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Dexamethasone Potential Therapy for Asthma Exacerbations in Pediatric Inpatients
Clinical question: In children hospitalized in a non-ICU setting with asthma exacerbation, how effective is dexamethasone compared to prednisone/prednisolone?
Background: Asthma is the second most common reason for hospital admission in childhood.1 National guidelines recommend treatment with systemic corticosteroids in addition to beta-agonists.2 Traditionally, prednisone/prednisolone has been used for asthma exacerbations, but multiple recent studies in ED settings have shown equal efficacy with dexamethasone for mild to moderate exacerbations. Benefits of dexamethasone use include a longer half-life (so single dose or two-day courses can be used), good enteral absorption, general palatability, less emesis, and better adherence. To this point, no studies have compared dexamethasone with prednisone/prednisolone therapy in hospitalized children.
Study design: Multicenter, retrospective cohort study.
Setting: Freestanding, tertiary care children’s hospitals.
Synopsis: The authors used the PHIS (Pediatric Health Information System) database, which includes clinical and billing data from 42 children’s hospitals, to compare children who received dexamethasone to those who were treated with prednisone/prednisolone therapy for asthma exacerbations in the inpatient setting. Patients were included if they were aged four to 17 years, were hospitalized between January 2007 and December 2012 with ICD-9 code for a principal diagnosis of asthma, and received either dexamethasone or prednisone/prednisolone.
Exclusion criteria included:
- Management in the ICU at the time of admission;
- All patient refined diagnosis related groups (APR-DRG) severity level moderate or extreme;
- Complex chronic conditions;
- Secondary diagnosis other than asthma requiring steroids, or treatment with racemic epinephrine;
- Only the first admission was included out of multiple hospitalizations within a 30-day period; and/or
- Patient was treated with both dexamethasone and prednisone/prednisolone.
The primary outcome evaluated was length of stay (LOS); secondary outcomes included readmissions, cost, and transfer to ICU during hospitalization. The authors compared the overall groups, then performed 1:1 propensity score matching to address residual confounding; this statistical technique closely matches patient characteristics between cohorts.
Overall, there were 40,257 hospitalizations, with 1,166 children (2.9%) receiving dexamethasone and 39,091 (97.1%) receiving prednisone/prednisolone. The use of dexamethasone varied greatly between hospitals (35/42 hospitals used dexamethasone, with rates ranging from 0.047% to 77.4%).
In the post-match cohort, 1,284 patients were evaluated, 642 in each group. In this cohort, patients with dexamethasone had significantly shorter LOS (67.4% had LOS less than one day vs. 59.5% in the prednisone/prednisolone group; 6.7% of dexamethasone patients had LOS of more than three days vs. 12% of prednisone/prednisolone patients). Costs were lower for the dexamethasone group, both for the index admission and for episode admission (defined as index admission plus seven-day readmissions). There was no difference in readmissions between the groups, and no patients in this cohort were transferred to the ICU.
There are several limitations to this study. Dexamethasone use varied widely among participating hospitals. The data source did not permit access to dosing, duration, or compliance with therapy and could not compare albuterol use between groups. The findings may not be generalizable to all populations, because it excluded patients with high severity and medical complexity and only evaluated tertiary care children’s hospitals.
Bottom line: Dexamethasone is a potential alternative therapy for asthma exacerbations in the inpatient setting. Further studies are needed to evaluate effectiveness, including dosing, frequency, and duration.
Citation: Parikh K, Hall M, Mittal V, et al. Comparative effectiveness of dexamethasone versus prednisone in children hospitalized with asthma. J Pediatr. 2015;167(3):639-644.
References
- Yu H, Wier LM, Elixhauser A. Hospital stays for children, 2009. HCUP statistical brief #118. Agency for Healthcare Research and Quality. August 2011. Accessed November 1, 2015.
- National Heart, Lung, and Blood Institute. National Asthma Education and Prevention Program expert panel report 3 (EPR-3): guidelines for the diagnosis and management of asthma–Summary Report 2007. Accessed November 1, 2015.
Clinical question: In children hospitalized in a non-ICU setting with asthma exacerbation, how effective is dexamethasone compared to prednisone/prednisolone?
Background: Asthma is the second most common reason for hospital admission in childhood.1 National guidelines recommend treatment with systemic corticosteroids in addition to beta-agonists.2 Traditionally, prednisone/prednisolone has been used for asthma exacerbations, but multiple recent studies in ED settings have shown equal efficacy with dexamethasone for mild to moderate exacerbations. Benefits of dexamethasone use include a longer half-life (so single dose or two-day courses can be used), good enteral absorption, general palatability, less emesis, and better adherence. To this point, no studies have compared dexamethasone with prednisone/prednisolone therapy in hospitalized children.
