Deepak Chitnis

BETHESDA, MD. – Senior citizens who have a motor vehicle collision are advised to maintain a regimen of physical activity in the weeks immediately following the crash; otherwise they risk developing persistent, severe pain later, a study showed.

“We’re interested in patients who didn’t require hospitalization and didn’t have severe injuries, which, as it turns out, is about 80% of older adults experiencing car accidents,” Dr. Timothy F. Platts-Mills of the department of emergency medicine at the University of North Carolina at Chapel Hill explained in an interview. Findings from previous studies have also suggested that leading a sedentary lifestyle can cause persistent pain, he added.

The study enrolled 156 adults aged 65 years of age or older who had emergency department visits less than 24 hours after being in a car crash. Each subject was given a Pain Activity Scale for the Elderly (PASE) survey to assess the level of physical activity they undertook at baseline and at 6 weeks after the accident. Subjects were then divided into two cohorts: individuals whose activity level dropped by 50% or more, and those who kept up their regular movement patterns.

In addition, patients were asked to assess their pain severity at baseline on a scale of 1-10; a score of 1-3 indicated mild pain, 4-6 indicated moderate pain, and 7-10 indicated severe pain. Subjects in both cohorts were then reevaluated at 6 months to determine whether pain persisted, and the intensity of pain that subjects experienced. Subjects were also asked to assess the level of difficulty they had when performing six Activities of Daily Living (ADL) exercises.

Of the subjects, 83% reported no difficulty performing ADLs prior to their car accident, but 60% had difficulty at 6 months. The average pain score was 5.4 when assessed after the accident in the emergency department, but dropped to 3.6 at 6-week follow-up; at baseline, 33% reported moderate pain and 41% reported severe pain. However, at 6 months, the mean pain score was significantly higher in subjects whose physical activity decreased by at least 50%, compared with those who maintained higher rates of activity: 4.2 vs. 2.2, respectively.

Of the subjects, 31% reported that their physical activity decreased by more than 50%. Of those, 37% reported experiencing depression, compared with 18% of those who did not decrease activity. Of those who became less active, 81% reported pain scores of 4 or higher, indicating “moderate to severe” pain, versus 68% in the cohort who maintained the same level of activity. Axial pain was higher in those who became less active (67% vs. 56%), but lower-extremity pain was slightly higher in the cohort who remained after the accidents as they had been before (32% vs. 28%).

“We then did an analysis where we adjusted for all of the characteristics that we saw in the emergency departments [since] people who decreased their activity might have also had more pain, or maybe a worse injury,” said Dr. Platts-Mills. “We controlled for characteristics of the patients – sociodemographic characteristics, pain severity, location of pain – and even after adjusting for all of those characteristics, we still saw [that] people who decreased their physical activity had higher rates of persistent pain.”

From this analysis, Dr. Platts-Mills and his coinvestigators were able to determine that subjects who were older (greater than 75 years of age), female, depressed, and experiencing axial pain were more likely to decrease their physical activity by at least 50%, thereby experiencing more persistent pain. Depression, pain in the emergency department, axial pain, and lower-extremity pain were all consistently higher in the decreased-activity cohort after adjustment.

“To me, what that suggests is that there may be a causal relationship there, so decreasing physical activity might actually be causing persistent pain, and that’s been suggested by some other works,” said Dr. Platts-Mills. “So the inference [is] that if we can promote physical activity in the early recovery period for older adults after an injury … then we may improve outcomes.”

This study was supported by an award from the National Institute on Aging. Dr. Platts-Mills did not report any other relevant financial disclosures.

[email protected]

BETHESDA, MD. – Senior citizens who have a motor vehicle collision are advised to maintain a regimen of physical activity in the weeks immediately following the crash; otherwise they risk developing persistent, severe pain later, a study showed.

“We’re interested in patients who didn’t require hospitalization and didn’t have severe injuries, which, as it turns out, is about 80% of older adults experiencing car accidents,” Dr. Timothy F. Platts-Mills of the department of emergency medicine at the University of North Carolina at Chapel Hill explained in an interview. Findings from previous studies have also suggested that leading a sedentary lifestyle can cause persistent pain, he added.

The study enrolled 156 adults aged 65 years of age or older who had emergency department visits less than 24 hours after being in a car crash. Each subject was given a Pain Activity Scale for the Elderly (PASE) survey to assess the level of physical activity they undertook at baseline and at 6 weeks after the accident. Subjects were then divided into two cohorts: individuals whose activity level dropped by 50% or more, and those who kept up their regular movement patterns.

In addition, patients were asked to assess their pain severity at baseline on a scale of 1-10; a score of 1-3 indicated mild pain, 4-6 indicated moderate pain, and 7-10 indicated severe pain. Subjects in both cohorts were then reevaluated at 6 months to determine whether pain persisted, and the intensity of pain that subjects experienced. Subjects were also asked to assess the level of difficulty they had when performing six Activities of Daily Living (ADL) exercises.

Of the subjects, 83% reported no difficulty performing ADLs prior to their car accident, but 60% had difficulty at 6 months. The average pain score was 5.4 when assessed after the accident in the emergency department, but dropped to 3.6 at 6-week follow-up; at baseline, 33% reported moderate pain and 41% reported severe pain. However, at 6 months, the mean pain score was significantly higher in subjects whose physical activity decreased by at least 50%, compared with those who maintained higher rates of activity: 4.2 vs. 2.2, respectively.

Of the subjects, 31% reported that their physical activity decreased by more than 50%. Of those, 37% reported experiencing depression, compared with 18% of those who did not decrease activity. Of those who became less active, 81% reported pain scores of 4 or higher, indicating “moderate to severe” pain, versus 68% in the cohort who maintained the same level of activity. Axial pain was higher in those who became less active (67% vs. 56%), but lower-extremity pain was slightly higher in the cohort who remained after the accidents as they had been before (32% vs. 28%).

“We then did an analysis where we adjusted for all of the characteristics that we saw in the emergency departments [since] people who decreased their activity might have also had more pain, or maybe a worse injury,” said Dr. Platts-Mills. “We controlled for characteristics of the patients – sociodemographic characteristics, pain severity, location of pain – and even after adjusting for all of those characteristics, we still saw [that] people who decreased their physical activity had higher rates of persistent pain.”

From this analysis, Dr. Platts-Mills and his coinvestigators were able to determine that subjects who were older (greater than 75 years of age), female, depressed, and experiencing axial pain were more likely to decrease their physical activity by at least 50%, thereby experiencing more persistent pain. Depression, pain in the emergency department, axial pain, and lower-extremity pain were all consistently higher in the decreased-activity cohort after adjustment.

“To me, what that suggests is that there may be a causal relationship there, so decreasing physical activity might actually be causing persistent pain, and that’s been suggested by some other works,” said Dr. Platts-Mills. “So the inference [is] that if we can promote physical activity in the early recovery period for older adults after an injury … then we may improve outcomes.”

This study was supported by an award from the National Institute on Aging. Dr. Platts-Mills did not report any other relevant financial disclosures.

[email protected]

BETHESDA, MD. – Senior citizens who have a motor vehicle collision are advised to maintain a regimen of physical activity in the weeks immediately following the crash; otherwise they risk developing persistent, severe pain later, a study showed.

