Health Research Tampere University and Department of PediatricsTampere University Hospital Tampere Finland
- Faculty of Medicine and Health Technology Tampere University Tampere Finland
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21
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Lipsett SC, Hall M, Ambroggio L, Hersh AL, Shah SS, Brogan TV, Gerber JS, Williams DJ, Grijalva CG, Blaschke AJ, Neuman MI. Antibiotic Choice and Clinical Outcomes in Ambulatory Children with Community-Acquired Pneumonia. J Pediatr 2021; 229:207-215.e1. [PMID: 33045236 PMCID: PMC7856045 DOI: 10.1016/j.jpeds.2020.10.005] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Revised: 09/09/2020] [Accepted: 10/05/2020] [Indexed: 12/23/2022]
Abstract
OBJECTIVES To describe antibiotic prescribing patterns in ambulatory children with community-acquired pneumonia and to assess the relationship between antibiotic selection and clinical outcomes. STUDY DESIGN This was a retrospective cohort study of ambulatory Medicaid-enrolled children 0-18 years of age diagnosed with community-acquired pneumonia from 2010 to 2016. The exposure was antibiotic class: narrow-spectrum (aminopenicillins), broad-spectrum (amoxicillin/clavulanate and cephalosporins), macrolide monotherapy, macrolides with narrow-spectrum antibiotics, or macrolides with broad-spectrum antibiotics. The associations between antibiotic selection and the outcomes of subsequent hospitalization and development of severe pneumonia (chest drainage procedure, intensive care admission, mechanical ventilation) were assessed, controlling for measures of illness severity. RESULTS Among 252 177 outpatient pneumonia visits, macrolide monotherapy was used in 43.2%, narrow-spectrum antibiotics in 26.1%, and broad-spectrum antibiotics in 24.7%. A total of 1488 children (0.59%) were subsequently hospitalized and 117 (0.05%) developed severe pneumonia. Compared with children receiving narrow-spectrum antibiotics, the odds of subsequent hospitalization were higher in children receiving broad-spectrum antibiotics (aOR, 1.34; 95% CI, 1.17-1.52) and lower in children receiving macrolide monotherapy (aOR, 0.64; 95% CI, 0.55-0.73) and macrolides with narrow-spectrum antibiotics (aOR, 0.62; 95% CI, 0.39-0.97). Children receiving macrolide monotherapy had lower odds of developing severe pneumonia than children receiving narrow-spectrum antibiotics (aOR, 0.56; 95% CI, 0.33-0.93). However, the absolute risk difference was <0.5% for all analyses. CONCLUSIONS Macrolides are the most commonly prescribed antibiotic for ambulatory children with community-acquired pneumonia. Subsequent hospitalization and severe pneumonia are rare. Future efforts should focus on reducing broad-spectrum and macrolide antibiotic prescribing.
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Affiliation(s)
- Susan C Lipsett
- Department of Pediatrics, Harvard Medical School, Boston, MA; Division of Emergency Medicine, Boston Children's Hospital, Boston, MA.
| | | | - Lilliam Ambroggio
- Sections of Emergency Medicine and Hospital Medicine, Department of Pediatrics, Children's Hospital Colorado, University of Colorado, Denver, CO
| | - Adam L Hersh
- Division of Pediatric Infectious Diseases, Department of Pediatrics, School of Medicine, University of Utah, Salt Lake City, UT
| | - Samir S Shah
- Division of Hospital Medicine, Cincinnati Children's Hospital Medicine Center, Cincinnati, OH; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Thomas V Brogan
- Division of Critical Care, Seattle Children's Hospital, Seattle, WA; Department of Pediatrics, School of Medicine, University of Washington, Seattle, WA
| | - Jeffrey S Gerber
- Division of Infectious Diseases, Children's Hospital of Philadelphia, Philadelphia, PA; Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Derek J Williams
- Division of Hospital Medicine, Department of Pediatrics, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, TN
| | - Carlos G Grijalva
- Department of Health Policy, Vanderbilt University School of Medicine, Nashville, TN
| | - Anne J Blaschke
- Division of Pediatric Infectious Diseases, Department of Pediatrics, School of Medicine, University of Utah, Salt Lake City, UT
| | - Mark I Neuman
- Department of Pediatrics, Harvard Medical School, Boston, MA; Division of Emergency Medicine, Boston Children's Hospital, Boston, MA
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22
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Could It Be Pneumonia? Lung Ultrasound in Children With Low Clinical Suspicion for Pneumonia. Pediatr Qual Saf 2020; 5:e326. [PMID: 32766497 PMCID: PMC7360217 DOI: 10.1097/pq9.0000000000000326] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2020] [Accepted: 06/13/2020] [Indexed: 01/09/2023] Open
Abstract
Supplemental Digital Content is available in the text. Background: Community-acquired pneumonia (CAP) is a significant cause of pediatric morbidity and mortality worldwide. Emergency department point of care ultrasound (POCUS) is a first-line modality for diagnosis of CAP. The current coronavirus disease 2019 pandemic creates a unique opportunity to incorporate lung POCUS into the evaluation of a broader range of children. It has increased the utility of lung POCUS in both evaluation and follow-up of pediatric coronavirus cases. An increased use of lung POCUS creates an opportunity for earlier diagnosis while allowing the opportunity for overdiagnosis of small infiltrates and atelectasis. We collated a case series to demonstrate the benefit of lung POCUS in a very broad range of children. Methods: We collected a case series of 5 patients between December 2018 and December 2019 who presented nonclassically and were diagnosed with CAP on POCUS by a pediatric emergency physician. Conclusion: Routine lung POCUS in ill children will allow treating physicians to identify and follow a pulmonary infiltrate consistent with CAP quickly. We anticipate that early and more frequent use of POCUS and earlier diagnosis of CAP may improve outcomes by decreasing healthcare encounters within the same illness and by reducing the incidence of late sequelae of pneumonia such as empyema and effusions. However, we acknowledge that this may come at the expense of the overtreatment of viral infiltrates and atelectasis. Further study is required to improve the specificity of lung POCUS in the evaluation of CAP.
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