BackgroundUnderlying comorbidities are common in children with pneumonia.ObjectiveTo determine as... more BackgroundUnderlying comorbidities are common in children with pneumonia.ObjectiveTo determine associations between comorbidity‐related functional limitations and risk for severe pneumonia outcomes.Design, Setting, and ParticipantsWe prospectively enrolled children <18 years with and without comorbidities presenting to the emergency department with clinical and radiographic pneumonia at two institutions. Comorbidities included chronic conditions requiring daily medications, frequent healthcare visits, or which limited age‐appropriate activities. Among children with comorbidities, functional limitations were defined as none or mild, moderate, and severe.Main Outcomes and MeasuresOutcomes included an ordinal severity outcome, categorized as very severe (mechanical ventilation, shock, or death), severe (intensive care without very severe features), moderate (hospitalization without severe features), or mild (discharged home), and length of stay (LOS). Multivariable ordinal logistic regression was used to examine associations between comorbidity‐related functional limitations and outcomes, while accounting for relevant covariates.ResultsA cohort of 1116 children, including 452 (40.5%) with comorbidities; 200 (44.2%) had none or mild functional limitations, 93 (20.6%) moderate, and 159 (35.2%) had severe limitations. In multivariable analysis, comorbidity‐related functional limitations were associated with the ordinal severity outcome and LOS (p < .001 for both). Children with severe functional limitations had tripling of the odds of a more severe ordinal (adjusted odds ratio [aOR]: 3.01, 95% confidence interval [2.05, 4.43]) and quadrupling of the odds for longer LOS (aOR: 4.72 [3.33, 6.70]) as compared to children without comorbidities.ConclusionComorbidity‐related functional limitations are important predictors of disease outcomes in children with pneumonia. Consideration of functional limitations, rather than the presence of comorbidity alone, is critical when assessing risk of severe outcomes.
BACKGROUND AND OBJECTIVES No standardized risk assessment tool exists for community-acquired pneu... more BACKGROUND AND OBJECTIVES No standardized risk assessment tool exists for community-acquired pneumonia (CAP) in children. This study aims to investigate the association between red blood cell distribution width (RDW) and pediatric CAP. Methods Data prospectively collected by the Etiology of Pneumonia in the Community study (2010–2012) was used. Study population was pediatric patients admitted to tertiary care hospitals in Nashville and Memphis, Tennessee with clinically and radiographically confirmed CAP. The earliest measured RDW value on admission was used, in quintiles and also as a continuous variable. Outcomes analyzed were: severe CAP (requiring ICU, mechanical ventilation, vasopressor support, or death) or moderate CAP (hospital admission only). Analysis used multivariable logistic regression and restricted cubic splines modeling. RESULTS In 1459 eligible children, the median age was 29 months (interquartile range: 12–73), median RDW was 13.3% (interquartile range: 12.5–14.3), and 289 patients (19.8%) developed severe disease. In comparison with the lowest RDW quintile (Q1), the adjusted odds ratio (95% CI) for severe CAP in subsequent quintiles were, Q2: 1.20 (0.72–1.99); Q3: 1.28 (0.76–2.14); Q4: 1.69 (1.01–2.82); Q5: 1.25 (0.73–2.13). Consistently, RDW restricted cubic splines demonstrated an independent, nonlinear, positive association with CAP severity (P = .027), with rapid increases in the risk of severe CAP with RDW values up to 15%. CONCLUSIONS Higher presenting RDW was associated with an increased risk of severe CAP in hospitalized children. Widely available and inexpensive, RDW can serve as an objective data point to help with clinical assessments.
Background: The Intermountain Cystic Fibrosis Pediatric Center utilizes ticarcillin–clavulanate 4... more Background: The Intermountain Cystic Fibrosis Pediatric Center utilizes ticarcillin–clavulanate 400 mg/kg/day divided every 6 h, (maximum 24 g/day). This dosing strategy is higher than the Cystic Fibrosis Foundation (CFF) recommendations and the Food and Drug Administration (FDA) approved package labeling. The purpose is to determine the safety of this dosing regimen. Methods: A retrospective study of pediatric cystic fibrosis (CF) patients admitted from January 1, 2005 to December 31, 2009 who received the dosing regimen for at least 7 days. Baseline and follow-up laboratory parameters were recorded. Statistical analysis was performed. Results: 127 patients met inclusion criteria. The mean (±SD) ticarcillin dose was 3.5 g (±2.16) every 6 h; while the mean (±SD) total ticarcillin dose was 13.5 g (±6.5) per day. No significant differences occurred in liver function tests, white blood count, and platelet count from baseline. Serum creatinine showed a statistically significant decrease from baseline. Conclusions: Higher than FDA approved doses of ticarcillin–clavulanate may be safely used in the treatment of exacerbations in pediatric cystic fibrosis patients.