“We’re interested in patients who didn’t require hospitalization and didn’t have severe injuries, which, as it turns out, is about 80% of older adults experiencing car accidents,” Dr. Timothy F. Platts-Mills of the department of emergency medicine at the University of North Carolina at Chapel Hill explained in an interview. Findings from previous studies have also suggested that leading a sedentary lifestyle can cause persistent pain, he added.

The study enrolled 156 adults aged 65 years of age or older who had emergency department visits less than 24 hours after being in a car crash. Each subject was given a Pain Activity Scale for the Elderly (PASE) survey to assess the level of physical activity they undertook at baseline and at 6 weeks after the accident. Subjects were then divided into two cohorts: individuals whose activity level dropped by 50% or more, and those who kept up their regular movement patterns.

In addition, patients were asked to assess their pain severity at baseline on a scale of 1-10; a score of 1-3 indicated mild pain, 4-6 indicated moderate pain, and 7-10 indicated severe pain. Subjects in both cohorts were then reevaluated at 6 months to determine whether pain persisted, and the intensity of pain that subjects experienced. Subjects were also asked to assess the level of difficulty they had when performing six Activities of Daily Living (ADL) exercises.

Of the subjects, 83% reported no difficulty performing ADLs prior to their car accident, but 60% had difficulty at 6 months. The average pain score was 5.4 when assessed after the accident in the emergency department, but dropped to 3.6 at 6-week follow-up; at baseline, 33% reported moderate pain and 41% reported severe pain. However, at 6 months, the mean pain score was significantly higher in subjects whose physical activity decreased by at least 50%, compared with those who maintained higher rates of activity: 4.2 vs. 2.2, respectively.

Of the subjects, 31% reported that their physical activity decreased by more than 50%. Of those, 37% reported experiencing depression, compared with 18% of those who did not decrease activity. Of those who became less active, 81% reported pain scores of 4 or higher, indicating “moderate to severe” pain, versus 68% in the cohort who maintained the same level of activity. Axial pain was higher in those who became less active (67% vs. 56%), but lower-extremity pain was slightly higher in the cohort who remained after the accidents as they had been before (32% vs. 28%).

“We then did an analysis where we adjusted for all of the characteristics that we saw in the emergency departments [since] people who decreased their activity might have also had more pain, or maybe a worse injury,” said Dr. Platts-Mills. “We controlled for characteristics of the patients – sociodemographic characteristics, pain severity, location of pain – and even after adjusting for all of those characteristics, we still saw [that] people who decreased their physical activity had higher rates of persistent pain.”

From this analysis, Dr. Platts-Mills and his coinvestigators were able to determine that subjects who were older (greater than 75 years of age), female, depressed, and experiencing axial pain were more likely to decrease their physical activity by at least 50%, thereby experiencing more persistent pain. Depression, pain in the emergency department, axial pain, and lower-extremity pain were all consistently higher in the decreased-activity cohort after adjustment.

“To me, what that suggests is that there may be a causal relationship there, so decreasing physical activity might actually be causing persistent pain, and that’s been suggested by some other works,” said Dr. Platts-Mills. “So the inference [is] that if we can promote physical activity in the early recovery period for older adults after an injury … then we may improve outcomes.”

This study was supported by an award from the National Institute on Aging. Dr. Platts-Mills did not report any other relevant financial disclosures.

[email protected]

NASHVILLE – Endocrinologists dealing with adult patients who survived cancer during childhood should ensure that they have an adequate understanding of the elevated risk that such patients are at for various endocrine conditions, such as hypogonadism, hypopituitarism, and ovarian failure.

This is according to the findings of a survey study presented at the annual meeting of the American Association of Clinical Endocrinologists by Dr. Sripriya Raman of Children’s Mercy Hospital and Clinics in Kansas City, Missouri.

“Incidences of childhood cancer have crept up from 1975 to 1995, but mortality has gone down, thanks to advancements in cancer therapy,” explained Dr. Raman. “Even among ethnic groups – whites, Hispanics, African Americans, and Asians – cancer incidence rates have either stabilized or increased slightly, which means we’re seeing more and more of these types of patients at our clinics.”

Dr. Raman and coinvestigators developed a survey of 19 questions: 10 questions on provider characteristics, 5 on demographic data, and 4 questions derived from two clinical vignettes. This survey was then sent to 294 endocrinologists belonging to either the Pediatric Endocrine Society (PES) or the AACE between October and December 2014; 274 surveys were returned either complete or near complete. Of those, 231 (84%) were from pediatric endocrinologists (PE) and 43 (16%) were from adult endocrinologists (AE).

None of the AE clinics reported having a focus clinic for childhood cancer survivors in their practices, compared with 54% of PE practices that reported having such a focus clinic (P < .001). Furthermore, 84% of practices that reported a general lack of adequate training, confidence, and general awareness of the long-term follow-up guidelines for treating childhood cancer survivors were AE, compared with 16% PE (P < .001).

Overall, 53% of practices reported receiving cancer treatment summaries for their patients on a consistent basis. Regarding the training they’ve received on how to treat childhood cancer survivors, 65% reported receiving “somewhat adequate training” but 22% reported receiving either very little or no training all. While 67% of practices reported feeling “somewhat confident” in their ability to properly treat childhood cancer survivors, 10% reported feeling either very little or no confidence. Infertility and growth hormone deficiency were the most commonly cited conditions reported by AE clinics that responded to the survey.

Of PE practices, 64% reported following at least six patients who were childhood cancer survivors, while only 19% of AE practices reported the same (P < .001). Regarding the clinical vignettes, PE practices scored higher than their AE counterparts on identifying childhood cancer survivors’ susceptibility to cranial radiation (76% vs. 50%; P = .001) and ovarian failure (28% vs. 13%; P = .048), but there was “no significant difference” in scores on the topics of hypopituitarism and hypogonadism.

Nearly 1 out of every 640 young adults in the United States are childhood cancer survivors, and roughly 40% of those will experience at least one endocrine disorder at some point in their adult life. To solve the issue of insufficient experience or preparation regarding treatment of these patients, Dr. Raman suggested that practices create personalized management plans with specific protocols derived from clinical guidelines and expert opinions. These protocols could either be cancer center based, community based, or a hybrid of the two, which would involve care at a community site along with “close collaboration with [a] cancer center.”

“There are no treatment guidelines specifically for endocrinologists,” said Dr. Raman. “There are screening guidelines, which are more guided towards oncologists [and] family practitioners who would be seeing these patients with the idea that they would be referred to endocrinologists once they identify a problem.”

Dr. Raman did not report any relevant financial disclosures.

[email protected]

NASHVILLE – Endocrinologists dealing with adult patients who survived cancer during childhood should ensure that they have an adequate understanding of the elevated risk that such patients are at for various endocrine conditions, such as hypogonadism, hypopituitarism, and ovarian failure.

This is according to the findings of a survey study presented at the annual meeting of the American Association of Clinical Endocrinologists by Dr. Sripriya Raman of Children’s Mercy Hospital and Clinics in Kansas City, Missouri.