Study design: Multicenter, retrospective cohort study.
Setting: Freestanding, tertiary care children’s hospitals.
Synopsis: The authors used the PHIS (Pediatric Health Information System) database, which includes clinical and billing data from 42 children’s hospitals, to compare children who received dexamethasone to those who were treated with prednisone/prednisolone therapy for asthma exacerbations in the inpatient setting. Patients were included if they were aged four to 17 years, were hospitalized between January 2007 and December 2012 with ICD-9 code for a principal diagnosis of asthma, and received either dexamethasone or prednisone/prednisolone.
Exclusion criteria included:
- Management in the ICU at the time of admission;
- All patient refined diagnosis related groups (APR-DRG) severity level moderate or extreme;
- Complex chronic conditions;
- Secondary diagnosis other than asthma requiring steroids, or treatment with racemic epinephrine;
- Only the first admission was included out of multiple hospitalizations within a 30-day period; and/or
- Patient was treated with both dexamethasone and prednisone/prednisolone.
The primary outcome evaluated was length of stay (LOS); secondary outcomes included readmissions, cost, and transfer to ICU during hospitalization. The authors compared the overall groups, then performed 1:1 propensity score matching to address residual confounding; this statistical technique closely matches patient characteristics between cohorts.
Overall, there were 40,257 hospitalizations, with 1,166 children (2.9%) receiving dexamethasone and 39,091 (97.1%) receiving prednisone/prednisolone. The use of dexamethasone varied greatly between hospitals (35/42 hospitals used dexamethasone, with rates ranging from 0.047% to 77.4%).
In the post-match cohort, 1,284 patients were evaluated, 642 in each group. In this cohort, patients with dexamethasone had significantly shorter LOS (67.4% had LOS less than one day vs. 59.5% in the prednisone/prednisolone group; 6.7% of dexamethasone patients had LOS of more than three days vs. 12% of prednisone/prednisolone patients). Costs were lower for the dexamethasone group, both for the index admission and for episode admission (defined as index admission plus seven-day readmissions). There was no difference in readmissions between the groups, and no patients in this cohort were transferred to the ICU.
There are several limitations to this study. Dexamethasone use varied widely among participating hospitals. The data source did not permit access to dosing, duration, or compliance with therapy and could not compare albuterol use between groups. The findings may not be generalizable to all populations, because it excluded patients with high severity and medical complexity and only evaluated tertiary care children’s hospitals.
Bottom line: Dexamethasone is a potential alternative therapy for asthma exacerbations in the inpatient setting. Further studies are needed to evaluate effectiveness, including dosing, frequency, and duration.
Citation: Parikh K, Hall M, Mittal V, et al. Comparative effectiveness of dexamethasone versus prednisone in children hospitalized with asthma. J Pediatr. 2015;167(3):639-644.
References
- Yu H, Wier LM, Elixhauser A. Hospital stays for children, 2009. HCUP statistical brief #118. Agency for Healthcare Research and Quality. August 2011. Accessed November 1, 2015.
- National Heart, Lung, and Blood Institute. National Asthma Education and Prevention Program expert panel report 3 (EPR-3): guidelines for the diagnosis and management of asthma–Summary Report 2007. Accessed November 1, 2015.
Clinical question: In children hospitalized in a non-ICU setting with asthma exacerbation, how effective is dexamethasone compared to prednisone/prednisolone?
Background: Asthma is the second most common reason for hospital admission in childhood.1 National guidelines recommend treatment with systemic corticosteroids in addition to beta-agonists.2 Traditionally, prednisone/prednisolone has been used for asthma exacerbations, but multiple recent studies in ED settings have shown equal efficacy with dexamethasone for mild to moderate exacerbations. Benefits of dexamethasone use include a longer half-life (so single dose or two-day courses can be used), good enteral absorption, general palatability, less emesis, and better adherence. To this point, no studies have compared dexamethasone with prednisone/prednisolone therapy in hospitalized children.
Study design: Multicenter, retrospective cohort study.
Setting: Freestanding, tertiary care children’s hospitals.