BackgroundElectronic health record‐based clinical decision support (CDS) is a promising antibioti... more BackgroundElectronic health record‐based clinical decision support (CDS) is a promising antibiotic stewardship strategy. Few studies have evaluated the effectiveness of antibiotic CDS in the pediatric emergency department (ED).ObjectiveTo compare the effectiveness of antibiotic CDS vs. usual care for promoting guideline‐concordant antibiotic prescribing for pneumonia in the pediatric ED.DesignPragmatic randomized clinical trial.Setting and ParticipantsEncounters for children (6 months‐18 years) with pneumonia presenting to two tertiary care children s hospital EDs in the United States.InterventionCDS or usual care was randomly assigned during 4‐week periods within each site. The CDS intervention provided antibiotic recommendations tailored to each encounter and in accordance with national guidelines.Main Outcome and MeasuresThe primary outcome was exclusive guideline‐concordant antibiotic prescribing within the first 24 h of care. Safety outcomes included time to first antibiotic order, encounter length of stay, delayed intensive care, and 3‐ and 7‐day revisits.Results1027 encounters were included, encompassing 478 randomized to usual care and 549 to CDS. Exclusive guideline‐concordant prescribing did not differ at 24 h (CDS, 51.7% vs. usual care, 53.3%; odds ratio [OR] 0.94 [95% confidence interval [CI]: 0.73, 1.20]). In pre‐specified stratified analyses, CDS was associated with guideline‐concordant prescribing among encounters discharged from the ED (74.9% vs. 66.0%; OR 1.53 [95% CI: 1.01, 2.33]), but not among hospitalized encounters. Mean time to first antibiotic was shorter in the CDS group (3.0 vs 3.4 h; p = .024). There were no differences in safety outcomes.ConclusionsEffectiveness of ED‐based antibiotic CDS was greatest among those discharged from the ED. Longitudinal interventions designed to target both ED and inpatient clinicians and to address common implementation challenges may enhance the effectiveness of CDS as a stewardship tool.
BackgroundUnderlying comorbidities are common in children with pneumonia.ObjectiveTo determine as... more BackgroundUnderlying comorbidities are common in children with pneumonia.ObjectiveTo determine associations between comorbidity‐related functional limitations and risk for severe pneumonia outcomes.Design, Setting, and ParticipantsWe prospectively enrolled children <18 years with and without comorbidities presenting to the emergency department with clinical and radiographic pneumonia at two institutions. Comorbidities included chronic conditions requiring daily medications, frequent healthcare visits, or which limited age‐appropriate activities. Among children with comorbidities, functional limitations were defined as none or mild, moderate, and severe.Main Outcomes and MeasuresOutcomes included an ordinal severity outcome, categorized as very severe (mechanical ventilation, shock, or death), severe (intensive care without very severe features), moderate (hospitalization without severe features), or mild (discharged home), and length of stay (LOS). Multivariable ordinal logistic regression was used to examine associations between comorbidity‐related functional limitations and outcomes, while accounting for relevant covariates.ResultsA cohort of 1116 children, including 452 (40.5%) with comorbidities; 200 (44.2%) had none or mild functional limitations, 93 (20.6%) moderate, and 159 (35.2%) had severe limitations. In multivariable analysis, comorbidity‐related functional limitations were associated with the ordinal severity outcome and LOS (p < .001 for both). Children with severe functional limitations had tripling of the odds of a more severe ordinal (adjusted odds ratio [aOR]: 3.01, 95% confidence interval [2.05, 4.43]) and quadrupling of the odds for longer LOS (aOR: 4.72 [3.33, 6.70]) as compared to children without comorbidities.ConclusionComorbidity‐related functional limitations are important predictors of disease outcomes in children with pneumonia. Consideration of functional limitations, rather than the presence of comorbidity alone, is critical when assessing risk of severe outcomes.