“Incidences of childhood cancer have crept up from 1975 to 1995, but mortality has gone down, thanks to advancements in cancer therapy,” explained Dr. Raman. “Even among ethnic groups – whites, Hispanics, African Americans, and Asians – cancer incidence rates have either stabilized or increased slightly, which means we’re seeing more and more of these types of patients at our clinics.”

Dr. Raman and coinvestigators developed a survey of 19 questions: 10 questions on provider characteristics, 5 on demographic data, and 4 questions derived from two clinical vignettes. This survey was then sent to 294 endocrinologists belonging to either the Pediatric Endocrine Society (PES) or the AACE between October and December 2014; 274 surveys were returned either complete or near complete. Of those, 231 (84%) were from pediatric endocrinologists (PE) and 43 (16%) were from adult endocrinologists (AE).

None of the AE clinics reported having a focus clinic for childhood cancer survivors in their practices, compared with 54% of PE practices that reported having such a focus clinic (P < .001). Furthermore, 84% of practices that reported a general lack of adequate training, confidence, and general awareness of the long-term follow-up guidelines for treating childhood cancer survivors were AE, compared with 16% PE (P < .001).

Overall, 53% of practices reported receiving cancer treatment summaries for their patients on a consistent basis. Regarding the training they’ve received on how to treat childhood cancer survivors, 65% reported receiving “somewhat adequate training” but 22% reported receiving either very little or no training all. While 67% of practices reported feeling “somewhat confident” in their ability to properly treat childhood cancer survivors, 10% reported feeling either very little or no confidence. Infertility and growth hormone deficiency were the most commonly cited conditions reported by AE clinics that responded to the survey.

Of PE practices, 64% reported following at least six patients who were childhood cancer survivors, while only 19% of AE practices reported the same (P < .001). Regarding the clinical vignettes, PE practices scored higher than their AE counterparts on identifying childhood cancer survivors’ susceptibility to cranial radiation (76% vs. 50%; P = .001) and ovarian failure (28% vs. 13%; P = .048), but there was “no significant difference” in scores on the topics of hypopituitarism and hypogonadism.

Nearly 1 out of every 640 young adults in the United States are childhood cancer survivors, and roughly 40% of those will experience at least one endocrine disorder at some point in their adult life. To solve the issue of insufficient experience or preparation regarding treatment of these patients, Dr. Raman suggested that practices create personalized management plans with specific protocols derived from clinical guidelines and expert opinions. These protocols could either be cancer center based, community based, or a hybrid of the two, which would involve care at a community site along with “close collaboration with [a] cancer center.”

“There are no treatment guidelines specifically for endocrinologists,” said Dr. Raman. “There are screening guidelines, which are more guided towards oncologists [and] family practitioners who would be seeing these patients with the idea that they would be referred to endocrinologists once they identify a problem.”

Dr. Raman did not report any relevant financial disclosures.

[email protected]

NASHVILLE – Endocrinologists dealing with adult patients who survived cancer during childhood should ensure that they have an adequate understanding of the elevated risk that such patients are at for various endocrine conditions, such as hypogonadism, hypopituitarism, and ovarian failure.

This is according to the findings of a survey study presented at the annual meeting of the American Association of Clinical Endocrinologists by Dr. Sripriya Raman of Children’s Mercy Hospital and Clinics in Kansas City, Missouri.

“Incidences of childhood cancer have crept up from 1975 to 1995, but mortality has gone down, thanks to advancements in cancer therapy,” explained Dr. Raman. “Even among ethnic groups – whites, Hispanics, African Americans, and Asians – cancer incidence rates have either stabilized or increased slightly, which means we’re seeing more and more of these types of patients at our clinics.”

Dr. Raman and coinvestigators developed a survey of 19 questions: 10 questions on provider characteristics, 5 on demographic data, and 4 questions derived from two clinical vignettes. This survey was then sent to 294 endocrinologists belonging to either the Pediatric Endocrine Society (PES) or the AACE between October and December 2014; 274 surveys were returned either complete or near complete. Of those, 231 (84%) were from pediatric endocrinologists (PE) and 43 (16%) were from adult endocrinologists (AE).

None of the AE clinics reported having a focus clinic for childhood cancer survivors in their practices, compared with 54% of PE practices that reported having such a focus clinic (P < .001). Furthermore, 84% of practices that reported a general lack of adequate training, confidence, and general awareness of the long-term follow-up guidelines for treating childhood cancer survivors were AE, compared with 16% PE (P < .001).

Overall, 53% of practices reported receiving cancer treatment summaries for their patients on a consistent basis. Regarding the training they’ve received on how to treat childhood cancer survivors, 65% reported receiving “somewhat adequate training” but 22% reported receiving either very little or no training all. While 67% of practices reported feeling “somewhat confident” in their ability to properly treat childhood cancer survivors, 10% reported feeling either very little or no confidence. Infertility and growth hormone deficiency were the most commonly cited conditions reported by AE clinics that responded to the survey.

Of PE practices, 64% reported following at least six patients who were childhood cancer survivors, while only 19% of AE practices reported the same (P < .001). Regarding the clinical vignettes, PE practices scored higher than their AE counterparts on identifying childhood cancer survivors’ susceptibility to cranial radiation (76% vs. 50%; P = .001) and ovarian failure (28% vs. 13%; P = .048), but there was “no significant difference” in scores on the topics of hypopituitarism and hypogonadism.

Nearly 1 out of every 640 young adults in the United States are childhood cancer survivors, and roughly 40% of those will experience at least one endocrine disorder at some point in their adult life. To solve the issue of insufficient experience or preparation regarding treatment of these patients, Dr. Raman suggested that practices create personalized management plans with specific protocols derived from clinical guidelines and expert opinions. These protocols could either be cancer center based, community based, or a hybrid of the two, which would involve care at a community site along with “close collaboration with [a] cancer center.”

“There are no treatment guidelines specifically for endocrinologists,” said Dr. Raman. “There are screening guidelines, which are more guided towards oncologists [and] family practitioners who would be seeing these patients with the idea that they would be referred to endocrinologists once they identify a problem.”

Dr. Raman did not report any relevant financial disclosures.

[email protected]

SAN DIEGO – Infants given high-dose acyclovir for the treatment of herpes simplex virus (HSV) infections experienced a number of adverse reactions, including seizure, hypotension, and thrombocytopenia, according to the results of a new study, but it is unclear if the root cause of these events is the drug or the infection itself.

“The dose currently approved by the [Food and Drug Administration] for use in this population for this indication is 10 mg/kg per dose, dosed ever 8 hours, [but] there have been studies that have indicated that a dose of 20 mg/kg per dose every 8 hours is more effective,” said Dr. Jessica E. Ericson, a third-year fellow in a department of pediatrics at Duke University, Durham, N.C., who presented the findings of this retrospective cohort study at the annual meeting of the Pediatric Academic Societies.

Dr. Ericson added that the 20 mg/kg per dose has “been recommended by the American Academy of Pediatrics Committee on Infectious Diseases and is generally considered to be the standard of care for this condition,” but stated that the “discrepancy between the current standard of care and the FDA-approved dose is likely due to a perceived lack of safety data that demonstrate that high-dose acyclovir is safe to use in young infants.”