Synopsis: The authors used the PHIS (Pediatric Health Information System) database, which includes clinical and billing data from 42 children’s hospitals, to compare children who received dexamethasone to those who were treated with prednisone/prednisolone therapy for asthma exacerbations in the inpatient setting. Patients were included if they were aged four to 17 years, were hospitalized between January 2007 and December 2012 with ICD-9 code for a principal diagnosis of asthma, and received either dexamethasone or prednisone/prednisolone.
Exclusion criteria included:
- Management in the ICU at the time of admission;
- All patient refined diagnosis related groups (APR-DRG) severity level moderate or extreme;
- Complex chronic conditions;
- Secondary diagnosis other than asthma requiring steroids, or treatment with racemic epinephrine;
- Only the first admission was included out of multiple hospitalizations within a 30-day period; and/or
- Patient was treated with both dexamethasone and prednisone/prednisolone.
The primary outcome evaluated was length of stay (LOS); secondary outcomes included readmissions, cost, and transfer to ICU during hospitalization. The authors compared the overall groups, then performed 1:1 propensity score matching to address residual confounding; this statistical technique closely matches patient characteristics between cohorts.
Overall, there were 40,257 hospitalizations, with 1,166 children (2.9%) receiving dexamethasone and 39,091 (97.1%) receiving prednisone/prednisolone. The use of dexamethasone varied greatly between hospitals (35/42 hospitals used dexamethasone, with rates ranging from 0.047% to 77.4%).
In the post-match cohort, 1,284 patients were evaluated, 642 in each group. In this cohort, patients with dexamethasone had significantly shorter LOS (67.4% had LOS less than one day vs. 59.5% in the prednisone/prednisolone group; 6.7% of dexamethasone patients had LOS of more than three days vs. 12% of prednisone/prednisolone patients). Costs were lower for the dexamethasone group, both for the index admission and for episode admission (defined as index admission plus seven-day readmissions). There was no difference in readmissions between the groups, and no patients in this cohort were transferred to the ICU.
There are several limitations to this study. Dexamethasone use varied widely among participating hospitals. The data source did not permit access to dosing, duration, or compliance with therapy and could not compare albuterol use between groups. The findings may not be generalizable to all populations, because it excluded patients with high severity and medical complexity and only evaluated tertiary care children’s hospitals.
Bottom line: Dexamethasone is a potential alternative therapy for asthma exacerbations in the inpatient setting. Further studies are needed to evaluate effectiveness, including dosing, frequency, and duration.
Citation: Parikh K, Hall M, Mittal V, et al. Comparative effectiveness of dexamethasone versus prednisone in children hospitalized with asthma. J Pediatr. 2015;167(3):639-644.
References
- Yu H, Wier LM, Elixhauser A. Hospital stays for children, 2009. HCUP statistical brief #118. Agency for Healthcare Research and Quality. August 2011. Accessed November 1, 2015.
- National Heart, Lung, and Blood Institute. National Asthma Education and Prevention Program expert panel report 3 (EPR-3): guidelines for the diagnosis and management of asthma–Summary Report 2007. Accessed November 1, 2015.
Urinalysis Is Reliable Infection Predictor in Infants
Clinical question: In infants younger than three months of age with bacteremic urinary tract infection (UTI), how sensitive and specific are urinalysis (UA) findings?
Background: Infants are commonly hospitalized with UTIs. The gold standard for diagnosis is considered to be urine culture. When compared to this gold standard, the sensitivity of UA findings for the diagnosis of UTI has been previously reported to be around 75% to 85%; however, a positive urine culture alone in the setting of negative UA may not be reflective of a UTI due to asymptomatic bacteriuria or contamination. The 2011 American Academy of Pediatrics clinical guideline for UTIs suggests that the diagnosis should require positive urine culture in addition to abnormal UA. These guidelines do not include infants younger than two months of age, and positive cultures in this age group are generally regarded as a UTI and treated as such. Positive culture results with the same organism in the urine and blood indicates very low likelihood of contamination or asymptomatic bacteriuria, and patients with bacteremic UTI are likely to have a true infection.
Study design: Multicenter, retrospective, cross-sectional study.
Setting: Twenty hospitals in eleven hospital systems.
Synopsis: Researchers used a multicenter microbiology database to identify infants younger than three months of age with bacteremic UTI (same pathogenic organism in blood and urine). Data was collected on UA, including microscopy [white blood cells per high-power field (WBC/HPF), bacteria], dipstick [nitrites, leukocyte esterase (LE)], and urine culture in colony-forming units per mL (CFU/mL).
Exclusions included:
- Major comorbidities (defined in this study as neuromuscular conditions such as spina bifida, previous urologic surgery other than circumcision, or immunodeficiency);
- Patients managed in an ICU setting; and
- Patients with indwelling urinary or central venous catheters at the time of culture.
