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Markham JL, Burns A, Hall M, Molloy MJ, Stephens JR, McCoy E, Ugalde IT, Steiner MJ, Cotter JM, House SA, Collins ME, Yu AG, Tchou MJ, Shah SS. Outcomes associated with initial narrow-spectrum versus broad-spectrum antibiotics in children hospitalized with urinary tract infections. J Hosp Med 2024. [PMID: 38734985 DOI: 10.1002/jhm.13390] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2024] [Revised: 04/16/2024] [Accepted: 04/23/2024] [Indexed: 05/13/2024]
Abstract
OBJECTIVE The aim of this study is to describe the proportion of children hospitalized with urinary tract infections (UTIs) who receive initial narrow- versus broad-spectrum antibiotics across children's hospitals and explore whether the use of initial narrow-spectrum antibiotics is associated with different outcomes. DESIGN, SETTING AND PARTICIPANTS We performed a retrospective cohort analysis of children aged 2 months to 17 years hospitalized with UTI (inclusive of pyelonephritis) using the Pediatric Health Information System (PHIS) database. MAIN OUTCOME AND MEASURES We analyzed the proportions of children initially receiving narrow- versus broad-spectrum antibiotics; additionally, we compiled antibiogram data for common uropathogenic organisms from participating hospitals to compare with the observed antibiotic susceptibility patterns. We examined the association of antibiotic type with adjusted outcomes including length of stay (LOS), costs, and 7- and 30-day emergency department (ED) revisits and hospital readmissions. RESULTS We identified 10,740 hospitalizations for UTI across 39 hospitals. Approximately 5% of encounters demonstrated initial narrow-spectrum antibiotics, with hospital-level narrow-spectrum use ranging from <1% to 25%. Approximately 80% of hospital antibiograms demonstrated >80% Escherichia coli susceptibility to cefazolin. In adjusted models, those who received initial narrow-spectrum antibiotics had shorter LOS (narrow-spectrum: 33.1 (95% confidence interval [CI]: 30.8-35.4) h versus broad-spectrum: 46.1 (95% CI: 44.1-48.2) h) and reduced costs [narrow-spectrum: $4570 ($3751-5568) versus broad-spectrum: $5699 ($5005-$6491)]. There were no differences in ED revisits or hospital readmissions. In summary, children's hospitals have low rates of narrow-spectrum antibiotic use for UTIs despite many reporting high rates of cefazolin-susceptible E. coli. These findings, coupled with the observed decreased LOS and costs among those receiving narrow-spectrum antibiotics, highlight potential antibiotic stewardship opportunities.
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Affiliation(s)
- Jessica L Markham
- Department of Pediatrics, Children's Mercy Kansas City, University of Missouri-Kansas City School of Medicine, Kansas City, Missouri, USA
- Department of Pediatrics, University of Kansas School of Medicine, Kansas City, Kansas, USA
| | - Alaina Burns
- Department of Pharmacy, Children's Mercy Kansas City, University of Missouri-Kansas City School of Pharmacy, Kansas City, Missouri, USA
| | - Matthew Hall
- Department of Pediatrics, Children's Mercy Kansas City, University of Missouri-Kansas City School of Medicine, Kansas City, Missouri, USA
- Children's Hospital Association, Lenexa, Kansas, USA
| | - Matthew J Molloy
- Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - John R Stephens
- Departments of Medicine and Pediatrics, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Elisha McCoy
- Department of Pediatrics, Le Bonheur Children's Hospital, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Irma T Ugalde
- Department of Emergency Medicine, McGovern Medical School, Houston, Texas, USA
| | - Michael J Steiner
- Departments of Medicine and Pediatrics, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Jillian M Cotter
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Samantha A House
- Department of Pediatrics, Dartmouth Health Children's, Lebanon, New Hampshire, USA
| | - Megan E Collins
- Department of Pediatrics, Children's Mercy Kansas City, University of Missouri-Kansas City School of Medicine, Kansas City, Missouri, USA
| | - Andrew G Yu
- Department of Pediatrics, University of Texas Southwestern Medical Center and Children's Health, Dallas, Texas, USA
| | - Michael J Tchou
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Samir S Shah
- Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
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Cotter JM, Hall M, Neuman MI, Blaschke AJ, Brogan TV, Cogen JD, Gerber JS, Hersh AL, Lipsett SC, Shapiro DJ, Ambroggio L. Antibiotic route and outcomes for children hospitalized with pneumonia. J Hosp Med 2024. [PMID: 38678444 DOI: 10.1002/jhm.13382] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2024] [Revised: 04/06/2024] [Accepted: 04/18/2024] [Indexed: 04/30/2024]
Abstract
BACKGROUND Emerging evidence suggests that initial oral and intravenous (IV) antibiotics have similar efficacy in pediatric community-acquired pneumonia (CAP), but further data are needed. OBJECTIVE We determined the association between hospital-level initial oral antibiotic rates and outcomes in pediatric CAP. DESIGNS, SETTINGS AND PARTICIPANTS This retrospective cohort study included children hospitalized with CAP at 43 hospitals in the Pediatric Health Information System (2016-2022). Hospitals were grouped by whether initial antibiotics were given orally in a high, moderate, or low proportion of patients. MAIN OUTCOME AND MEASURES Regression models examined associations between high versus low oral-utilizing hospitals and length of stay (LOS, primary outcome), intensive care unit (ICU) transfers, escalated respiratory care, complicated CAP, cost, readmissions, and emergency department (ED) revisits. RESULTS Initial oral antibiotics were used in 16% (interquartile range: 10%-20%) of 30,207 encounters, ranging from 1% to 68% across hospitals. Comparing high versus low oral-utilizing hospitals (oral rate: 32% [27%-47%] and 10% [9%-11%], respectively), there were no differences in LOS, intensive care unit, complicated CAP, cost, or ED revisits. Escalated respiratory care occurred in 1.3% and 0.5% of high and low oral-utilizing hospitals, respectively (relative ratio [RR]: 2.96 [1.12, 7.81]), and readmissions occurred in 1.5% and 0.8% (RR: 1.68 [1.31, 2.17]). Initial oral antibiotics varied across hospitals without a difference in LOS. While high oral-utilizing hospitals had higher escalated respiratory care and readmission rates, these were rare, the clinical significance of these small differences is uncertain, and there were no differences in other clinically relevant outcomes. This suggests some children may benefit from initial IV antibiotics, but most would probably do well with oral antibiotics.
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Affiliation(s)
- Jillian M Cotter
- Department of Pediatrics, Section of Hospital Medicine, Children's Hospital Colorado, University of Colorado, Aurora, Colorado, USA
| | - Mathew Hall
- Children's Hospital Association, Lenexa, Kansas, 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
| | - Anne J Blaschke
- Department of Pediatrics, Division of Pediatric Infectious Diseases, School of Medicine, University of Utah, Salt Lake City, Utah, 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
| | - Jonathan D Cogen
- Division of Pulmonary Medicine and Sleep Medicine, Seattle Children's Hospital, 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
| | - Adam L Hersh
- Department of Pediatrics, Division of Pediatric Infectious Diseases, School of Medicine, University of Utah, Salt Lake City, Utah, 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
| | - Daniel J Shapiro
- Division of Pediatric Emergency Medicine, University of California, San Francisco, San Francisco, California, USA
| | - Lilliam Ambroggio
- Department of Pediatrics, Section of Hospital Medicine, Children's Hospital Colorado, University of Colorado, Aurora, Colorado, USA
- Department of Pediatrics, Section of Emergency Medicine, Children's Hospital Colorado, University of Colorado, Aurora, Colorado, USA
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Tchou MJ, Hall M, Markham JL, Stephens JR, Steiner MJ, McCoy E, Aronson PL, Shah SS, Molloy MJ, Cotter JM. Changing patterns of routine laboratory testing over time at children's hospitals. J Hosp Med 2024. [PMID: 38643414 DOI: 10.1002/jhm.13372] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2023] [Revised: 03/19/2024] [Accepted: 04/09/2024] [Indexed: 04/22/2024]
Abstract
BACKGROUND Research into low-value routine testing at children's hospitals has not consistently evaluated changing patterns of testing over time. OBJECTIVES To identify changes in routine laboratory testing rates at children's hospitals over ten years and the association with patient outcomes. DESIGN, SETTINGS, AND PARTICIPANTS We performed a multi-center, retrospective cohort study of children aged 0-18 hospitalized with common, lower-severity diagnoses at 28 children's hospitals in the Pediatric Health Information Systems database. MAIN OUTCOMES AND MEASURES We calculated average annual testing rates for complete blood counts, electrolytes, and inflammatory markers between 2010 and 2019 for each hospital. A > 2% average testing rate change per year was defined as clinically meaningful and used to separate hospitals into groups: increasing, decreasing, and unchanged testing rates. Groups were compared for differences in length of stay, cost, and 30-day readmission or ED revisit, adjusted for demographics and case mix index. RESULTS Our study included 576,572 encounters for common, low-severity diagnoses. Individual hospital testing rates in each year of the study varied from 0.3 to 1.4 tests per patient day. The average yearly change in hospital-specific testing rates ranged from -6% to +7%. Four hospitals remained in the lowest quartile of testing and two in the highest quartile throughout all ten years of the study. We grouped hospitals with increasing (8), decreasing (n = 5), and unchanged (n = 15) testing rates. No difference was found across subgroups in costs, length of stay, 30-day ED revisit, or readmission rates. Comparing resource utilization trends over time provides important insights into achievable rates of testing reduction.