Levels of elevated creatine, neutropenia, leukopenia, and thrombocytopenia were measured to assess laboratory AEs, with benchmarks set by the investigators for what defined an adverse event (AE) and a serious AE for each outcome measure. For elevated creatine, greater than 1.7 mg/dL was considered an AE and greater than 3.0 mg/dL was considered a serious AE; for neutropenia, an AE was less than 5,000/mm³ and a serious AE was less than 100/mm³; for leukopenia, less than 5,000/mm³ was an AE and less than 2,000/mm³ was a serious AE; and for thrombocytopenia, less than 100,000/mm³ was considered an AE and less than 20,000/mm³ was considered serious.

Clinical AEs were found in 31% of the 359 infants who received a 20 mg/kg per dose every 8 hours, the most common of which were hypotension (16%) and seizure (11%).

Laboratory AEs were less prevalent: 5% had a creatine AE, and 1% had a serious creatine AE; 3% had a neutropenia AE, and 0.3% had a serious neutropenia AE; 12% had a leukopenia AE, and 0.6% had a serious leukopenia AE; and 19% had a thrombocytopenia AE, while 5% had a serious thrombocytopenia AE.

A total of 38 infants (11%) died; no renal failure requiring dialysis was reported.

Previous studies had noted that renal toxicity and thrombocytopenia were expected AEs, Dr. Ericson said. All infants were discharged from a neonatal intensive care unit managed by the Pediatrix Medical Group, and were exposed to acyclovir for no fewer than 14 days specifically for the treatment of HSV infections. All infants were treated for fewer than 120 days, and all data came from the years 2002–2012. Median birth weight was 2,191 g, and median gestational age was 34 weeks.

Regarding limitations to the study, Dr. Ericson explained that there was no control group cohort because “as high-dose acyclovir is used for at least 14 days, typically only with evidence of HSV disease, there is no obvious control group to use for comparison.” Additionally, lab collection was conducted at the discretion of the treating physician, as this wasn’t a standard trial protocol.

Because this trial wasn’t a observational study, Dr. Ericson explained, it’s possible that some of the laboratory events were due to the underlying HSV disease and not the exposure to acyclovir. However, because serious AEs were rare, Dr. Ericson concluded by saying that the high-dose acyclovir should be the preferred treatment option “when neonatal HSV disease is suspected.”

Dr. Ericson did not report any relevant financial disclosures.

[email protected]

SAN DIEGO – Infants given high-dose acyclovir for the treatment of herpes simplex virus (HSV) infections experienced a number of adverse reactions, including seizure, hypotension, and thrombocytopenia, according to the results of a new study, but it is unclear if the root cause of these events is the drug or the infection itself.

“The dose currently approved by the [Food and Drug Administration] for use in this population for this indication is 10 mg/kg per dose, dosed ever 8 hours, [but] there have been studies that have indicated that a dose of 20 mg/kg per dose every 8 hours is more effective,” said Dr. Jessica E. Ericson, a third-year fellow in a department of pediatrics at Duke University, Durham, N.C., who presented the findings of this retrospective cohort study at the annual meeting of the Pediatric Academic Societies.

Dr. Ericson added that the 20 mg/kg per dose has “been recommended by the American Academy of Pediatrics Committee on Infectious Diseases and is generally considered to be the standard of care for this condition,” but stated that the “discrepancy between the current standard of care and the FDA-approved dose is likely due to a perceived lack of safety data that demonstrate that high-dose acyclovir is safe to use in young infants.”

Levels of elevated creatine, neutropenia, leukopenia, and thrombocytopenia were measured to assess laboratory AEs, with benchmarks set by the investigators for what defined an adverse event (AE) and a serious AE for each outcome measure. For elevated creatine, greater than 1.7 mg/dL was considered an AE and greater than 3.0 mg/dL was considered a serious AE; for neutropenia, an AE was less than 5,000/mm³ and a serious AE was less than 100/mm³; for leukopenia, less than 5,000/mm³ was an AE and less than 2,000/mm³ was a serious AE; and for thrombocytopenia, less than 100,000/mm³ was considered an AE and less than 20,000/mm³ was considered serious.

Clinical AEs were found in 31% of the 359 infants who received a 20 mg/kg per dose every 8 hours, the most common of which were hypotension (16%) and seizure (11%).

Laboratory AEs were less prevalent: 5% had a creatine AE, and 1% had a serious creatine AE; 3% had a neutropenia AE, and 0.3% had a serious neutropenia AE; 12% had a leukopenia AE, and 0.6% had a serious leukopenia AE; and 19% had a thrombocytopenia AE, while 5% had a serious thrombocytopenia AE.

A total of 38 infants (11%) died; no renal failure requiring dialysis was reported.

Previous studies had noted that renal toxicity and thrombocytopenia were expected AEs, Dr. Ericson said. All infants were discharged from a neonatal intensive care unit managed by the Pediatrix Medical Group, and were exposed to acyclovir for no fewer than 14 days specifically for the treatment of HSV infections. All infants were treated for fewer than 120 days, and all data came from the years 2002–2012. Median birth weight was 2,191 g, and median gestational age was 34 weeks.

Regarding limitations to the study, Dr. Ericson explained that there was no control group cohort because “as high-dose acyclovir is used for at least 14 days, typically only with evidence of HSV disease, there is no obvious control group to use for comparison.” Additionally, lab collection was conducted at the discretion of the treating physician, as this wasn’t a standard trial protocol.

Because this trial wasn’t a observational study, Dr. Ericson explained, it’s possible that some of the laboratory events were due to the underlying HSV disease and not the exposure to acyclovir. However, because serious AEs were rare, Dr. Ericson concluded by saying that the high-dose acyclovir should be the preferred treatment option “when neonatal HSV disease is suspected.”

Dr. Ericson did not report any relevant financial disclosures.

[email protected]

SAN DIEGO – Infants given high-dose acyclovir for the treatment of herpes simplex virus (HSV) infections experienced a number of adverse reactions, including seizure, hypotension, and thrombocytopenia, according to the results of a new study, but it is unclear if the root cause of these events is the drug or the infection itself.

“The dose currently approved by the [Food and Drug Administration] for use in this population for this indication is 10 mg/kg per dose, dosed ever 8 hours, [but] there have been studies that have indicated that a dose of 20 mg/kg per dose every 8 hours is more effective,” said Dr. Jessica E. Ericson, a third-year fellow in a department of pediatrics at Duke University, Durham, N.C., who presented the findings of this retrospective cohort study at the annual meeting of the Pediatric Academic Societies.

Dr. Ericson added that the 20 mg/kg per dose has “been recommended by the American Academy of Pediatrics Committee on Infectious Diseases and is generally considered to be the standard of care for this condition,” but stated that the “discrepancy between the current standard of care and the FDA-approved dose is likely due to a perceived lack of safety data that demonstrate that high-dose acyclovir is safe to use in young infants.”

Levels of elevated creatine, neutropenia, leukopenia, and thrombocytopenia were measured to assess laboratory AEs, with benchmarks set by the investigators for what defined an adverse event (AE) and a serious AE for each outcome measure. For elevated creatine, greater than 1.7 mg/dL was considered an AE and greater than 3.0 mg/dL was considered a serious AE; for neutropenia, an AE was less than 5,000/mm³ and a serious AE was less than 100/mm³; for leukopenia, less than 5,000/mm³ was an AE and less than 2,000/mm³ was a serious AE; and for thrombocytopenia, less than 100,000/mm³ was considered an AE and less than 20,000/mm³ was considered serious.

