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Pediatric Hospital Medicine Top 10 Articles

Pediatric Hospital Medicine Top 10 Articles. Elena Aragona Jamie Librizzi. Objectives. Summarize important evidence-based literature relating to pediatric hospital medicine Appraise key PHM articles as they relate to clinical practice. Apparent Life-Threatening Events. Patient 1:

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Pediatric Hospital Medicine Top 10 Articles

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  1. Pediatric Hospital MedicineTop 10 Articles Elena Aragona Jamie Librizzi

  2. Objectives • Summarize important evidence-based literature relating to pediatric hospital medicine • Appraise key PHM articles as they relate to clinical practice

  3. Apparent Life-Threatening Events • Patient 1: 5 month old female p/w ALTE • Difficulty catching breath • Face turned red • Lasted ~10 seconds • 15min after feed • Patient 2: Ex 34 wk 2mo M p/w ALTE • Hx ALTE 2 wks ago • Went limp for ~30 seconds • Not associated with feed

  4. P: In infants presenting with ALTEI/C: are there any factorsO: that increase risk of subsequent event?

  5. Management of Apparent Life-Threatening Events in Infants: A Systematic Review • Objective: lit review to determine • Hx and PE features that suggest inc risk of future adverse event and/or serious dx • What testing is indicated • Methods: • Pertinent articles identified and critically appraised • 1970-2011 • ALTE in children <24mo • Results: • 37 studies identified • 14 investigated history/PE features • 31 evaluated diagnostic testing • All studies observational; none well suited to define w/u or determine prognosis…

  6. Management of Apparent Life-Threatening Events in Infants: A Systematic Review • Results: • Features associated with future adverse event and/or serious underlying diagnosis • Prematurity • Multiple ALTE • Suspected child abuse • Little evidence to support routine testing of all patients without these risk factors

  7. Meningitis • ED calls re: 6yo M with fever & headache found to have CSF pleocytosis, would like to admit on IV abx for bacterial meningitis r/o

  8. P: In children presenting pleocytosisI/C: Is there a clinical score to identify children with high risk forO: Bacterial Meningitis

  9. JAMA

  10. Clinical Prediction Rule for Identifying Children with CSF Pleocytosis at Very Low Risk of Bacterial Meningitis • Objective: • To validate clinical prediction rule (Bacterial Meningitis Score) • Methods: • Review records of children with meningitis evaluated in ED of 20 academic medical centers over 4 years • Inclusion: 29d – 19yo with ICD9 diagnosis of meningitis • Exclusion: • Critical illness, purpura, VP shunt, recent neurosurgery, immunosuppression, other bacterial infection requiring inptabx, active lyme disease, pts with abx within 72h of LP • Bacterial meningitis: + CSF culture OR CSF pleocytosis with + BCxOR CSF pleocytosis with + CSF latex agllutination test for bacteria • N = 2903 (met inclusion criteria, data available)

  11. Clinical Prediction Rule for Identifying Children with CSF Pleocytosis at Very Low Risk of Bacterial Meningitis • Results: • 1714 low risk patients • 2 had bacterial meningitis (infants 1-2mo w E Coli meningitis and UTI; neg UA at presentation) • NPV: 99.9%, (95% CI 99.6%-100%) • 1189 not low risk • 119 (10%) had bacterial meningitis • >/= 1 risk factor • Sensitivity 98.3% (95% CI 94.2%-99.8%) • Specificity 61.5% (95% CI 59.7%-63.3% • Use caution when applying to infants <2mo • In patients >2mo, >/=1 risk factor had sensitivity 100% • Pts <2mo, >/=1 risk factor had sensitivity 92.3%

  12. Blood Cultures • 20mo M with L thigh cellulitis • Failed outpt therapy; plan to admit on clindamycin • Blood culture?

  13. P: In patients with asthma, bronchiolitis, pneumonia, SSTII: does obtaining blood cultureC: versus no blood cultureO: affect outcomes?