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Affiliation(s)
- Michael J Tchou
- Department of Pediatrics, Section of Hospital Medicine, University of Colorado-Anschutz Medical Center and Children's Hospital Colorado, Aurora, Colorado, USA
| | - Matt Hall
- Children's Hospital Association, Lenexa, Kansas, USA
| | - Jessica L Markham
- Department of Pediatrics, Children's Mercy Kansas City and University of Missouri-Kansas City, Kansas City, Missouri, USA
| | - John R Stephens
- North Carolina Children's Hospital and School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Michael J Steiner
- North Carolina Children's Hospital and School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Elisha McCoy
- Department of Internal Medicine, University of Tennessee Health Science Center, Memphis, Tennessee, USA
- Department of General Pediatrics, Le Bonheur Children's Hospital, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Paul L Aronson
- Departments of Pediatrics and Emergency Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Samir S Shah
- Cincinnati Children's Hospital Medical Center and University of Cincinnati, Cincinnati, Ohio, USA
| | - Matthew J Molloy
- Cincinnati Children's Hospital Medical Center and University of Cincinnati, Cincinnati, Ohio, USA
| | - Jillian M Cotter
- Department of Pediatrics, Section of Hospital Medicine, University of Colorado-Anschutz Medical Center and Children's Hospital Colorado, Aurora, Colorado, USA
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Collins ME, Hall M, Shah SS, Molloy MJ, Aronson PL, Cotter JM, Steiner MJ, McCoy E, Tchou MJ, Stephens JR, Markham JL. Phlebotomy-free days in children hospitalized with common infections and their association with clinical outcomes. J Hosp Med 2024; 19:251-258. [PMID: 38348499 DOI: 10.1002/jhm.13282] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Revised: 12/08/2023] [Accepted: 01/01/2024] [Indexed: 04/04/2024]
Abstract
BACKGROUND Phlebotomy for hospitalized children has consequences (e.g., pain, iatrogenic anemia), and unnecessary testing is a modifiable source of waste in healthcare. Days without blood draws or phlebotomy-free days (PFDs) has the potential to serve as a hospital quality measure. OBJECTIVE To describe: (1) the frequency of PFDs in children hospitalized with common infections and (2) the association of PFDs with clinical outcomes. DESIGN, SETTINGS AND PARTICIPANTS We performed a cross-sectional study of children hospitalized 2018-2019 with common infections at 38 hospitals using the Pediatric Health Information System database. We included infectious All Patients Refined Diagnosis Related Groups with a median length of stay (LOS) >2 days. We excluded patients with medical complexity, interhospital transfers, those receiving intensive care, and in-hospital mortality. MAIN OUTCOME AND MEASURES We defined PFDs as hospital days (midnight to midnight) without laboratory blood testing and measured the proportion of PFDs divided by total hospital LOS (PFD ratio) for each condition and hospital. Higher PFD ratios signify more days without phlebotomy. Hospitals were grouped into low, moderate, and high average PFD ratios. Adjusted outcomes (LOS, costs, and readmissions) were compared across groups. RESULTS We identified 126,135 encounters. Bronchiolitis (0.78) and pneumonia (0.54) had the highest PFD ratios (most PFDs), while osteoarticular infections (0.28) and gastroenteritis (0.30) had the lowest PFD ratios. There were no differences in adjusted clinical outcomes across PFD ratio groups. Among children hospitalized with common infections, PFD ratios varied across conditions and hospitals, with no association with outcomes. Our data suggest overuse of phlebotomy and opportunities to improve the care of hospitalized children.
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Affiliation(s)
- Megan E Collins
- Department of Pediatrics, Children's Mercy Kansas City, University of Missouri-Kansas City School of Medicine, Kansas City, Missouri, USA
| | - Matt Hall
- Department of Pediatrics, Children's Mercy Kansas City, University of Missouri-Kansas City School of Medicine, Kansas City, Missouri, USA
- Children's Hospital Association, Lenexa, Kansas, USA
| | - Samir S Shah
- Division of Hospital Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Matthew J Molloy
- Division of Hospital Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Paul L Aronson
- Departments of Pediatrics and Emergency Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Jillian M Cotter
- University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, Colorado, USA
| | | | - Elisha McCoy
- Department of Pediatrics, Le Bonheur Children's Hospital, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Michael J Tchou
- University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, Colorado, USA
| | - John R Stephens
- University of North Carolina, Chapel Hill, North Carolina, USA
| | - Jessica L Markham
- Department of Pediatrics, Children's Mercy Kansas City, University of Missouri-Kansas City School of Medicine, Kansas City, Missouri, USA
- University of Kansas School of Medicine, Kansas City, Kansas, USA
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Cotter JM, Stokes CL, Tong S, Birkholz M, Child J, Cost C, Coughlin R, Cox S, Dolan SA, Dorris K, Hazleton KZ, Lugo V, Norcross M, Pearce K, Dominguez SR. A Multimodal Intervention to Reduce C. difficile Infections and Stool Testing. Pediatrics 2024; 153:e2023061981. [PMID: 38352983 DOI: 10.1542/peds.2023-061981] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/13/2023] [Indexed: 03/02/2024] Open
Abstract
BACKGROUND AND OBJECTIVES The introduction of multiplex gastrointestinal panels at our institution resulted in increased Clostridioides difficile (C. difficile) detection and stool test utilization. We aimed to reduce hospital-onset C. difficile infections (HO-CDIs), C. difficile detection, and overall stool testing by 20% within 1 year. METHODS We conducted a quality improvement project from 2018 to 2020 at a large children's hospital. Interventions included development of a C. difficile testing and treatment clinical care pathway, new options for gastrointestinal panel testing with or without C. difficile (results were suppressed if not ordered), clinical decision support tool to restrict testing, and targeted prevention efforts. Outcomes included the rate of HO-CDI (primary), C. difficile detection, and overall stool testing. All measures were evaluated monthly among hospitalized children per 10 000 patient-days (PDs) using statistical process-control charts. For balancing measures, we tracked suppressed C. difficile results that were released during real-time monitoring because of concern for true infection and C. difficile-related adverse events. RESULTS HO-CDI decreased by 55%, from 11 to 5 per 10 000 PDs. C. difficile detection decreased by 44%, from 18 to 10 per 10 000 PDs, and overall test utilization decreased by 29%, from 99 to 70 per 10 000 PDs. The decrease in stool tests resulted in annual savings of $55 649. Only 2.3% of initially suppressed positive C. difficile results were released, and no patients had adverse events. CONCLUSIONS Diagnostic stewardship strategies, coupled with an evidence-based clinical care pathway, can be used to decrease C. difficile and improve overall test utilization.
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Affiliation(s)
- Jillian M Cotter
- Department of Pediatrics, University of Colorado, Aurora, Colorado
- Children's Hospital Colorado, Aurora, Colorado
| | - Claire L Stokes
- Department of Pediatrics, University of Colorado, Aurora, Colorado
- Children's Hospital Colorado, Aurora, Colorado
| | - Suhong Tong
- Department of Pediatrics, University of Colorado, Aurora, Colorado
| | - Meghan Birkholz
- Department of Pediatrics, University of Colorado, Aurora, Colorado
- Children's Hospital Colorado, Aurora, Colorado
| | - Jason Child
- Children's Hospital Colorado, Aurora, Colorado
| | - Carrye Cost
- Department of Pediatrics, University of Colorado, Aurora, Colorado
- Children's Hospital Colorado, Aurora, Colorado
| | | | - Stephanie Cox
- Department of Pediatrics, University of Colorado, Aurora, Colorado
- Children's Hospital Colorado, Aurora, Colorado
| | | | - Kathleen Dorris
- Department of Pediatrics, University of Colorado, Aurora, Colorado
- Children's Hospital Colorado, Aurora, Colorado
| | - Keith Z Hazleton
- Department of Pediatrics, University of Colorado, Aurora, Colorado
- Children's Hospital Colorado, Aurora, Colorado
| | | | | | | | - Samuel R Dominguez
- Department of Pediatrics, University of Colorado, Aurora, Colorado
- Children's Hospital Colorado, Aurora, Colorado
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Ramgopal S, Cotter JM, Navanandan N, Ambroggio L, Michelson KA, Florin TA. Radiographic uncertainty and outcomes of children with lower respiratory tract infections. Pediatr Pulmonol 2024. [PMID: 38415980 DOI: 10.1002/ppul.26943] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2024] [Accepted: 02/18/2024] [Indexed: 02/29/2024]
Affiliation(s)
- Sriram Ramgopal
- Department of Pediatrics, Division of Emergency Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Jillian M Cotter
- Department of Pediatrics, Section of Hospital Medicine, Children's Hospital Colorado, University of Colorado, Aurora, Colorado, USA
| | - Nidhya Navanandan
- Department of Pediatrics, Section of Emergency Medicine, Children's Hospital Colorado, University of Colorado, Aurora, Colorado, USA
| | - Lilliam Ambroggio
- Department of Pediatrics, Section of Hospital Medicine, Children's Hospital Colorado, University of Colorado, Aurora, Colorado, USA
- Department of Pediatrics, Section of Emergency Medicine, Children's Hospital Colorado, University of Colorado, Aurora, Colorado, USA
| | - Kenneth A Michelson
- Department of Pediatrics, Division of Emergency Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Todd A Florin
- Department of Pediatrics, Division of Emergency Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
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Gilley SP, Ta A, Pryor W, Roper B, Erickson M, Fenton LZ, Tchou MJ, Cotter JM, Moore JM. What Do We C in Children With Scurvy? A Case Series Focused on Musculoskeletal Symptoms. Hosp Pediatr 2024; 14:e98-e103. [PMID: 38234212 DOI: 10.1542/hpeds.2023-007336] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2024]
Abstract
OBJECTIVES Vitamin C deficiency in children commonly presents with musculoskeletal symptoms such as gait disturbance, refusal to bear weight, and bone or joint pain. We aimed to identify features that could facilitate early diagnosis of scurvy and estimate the cost of care for patients with musculoskeletal symptoms related to scurvy. METHODS We conducted a retrospective chart review of patients at a single site with diagnostic codes for vitamin C deficiency, ascorbic acid deficiency, or scurvy. Medical records were reviewed to identify characteristics including presenting symptoms, medical history, and diagnostic workup. The Pediatric Health Information System was used to estimate diagnostic and hospitalization costs for each patient. RESULTS We identified 47 patients with a diagnosis of scurvy, 49% of whom had a neurodevelopmental disorder. Sixteen of the 47 had musculoskeletal symptoms and were the focus of the cost analysis. Three of the 16 had moderate or severe malnutrition, and 3 had overweight or obesity. Six patients presented to an emergency department for care, 11 were managed inpatient, and 3 required critical care. Diagnostic workups included MRI, computed tomography, echocardiogram, endoscopy, lumbar puncture, and/or EEG. Across all patients evaluated, the cost of emergency department utilization, imaging studies, diagnostic procedures, and hospitalization totaled $470 144 (median $14 137 per patient). CONCLUSIONS Children across the BMI spectrum, particularly those with neurodevelopmental disorders, can develop vitamin C deficiency. Increased awareness of scurvy and its signs and symptoms, particularly musculoskeletal manifestations, may reduce severe disease, limit adverse effects related to unnecessary tests/treatments, and facilitate high-value care.