Clinical AEs were found in 31% of the 359 infants who received a 20 mg/kg per dose every 8 hours, the most common of which were hypotension (16%) and seizure (11%).

Laboratory AEs were less prevalent: 5% had a creatine AE, and 1% had a serious creatine AE; 3% had a neutropenia AE, and 0.3% had a serious neutropenia AE; 12% had a leukopenia AE, and 0.6% had a serious leukopenia AE; and 19% had a thrombocytopenia AE, while 5% had a serious thrombocytopenia AE.

A total of 38 infants (11%) died; no renal failure requiring dialysis was reported.

Previous studies had noted that renal toxicity and thrombocytopenia were expected AEs, Dr. Ericson said. All infants were discharged from a neonatal intensive care unit managed by the Pediatrix Medical Group, and were exposed to acyclovir for no fewer than 14 days specifically for the treatment of HSV infections. All infants were treated for fewer than 120 days, and all data came from the years 2002–2012. Median birth weight was 2,191 g, and median gestational age was 34 weeks.

Regarding limitations to the study, Dr. Ericson explained that there was no control group cohort because “as high-dose acyclovir is used for at least 14 days, typically only with evidence of HSV disease, there is no obvious control group to use for comparison.” Additionally, lab collection was conducted at the discretion of the treating physician, as this wasn’t a standard trial protocol.

Because this trial wasn’t a observational study, Dr. Ericson explained, it’s possible that some of the laboratory events were due to the underlying HSV disease and not the exposure to acyclovir. However, because serious AEs were rare, Dr. Ericson concluded by saying that the high-dose acyclovir should be the preferred treatment option “when neonatal HSV disease is suspected.”

Dr. Ericson did not report any relevant financial disclosures.

[email protected]

SAN DIEGO – Prophylactic indomethacin does not have any association with reducing the risk of bronchopulmonary dysplasia (BPD) or death in infants born extremely premature, according to an observational study presented by Dr. Erik Jensen, a neonatologist at the Children’s Hospital of Philadelphia, at the annual meeting of the Pediatric Academic Societies.

“Observational studies consistently show that patent ductus arteriosus [PDA] is a strong risk factor for [BPD] in very preterm infants [but] it remains uncertain whether PDA is a cause, or simply a marker, of increased BPD risk,” said Dr. Jensen. “Data from randomized trials indicate that prophylactic indomethacin reduces the risk of subsequent symptomatic PDA, yet there is no evidence from these studies that prophylactic indomethacin reduces BPD.”

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Infants in the study who received prophylactic indomethacin experienced BPD at a rate of 44%, the exact same as those who did not receive prophylactic indomethacin. The rates of death before 36 weeks postmenstrual age also were not significantly different: 17% in infants receiving prophylactic indomethacin vs. 13% in infants who did not. Death or BPD occurred in 54% of prophylactic indomethacin subjects, and in 51% of infants who did not receive prophylactic indomethacin. An infant was defined as having BPD if they received supplemental oxygen at 36 weeks postmenstrual age.

All subjects in the study were enrolled in the Eunice Kennedy Shriver National Institute of Child Health and Human Development’s Neonatal Research Network generic database between 2008 and 2012, and were less than 29 weeks’ gestational age. The mean age of infants who received prophylactic indomethacin was 25.9 weeks, and the mean age was 26.7 weeks for infants who did not (P < .001). Mean body weight was 777 g for those who received prophylactic indomethacin vs. 912 g for those who did not (P < .001). Males made up 49% of the prophylactic indomethacin cohort and 52% of the other cohort (P < .006).

In total, 8,039 infants were included in the study, with 2,671 receiving prophylactic indomethacin and 5,368 infants who did not receive the drug; of those, commencement of PDA treatment was variable from center to center. PDA treatment after day 1 occurred in 21% of infants who received prophylactic indomethacin, and in 36% of those who did not (P < .001).

Dr. Jensen did not report any relevant financial disclosures.

[email protected]

SAN DIEGO – Prophylactic indomethacin does not have any association with reducing the risk of bronchopulmonary dysplasia (BPD) or death in infants born extremely premature, according to an observational study presented by Dr. Erik Jensen, a neonatologist at the Children’s Hospital of Philadelphia, at the annual meeting of the Pediatric Academic Societies.

“Observational studies consistently show that patent ductus arteriosus [PDA] is a strong risk factor for [BPD] in very preterm infants [but] it remains uncertain whether PDA is a cause, or simply a marker, of increased BPD risk,” said Dr. Jensen. “Data from randomized trials indicate that prophylactic indomethacin reduces the risk of subsequent symptomatic PDA, yet there is no evidence from these studies that prophylactic indomethacin reduces BPD.”

© Fuse/Thinkstock

Infants in the study who received prophylactic indomethacin experienced BPD at a rate of 44%, the exact same as those who did not receive prophylactic indomethacin. The rates of death before 36 weeks postmenstrual age also were not significantly different: 17% in infants receiving prophylactic indomethacin vs. 13% in infants who did not. Death or BPD occurred in 54% of prophylactic indomethacin subjects, and in 51% of infants who did not receive prophylactic indomethacin. An infant was defined as having BPD if they received supplemental oxygen at 36 weeks postmenstrual age.

All subjects in the study were enrolled in the Eunice Kennedy Shriver National Institute of Child Health and Human Development’s Neonatal Research Network generic database between 2008 and 2012, and were less than 29 weeks’ gestational age. The mean age of infants who received prophylactic indomethacin was 25.9 weeks, and the mean age was 26.7 weeks for infants who did not (P < .001). Mean body weight was 777 g for those who received prophylactic indomethacin vs. 912 g for those who did not (P < .001). Males made up 49% of the prophylactic indomethacin cohort and 52% of the other cohort (P < .006).

In total, 8,039 infants were included in the study, with 2,671 receiving prophylactic indomethacin and 5,368 infants who did not receive the drug; of those, commencement of PDA treatment was variable from center to center. PDA treatment after day 1 occurred in 21% of infants who received prophylactic indomethacin, and in 36% of those who did not (P < .001).

Dr. Jensen did not report any relevant financial disclosures.

[email protected]

SAN DIEGO – Prophylactic indomethacin does not have any association with reducing the risk of bronchopulmonary dysplasia (BPD) or death in infants born extremely premature, according to an observational study presented by Dr. Erik Jensen, a neonatologist at the Children’s Hospital of Philadelphia, at the annual meeting of the Pediatric Academic Societies.

“Observational studies consistently show that patent ductus arteriosus [PDA] is a strong risk factor for [BPD] in very preterm infants [but] it remains uncertain whether PDA is a cause, or simply a marker, of increased BPD risk,” said Dr. Jensen. “Data from randomized trials indicate that prophylactic indomethacin reduces the risk of subsequent symptomatic PDA, yet there is no evidence from these studies that prophylactic indomethacin reduces BPD.”

