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Can We Simplify the Management of Complicated Pneumonia in Children?

Can We Simplify the Management of Complicated Pneumonia in Children?. Samir S. Shah, MD, MSCE. Divisions of Infectious Diseases and General Pediatrics The Children’s Hospital of Philadelphia Departments of Pediatrics and Biostatistics and Epidemiology

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Can We Simplify the Management of Complicated Pneumonia in Children?

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  1. Can We Simplify the Management of Complicated Pneumonia in Children? Samir S. Shah, MD, MSCE Divisions of Infectious Diseases and General Pediatrics The Children’s Hospital of Philadelphia Departments of Pediatrics and Biostatistics and Epidemiology University of Pennsylvania School of Medicine

  2. Objectives • Explore the use of administrative data to clarify the • changing epidemiology of pneumonia and complicated pneumonia • role of operative vs. non-operative interventions in the management of children with complicated pneumonia

  3. Background: Pneumonia • Community-acquired pneumonia (CAP) is a common serious bacterial infection in children • >600,000 hospitalizations in the U.S. each year • Up to one-third of children hospitalized with CAP have a pleural effusion (complicated pneumonia)

  4. What do we mean by the term complicated pneumonia?

  5. Case • 3-year-old boy with cough and fever • Evaluated 2 weeks ago • Diagnosed with asthma and clinical pneumonia • Treated with albuterol and amoxicillin • Returns with continued cough and fevers to 39.2°C

  6. Case: Chest X-ray

  7. Case: Chest CT

  8. Changing Epidemiology of Invasive Pneumococcal Disease • Licensure of a 7-valent pneumococcal conjugate vaccine in 2000 • Decrease in invasive pneumococcal infections • Subsequent increase in the rate of infections caused by • penicillin-resistant S. pneumoniae • serotypes not included in the current vaccine • Increasing prevalence of infections caused by methicillin-resistant S. aureus

  9. National Hospital Discharges(all ages) ■= Bacteremia of any etiology ▲= Pneumococcal bacteremia Shah SS, et al. Clin Infect Dis 2006;42:e1-5

  10. Pneumococcal Bacteremia By Serotype Category ♦=vaccine serotype ■=vaccine-related serotype ○=non-vaccine serotype Steenhoff A, Shah SS, et al. Clin Infect Dis 2006;42:907-914

  11. Invasive Disease Caused by Penicillin-Susceptible and Non-susceptible Pneumococci (ages <2) Kyaw MH, et al N Engl J Med 2006;354:1455-1463

  12. What does this have to do with pneumonia?

  13. Have rates of pneumonia or complicated pneumonia changed over time?

  14. Datasource: National Hospital Discharge Survey (NHDS) • Created by the National Center for Health Statistics • Includes only non-federal US hospitals • All hospitals with >1,000 beds • Representative sample of others based on location, size & specialty • Includes ~500 hospitals & 250,000 discharges each year • Weighting of records by hospital size/region allows for calculation of nationally representative estimates

  15. Eligibility • Inclusion • Ages 1-18 years • Discharged 1993-2006 • Diagnosis of community-acquired pneumonia • Exclusion • Age <1 to eliminate bronchiolitis • Known underlying predisposition to pneumonia (e.g., malignancy, HIV, cystic fibrosis)

  16. Definitions of Pneumonia • Community-acquired pneumonia (CAP) • Pneumonia as 1°diagnosis OR • Pneumonia-related symptom as 1° diagnosis (e.g., cough) & pneumonia as 2° diagnosis OR • Empyema or pleurisy as 1° diagnosis and pneumonia as 2° diagnosis • Sensitivity of 89% and specificity of 80% compared with medical record review Whittle J, et al. Am J Med Qual 1997;12:187-193

  17. Definitions of Complications Abbreviations: HUS, hemolytic-uremic syndrome; SIRS, systemic inflammatory response syndrome

  18. Challenges • Accuracy of ICD-9 codes to identify conditions of interest • Does our definition exclude the sickest patients? • Change in ICD-9 codes over time (e.g., addition of 4th or 5th digits) • Review annual ICD-9 addendum • Complex survey statistics (i.e., sample weights) to calculate national estimates • May limit accuracy of data for subpopulations • Insufficient data in publicly available dataset to calculate standard errors for some subpopulations

  19. Regional Variation in Pediatric CAP Hospitalizations (Pennsylvania) Gorton CP, et al. Pediatrics 2006;117:176-180

  20. The epidemiology of pneumonia and complicated pneumonia is complex and changing

  21. Evolution of Empyema • Exudative • Neutrophil migration into pleural space • Fibrinopurulent • Fibrin deposition • Loculations impair lung expansion • Organizing • Fibroblast formation produces an inelastic membrane or “fibrinous peel”

  22. Management of Empyema • Radiologic assessment • CXR (upright & decubitus) • Ultrasound • CT scan

  23. Management of Empyema • Surgical options • Thoracentesis (needle aspiration) • Tube thoracostomy (+ fibrinolysis) • Video-assisted thoracoscopy* • Thoracotomy* *Require post-procedure thoracostomy tube

  24. Management of Empyema • No consensus on optimal initial drainage strategy • Technique? • Timing?

  25. Why use administrative data to study complicated pneumonia? • Sonnappa et al. • Kurt et al. • Avansino et al. • Li et al. • Shah et al.