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Affiliation(s)
| | - Allison Ta
- Department of Pediatrics, Sections of Nutrition
- Department of Pediatrics, Section of Gastroenterology, Hepatology and Nutrition, University of Cincinnati School of Medicine, Cincinnati, Ohio
- Digestive Health Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - William Pryor
- Departments of Radiology
- Department of Radiology, University of North Carolina, Chapel Hill, North Carolina
| | - Brennan Roper
- Orthopedics, University of Colorado School of Medicine, Aurora, Colorado
- Department of Orthopedics, University of Texas, Houston, Houston, Texas
| | - Mark Erickson
- Orthopedics, University of Colorado School of Medicine, Aurora, Colorado
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Dunbar KS, Fox SN, Thomas JF, Brittan MS, Soskolne G, Cotter JM. When to Transfer: Predictors of Pediatric High Flow Nasal Cannula Failure at a Community Hospital. Hosp Pediatr 2024; 14:45-51. [PMID: 38093648 DOI: 10.1542/hpeds.2023-007298] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2024]
Abstract
OBJECTIVES To identify risk factors of high flow nasal cannula (HFNC) failure at a US pediatric hospital without a co-located ICU. METHODS Retrospective cohort study of patients aged 0 to 18 years who were started on HFNC in the emergency department or inpatient unit at a community hospital over a 16-month period. Children with chronic medical conditions were excluded. Outcome was HFNC failure, defined as HFNC need greater than floor limit, noninvasive positive pressure, or mechanical ventilation. In bivariate analysis, we compared demographic and clinical factors between those with and without failure. We included variables in a multivariable model on the basis of statistical significance. We used Poisson regression with robust error variance to calculate the adjusted relative risk (aRR) of failure for each variable. RESULTS Of 195 children, 51% had HFNC failure. In adjusted analysis, failure was higher in all age groups <12 months as compared with older children. For example, children aged 3 to 5 months had a higher risk of failure compared with patients 12 months or older (aRR 1.85, confidence interval [CI] 1.34-2.54). Patients with an asthma exacerbation had a higher risk of failure (aRR 1.39, CI 1.03-1.88). Patients whose respiratory rate or heart rate did not improve also had a higher risk of failure (aRR 1.73, CI 1.24-2.41; aRR 1.47, CI 1.14-1.90). CONCLUSIONS Patients who were younger, had asthma, and did not have improved respiratory rate or heart rate after HFNC were more likely to experience HFNC failure.
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Affiliation(s)
- Kimiko S Dunbar
- Section of Pediatric Hospital Medicine, Children's Hospital Colorado, University of Colorado Denver, Aurora Colorado
- University of Colorado School of Medicine, Aurora, Colorado
| | - Sarah N Fox
- University of Colorado School of Medicine, Aurora, Colorado
| | - Jacob F Thomas
- Adult and Child Consortium for Health Outcomes Research and Delivery Science
- University of Colorado School of Medicine, Aurora, Colorado
| | - Mark S Brittan
- Section of Pediatric Hospital Medicine, Children's Hospital Colorado, University of Colorado Denver, Aurora Colorado
- Adult and Child Consortium for Health Outcomes Research and Delivery Science
- University of Colorado School of Medicine, Aurora, Colorado
| | - Gayle Soskolne
- Section of Pediatric Hospital Medicine, Children's Hospital Colorado, University of Colorado Denver, Aurora Colorado
- University of Colorado School of Medicine, Aurora, Colorado
| | - Jillian M Cotter
- Section of Pediatric Hospital Medicine, Children's Hospital Colorado, University of Colorado Denver, Aurora Colorado
- University of Colorado School of Medicine, Aurora, Colorado
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Ho EC, Cotter JM, Thomas J, Birkholz M, Dominguez SR. Factors Associated With Actionable Gastrointestinal Panel Results in Hospitalized Children. Hosp Pediatr 2023; 13:1115-1123. [PMID: 37936503 DOI: 10.1542/hpeds.2023-007273] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2023]
Abstract
OBJECTIVES There is uncertainty regarding which hospitalized patients with acute gastroenteritis (AGE) benefit from gastrointestinal panel (GIP) testing. Unnecessary testing may lead to increased costs, overdiagnosis, and overtreatment. In general, AGE management and outcomes are most impacted if an actionable (bacterial or parasitic) result is obtained. We aimed to assess which clinical reasons for ordering GIP testing ("order indications") and patient factors were associated with actionable results. METHODS This is a cross-sectional study of pediatric patients hospitalized between 2015 and 2018 at a large pediatric health care system with diarrhea and a GIP performed. Multivariable regression analysis was used to determine associations between actionable GIP results and order indication, stool frequency, and demographics. Findings were evaluated in patients with complex chronic conditions (CCC) and non-CCC patients. RESULTS There were 1124 GIPs performed in 967 encounters. Non-CCC patients had more actionable results than CCC patients, and reasons for testing differed. Across both cohorts, age ≥1 year old was positively associated with actionable results. For non-CCC patients, actionable results were associated with "diarrhea with blood or pus" order indication and nonwinter season; international travel was associated with non-Clostridioides difficile bacteria and parasites. No order indications were associated with actionable results for CCC patients. CONCLUSIONS Patient factors and order indications that may help identify children hospitalized for AGE with actionable GIP results include older age (regardless of CCC status), as well as bloody stools and international travel in previously healthy children. Prospective validation of these findings could help improve diagnostic stewardship and decrease unnecessary testing.
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Affiliation(s)
- Erin C Ho
- Department of Pediatrics
- Sections of Infectious Disease
| | | | - Jacob Thomas
- Adult and Child Consortium for Health Outcomes, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, Colorado
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Navanandan N, Florin TA, Leonard J, Ramgopal S, Cotter JM, Shah SS, Ruddy RM, Ambroggio L. Impact of Adjunct Corticosteroid Therapy on Quality of Life for Children With Suspected Pneumonia. Pediatr Emerg Care 2023; 39:482-487. [PMID: 37306694 PMCID: PMC10351650 DOI: 10.1097/pec.0000000000002984] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
OBJECTIVE To determine the association between adjunct corticosteroid therapy and quality of life (QoL) outcomes in children with signs and symptoms of lower respiratory tract infection and clinical suspicion for community-acquired pneumonia (CAP) in the emergency department (ED). METHODS Secondary analysis from a prospective cohort study of children aged 3 months to 18 years with signs and symptoms of LRTI and a chest radiograph for suspected CAP in the ED, excluding children with recent (within 14 days) systemic corticosteroid use. The primary exposure was receipt of corticosteroids during the ED visit. Outcomes were QoL measures and unplanned visits. Multivariable regression was used to evaluate the association between corticosteroid therapy and outcomes. RESULTS Of 898 children, 162 (18%) received corticosteroids. Children who received corticosteroids were more frequently boys (62%), Black (45%), had history of asthma (58%), previous pneumonia (16%), presence of wheeze (74%), and more severe illness at presentation (6%). Ninety-six percent were treated for asthma as defined by report of asthma or receipt of ß-agonist in the ED. Receipt of corticosteroids was not associated with QoL measures: days of activity missed (adjusted incident rate ratio [aIRR], 0.84; 95% confidence interval [CI], 0.63-1.11) and days of work missed (aIRR, 0.88; 95% CI, 0.60-1.27). There was a statistically significant interaction between age (>2 years) and corticosteroids receipt; the patients had fewer days of activity missed (aIRR, 0.62; 95% CI, 0.46-0.83), with no effect on children 2 years or younger (aIRR, 0.83; 95% CI, 0.54-1.27). Corticosteroid treatment was not associated with unplanned visit (odds ratio, 1.37; 95% CI, 0.69-2.75). CONCLUSIONS In this cohort of children with suspected CAP, receipt of corticosteroids was associated with asthma history and was not associated with missed days of activity or work, except in a subset of children aged older than 2 years.
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Affiliation(s)
- Nidhya Navanandan
- Section of Emergency Medicine, Children’s Hospital Colorado, Department of Pediatrics, University of Colorado, Aurora, CO
| | - Todd A. Florin
- Division of Pediatric Emergency Medicine, Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Jan Leonard
- Section of Emergency Medicine, Children’s Hospital Colorado, Department of Pediatrics, University of Colorado, Aurora, CO
| | - Sriram Ramgopal
- Division of Pediatric Emergency Medicine, Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Jillian M. Cotter
- Section of Pediatric Hospital Medicine, Children’s Hospital Colorado, Department of Pediatrics, University of Colorado, Aurora, CO
| | - Samir S. Shah
- Division of Hospital Medicine and Cincinnati Children’s Hospital Medical Center and the University of Cincinnati College of Medicine, Cincinnati, OH
| | - Richard M. Ruddy
- Division of Emergency Medicine, Cincinnati Children’s Hospital Medical Center and the University of Cincinnati College of Medicine, Cincinnati, OH
| | - Lilliam Ambroggio
- Section of Emergency Medicine, Children’s Hospital Colorado, Department of Pediatrics, University of Colorado, Aurora, CO
- Section of Pediatric Hospital Medicine, Children’s Hospital Colorado, Department of Pediatrics, University of Colorado, Aurora, CO
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Ramgopal S, Cotter JM, Navanandan N, Shah SS, Ruddy RM, Ambroggio L, Florin TA. Viral Detection Is Associated With Severe Disease in Children With Suspected Community-Acquired Pneumonia. Pediatr Emerg Care 2023; 39:465-469. [PMID: 37308159 DOI: 10.1097/pec.0000000000002982] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
OBJECTIVE To evaluate the role of virus detection on disease severity among children presenting to the emergency department (ED) with suspected community-acquired pneumonia (CAP). METHODS We performed a single-center prospective study of children presenting to a pediatric ED with signs and symptoms of a lower respiratory tract infection and who had a chest radiograph performed for suspected CAP. We included patients who had virus testing, with results classified as negative for virus, human rhinovirus, respiratory syncytial virus (RSV), influenza, and other viruses. We evaluated the association between virus detection and disease severity using a 4-tiered measure of disease severity based on clinical outcomes, ranging from mild ( discharged from the ED) to severe (receipt of positive-pressure ventilation, vasopressors, thoracostomy tube placement, or extracorporeal membrane oxygenation, intensive care unit admission, diagnosis of severe sepsis or septic shock, or death) in models adjusted for age, procalcitonin, C-reactive protein, radiologist interpretation of the chest radiograph, presence of wheeze, fever, and provision of antibiotics. RESULTS Five hundred seventy-three patients were enrolled in the parent study, of whom viruses were detected in 344 (60%), including 159 (28%) human rhinovirus, 114 (20%) RSV, and 34 (6%) with influenza. In multivariable models, viral infections were associated with increasing disease severity, with the greatest effect noted with RSV (adjusted odds ratio [aOR], 2.50; 95% confidence interval [CI], 1.30-4.81) followed by rhinovirus (aOR, 2.18; 95% CI, 1.27-3.76). Viral detection was not associated with increased severity among patients with radiographic pneumonia (n = 223; OR, 1.82; 95% CI, 0.87-3.87) but was associated with severity among patients without radiographic pneumonia (n = 141; OR, 2.51; 95% CI, 1.40-4.59). CONCLUSIONS The detection of a virus in the nasopharynx was associated with more severe disease compared with no virus; this finding persisted after adjustment for age, biomarkers, and radiographic findings. Viral testing may assist with risk stratification of patients with lower respiratory tract infections.