A total of 276 infants with bacteremic UTI were identified, with 31 exclusions (12 with no UA performed, 19 with cultures with <50,000 CFU/mL). The remaining 245 infants were included for analysis. The control group was a random sampling of 115 similarly aged infants who underwent evaluation for serious bacterial infection and had negative urine cultures.
Comparison between the study group (bacteremic UTI) and the controls showed:
- LE (including any “positive” LE) had a sensitivity of 97.6%, specificity of 93.9%;
- Considering “trace” LE as negative changed the sensitivity and specificity to 95.7% and 97.4%, respectively; and
- Positive nitrites had a specificity of 100%.
A definition of positive UA that includes pyuria (greater than 3 WBC/HPF) and/or any LE was highly sensitive (99.5%) and specific (87.8%). All but one of 203 infants with bacteremic UTI who had complete UA results were positive for LE and/or WBC/HPF. The one exception was a 64-day-old girl with Group B Streptococcus infection. Bacteria on microscopy showed poor specificity.
The authors discussed two possible explanations for the study’s finding of high sensitivity of the UA, including:
- The UA is in fact highly sensitive, and previous studies have been flawed by a faulty gold standard (positive cultures due to asymptomatic bacteriuria or contamination); or
- Screening tests are more sensitive in the setting of severe disease (in this case, UTI with bacteremia).
The second explanation is controversial, and the authors of this article cite previous studies showing minimal differences between UTI with or without bacteremia.
Bottom line: In infants younger than three months of age with bacteremic UTI, the findings of pyuria and/or any LE on UA are reliable predictors of infection, with higher sensitivity than previously reported.
Citation: Schroeder AR, Chang PW, Shen MW, Biondi EA, Greenhow TL. Diagnostic accuracy of the urinalysis for urinary tract infection in infants <3 months of age. Pediatrics. 2015;135(6):965-71.
Clinical question: In infants younger than three months of age with bacteremic urinary tract infection (UTI), how sensitive and specific are urinalysis (UA) findings?
Background: Infants are commonly hospitalized with UTIs. The gold standard for diagnosis is considered to be urine culture. When compared to this gold standard, the sensitivity of UA findings for the diagnosis of UTI has been previously reported to be around 75% to 85%; however, a positive urine culture alone in the setting of negative UA may not be reflective of a UTI due to asymptomatic bacteriuria or contamination. The 2011 American Academy of Pediatrics clinical guideline for UTIs suggests that the diagnosis should require positive urine culture in addition to abnormal UA. These guidelines do not include infants younger than two months of age, and positive cultures in this age group are generally regarded as a UTI and treated as such. Positive culture results with the same organism in the urine and blood indicates very low likelihood of contamination or asymptomatic bacteriuria, and patients with bacteremic UTI are likely to have a true infection.
Study design: Multicenter, retrospective, cross-sectional study.
Setting: Twenty hospitals in eleven hospital systems.
Synopsis: Researchers used a multicenter microbiology database to identify infants younger than three months of age with bacteremic UTI (same pathogenic organism in blood and urine). Data was collected on UA, including microscopy [white blood cells per high-power field (WBC/HPF), bacteria], dipstick [nitrites, leukocyte esterase (LE)], and urine culture in colony-forming units per mL (CFU/mL).
Exclusions included:
- Major comorbidities (defined in this study as neuromuscular conditions such as spina bifida, previous urologic surgery other than circumcision, or immunodeficiency);
- Patients managed in an ICU setting; and
- Patients with indwelling urinary or central venous catheters at the time of culture.
A total of 276 infants with bacteremic UTI were identified, with 31 exclusions (12 with no UA performed, 19 with cultures with <50,000 CFU/mL). The remaining 245 infants were included for analysis. The control group was a random sampling of 115 similarly aged infants who underwent evaluation for serious bacterial infection and had negative urine cultures.
Comparison between the study group (bacteremic UTI) and the controls showed:
- LE (including any “positive” LE) had a sensitivity of 97.6%, specificity of 93.9%;
- Considering “trace” LE as negative changed the sensitivity and specificity to 95.7% and 97.4%, respectively; and
- Positive nitrites had a specificity of 100%.
A definition of positive UA that includes pyuria (greater than 3 WBC/HPF) and/or any LE was highly sensitive (99.5%) and specific (87.8%). All but one of 203 infants with bacteremic UTI who had complete UA results were positive for LE and/or WBC/HPF. The one exception was a 64-day-old girl with Group B Streptococcus infection. Bacteria on microscopy showed poor specificity.