  26. Sonnappa et al. • 1st randomized study of VATS vs. thoracostomy tube drainage • 60 patients enrolled from January 2002 to February 2005 • Groups similar in • Age & Sex • Preadmission symptoms • Effusion stage • Causative bacteria (mostly S. pneumoniae) Sonnappa S. Am J Respir Crit Care Med 20006;174:221-227

  27. Sonnappa et al. Kurt BA, et al. Pediatrics 2006;118:e547-e553

  28. Kurt et al. • 1st randomized study of VATS vs. thoracostomy tube drainage in U.S. • 18 patients enrolled from November 2003-May 2005 • Groups similar in • Age & sex • Preadmission symptoms & antibiotics • Effusion size • Presence of loculation Kurt BA, et al. Pediatrics 2006;118:e547-e553

  29. Kurt et al. Kurt BA, et al. Pediatrics 2006;118:e547-e553

  30. Key Differences • Differences • Kurt et al. used substantially larger chest tubes (16-24 Fr vs. 8-10 Fr) • Sonnappa et al. used more aggressive fibrinolysis • LOS presented as mean (Kurt) or median (Sonnappa) • Limitations • Single centers • Few patients

  31. Can a meta-analysis more address this issue more definitively?

  32. Avansino et al. • Systematic review of therapy for empyema (outcome data from 3781 children) Avansino JR. Pediatrics 2005;115:1652-1659

  33. Avansino et al. • In the pooled analysis, primary operative therapy reduced • LOS by 45% (199 patients, 4 studies) • Repeat procedures by 90% (492 patients, 9 studies) • Results biased towards favoring operative therapy • Non-operative group= needle thoracentesis or chest tube drainage Avansino JR, et al. Pediatrics 2005;115:1652-9

  34. Avansino et al. - Limitations • Poor study quality • No randomized studies performed at time of review • Inclusion only of small (all <70 patients) observational studies with heterogeneous study designs • Primary outcome of interest “therapeutic failure” not chosen a priori • Failure to adjust for confounding variables • Timing of intervention • Chemical fibrinolysis • Empiric antibiotic therapy

  35. Where do things stand? • Randomized studies • Small & single center • Multicenter studies difficult to conduct because prevailing personal & institutional dogmas • Pooled analyses • Few high quality studies • Administrative data • Seriously?

  36. Li et al. • 2003 Kids’ Inpatient Database • Inclusions • Age 0-18 years • ICD-9 codes for “empyema” (510.0 & 510.9) • Exclusions • Co-morbid illness • Transfer from another hospital Li ST. Arch Pediatr Adolesc Med 2008;162:44-48

  37. Li et al. • 1173 patients • Primary operative management (POM) vs. Non-operative management (NM) • POM= decortication within 2 days of admission • NM= everything else, including decortication 3 or more days after admission Li ST. Arch Pediatr Adolesc Med 2008;162:44-48

  38. Li et al. Li ST. Arch Pediatr Adolesc Med 2008;162:44-48

  39. Li et al. - Limitations • ICD-9 codes incomplete • Other codes that suggest effusion were not included • 511.1 – effusion, with mention of bacterial cause other than tuberculosis • 513.0 – abscess of lung • Diagnosis of pneumonia not required • Potential for inclusion of effusions not related to pneumonia (e.g., post-op) • NM group heterogeneous • For example, those drained early by chest tube may be different than those drained late by VATS and those never drained

  40. Shah et al. • Pediatric Health Information System (PHIS) • Inpatient data from 27 not-for-profit, tertiary care, U.S. children’s hospitals • Inclusions • Age 12 months to 18 years of age • Discharged between 2001-2005 • ICD-9 codes 510.0, 510,9, 511.1, or 513.0 as primary diagnosis plus pneumonia (480-486) • Pleural fluid drainage within 48 h of hospitalization • Exclusion • Co-morbid illness Shah SS. Arch Pediatr Adolesc Med 2008;162:675-681

  41. Shah et al. - PHIS Study Population Shah SS. Arch Pediatr Adolesc Med 2008;162:675-681

  42. Shah et al. - Initial Procedure Shah SS. Arch Pediatr Adolesc Med 2008;162:675-681

  43. Thoracotomy % OF P R O C E D U R E S VATS Chest Tube Hospital Shah et al. - Procedure Variation by Hospital

  44. MEDIAN LOS Hospital Shah et al. - Variation in LOS by Hospital* *7% of patients had a LOS >28 days

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