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Affiliation(s)
- Sriram Ramgopal
- From the Division of Emergency Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Jillian M Cotter
- Section of Pediatric Hospital Medicine, Children's Hospital Colorado, Department of Pediatrics, University of Colorado, Aurora, CO
| | - Nidhya Navanandan
- Section of Emergency Medicine, Children's Hospital Colorado, Department of Pediatrics, University of Colorado, Aurora, CO
| | - Samir S Shah
- Divisions of Hospital Medicine and Infectious Diseases, Cincinnati Children's Hospital Medical Center and the University of Cincinnati College of Medicine, Cincinnati, OH
| | - Richard M Ruddy
- Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center and University of Cincinnati College of Medicine, Cincinnati, OH
| | | | - Todd A Florin
- From the Division of Emergency Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL
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Markham JL, Hall M, Collins ME, Shah SS, Molloy MJ, Aronson PL, Cotter JM, Steiner MJ, McCoy E, Tchou MJ, Stephens JR. Variation in stool testing for children with acute gastrointestinal infections. J Hosp Med 2023. [PMID: 36988413 DOI: 10.1002/jhm.13087] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2022] [Revised: 02/24/2023] [Accepted: 03/08/2023] [Indexed: 03/30/2023]
Abstract
BACKGROUND AND OBJECTIVE Children with gastrointestinal infections often require acute care.The objectives of this study were to describe variations in patterns of stool testing across children's hospitals and determine whether such variation was associated with utilization outcomes. DESIGN, SETTINGS AND PARTICIPANTS We performed a multicenter, cross-sectional study using the Pediatric Health Information System (PHIS) database. We identified stool testing (multiplex polymerase chain reaction [PCR], stool culture, ova and parasite, Clostridioides difficile, and other individual stool bacterial or viral tests) in children diagnosed with acute gastrointestinal infections. MAIN OUTCOME AND MEASURES We calculated the overall testing rates and hospital-level stool testing rates, stratified by setting (emergency department [ED]-only vs. hospitalized). We stratified individual hospitals into low, moderate, or high testing institutions. Generalized estimating equations were then used to examine the association of hospital testing groups and outcomes, specifically, length of stay (LOS), costs, and revisit rates. RESULTS We identified 498,751 ED-only and 40,003 encounters for hospitalized children from 2016 to 2020. Compared to ED-only encounters, stool studies were obtained with increased frequency among encounters for hospitalized children (ED-only: 0.1%-2.3%; Hospitalized: 1.5%-13.8%, all p < 0.001). We observed substantial variation in stool testing rates across hospitals, particularly during encounters for hospitalized children (e.g., rates of multiplex PCRs ranged from 0% to 16.8% for ED-only and 0% to 65.0% for hospitalized). There were no statistically significant differences in outcomes among low, moderate, or high testing institutions in adjusted models. CONCLUSIONS Children with acute gastrointestinal infections experience substantial variation in stool testing within and across hospitals, with no difference in utilization outcomes. These findings highlight the need for guidelines to address diagnostic stewardship.
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Affiliation(s)
- Jessica L Markham
- Department of Pediatrics, Children's Mercy Kansas City, University of Missouri-Kansas City School of Medicine, Kansas City, Missouri, USA
- Department of Pediatrics, University of Kansas School of Medicine, Kansas City, Kansas, USA
| | - Matt Hall
- Department of Pediatrics, Children's Mercy Kansas City, University of Missouri-Kansas City School of Medicine, Kansas City, Missouri, USA
- Children's Hospital Association, Lenexa, Kansas, USA
| | - Megan E Collins
- Department of Pediatrics, Children's Mercy Kansas City, University of Missouri-Kansas City School of Medicine, Kansas City, Missouri, USA
| | - Samir S Shah
- Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Matthew J Molloy
- Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Paul L Aronson
- Departments of Pediatrics and of Emergency Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Jillian M Cotter
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Michael J Steiner
- Department of Pediatrics, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Elisha McCoy
- Department of Pediatrics, Le Bonheur Children's Hospital, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Michael J Tchou
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - John R Stephens
- Department of Medicine, University of North Carolina, Chapel Hill, North Carolina, USA
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Ramgopal S, Cotter JM, Navanandan N, Ambroggio L, Florin TA. Disease severity of community-acquired pneumonia among children with medical complexity. Pediatr Pulmonol 2023; 58:967-970. [PMID: 36471562 DOI: 10.1002/ppul.26269] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Revised: 11/02/2022] [Accepted: 12/03/2022] [Indexed: 12/12/2022]
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, USA
| | - Jillian M Cotter
- Department of Pediatrics, Section of Pediatric Hospital Medicine, Children's Hospital Colorado, University of Colorado, Aurora, Colorado, USA
| | - Nidhya Navanandan
- Department of Pediatrics, Section of Emergency Medicine, Children's Hospital Colorado, University of Colorado, Aurora, Colorado, USA
| | - Lilliam Ambroggio
- Department of Pediatrics, Sections of Emergency Medicine and Hospital Medicine, Children's Hospital Colorado, University of Colorado, Aurora, Colorado, USA
| | - Todd A Florin
- Division of Emergency Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
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Morrison JM, Cotter JM, Jenkins AM, Kyler KE, Girdwood SCT. Fostering sustainable interinstitutional peer mentorship groups to support professional goals in hospital medicine. J Hosp Med 2022. [PMID: 36583263 PMCID: PMC10310880 DOI: 10.1002/jhm.13040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Revised: 12/20/2022] [Accepted: 12/22/2022] [Indexed: 12/31/2022]
Affiliation(s)
- John M Morrison
- Department of Pediatrics, Johns Hopkins University School of Medicine, Division of Pediatric Hospital Medicine, Johns Hopkins All Children's Hospital, Florida, Saint Petersburg, USA
| | - Jillian M Cotter
- Department of Pediatrics, Section of Hospital Medicine, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Ashley M Jenkins
- Department of Medicine and Department of Pediatrics, University of Rochester Medical Center, Rochester, New York, USA
| | - Kathryn E Kyler
- Division of Hospital Medicine, Children's Mercy Hospital, University of Missouri-Kansas School of Medicine, Kansas City, Missouri, USA
| | - Sonya C Tang Girdwood
- Department of Pediatrics, Divisions of Hospital Medicine & Clinical Pharmacology, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
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15
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Cotter JM, Florin TA, Moss A, Suresh K, Navanandan N, Ramgopal S, Shah SS, Ruddy R, Kempe A, Ambroggio L. Antibiotic use and outcomes among children hospitalized with suspected pneumonia. J Hosp Med 2022; 17:975-983. [PMID: 36380654 PMCID: PMC9722550 DOI: 10.1002/jhm.13002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2022] [Revised: 10/18/2022] [Accepted: 10/20/2022] [Indexed: 11/17/2022]
Abstract
BACKGROUND Although viral etiologies predominate, antibiotics are frequently prescribed for community-acquired pneumonia (CAP). OBJECTIVE We evaluated the association between antibiotic use and outcomes among children hospitalized with suspected CAP. DESIGNS, SETTINGS AND PARTICIPANTS We performed a secondary analysis of a prospective cohort of children hospitalized with suspected CAP. INTERVENTION The exposure was the receipt of antibiotics in the emergency department (ED). MAIN OUTCOME AND MEASURES Clinical outcomes included length of stay (LOS), care escalation, postdischarge treatment failure, 30-day ED revisit, and quality-of-life (QoL) measures from a follow-up survey 7-15 days post discharge. To minimize confounding by indication (e.g., radiographic CAP), we performed inverse probability treatment weighting with propensity analyses. RESULTS Among 523 children, 66% were <5 years, 88% were febrile, 55% had radiographic CAP, and 55% received ED antibiotics. The median LOS was 41 h (IQR: 25, 54). After propensity analyses, there were no differences in LOS, escalated care, treatment failure, or revisits between children who received antibiotics and those who did not. Seventy-one percent of patients completed follow-up surveys after discharge. Among 16% of patients with fevers after discharge, the median fever duration was 2 days, and those who received antibiotics had a 37% decrease in the mean number of days with fever (95% confidence interval: 20% and 51%). We found no statistical differences in other QoL measures.