© Fuse/Thinkstock

Infants in the study who received prophylactic indomethacin experienced BPD at a rate of 44%, the exact same as those who did not receive prophylactic indomethacin. The rates of death before 36 weeks postmenstrual age also were not significantly different: 17% in infants receiving prophylactic indomethacin vs. 13% in infants who did not. Death or BPD occurred in 54% of prophylactic indomethacin subjects, and in 51% of infants who did not receive prophylactic indomethacin. An infant was defined as having BPD if they received supplemental oxygen at 36 weeks postmenstrual age.

All subjects in the study were enrolled in the Eunice Kennedy Shriver National Institute of Child Health and Human Development’s Neonatal Research Network generic database between 2008 and 2012, and were less than 29 weeks’ gestational age. The mean age of infants who received prophylactic indomethacin was 25.9 weeks, and the mean age was 26.7 weeks for infants who did not (P < .001). Mean body weight was 777 g for those who received prophylactic indomethacin vs. 912 g for those who did not (P < .001). Males made up 49% of the prophylactic indomethacin cohort and 52% of the other cohort (P < .006).

In total, 8,039 infants were included in the study, with 2,671 receiving prophylactic indomethacin and 5,368 infants who did not receive the drug; of those, commencement of PDA treatment was variable from center to center. PDA treatment after day 1 occurred in 21% of infants who received prophylactic indomethacin, and in 36% of those who did not (P < .001).

Dr. Jensen did not report any relevant financial disclosures.

[email protected]

SAN DIEGO – Hospitals treating neurologically impaired children with pneumonia typically have the best clinical outcomes, shortest lengths of stay, and lowest readmission rates when fewer diagnostic tests are performed.

This suggests that testing protocols across hospital centers should be standardized so clinicians perform as few testing procedures as possible, thus ensuring an elevated standard of care, said Dr. Joanna E. Thomson, a pediatric hospitalist at the Cincinnati Children’s Hospital Medical Center.

“This population of children accounts for an increasing and disproportionate amount of inpatient hospital resources,” Dr. Thomson said at the annual meeting of the Pediatric Academic Societies. “While they represent just 14% of pediatric admissions, they account for 25% of pediatric hospital days and 30% of pediatric hospital charges.”

As defined by Dr. Thomson and her coinvestigators, neurological impairment (NI) was defined as any “neurologic disease resulting in functional or intellectual impairment,” such as cerebral palsy or epilepsy. Within the population of children with NI, pneumonia is a common reason for intensive care unit admission and the most common cause of death, but diagnostic testing, treatment, and outcomes vary widely from center to center.

After reviewing data on all children aged 1-18 years admitted to one of 40 U.S. children’s hospitals in the Pediatric Health Information Systems (PHIS) database for pneumonia from 2007 to 2012, Dr. Thomson and her associates selected 28,123 subjects for inclusion in the retrospective cohort study. The study had two primary outcomes: assess the variability of diagnostic testing performed at each center and determine the association of hospital-level diagnostic test utilization and hospitalization outcomes, mainly length of stay and 30-day readmission rates.

K-mean clustering was used to divide each hospital center into one of three groups – A, B, or C – based on diagnostic testing habits, with the proportion of patients receiving such testing compared across all included centers. Diagnostic testing was defined as laboratory studies and radiologic imaging ordered within the first 48 hours of admission. Kruskal-Wallis tests were used to compare the outcomes at each hospital.

Hospital centers in group C tended to perform significantly fewer tests than those in groups A and B, Dr. Thomson said.

Complete blood counts were performed on 56% of patients in group C centers, compared with 78% in group A and 72% in group B. Similarly, C-reactive protein tests were administered to 17% of patients in group A, 34% in group B, and 15% in group C. Viral studies were done on 24% of patients in group C, but 44% in group A and 52% in group B. Blood cultures were taken from 44% of patients in group C, but 63% in group A and 66% in group B. Urine culture tests were performed for 9% in group C, 22% of patients in group A, and 17% in group B, she reported.

The only test measured for which group C was not the lowest was respiratory culture: group C centers tested 5% of patients, while those in group A tested 15% and group B only tested 3% of patients.

Length of stay and 30-day readmission rates also were consistently lower for group C than groups A and B. Median length of stay across groups was 3.2 days; no hospital center in group C had a mean length of stay higher than 3.2, compared with 14 centers in group A and 5 in group B. The median 30-day readmission rate was 7.9% across all groups, a rate exceeded by 11 group A centers, 6 group B centers, and only 2 group C centers.

“We found [that] substantial hospital level variation exists in both diagnostic testing and outcomes,” Dr. Thomson said, adding that, since centers performing the fewest tests yielded the best outcomes, the findings here “represent an opportunity to improve the value of care provided to this important pediatric population” and that “overall testing can likely decrease without compromising the care we provide.”

Dr. Thomson did not report any relevant financial disclosures.

[email protected]

SAN DIEGO – Hospitals treating neurologically impaired children with pneumonia typically have the best clinical outcomes, shortest lengths of stay, and lowest readmission rates when fewer diagnostic tests are performed.

This suggests that testing protocols across hospital centers should be standardized so clinicians perform as few testing procedures as possible, thus ensuring an elevated standard of care, said Dr. Joanna E. Thomson, a pediatric hospitalist at the Cincinnati Children’s Hospital Medical Center.

“This population of children accounts for an increasing and disproportionate amount of inpatient hospital resources,” Dr. Thomson said at the annual meeting of the Pediatric Academic Societies. “While they represent just 14% of pediatric admissions, they account for 25% of pediatric hospital days and 30% of pediatric hospital charges.”

As defined by Dr. Thomson and her coinvestigators, neurological impairment (NI) was defined as any “neurologic disease resulting in functional or intellectual impairment,” such as cerebral palsy or epilepsy. Within the population of children with NI, pneumonia is a common reason for intensive care unit admission and the most common cause of death, but diagnostic testing, treatment, and outcomes vary widely from center to center.

After reviewing data on all children aged 1-18 years admitted to one of 40 U.S. children’s hospitals in the Pediatric Health Information Systems (PHIS) database for pneumonia from 2007 to 2012, Dr. Thomson and her associates selected 28,123 subjects for inclusion in the retrospective cohort study. The study had two primary outcomes: assess the variability of diagnostic testing performed at each center and determine the association of hospital-level diagnostic test utilization and hospitalization outcomes, mainly length of stay and 30-day readmission rates.

K-mean clustering was used to divide each hospital center into one of three groups – A, B, or C – based on diagnostic testing habits, with the proportion of patients receiving such testing compared across all included centers. Diagnostic testing was defined as laboratory studies and radiologic imaging ordered within the first 48 hours of admission. Kruskal-Wallis tests were used to compare the outcomes at each hospital.

Hospital centers in group C tended to perform significantly fewer tests than those in groups A and B, Dr. Thomson said.

Complete blood counts were performed on 56% of patients in group C centers, compared with 78% in group A and 72% in group B. Similarly, C-reactive protein tests were administered to 17% of patients in group A, 34% in group B, and 15% in group C. Viral studies were done on 24% of patients in group C, but 44% in group A and 52% in group B. Blood cultures were taken from 44% of patients in group C, but 63% in group A and 66% in group B. Urine culture tests were performed for 9% in group C, 22% of patients in group A, and 17% in group B, she reported.