  14. Do We Need This Blood Culture? Kavita Parikh, Aisha Barber Davis, Padmaja Pavuluri Hospital Pediatrics 2014; 4; 78 DOI: 10.1542/hpeds.2013-0053

  15. Do We Need This Blood Culture? • Objective: • To assess BCx rates & results for 4 leading pediatric diagnoses in low-risk patients • Methods: • Retrospective cohort • Review records over 1 y at CNMC • Inclusion: 6mo – 18yo with bronchiolitis, asthma, SSTI, CAP • Exclusion: complex pts • N = 5159 (1629 inpt, 3530 outpt/ED)

  16. Do We Need This Blood Culture? • Results: • BCx in 343 pts: • 21% of inpts, 3% of ED/outpts • 4% in asthma • 15% in bronchiolitis • 36% in pna • 46% in SSTI • BCx results • Asthma – all neg • Bronchiolitis – all neg • SSTI – 98% neg or contaminant • 2 MRSA, 1 GAS • CAP – 99% neg or contaminant • 1 strep pneumo, 1 moraxella • BCx • Longer LOS in asthma, bronchiolitis • If + (n=5), no change in management • Some got rptBCx though • ~$100,000 microbiology costs at our institution

  17. SBI Rule Out in Infant • 3 wk M with fever • Well appearing, labs reassuring • Admitted on IV antibiotics

  18. P: Neonates <1 mo admitted w/fever for IV antibiotics I: Discharge at 36hC: Discharge at 48 hourO: No missed/untreated SBI

  19. Time to Detection of Bacterial Cultures in Infants Aged 0-90 days Rianna C. Evans and Brian Fine Hospital Pediatrics 2013;3;97 DOI: 10.152/hpeds.2012-0025

  20. Time to Detection of Bacterial Cultures in Infants Aged 0-90 days • Objective: determine if bacterial cultures in infants <90d would grow pathogenic bacteria in <36h • Methods • Retrospective Chart Review over 3.5y @ single institution • Infants 0 to 90 d evaluated in ED or inpt for SBI • Excluded: indwelling catheters, ‘sick’, rpt cx • Data Collection • Manual chart review of all blood, urine, CSF cultures • True + vs. contaminant - Determined based on tx

  21. Time to Detection of Bacterial Cultures in Infants Aged 0-90 days • CNMC: • BCx: checked q10min, alarm if +  gram stain, team called • First subsequent read at 16-18 hours, then q24h • CSF cultures • Goal gram stain within 1 hour • First time to check culture: 16-18 hours, then q24h • Urine cultures • First read at 16-18 hours, then daily • Can call at night and ask someone to check if still neg

  22. Time to Detection of Bacterial Cultures in Infants Aged 0-90 days • Results • 2092 blood cultures; 101/115 + blood cultures included in analysis • 97% true pathogen (n=38) Bcx grew in 36h • 2283 urine cultures; 192/232 + urine cultures included in analysis • 95% true pathogen (n=111) Ucxgrew in 36h • 1159 csf cultures; all 14+ included in analysis • 86% true pathogen (n=7) CSFcx grew in 36h

  23. UTI Length of Treatment in Infant • 3mo F with fever found to have UTI • Admitted on Ceftriaxone

  24. P: Infants admitted with UTII: Transition to oral antibiotics after 3dC: versus longer IV therapyO: Treatment failure

  25. Length of Intravenous Antibiotic Therapy and Treatment Failure in Infants with Urinary Tract Infections Patrick W. Brady, Patrick J. Conway and Anthony Goudie Pediatrics 2010; 126; 196 DOI: 10.1542/peds.2009-2948

  26. Length of IV Abx Therapy in Infants with UTI • Objective: • To assess short (<=3d) v long (>=4d) IV abx therapy and treatment failure in infants <6mo admitted with UTI • Treatment failure = readmit within 30d • Methods: • Retrospective cohort, infants <6mo admitted to 24 children's hospitals over 5y with UTI or pyelo (PHIS) • Excluded kids w complex conditions

  27. Length of IV Abx Therapy in Infants with UTI • Results: 12,333 kids met inclusion criteria • Male gender, neonatal status, black, Hispanic, non-private insurance, known bacteremia, GU abnormality – inc likelihood of receiving IV abx

  28. Length of IV Abx Therapy in Infants with UTI • Results • Treatment failure overall: 1.9% • 1.6% in short-course, 2.2% in long-course • Ie maybe sicker pts got long iv abxs and more likely to fail • Outcome by pt characteristic and length of IV abx • ie gender, age by 1month intervals, race, bacteremia, GU abnormality) • Only GU abnormality and severity of illness associated w treatment failure • Multivariate adjustment (addressed confounders ie severity of illness) – no association between treatment group and outcome

  29. Osteomyelitis • 10y male admitted for fever, L foot pain • MRI confirmed evidence of osteomyelitis • Patient started on Clinda IV

  30. P: In patients with osteomyelitis does I: Early transition to PO Abx C: Versus prolonged IV therapy O: Affect clinical outcomes?