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Affiliation(s)
- Jillian M Cotter
- Section of Hospital Medicine, Department of Pediatrics, Children's Hospital Colorado, University of Colorado, Aurora, Colorado, USA
| | - Todd A Florin
- Department of Pediatrics, Division of Pediatric Emergency Medicine, Ann and Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Angela Moss
- Adult and Child Consortium for Health Outcomes Research and Delivery Science, University of Colorado, Aurora, Colorado, USA
| | - Krithika Suresh
- Adult and Child Consortium for Health Outcomes Research and Delivery Science, University of Colorado, Aurora, Colorado, USA
- Department of Biostatistics and Informatics, Colorado School of Public Health, University of Colorado, Aurora, Colorado, USA
| | - Nidhya Navanandan
- Section of Emergency Medicine, Department of Pediatrics, Children's Hospital Colorado, University of Colorado, Aurora, Colorado, USA
| | - Sriram Ramgopal
- Department of Pediatrics, Division of Pediatric Emergency Medicine, Ann and Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Samir S Shah
- Cincinnati Children's Hospital Medical Center and the University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Richard Ruddy
- Cincinnati Children's Hospital Medical Center and the University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Allison Kempe
- Adult and Child Consortium for Health Outcomes Research and Delivery Science, University of Colorado, Aurora, Colorado, USA
| | - Lilliam Ambroggio
- Section of Hospital Medicine, Department of Pediatrics, Children's Hospital Colorado, University of Colorado, Aurora, Colorado, USA
- Section of Emergency Medicine, Department of Pediatrics, Children's Hospital Colorado, University of Colorado, Aurora, Colorado, USA
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16
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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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] [What about the content of this article? (0)] [Affiliation(s)] [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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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] [What about the content of this article? (0)] [Affiliation(s)] [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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Cogen JD, Hall M, Faino AV, Ambroggio L, Blaschke AJ, Brogan TV, Cotter JM, Gibson RL, Grijalva CG, Hersh AL, Lipsett SC, Shah SS, Shapiro DJ, Neuman MI, Gerber JS. Antibiotics and outcomes of CF pulmonary exacerbations in children infected with MRSA and Pseudomonas aeruginosa. J Cyst Fibros 2022; 22:313-319. [PMID: 35945130 DOI: 10.1016/j.jcf.2022.08.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2022] [Revised: 07/29/2022] [Accepted: 08/01/2022] [Indexed: 10/15/2022]
Abstract
BACKGROUND Limited data exist to inform antibiotic selection among people with cystic fibrosis (CF) with airway infection by multiple CF-related microorganisms. This study aimed to determine among children with CF co-infected with methicillin-resistant Staphylococcus aureus (MRSA) and Pseudomonas aeruginosa (Pa) if the addition of anti-MRSA antibiotics to antipseudomonal antibiotic treatment for pulmonary exacerbations (PEx) would be associated with improved clinical outcomes compared with antipseudomonal antibiotics alone. METHODS Retrospective cohort study using data from the CF Foundation Patient Registry-Pediatric Health Information System linked dataset. The odds of returning to baseline lung function and having a subsequent PEx requiring intravenous antibiotics were compared between PEx treated with anti-MRSA and antipseudomonal antibiotics and those treated with antipseudomonal antibiotics alone, adjusting for confounding by indication using inverse probability of treatment weighting. RESULTS 943 children with CF co-infected with MRSA and Pa contributed 2,989 PEx for analysis. Of these, 2,331 (78%) PEx were treated with both anti-MRSA and antipseudomonal antibiotics and 658 (22%) PEx were treated with antipseudomonal antibiotics alone. Compared with PEx treated with antipseudomonal antibiotics alone, the addition of anti-MRSA antibiotics to antipseudomonal antibiotic therapy was not associated with a higher odds of returning to ≥90% or ≥100% of baseline lung function or a lower odds of future PEx requiring intravenous antibiotics. CONCLUSIONS Children with CF co-infected with MRSA and Pa may not benefit from the addition of anti-MRSA antibiotics for PEx treatment. Prospective studies evaluating optimal antibiotic selection strategies for PEx treatment are needed to optimize clinical outcomes following PEx treatment.
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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 DOI: 10.1542/peds.2021-055641] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [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
| | | | - Jillian M Cotter
- Department of Pediatrics
- Pediatric Hospital Medicine, Department of Pediatrics, Children's Hospital Colorado, University of Colorado, Aurora, Colorado
| | | | - Richard M Ruddy
- Emergency Medicine, Cincinnati Children's Hospital Medical Center and University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Lilliam Ambroggio
- Department of Pediatrics
- Sections of Emergency Medicine
- Pediatric Hospital Medicine, 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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21
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Stephens JR, Hall M, Molloy MJ, Markham JL, Cotter JM, Tchou MJ, Aronson PL, Steiner MJ, McCoy E, Collins ME, Shah SS. Establishment of achievable benchmarks of care in the neurodiagnostic evaluation of simple febrile seizures. J Hosp Med 2022; 17:327-341. [PMID: 35560723 DOI: 10.1002/jhm.12833] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2021] [Revised: 03/02/2022] [Accepted: 03/16/2022] [Indexed: 11/08/2022]
Abstract
BACKGROUND Current guidelines recommend against neurodiagnostic testing for the evaluation of simple febrile seizures. OBJECTIVES (1) Assess overall and institutional rates of neurodiagnostic testing and (2) establish achievable benchmarks of care (ABCs) for children evaluated for simple febrile seizures at children's hospitals. DESIGN, SETTING, AND PARTICIPANTS Cross-sectional study of children 6 months to 5 years evaluated in the emergency department (ED) 2016-2019 with simple febrile seizures at 38 children's hospitals in Pediatric Health Information System database. We excluded children with epilepsy, complex febrile seizures, complex chronic conditions, and intensive care. OUTCOME MEASURES Proportions of children who received neuroimaging, electroencephalogram (EEG), or lumbar puncture (LP) and rates of hospitalization for study cohort and individual hospitals. Hospital-specific outcomes were adjusted for patient demographics and severity of illness. We utilized hospital-specific values for each measure to calculate ABCs. RESULTS We identified 51,015 encounters. Among the study cohort 821 (1.6%) children had neuroimaging, 554 (1.1%) EEG, 314 (0.6%) LP, and 2023 (4.0%) were hospitalized. Neurodiagnostic testing rates varied across hospitals: neuroimaging 0.4%-6.7%, EEG 0%-8.2%, LP 0%-12.7% in patients <1-year old and 0%-3.1% in patients ≥1 year. Hospitalization rate ranged from 0%-14.5%. Measured outcomes were higher among hospitalized versus ED-only patients: neuroimaging 15.3% versus 1.0%, EEG% 24.7 versus 0.1% (p < .001). Calculated ABCs were 0.6% for neuroimaging, 0.1% EEG, 0% LP, and 1.0% hospitalization. CONCLUSIONS Rates of neurodiagnostic testing and hospitalization for simple febrile seizures were low but varied across hospitals. Calculated ABCs were 0%-1% for all measures, demonstrating that adherence to current guidelines is attainable.
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Affiliation(s)
- John R Stephens
- Department of Pediatrics, North Carolina Children's Hospital, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
| | - Matt Hall
- Children's Hospital Association, Overland Park, Kansas, USA
| | - Matthew J Molloy
- Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati, Cincinnati, Ohio, USA
| | - Jessica L Markham
- Department of Pediatrics, Children's Mercy Kansas City, University of Missouri-Kansas City, Kansas City, Missouri, USA
| | - Jillian M Cotter
- Department of Pediatrics, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Michael J Tchou
- Department of Pediatrics, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Paul L Aronson
- Departments of Pediatrics and Emergency Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Michael J Steiner
- Department of Pediatrics, North Carolina Children's Hospital, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
| | - Elisha McCoy
- Department of Pediatrics, Le Bonheur Children's Hospital, Memphis, Tennessee, USA
| | - Megan E Collins
- Department of Pediatrics, Children's Mercy Kansas City, University of Missouri-Kansas City, Kansas City, Missouri, USA
| | - Samir S Shah
- Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati, Cincinnati, Ohio, USA
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22
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Ambroggio L, Cotter JM, Hall M. Methodological progress note: A clinician's guide to propensity scores. J Hosp Med 2022; 17:283-286. [PMID: 35535919 DOI: 10.1002/jhm.12791] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2021] [Revised: 12/30/2021] [Accepted: 12/31/2021] [Indexed: 11/12/2022]
Affiliation(s)
- Lilliam Ambroggio
- Department of Pediatrics, Section of Emergency Medicine, Children's Hospital of Colorado, University of Colorado, Denver, Colorado, USA
- Department of Pediatrics, Section of Hospital Medicine, Children's Hospital of Colorado, University of Colorado, Denver, Colorado, USA
| | - Jillian M Cotter
- Department of Pediatrics, Section of Hospital Medicine, Children's Hospital of Colorado, University of Colorado, Denver, Colorado, USA
| | - Matthew Hall
- Children's Hospital Association, Lenexa, Kansas, USA
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23
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Abstract
OBJECTIVES Procalcitonin (PCT) is a relatively novel biomarker that may be superior to C-reactive protein (CRP) in identifying bacterial infection. PCT use in pediatric hospitals is relatively unknown. We aimed to evaluate PCT and CRP use, describe PCT testing variability across children's hospitals, and compare temporal rates of PCT and CRP testing for patients admitted with pneumonia, sepsis, or fever in young infants. METHODS In this multicenter cohort study, we identified children ≤18 years old hospitalized from 2014-2018 with pneumonia, sepsis, or fever in infants <2 months by using the Pediatric Health Information System. To determine use, we evaluated the proportion of encounters with PCT or CRP testing from 2017-2018. We generated heat maps to describe PCT use across hospitals. We also compared PCT and CRP rates over time from 2014 to 2018. RESULTS From 2017-2018, PCT testing occurred in 3988 of 34c231 (12%) hospitalizations. Febrile infants had the highest PCT testing proportion (18%), followed by sepsis (15%) and pneumonia (9%). There was across-hospital variability in PCT testing, particularly for febrile infants. Over time, the odds of PCT testing increased at a significantly greater rate than that of CRP. CONCLUSIONS Despite limited guideline recommendations for PCT testing during the study period, PCT use increased over time with across-hospital variability. For pneumonia and sepsis, given the importance of high-value care, we need to understand the impact of PCT on patient outcomes. With recent guidelines recommending PCT in the evaluation of febrile infants, we identified baseline testing behaviors for future studies on guideline impact.