BACKGROUND AND OBJECTIVES No standardized risk assessment tool exists for community-acquired pneu... more BACKGROUND AND OBJECTIVES No standardized risk assessment tool exists for community-acquired pneumonia (CAP) in children. This study aims to investigate the association between red blood cell distribution width (RDW) and pediatric CAP. Methods Data prospectively collected by the Etiology of Pneumonia in the Community study (2010–2012) was used. Study population was pediatric patients admitted to tertiary care hospitals in Nashville and Memphis, Tennessee with clinically and radiographically confirmed CAP. The earliest measured RDW value on admission was used, in quintiles and also as a continuous variable. Outcomes analyzed were: severe CAP (requiring ICU, mechanical ventilation, vasopressor support, or death) or moderate CAP (hospital admission only). Analysis used multivariable logistic regression and restricted cubic splines modeling. RESULTS In 1459 eligible children, the median age was 29 months (interquartile range: 12–73), median RDW was 13.3% (interquartile range: 12.5–14.3), and 289 patients (19.8%) developed severe disease. In comparison with the lowest RDW quintile (Q1), the adjusted odds ratio (95% CI) for severe CAP in subsequent quintiles were, Q2: 1.20 (0.72–1.99); Q3: 1.28 (0.76–2.14); Q4: 1.69 (1.01–2.82); Q5: 1.25 (0.73–2.13). Consistently, RDW restricted cubic splines demonstrated an independent, nonlinear, positive association with CAP severity (P = .027), with rapid increases in the risk of severe CAP with RDW values up to 15%. CONCLUSIONS Higher presenting RDW was associated with an increased risk of severe CAP in hospitalized children. Widely available and inexpensive, RDW can serve as an objective data point to help with clinical assessments.
Background: The Intermountain Cystic Fibrosis Pediatric Center utilizes ticarcillin–clavulanate 4... more Background: The Intermountain Cystic Fibrosis Pediatric Center utilizes ticarcillin–clavulanate 400 mg/kg/day divided every 6 h, (maximum 24 g/day). This dosing strategy is higher than the Cystic Fibrosis Foundation (CFF) recommendations and the Food and Drug Administration (FDA) approved package labeling. The purpose is to determine the safety of this dosing regimen. Methods: A retrospective study of pediatric cystic fibrosis (CF) patients admitted from January 1, 2005 to December 31, 2009 who received the dosing regimen for at least 7 days. Baseline and follow-up laboratory parameters were recorded. Statistical analysis was performed. Results: 127 patients met inclusion criteria. The mean (±SD) ticarcillin dose was 3.5 g (±2.16) every 6 h; while the mean (±SD) total ticarcillin dose was 13.5 g (±6.5) per day. No significant differences occurred in liver function tests, white blood count, and platelet count from baseline. Serum creatinine showed a statistically significant decrease from baseline. Conclusions: Higher than FDA approved doses of ticarcillin–clavulanate may be safely used in the treatment of exacerbations in pediatric cystic fibrosis patients.
BackgroundElectronic health record‐based clinical decision support (CDS) is a promising antibioti... more BackgroundElectronic health record‐based clinical decision support (CDS) is a promising antibiotic stewardship strategy. Few studies have evaluated the effectiveness of antibiotic CDS in the pediatric emergency department (ED).ObjectiveTo compare the effectiveness of antibiotic CDS vs. usual care for promoting guideline‐concordant antibiotic prescribing for pneumonia in the pediatric ED.DesignPragmatic randomized clinical trial.Setting and ParticipantsEncounters for children (6 months‐18 years) with pneumonia presenting to two tertiary care children s hospital EDs in the United States.InterventionCDS or usual care was randomly assigned during 4‐week periods within each site. The CDS intervention provided antibiotic recommendations tailored to each encounter and in accordance with national guidelines.Main Outcome and MeasuresThe primary outcome was exclusive guideline‐concordant antibiotic prescribing within the first 24 h of care. Safety outcomes included time to first antibiotic order, encounter length of stay, delayed intensive care, and 3‐ and 7‐day revisits.Results1027 encounters were included, encompassing 478 randomized to usual care and 549 to CDS. Exclusive guideline‐concordant prescribing did not differ at 24 h (CDS, 51.7% vs. usual care, 53.3%; odds ratio [OR] 0.94 [95% confidence interval [CI]: 0.73, 1.20]). In pre‐specified stratified analyses, CDS was associated with guideline‐concordant prescribing among encounters discharged from the ED (74.9% vs. 66.0%; OR 1.53 [95% CI: 1.01, 2.33]), but not among hospitalized encounters. Mean time to first antibiotic was shorter in the CDS group (3.0 vs 3.4 h; p = .024). There were no differences in safety outcomes.ConclusionsEffectiveness of ED‐based antibiotic CDS was greatest among those discharged from the ED. Longitudinal interventions designed to target both ED and inpatient clinicians and to address common implementation challenges may enhance the effectiveness of CDS as a stewardship tool.
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