The only test measured for which group C was not the lowest was respiratory culture: group C centers tested 5% of patients, while those in group A tested 15% and group B only tested 3% of patients.

Length of stay and 30-day readmission rates also were consistently lower for group C than groups A and B. Median length of stay across groups was 3.2 days; no hospital center in group C had a mean length of stay higher than 3.2, compared with 14 centers in group A and 5 in group B. The median 30-day readmission rate was 7.9% across all groups, a rate exceeded by 11 group A centers, 6 group B centers, and only 2 group C centers.

“We found [that] substantial hospital level variation exists in both diagnostic testing and outcomes,” Dr. Thomson said, adding that, since centers performing the fewest tests yielded the best outcomes, the findings here “represent an opportunity to improve the value of care provided to this important pediatric population” and that “overall testing can likely decrease without compromising the care we provide.”

Dr. Thomson did not report any relevant financial disclosures.

[email protected]

SAN DIEGO – Hospitals treating neurologically impaired children with pneumonia typically have the best clinical outcomes, shortest lengths of stay, and lowest readmission rates when fewer diagnostic tests are performed.

This suggests that testing protocols across hospital centers should be standardized so clinicians perform as few testing procedures as possible, thus ensuring an elevated standard of care, said Dr. Joanna E. Thomson, a pediatric hospitalist at the Cincinnati Children’s Hospital Medical Center.

“This population of children accounts for an increasing and disproportionate amount of inpatient hospital resources,” Dr. Thomson said at the annual meeting of the Pediatric Academic Societies. “While they represent just 14% of pediatric admissions, they account for 25% of pediatric hospital days and 30% of pediatric hospital charges.”

As defined by Dr. Thomson and her coinvestigators, neurological impairment (NI) was defined as any “neurologic disease resulting in functional or intellectual impairment,” such as cerebral palsy or epilepsy. Within the population of children with NI, pneumonia is a common reason for intensive care unit admission and the most common cause of death, but diagnostic testing, treatment, and outcomes vary widely from center to center.

After reviewing data on all children aged 1-18 years admitted to one of 40 U.S. children’s hospitals in the Pediatric Health Information Systems (PHIS) database for pneumonia from 2007 to 2012, Dr. Thomson and her associates selected 28,123 subjects for inclusion in the retrospective cohort study. The study had two primary outcomes: assess the variability of diagnostic testing performed at each center and determine the association of hospital-level diagnostic test utilization and hospitalization outcomes, mainly length of stay and 30-day readmission rates.

K-mean clustering was used to divide each hospital center into one of three groups – A, B, or C – based on diagnostic testing habits, with the proportion of patients receiving such testing compared across all included centers. Diagnostic testing was defined as laboratory studies and radiologic imaging ordered within the first 48 hours of admission. Kruskal-Wallis tests were used to compare the outcomes at each hospital.

Hospital centers in group C tended to perform significantly fewer tests than those in groups A and B, Dr. Thomson said.

Complete blood counts were performed on 56% of patients in group C centers, compared with 78% in group A and 72% in group B. Similarly, C-reactive protein tests were administered to 17% of patients in group A, 34% in group B, and 15% in group C. Viral studies were done on 24% of patients in group C, but 44% in group A and 52% in group B. Blood cultures were taken from 44% of patients in group C, but 63% in group A and 66% in group B. Urine culture tests were performed for 9% in group C, 22% of patients in group A, and 17% in group B, she reported.

The only test measured for which group C was not the lowest was respiratory culture: group C centers tested 5% of patients, while those in group A tested 15% and group B only tested 3% of patients.

Length of stay and 30-day readmission rates also were consistently lower for group C than groups A and B. Median length of stay across groups was 3.2 days; no hospital center in group C had a mean length of stay higher than 3.2, compared with 14 centers in group A and 5 in group B. The median 30-day readmission rate was 7.9% across all groups, a rate exceeded by 11 group A centers, 6 group B centers, and only 2 group C centers.

“We found [that] substantial hospital level variation exists in both diagnostic testing and outcomes,” Dr. Thomson said, adding that, since centers performing the fewest tests yielded the best outcomes, the findings here “represent an opportunity to improve the value of care provided to this important pediatric population” and that “overall testing can likely decrease without compromising the care we provide.”

Dr. Thomson did not report any relevant financial disclosures.

[email protected]

SAN DIEGO – Oral antibiotic therapy should be the preferred postdischarge treatment for pediatric patients with complicated pneumonia, as peripherally inserted central catheter (PICC) treatment has higher rates of treatment failure, adverse drug reactions, and related revisits, according to Dr. Samir S. Shah.

“Pneumonia is important because it is costly; in terms of cumulative costs to children’s hospitals, it is the second-most costly condition,” explained Dr. Shah, director of the division of hospital medicine at the Cincinnati Children’s Hospital Medical Center, who presented the findings of this retrospective cohort study at the annual meeting of the Pediatric Academic Societies.

“It is also potentially serious,” Dr. Shah continued. “Up to 15% of children hospitalized with pneumonia may have their course complicated by empyema, [and] even more problematic is that the incidences of complicated pneumonia are increasing.”

Dr. Shah and his coinvestigators examined the records for all children hospitalized between Jan. 1, 2009, and Dec. 31, 2012, with complicated pneumonia at 36 centers from across the United States. The primary outcome was treatment failure. Secondary outcomes were revisits related to the index admission, such as PICC complications, adverse drug reactions, and overall revisits.

The rate of treatment failure was higher in patients receiving PICC: 3.2% vs. 2.6% for those receiving oral antibiotics after discharge. Adverse drug reactions occurred in 3.2% of subjects receiving PICC, compared with only 0.2% of subjects in the oral antibiotics cohorts. Both related and overall revisits were higher in the PICC cohort than in the oral antibiotics cohort, too: 6.1% vs. 3.0% for related revisits, and 17.8% vs. 5.8% for overall revisits (P < .05). Treatment failure occurred in 49 children across both cohorts (2.3%).

Of the 2,123 children deemed eligible and included in the study, 281 were prescribed PICC as postdischarge treatment (13.2%), and the use of PICC overall varied from hospital to hospital; some centers prescribed PICC treatment in as many as 71% of cases, while some never prescribed it. Serum sickness, drug-induced neutropenia, and PICC thrombosis, dislodgment, and fever were the most commonly reported adverse effects across both cohorts. Treatment failure was reported in 49 (2.3%) cases.

“There were some problems with matching,” explained Dr. Shah, who is also professor of pediatrics at the University of Cincinnati. “Because many centers had small numbers of kids discharged with PICC therapy, we could not account for differences across hospitals.”

A review of charts’ ICD-9 codes in the nationwide Pediatric Health Information System (PHIS) and the Pediatric Research in Inpatient Settings (PRIS) Network was used to collect the patient population, and providers at each of the 36 institutions included reviewed medical records to confirm patient eligibility, define treatment groups, determine which antibiotic each patient was discharged with, and verify outcomes.

“This was an observational study, [and] there are limitations that go with that,” said Dr. Shah. “We adjusted for confounding using propensity score matching, but there are unmeasured confounding factors; [however,] because we matched across hospitals, we could better account for confounding by indication at the patient level.”