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Affiliation(s)
- Jillian M Cotter
- Department of Pediatrics, School of Medicine, University of Colorado and Children's Hospital Colorado, Aurora, Colorado
| | - Isabel Hardee
- Department of Pediatrics, School of Medicine, University of Colorado and Children's Hospital Colorado, Aurora, Colorado
| | - Angela Moss
- Adult and Child Consortium for Health Outcomes Research and Delivery Science, University of Colorado, Aurora, Colorado
| | - Amanda Dempsey
- Department of Pediatrics, School of Medicine, University of Colorado and Children's Hospital Colorado, Aurora, Colorado
- Adult and Child Consortium for Health Outcomes Research and Delivery Science, University of Colorado, Aurora, Colorado
| | - Lilliam Ambroggio
- Department of Pediatrics, School of Medicine, University of Colorado and Children's Hospital Colorado, Aurora, Colorado
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24
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Jain PN, Cotter JM, Tchou MJ. Practicing High-Value Pediatric Care During a Pandemic: The Challenges and Opportunities. J Hosp Med 2021; 16:631-633. [PMID: 34613900 DOI: 10.12788/jhm.3688] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2021] [Accepted: 07/16/2021] [Indexed: 11/20/2022]
Affiliation(s)
- Priya N Jain
- Department of Pediatrics, East Tennessee State University, Johnson City, TN
| | - Jillian M Cotter
- Department of Pediatrics, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, Colorado
| | - Michael J Tchou
- Department of Pediatrics, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, Colorado
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25
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Stephens JR, Hall M, Cotter JM, Molloy MJ, Tchou MJ, Markham JL, Shah SS, Steiner MJ, Aronson PL. Trends and Variation in Length of Stay Among Hospitalized Febrile Infants ≤60 Days Old. Hosp Pediatr 2021; 11:915-926. [PMID: 34385333 DOI: 10.1542/hpeds.2021-005936] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
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.
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Affiliation(s)
- John R Stephens
- North Carolina Children's Hospital and School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Matt Hall
- Children's Hospital Association, Overland Park, Kansas
| | - Jillian M Cotter
- Children's Hospital Colorado and School of Medicine, University of Colorado, Aurora, Colorado
| | - Matthew J Molloy
- Cincinnati Children's Hospital Medical Center and University of Cincinnati, Cincinnati, Ohio
| | - Michael J Tchou
- Children's Hospital Colorado and School of Medicine, University of Colorado, Aurora, Colorado
| | - Jessica L Markham
- Children's Mercy Hospital and University of Missouri-Kansas City, Kansas City, Missouri
| | - Samir S Shah
- Cincinnati Children's Hospital Medical Center and University of Cincinnati, Cincinnati, Ohio
| | - Michael J Steiner
- North Carolina Children's Hospital and School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Paul L Aronson
- Departments of Pediatrics and Emergency Medicine, School of Medicine, Yale University, New Haven, Connecticut
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26
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Stephens JR, Hall M, Markham JL, Tchou MJ, Cotter JM, Shah SS, Steiner MJ, Gay JC. Outcomes Associated With High- Versus Low-Frequency Laboratory Testing Among Hospitalized Children. Hosp Pediatr 2021; 11:563-570. [PMID: 33952575 DOI: 10.1542/hpeds.2020-005561] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
BACKGROUND AND OBJECTIVES Previous pediatric studies have revealed substantial variation in laboratory testing for specific conditions, but clinical outcomes associated with high- versus low-frequency testing are unclear. We hypothesized that hospitals with high- versus low-testing frequency would have worse clinical outcomes. METHODS We conducted a multicenter retrospective cohort study of patients 0 to 18 years old with low-acuity hospitalizations in the years 2018-2019 for 1 of 10 common All Patient Refined Diagnosis Related Groups. We identified hospitals with high-, moderate-, and low-frequency testing for 3 common groups of laboratory tests: complete blood cell count, basic chemistry studies, and inflammatory markers. Outcomes included length of stay, 7- and 30-day emergency department revisit and readmission rates, and hospital costs, comparing hospitals with high- versus low-frequency testing. RESULTS We identified 132 391 study encounters across 44 hospitals. Laboratory testing frequency varied by hospital and condition. We identified hospitals with high- (13), moderate- (20), and low-frequency (11) laboratory testing. When we compared hospitals with high- versus low-frequency testing, there were no differences in adjusted hospital costs (rate ratio 0.89; 95% confidence interval 0.71-1.12), length of stay (rate ratio 0.98; 95% confidence interval 0.91-1.06), 7-day (odds ratio 0.99; 95% confidence interval 0.81-1.21) or 30-day (odds ratio 1.01; 95% confidence interval 0.82-1.25) emergency department revisit rates, or 7-day (odds ratio 0.84; 95% confidence interval 0.65-1.25) or 30-day (odds ratio 0.91; 95% confidence interval 0.76-1.09) readmission rates. CONCLUSIONS In a multicenter study of children hospitalized for common low-acuity conditions, laboratory testing frequency varied widely across hospitals, without substantial differences in outcomes. Our results suggest opportunities to reduce laboratory overuse across conditions and children's hospitals.
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Affiliation(s)
- John R Stephens
- North Carolina Children's Hospital and School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina;
| | - Matt Hall
- Children's Hospital Association, Overland Park, Kansas
| | - Jessica L Markham
- Children's Mercy Hospital and University of Missouri-Kansas City, Kansas City, Missouri
| | - Michael J Tchou
- Children's Hospital Colorado and School of Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Jillian M Cotter
- Children's Hospital Colorado and School of Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Samir S Shah
- Cincinnati Children's Hospital Medical Center and University of Cincinnati, Cincinnati, Ohio; and
| | - Michael J Steiner
- North Carolina Children's Hospital and School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - James C Gay
- Monroe Carell Jr Children's Hospital at Vanderbilt, Nashville, Tennessee
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27
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Cotter JM, Thomas J, Birkholz M, Ambroggio L, Holstein J, Dominguez SR. Clinical Impact of a Diagnostic Gastrointestinal Panel in Children. Pediatrics 2021; 147:peds.2020-036954. [PMID: 33837134 DOI: 10.1542/peds.2020-036954] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/03/2021] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVES Many hospitals have transitioned from conventional stool diagnostics to rapid multiplex polymerase chain reaction gastrointestinal panels (GIP). The clinical impact of this testing has not been evaluated in children. In this study, we compare use, results, and patient outcomes between conventional diagnostics and GIP testing. METHODS This is a multicenter cross-sectional study of children who underwent stool testing from 2013 to 2017. We used bivariate analyses to compare test use, results, and patient outcomes, including length of stay (LOS), ancillary testing, and hospital charges, between the GIP era (24 months after GIP introduction) and conventional diagnostic era (historic control, 24 months before). RESULTS There were 12 222 tests performed in 8720 encounters. In the GIP era, there was a 21% increase in the proportion of children who underwent stool testing, with a statistically higher percentage of positive results (40% vs 11%), decreased time to result (4 vs 31 hours), and decreased time to treatment (11 vs 35 hours). Although there was a decrease in LOS by 2 days among those who received treatment of a bacterial and/or parasitic pathogen (5.1 vs 3.1; P < .001), this represented only 3% of tested children. In the overall population, there was no statistical difference in LOS, ancillary testing, or charges. CONCLUSIONS The GIP led to increased pathogen detection and faster results. This translated into improved outcomes for only a small subset of patients, suggesting that unrestricted GIP use leads to low-value care. Similar to other novel rapid diagnostic panels, there is a critical need for diagnostic stewardship to optimize GIP testing.
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Affiliation(s)
| | - Jacob Thomas
- Adult and Child Consortium for Health Outcomes Research and Delivery Science, University of Colorado School of Medicine, Aurora, Colorado; and
| | | | - Lilliam Ambroggio
- Department of Pediatrics, Sections of Hospital Medicine.,Emergency Medicine, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, Colorado
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28
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Cotter JM, Hall M, Girdwood ST, Stephens JR, Markham JL, Gay JC, Shah SS. Opportunities for Stewardship in the Transition From Intravenous to Enteral Antibiotics in Hospitalized Pediatric Patients. J Hosp Med 2021; 16:70-76. [PMID: 33496660 PMCID: PMC7850597 DOI: 10.12788/jhm.3538] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Revised: 09/16/2020] [Accepted: 09/18/2020] [Indexed: 11/20/2022]
Abstract
BACKGROUND/OBJECTIVE Pediatric patients hospitalized with bacterial infections often receive intravenous (IV) antibiotics. Early transition to enteral antibiotics can reduce hospital duration, cost, and complications. We aimed to identify opportunities to transition from IV to enteral antibiotics, describe variation of transition among hospitals, and evaluate feasibility of novel stewardship metrics. METHODS This multisite retrospective cohort study used the Pediatric Health Information System to identify pediatric patients hospitalized with pneumonia, neck infection, orbital infection, urinary tract infection (UTI), osteomyelitis, septic arthritis, or skin and soft tissue infection (SSTI) between 2017 and 2018. Opportunity days were defined as days on which patients received both IV antibiotics and enteral medications, suggesting enteral tolerance. Percent opportunity was defined as opportunity days divided by days on any antibiotics. Both outcomes excluded IV antibiotics that have no alternative oral formulation. We evaluated outcomes per infection and antibiotic and assessed across-hospital variation. RESULTS We identified 88,522 aggregate opportunity days in 100,103 hospitalizations. On 57% of the antibiotic days, there was an opportunity to switch patients to enteral therapy, with greatest opportunity days in SSTI, neck infection, and pneumonia encounters, and with clindamycin, ceftriaxone, and ampicillin-sulbactam. Percent opportunity varied by infection (73% in septic arthritis to 40% in pneumonia). There was significant across-hospital variation in percent opportunity for all infections. CONCLUSION This multicenter study demonstrated the potential opportunity to transition from IV to enteral therapy in over half of antibiotic days. Opportunity varied by infection, antibiotic, and hospital. Across-hospital variation demonstrated likely missed opportunities for earlier transition and the need to define optimal transition times. Stewardship efforts promoting earlier transition for highly bioavailable antibiotics could reduce healthcare utilization and promote high-value care. We identified feasible stewardship metrics.