  31. Prolonged Intravenous Therapy Versus Early Transition to Oral Antimicrobial Therapy for Acute Osteomyelitis in Children TheoklisZaoutis, et al. Pediatrics 2009; 123;636 DOI: 10.15442/peds.2008-0596

  32. Prolonged Intravenous Therapy Versus Early Transition to Oral Antimicrobial Therapy for Acute Osteomyelitis in Children TheoklisZaoutis, et al. Pediatrics 2009; 123;636 DOI: 10.15442/peds.2008-0596

  33. Prolonged IV Therapy Versus Early Transition to PO for Osteomyelitis • Objective: Compare the effectiveness of early transition from IV to PO for acute, uncomplicated osteo • Methods: Retrospective cohort study (PHIS) • Children aged 2m-17y dx with osteo between 2000-2005 at 29 free-standing children’s hospitals • Results: • 1o outcome: Tx failure (readmission w/in 6m) • 2o outcome: Readmit w/in 6m for line complication, adverse drug rxn, C. Diff, agranulocytosis

  34. Prolonged IV Therapy Versus Early Transition to PO for Osteomyelitis Results: 1021 prolonged IV, 948 PO • Overall readmission rate significantly higher in prolonged IV group (10% vs 6%, p= 0.017) • 1o outcome • 5% for prolonged IV group; 4% PO group • No significant association btw Tx failure and mode Abx therapy • 2o outcome • Prolonged IV therapy group more likely to experience Tx-related complication • 3% readmitted for catheter complications, 1.6% for Abx complications (vs 0.4% in PO group, p= 0.005)

  35. GERD • 2m FT male admitted for persistent emesis with feeds associated with back arching, fussiness • Pt growing appropriately • Work-up only reveals reflux

  36. GERD • 2m FT male admitted for persistent emesis with feeds associated with back arching, fussiness • Pt growing appropriately • Work-up only reveals reflux

  37. Are there risks associated with empiric acid suppression treatment of infants and children suspected of having GERD Erica Y. Chung and Jeremy Yardley Hospital Pediatrics 2013;3;16 DOI: 10.1542/hpeds.2012-0077

  38. Are there risks associated with acid suppression therapy? • Objective: Evaluate the potential serious adverse effects associated with acid suppressive meds in the pediatric population • Methods: PubMed search • Ages 0-18y; placebo-controlled or comparisons with a nonacid suppression arm • Results: 14 studies included • NICU, PICU, non-critical care

  39. Are there risks associated with acid suppression therapy? Results • NICU • Increased risk NEC, sepsis/bacteremia • PICU • Mixed results on VAP • Non-critical care • Increased rate PNA, LRTI, gastroenteritis • Associated with C. Diff associated disease

  40. Bronchiolitis • 6wk female admitted with URI symptoms, increased WOB and fever found to be RSV+ • Should she be evaluated for SBI?

  41. P: In infants with bronchiolitis I: Is testing for serious bacterial infection C: Compared to not testing O: Indicated?

  42. Risk of serious bacterial infection in young febrile infants with RSV infections Levine D, et al. Pediatrics 2004; 113;1728-1734 DOI: 10.1542/peds.113.6.1662

  43. Serious Bacterial Infections in Infants with RSV • Methods: Multi-center prospective, cross-sectional study (1998-2001) • All febrile infants, aged 0-60d undergoing SBI eval • RSV testing by antigen detection from NP swabs • Results • 1248 enrolled (22% tested + RSV) • Overall SBI rate 11.4% (0.7% meningitis, 2% bacteremia, 9.1% UTI) • RSV+ infants less likely to have SBI (7% vs 12.5%; RR 0.6)

  44. Table 3. SBI by RSV Status

  45. Serious Bacterial Infections in Infants with RSV Results: Age-stratified • <28d: Overall rate of SBI did not differ significantly btw those who were RSV+ and RSV- (10.1% vs 14.2%, RR 0.71, 95% CI 0.35-1.5) • 29-60d: Overall rate of SBI was 5.5% (no bacteremia or meningitis) with statistically significant difference between RSV+ and RSV- (5.5% vs 11.7%, RR 0.47, 85% CI 0.24-0.91)

  46. HSV • 20d male presenting with fever and irritability • No maternal history of HSV • Full SBI evaluation initiated • Should HSV and empiric Acyclovir be done?

  47. P: In infants presenting for evaluation I/C: What history/PE/labs are associated O: With HSV infection

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