The authors discussed two possible explanations for the study’s finding of high sensitivity of the UA, including:
- The UA is in fact highly sensitive, and previous studies have been flawed by a faulty gold standard (positive cultures due to asymptomatic bacteriuria or contamination); or
- Screening tests are more sensitive in the setting of severe disease (in this case, UTI with bacteremia).
The second explanation is controversial, and the authors of this article cite previous studies showing minimal differences between UTI with or without bacteremia.
Bottom line: In infants younger than three months of age with bacteremic UTI, the findings of pyuria and/or any LE on UA are reliable predictors of infection, with higher sensitivity than previously reported.
Citation: Schroeder AR, Chang PW, Shen MW, Biondi EA, Greenhow TL. Diagnostic accuracy of the urinalysis for urinary tract infection in infants <3 months of age. Pediatrics. 2015;135(6):965-71.
Clinical question: In infants younger than three months of age with bacteremic urinary tract infection (UTI), how sensitive and specific are urinalysis (UA) findings?
Background: Infants are commonly hospitalized with UTIs. The gold standard for diagnosis is considered to be urine culture. When compared to this gold standard, the sensitivity of UA findings for the diagnosis of UTI has been previously reported to be around 75% to 85%; however, a positive urine culture alone in the setting of negative UA may not be reflective of a UTI due to asymptomatic bacteriuria or contamination. The 2011 American Academy of Pediatrics clinical guideline for UTIs suggests that the diagnosis should require positive urine culture in addition to abnormal UA. These guidelines do not include infants younger than two months of age, and positive cultures in this age group are generally regarded as a UTI and treated as such. Positive culture results with the same organism in the urine and blood indicates very low likelihood of contamination or asymptomatic bacteriuria, and patients with bacteremic UTI are likely to have a true infection.
Study design: Multicenter, retrospective, cross-sectional study.
Setting: Twenty hospitals in eleven hospital systems.
Synopsis: Researchers used a multicenter microbiology database to identify infants younger than three months of age with bacteremic UTI (same pathogenic organism in blood and urine). Data was collected on UA, including microscopy [white blood cells per high-power field (WBC/HPF), bacteria], dipstick [nitrites, leukocyte esterase (LE)], and urine culture in colony-forming units per mL (CFU/mL).
Exclusions included:
- Major comorbidities (defined in this study as neuromuscular conditions such as spina bifida, previous urologic surgery other than circumcision, or immunodeficiency);
- Patients managed in an ICU setting; and
- Patients with indwelling urinary or central venous catheters at the time of culture.
A total of 276 infants with bacteremic UTI were identified, with 31 exclusions (12 with no UA performed, 19 with cultures with <50,000 CFU/mL). The remaining 245 infants were included for analysis. The control group was a random sampling of 115 similarly aged infants who underwent evaluation for serious bacterial infection and had negative urine cultures.
Comparison between the study group (bacteremic UTI) and the controls showed:
- LE (including any “positive” LE) had a sensitivity of 97.6%, specificity of 93.9%;
- Considering “trace” LE as negative changed the sensitivity and specificity to 95.7% and 97.4%, respectively; and
- Positive nitrites had a specificity of 100%.
A definition of positive UA that includes pyuria (greater than 3 WBC/HPF) and/or any LE was highly sensitive (99.5%) and specific (87.8%). All but one of 203 infants with bacteremic UTI who had complete UA results were positive for LE and/or WBC/HPF. The one exception was a 64-day-old girl with Group B Streptococcus infection. Bacteria on microscopy showed poor specificity.
The authors discussed two possible explanations for the study’s finding of high sensitivity of the UA, including:
- The UA is in fact highly sensitive, and previous studies have been flawed by a faulty gold standard (positive cultures due to asymptomatic bacteriuria or contamination); or
- Screening tests are more sensitive in the setting of severe disease (in this case, UTI with bacteremia).
The second explanation is controversial, and the authors of this article cite previous studies showing minimal differences between UTI with or without bacteremia.
Bottom line: In infants younger than three months of age with bacteremic UTI, the findings of pyuria and/or any LE on UA are reliable predictors of infection, with higher sensitivity than previously reported.
Citation: Schroeder AR, Chang PW, Shen MW, Biondi EA, Greenhow TL. Diagnostic accuracy of the urinalysis for urinary tract infection in infants <3 months of age. Pediatrics. 2015;135(6):965-71.