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Affiliation(s)
- Jillian M Cotter
- Children’s Hospital Colorado, University of Colorado School of Medicine, Aurora, Colorado
| | - Matt Hall
- Children’s Hospital Association, Lenexa, Kansas
| | - Sonya Tang Girdwood
- Cincinnati Children’s Hospital Medical Center and the University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - John R Stephens
- North Carolina Children’s Hospital, University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - Jessica L Markham
- Children’s Mercy Kansas City, University of Missouri Kansas City (Kansas City, MO)
| | - James C Gay
- Monroe Carell Children’s Hospital at Vanderbilt, Nashville, Tennessee
| | - Samir S Shah
- Cincinnati Children’s Hospital Medical Center and the University of Cincinnati College of Medicine, Cincinnati, Ohio
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29
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MacBrayne CE, Williams MC, Poole NM, Pearce K, Cotter JM, Parker SK. Inpatient Treatment of Acute Otitis Media at a Pediatric Hospital: A Missed Teaching Opportunity for Antimicrobial Stewardship. Hosp Pediatr 2020; 10:615-619. [PMID: 32554625 DOI: 10.1542/hpeds.2020-0090] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
BACKGROUND Acute otitis media (AOM) is a common pediatric condition known to contribute to excessive antibiotic use in the outpatient setting. Treatment of AOM in the inpatient setting has not been described. The objective was to describe the clinical features and inpatient management of AOM to harness this entity to teach learners about judicious antibiotic prescribing in all settings. METHODS This is a single-center retrospective cohort study of inpatients treated for AOM from January 2015 to December 2018. Patients were included if they had an antibiotic ordered and either a provider-selected order indication of otitis media or an International Classification of Diseases, 10th Revision billing code of AOM. A chart review was performed to identify primary diagnoses, examination features, and treatment, including excess days of therapy. RESULTS We included 840 hospitalized patients treated for AOM in this study. At least 71% of patients had a concurrent viral respiratory illness. Examinations were frequently discordant (34%), and 47% lacked documentation of a physical examination finding of a bulging tympanic membrane, contributing to 3417 potential excess days of therapy. Of the total patients treated for AOM, 40% were given excess duration of therapy. The vast majority (97%) of patients who qualified for a wait-and-watch approach were treated. CONCLUSIONS AOM is not being rigorously diagnosed or treated in a guideline-adherent manner in the inpatient setting. This is a lost opportunity for teaching antibiotic stewardship. Interventions, such as promoting the wait-and-watch approach and deferring treatment decisions to inpatient providers, could help promote the judicious use of antibiotics.
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Affiliation(s)
| | | | | | | | - Jillian M Cotter
- Pediatric Hospital Medicine, School of Medicine, University of Colorado and Children's Hospital Colorado, Aurora, Colorado
| | - Sarah K Parker
- Departments of Pediatric Infectious Diseases
- Epidemiology, and
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30
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Cotter JM, Thomas J, Birkholz M, Brittan M, Ambroggio L, Dolan S, Pearce K, Todd J, Dominguez SR. Impact of Multiplex Testing on the Identification of Pediatric Clostridiodes Difficile. J Pediatr 2020; 218:157-165.e3. [PMID: 32089179 DOI: 10.1016/j.jpeds.2019.11.036] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2019] [Revised: 11/13/2019] [Accepted: 11/22/2019] [Indexed: 12/18/2022]
Abstract
OBJECTIVES To evaluate whether the implementation of a multiplex gastrointestinal pathogen panel (GIP) was associated with changes in Clostridioides difficile (C difficile) testing and detection rates. STUDY DESIGN We conducted an observational study using interrupted time series analysis and included pediatric patients with testing capable of detecting C difficile. From 2013 to 2015 ("conventional diagnostic era"), stool testing included C difficile-selective polymerase chain reaction and other pathogen-specific tests. From 2015 to 2017 ("GIP era"), C difficile polymerase chain reaction was available along with the GIP, which detected 22 pathogens including C difficile, and replaced the need for additional tests. Outcomes included C difficile testing and detection rates in ambulatory, emergency department, and inpatient settings. RESULTS There were 6841 tests performed and 1214 C difficile positive results. Across the 3 settings, GIP era had significantly higher C difficile testing (1.7-2.3 times higher) and C difficile detection rates (1.9-3.4 times higher) compared with conventional diagnostic era. After adjusting for the number of tests performed, detection rates were no longer significantly different. Of C difficile positive GIPs, 31% were coinfected with another organism. With GIP testing, patients 1 year of age had a significantly higher C difficile percent positivity than 2-year-old (P = .02) and 3- to 18-year-old children (P < .01). Younger children with C difficile were more likely to be coinfected (P < .01). CONCLUSIONS Introducing a multiplex panel led to increased C difficile testing, which resulted in increased C difficile detection rates and potential identification and treatment of colonized patients. This highlights an important target for diagnostic stewardship and the challenges associated with multiplex testing.
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Affiliation(s)
- Jillian M Cotter
- Section of Hospital Medicine, Department of Pediatrics, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO.
| | - Jacob Thomas
- Adult and Child Consortium for Health Outcomes Research and Delivery Science, University of Colorado, Aurora, CO
| | - Meghan Birkholz
- Section of Infectious Diseases, Department of Pediatrics, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO
| | - Mark Brittan
- Section of Hospital Medicine, Department of Pediatrics, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO; Adult and Child Consortium for Health Outcomes Research and Delivery Science, University of Colorado, Aurora, CO
| | - Lilliam Ambroggio
- Section of Hospital Medicine, Department of Pediatrics, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO; Section of Emergency Medicine, Department of Pediatrics, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO
| | - Susan Dolan
- Department of Epidemiology, University of Colorado Denver School of Medicine and Children's Hospital Colorado, Aurora, CO
| | - Kelly Pearce
- Department of Epidemiology, University of Colorado Denver School of Medicine and Children's Hospital Colorado, Aurora, CO
| | - James Todd
- Section of Infectious Diseases, Department of Pediatrics, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO
| | - Samuel R Dominguez
- Section of Infectious Diseases, Department of Pediatrics, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO
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31
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Cotter JM, Nicholson MR, Kociolek LK. An Infectious Diseases Perspective on Fecal Microbiota Transplantation for Clostridioides difficile Infection in Children. J Pediatric Infect Dis Soc 2019; 8:580-584. [PMID: 31550348 PMCID: PMC7317149 DOI: 10.1093/jpids/piz062] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2019] [Accepted: 08/06/2019] [Indexed: 01/05/2023]
Abstract
Fecal microbiota transplantation (FMT) is efficacious for treatment of recurrent Clostridioides difficile infections (rCDIs). Pediatric experience with FMT for rCDIs is increasing, particularly at large centers. While retrospective studies suggest that FMT is generally safe in the short term, particularly in immunocompetent patients and with rigorous donor screening, additional large prospective studies are needed. This particularly includes those at high risk for infectious complications, such as immunocompromised hosts. Further, long-term implications of altering the intestinal microbiome with FMT are not well understood. The role of FMT in children, particularly in high-risk patients, will require continual reexamination with future availability of pediatric safety and efficacy data. This review summarizes key points for infectious diseases physicians to consider when evaluating a child for FMT.
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Affiliation(s)
- Jillian M Cotter
- Department of Pediatrics, University of Colorado School of Medicine, Division of Hospital Medicine, Children’s Hospital Colorado, Aurora
| | - Maribeth R Nicholson
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Larry K Kociolek
- Department of Pediatrics, Northwestern University Feinberg School of Medicine, Division of Infectious Diseases, Ann & Robert H. Lurie Children’s Hospital of Chicago, Illinois
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Cotter JM, Tyler A, Reese J, Ziniel S, Federico MJ, Anderson Iii WC, Kupfer O, Szefler SJ, Kerby G, Hoch HE. Steroid variability in pediatric inpatient asthmatics: survey on provider preferences of dexamethasone versus prednisone. J Asthma 2019; 57:942-948. [PMID: 31113252 DOI: 10.1080/02770903.2019.1622713] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Objective: Our hospital's pediatric Emergency Department (ED) began using dexamethasone for treating asthma exacerbations after ED studies showed non-inferiority of dexamethasone compared to prednisone. However, providers have not reached consensus on optimal inpatient steroid regimen. This study evaluates provider preference for inpatient steroid treatment.Methods: A survey was distributed to providers who care for inpatient pediatric asthmatics. Respondents answered questions about steroid choice and timing. Data were summarized as percentages; bivariate comparisons were analyzed with Pearson's chi-squared test.Results: Ninety-two providers completed the survey (60% response rate). When patients received dexamethasone in the ED, subsequent inpatient management was variable: 44% continued dexamethasone, 14% switched to prednisone, 2% said no additional steroids, and 40% said it depended on the scenario. Hospitalists were more likely to continue dexamethasone than pulmonologists (61% and 15%, respectively; p < .001). Factors that influenced providers to switch to prednisone in the inpatient setting included severity of exacerbation (73%) and asthma history (47%). Fifty-one percent felt uncomfortable using dexamethasone because of "minimal data to support [its] use inpatient." In case-based questions, 28% selected dexamethasone dosing intervals outside the recommended range. Thirteen percent reported experiencing errors in clinical practice.Conclusions: Use of dexamethasone in the ED for asthma exacerbations has led to uncertainty in inpatient steroid prescribing practices. Providers often revert to prednisone, especially in severe asthma exacerbations, possibly due to experience with prednisone and limited research on dexamethasone in the inpatient setting. Further research comparing the effectiveness of dexamethasone to prednisone in inpatient asthmatic children with various severities of illness is needed.
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Affiliation(s)
- Jillian M Cotter
- Section of Hospital Medicine, Children's Hospital Colorado, Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO, USA
| | - Amy Tyler
- Section of Hospital Medicine, Children's Hospital Colorado, Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO, USA
| | - Jennifer Reese
- Section of Hospital Medicine, Children's Hospital Colorado, Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO, USA
| | - Sonja Ziniel
- Section of Hospital Medicine, Children's Hospital Colorado, Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO, USA
| | - Monica J Federico
- Breathing Institute, Children's Hospital Colorado and University of Colorado School of Medicine, Aurora, CO, USA
| | - William C Anderson Iii
- Allergy and Immunology Section, Children's Hospital Colorado, Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO, USA
| | - Oren Kupfer
- Breathing Institute, Children's Hospital Colorado and University of Colorado School of Medicine, Aurora, CO, USA
| | - Stanley J Szefler
- Breathing Institute, Children's Hospital Colorado and University of Colorado School of Medicine, Aurora, CO, USA
| | - Gwendolyn Kerby
- Breathing Institute, Children's Hospital Colorado and University of Colorado School of Medicine, Aurora, CO, USA
| | - Heather E Hoch
- Breathing Institute, Children's Hospital Colorado and University of Colorado School of Medicine, Aurora, CO, USA
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Tyler A, Cotter JM, Moss A, Topoz I, Dempsey A, Reese J, Szefler S, Hoch H. Outcomes for Pediatric Asthmatic Inpatients After Implementation of an Emergency Department Dexamethasone Treatment Protocol. Hosp Pediatr 2019; 9:92-99. [PMID: 30670462 DOI: 10.1542/hpeds.2018-0099] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
OBJECTIVES Evidence supports using dexamethasone for mild-to-moderate asthma exacerbations in the emergency department, but the effectiveness of dexamethasone versus prednisone for asthmatic patients who are hospitalized is unclear. Our aim was to compare outcomes for inpatients before and after our emergency department's adoption of dexamethasone for the treatment of acute asthma exacerbations. METHODS In this single-center retrospective cohort study, we employed interrupted time series analyses to control for secular trends while evaluating our outcomes of length of stay, total inflation-adjusted hospital charges, and ICU transfer rates for patients admitted with asthma. RESULTS Data were analyzed over 36 months (January 2014-April 2017) and included 1015 subjects (606 in the preprotocol change [pre-PC] group and 409 in the postprotocol change [post-PC] group). In the pre-PC group, prednisone only was used in 96% of subjects. In the post-PC group, prednisone only was used in 7% of subjects, dexamethasone in 65% of subjects, and a combination of the 2 steroids in 28% of subjects. Controlling for other variables in the interrupted time series model, we found no significant immediate differences between the pre-PC and post-PC periods for the outcomes of length of stay (P = .68), total charges (P = .66), and ICU transfers (P = .98). The rate of ICU transfers was stable pre-PC and increased by 10% (95% confidence interval: 2%-19%) per month (odds ratio = 1.10; 95% confidence interval: 1.02-1.19; P = .02) in the post-PC period. CONCLUSIONS After dexamethasone replaced prednisone as the most commonly prescribed steroid type for inpatients with asthma at our institution, we found no immediate changes in outcomes for asthmatic patients who were hospitalized but an upward trend in ICU transfers.
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Affiliation(s)
- Amy Tyler
- Children's Hospital Colorado, Aurora, Colorado; .,Department of Pediatrics, School of Medicine, University of Colorado, Aurora, Colorado; and
| | - Jillian M Cotter
- Children's Hospital Colorado, Aurora, Colorado.,Department of Pediatrics, School of Medicine, University of Colorado, Aurora, Colorado; and
| | - Angela Moss
- Adult and Child Consortium for Health Outcomes Research and Delivery Science, Aurora, Colorado
| | - Irina Topoz
- Children's Hospital Colorado, Aurora, Colorado.,Department of Pediatrics, School of Medicine, University of Colorado, Aurora, Colorado; and
| | - Amanda Dempsey
- Children's Hospital Colorado, Aurora, Colorado.,Department of Pediatrics, School of Medicine, University of Colorado, Aurora, Colorado; and.,Adult and Child Consortium for Health Outcomes Research and Delivery Science, Aurora, Colorado
| | - Jennifer Reese
- Children's Hospital Colorado, Aurora, Colorado.,Department of Pediatrics, School of Medicine, University of Colorado, Aurora, Colorado; and
| | - Stanley Szefler
- Children's Hospital Colorado, Aurora, Colorado.,Department of Pediatrics, School of Medicine, University of Colorado, Aurora, Colorado; and
| | - Heather Hoch
- Children's Hospital Colorado, Aurora, Colorado.,Department of Pediatrics, School of Medicine, University of Colorado, Aurora, Colorado; and
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Cotter JM, Mack CL. Primary sclerosing cholangitis: Unique aspects of disease in children. Clin Liver Dis (Hoboken) 2017; 10:120-123. [PMID: 30992770 PMCID: PMC6467120 DOI: 10.1002/cld.672] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2017] [Revised: 09/11/2017] [Accepted: 09/24/2017] [Indexed: 02/04/2023] Open
Affiliation(s)
- Jillian M. Cotter
- Section of Hospital Medicine, Children's Hospital ColoradoUniversity of Colorado School of Medicine
| | - Cara L. Mack
- Section of Pediatric Gastroenterology, Hepatology and Nutrition, Children's Hospital ColoradoUniversity of Colorado School of Medicine, Digestive Health InstituteAuroraCO
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Rosenthal P, Cotter JM, Baum J. Treatment of persistent corneal epithelial defect with extended wear of a fluid-ventilated gas-permeable scleral contact lens. Am J Ophthalmol 2000; 130:33-41. [PMID: 11004257 DOI: 10.1016/s0002-9394(00)00379-2] [Citation(s) in RCA: 119] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE To report treatment of persistent corneal epithelial defects unresponsive to other therapies by extended wear of a fluid-ventilated gas-permeable scleral contact lens. METHODS In this retrospective study, 14 eyes of 13 consecutive patients referred for the treatment of persistent corneal epithelial defects that failed to heal with conventional therapies or developed epithelial defects after penetrating keratoplasty for persistent corneal epithelial defects were fitted with an extended-wear gas-permeable scleral lens. These included seven eyes of six patients with Stevens-Johnson syndrome and seven eyes of seven patients who did not have Stevens-Johnson syndrome. Twelve eyes had undergone recent penetrating keratoplasty. All 14 eyes were fitted with a gas-permeable scleral contact lens designed to avoid the intrusion of air bubbles under its optic. An antibiotic and corticosteroid were added to the lens fluid reservoir or instilled before each lens insertion in 12 of 14 eyes. The lenses were worn continuously except for brief periods of removal for purposes of cleaning, replacement of the lens fluid reservoir, and examination and photography of the cornea. RESULTS Five of the seven persistent corneal epithelial defects associated with Stevens-Johnson syndrome healed. The persistent corneal epithelial defects of four of these eyes re-epithelialized within 7 days, and a fifth healed in 27 days of gas-permeable scleral lens extended wear. A sixth persistent corneal epithelial defect that failed to heal initially re-epithelialized after a subsequent penetrating keratoplasty and gas-permeable scleral lens extended wear. The seventh eye healed after 3 days of gas-permeable scleral lens extended wear, but the persistent corneal epithelial defect subsequently recurred. Three of seven non-Stevens-Johnson syndrome persistent corneal epithelial defects re-epithelialized within 36 hours, 6 days, and 36 days, respectively. Of the six (six of 14) persistent corneal epithelial defects that failed to heal with a gas-permeable scleral lens extended wear, one subsequently healed after multiple amniotic membrane grafts. Microbial keratitis occurred in four eyes (four of 14) and graft failure in one eye, all of which required repeat penetrating keratoplasty. CONCLUSION Extended wear of an appropriately designed gas-permeable scleral contact lens was effective in promoting the healing of persistent corneal epithelial defects in some eyes that failed to heal after other therapeutic measures. Re-epithelialization appears to be aided by a combination of oxygenation, moisture, and protection of the fragile epithelium afforded by the scleral lens. However, microbial keratitis represents a significant risk.
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Affiliation(s)
- P Rosenthal
- The Boston Foundation for Sight (Drs Rosenthal and Cotter), Boston, Massachusetts 02467, USA.
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Cotter JM, Rosenthal P. Scleral contact lenses. J Am Optom Assoc 1998; 69:33-40. [PMID: 9479934] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Scleral contact lenses provide unique therapeutic and vision rehabilitative properties that overcome the therapeutic gaps encountered with conventional contact lens therapies. CASE REPORTS Four case reports are presented in which serious visual impairment was remediated with the application of scleral contact lenses: kerataconus, Terriens marginal degeneration, penetrating keratoplasty from Fuchs' dystrophy, and Stevens-Johnson syndrome. CONCLUSION The availability of new and diverse materials--in particular, the use of highly oxygen-permeable materials for scleral contact lenses--has allowed reevaluation of the clinical role of scleral lenses in the management of irregular corneal surface disorders and ocular surface disease.
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Affiliation(s)
- J M Cotter
- Boston Foundation for Sight, Massachusetts, USA
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Rosenthal P, Cotter JM. Surgical reconstruction of the ocular surface in advanced ocular cicatricial pemphigoid and Stevens-Johnson syndrome. Am J Ophthalmol 1996; 122:914-5. [PMID: 8956662 DOI: 10.1016/s0002-9394(14)70405-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
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Rosenthal P, Cotter JM. Clinical performance of a spline-based apical vaulting keratoconus corneal contact lens design. CLAO J 1995; 21:42-6. [PMID: 7712606] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
We refit 68 eyes with keratoconus and recurring contact lens induced apical corneal erosions with rigid corneal contact lenses having computer-generated spline curves. This junctionless design incorporates two independently configurable fitting zones on the back surface of the lenses that enable them to fit most keratoconus eyes with an apical vault rather than the traditional two or three point touch. Apical staining was eliminated in 49 eyes (72%), significantly reduced in 13 eyes (19%), and remained unchanged in six eyes (9%). Corneal abrasion related symptoms of contact lens wear intolerance resolved in 41 of 43 eyes.
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Gonzalez de Chavez C, Fernandez-Robayna F, Ojeda M, Cotter JM, Saavedra JA, Zerolo JM, Parache J. [Urodynamic and clinical examinations, following extended abdominal hysterectomy (author's transl)]. Zentralbl Gynakol 1980; 102:862-866. [PMID: 7456884] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/21/2023]
Abstract
Changes relating to the clinical conditions and urinary mechanics of 32 patients were studied after radical abdominal hysterectomy (Wertheim-Meigs). Clinical and urodynamic factors (urethral and vesical factors) were also evaluated.
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