Dr. Shah did not report any relevant financial disclosures.

[email protected]

SAN DIEGO – Oral antibiotic therapy should be the preferred postdischarge treatment for pediatric patients with complicated pneumonia, as peripherally inserted central catheter (PICC) treatment has higher rates of treatment failure, adverse drug reactions, and related revisits, according to Dr. Samir S. Shah.

“Pneumonia is important because it is costly; in terms of cumulative costs to children’s hospitals, it is the second-most costly condition,” explained Dr. Shah, director of the division of hospital medicine at the Cincinnati Children’s Hospital Medical Center, who presented the findings of this retrospective cohort study at the annual meeting of the Pediatric Academic Societies.

“It is also potentially serious,” Dr. Shah continued. “Up to 15% of children hospitalized with pneumonia may have their course complicated by empyema, [and] even more problematic is that the incidences of complicated pneumonia are increasing.”

Dr. Shah and his coinvestigators examined the records for all children hospitalized between Jan. 1, 2009, and Dec. 31, 2012, with complicated pneumonia at 36 centers from across the United States. The primary outcome was treatment failure. Secondary outcomes were revisits related to the index admission, such as PICC complications, adverse drug reactions, and overall revisits.

The rate of treatment failure was higher in patients receiving PICC: 3.2% vs. 2.6% for those receiving oral antibiotics after discharge. Adverse drug reactions occurred in 3.2% of subjects receiving PICC, compared with only 0.2% of subjects in the oral antibiotics cohorts. Both related and overall revisits were higher in the PICC cohort than in the oral antibiotics cohort, too: 6.1% vs. 3.0% for related revisits, and 17.8% vs. 5.8% for overall revisits (P < .05). Treatment failure occurred in 49 children across both cohorts (2.3%).

Of the 2,123 children deemed eligible and included in the study, 281 were prescribed PICC as postdischarge treatment (13.2%), and the use of PICC overall varied from hospital to hospital; some centers prescribed PICC treatment in as many as 71% of cases, while some never prescribed it. Serum sickness, drug-induced neutropenia, and PICC thrombosis, dislodgment, and fever were the most commonly reported adverse effects across both cohorts. Treatment failure was reported in 49 (2.3%) cases.

“There were some problems with matching,” explained Dr. Shah, who is also professor of pediatrics at the University of Cincinnati. “Because many centers had small numbers of kids discharged with PICC therapy, we could not account for differences across hospitals.”

A review of charts’ ICD-9 codes in the nationwide Pediatric Health Information System (PHIS) and the Pediatric Research in Inpatient Settings (PRIS) Network was used to collect the patient population, and providers at each of the 36 institutions included reviewed medical records to confirm patient eligibility, define treatment groups, determine which antibiotic each patient was discharged with, and verify outcomes.

“This was an observational study, [and] there are limitations that go with that,” said Dr. Shah. “We adjusted for confounding using propensity score matching, but there are unmeasured confounding factors; [however,] because we matched across hospitals, we could better account for confounding by indication at the patient level.”

Dr. Shah did not report any relevant financial disclosures.

[email protected]

SAN DIEGO – Oral antibiotic therapy should be the preferred postdischarge treatment for pediatric patients with complicated pneumonia, as peripherally inserted central catheter (PICC) treatment has higher rates of treatment failure, adverse drug reactions, and related revisits, according to Dr. Samir S. Shah.

“Pneumonia is important because it is costly; in terms of cumulative costs to children’s hospitals, it is the second-most costly condition,” explained Dr. Shah, director of the division of hospital medicine at the Cincinnati Children’s Hospital Medical Center, who presented the findings of this retrospective cohort study at the annual meeting of the Pediatric Academic Societies.

“It is also potentially serious,” Dr. Shah continued. “Up to 15% of children hospitalized with pneumonia may have their course complicated by empyema, [and] even more problematic is that the incidences of complicated pneumonia are increasing.”

Dr. Shah and his coinvestigators examined the records for all children hospitalized between Jan. 1, 2009, and Dec. 31, 2012, with complicated pneumonia at 36 centers from across the United States. The primary outcome was treatment failure. Secondary outcomes were revisits related to the index admission, such as PICC complications, adverse drug reactions, and overall revisits.

The rate of treatment failure was higher in patients receiving PICC: 3.2% vs. 2.6% for those receiving oral antibiotics after discharge. Adverse drug reactions occurred in 3.2% of subjects receiving PICC, compared with only 0.2% of subjects in the oral antibiotics cohorts. Both related and overall revisits were higher in the PICC cohort than in the oral antibiotics cohort, too: 6.1% vs. 3.0% for related revisits, and 17.8% vs. 5.8% for overall revisits (P < .05). Treatment failure occurred in 49 children across both cohorts (2.3%).

Of the 2,123 children deemed eligible and included in the study, 281 were prescribed PICC as postdischarge treatment (13.2%), and the use of PICC overall varied from hospital to hospital; some centers prescribed PICC treatment in as many as 71% of cases, while some never prescribed it. Serum sickness, drug-induced neutropenia, and PICC thrombosis, dislodgment, and fever were the most commonly reported adverse effects across both cohorts. Treatment failure was reported in 49 (2.3%) cases.

“There were some problems with matching,” explained Dr. Shah, who is also professor of pediatrics at the University of Cincinnati. “Because many centers had small numbers of kids discharged with PICC therapy, we could not account for differences across hospitals.”

A review of charts’ ICD-9 codes in the nationwide Pediatric Health Information System (PHIS) and the Pediatric Research in Inpatient Settings (PRIS) Network was used to collect the patient population, and providers at each of the 36 institutions included reviewed medical records to confirm patient eligibility, define treatment groups, determine which antibiotic each patient was discharged with, and verify outcomes.

“This was an observational study, [and] there are limitations that go with that,” said Dr. Shah. “We adjusted for confounding using propensity score matching, but there are unmeasured confounding factors; [however,] because we matched across hospitals, we could better account for confounding by indication at the patient level.”

Dr. Shah did not report any relevant financial disclosures.

[email protected]

SAN DIEGO– Adoption of and strict adherence to a clinical pathway for diagnosis and treatment of bronchiolitis, especially in pediatric patients, can alleviate costs for both patients and hospitals in the ED and inpatient settings, and allow for shorter lengths of stay, according to a retrospective cohort study.

“This is an important topic because bronchiolitis is the leading cause of infant hospitalization in the U.S., and the cost of bronchiolitis hospitalization has been increasing,” Dr. Mersine A. Bryan of Seattle Children’s Hospital said at the annual meeting of the Pediatric Academic Societies.

“The care for bronchiolitis is supportive, meaning that testing and medical treatments are generally unnecessary, and can add to costs without improving outcomes. Because of that, bronchiolitis is a good candidate for clinical pathways and clinical practice guidelines,” Dr. Bryan said.

She and her coinvestigators looked at 282 children aged 0-24 months who presented at Seattle Children’s Hospital’s emergency department or inpatient setting with bronchiolitis between December 2009 and July 2012. A total of 18 process-of-care quality measures were instituted – 12 designed for inpatient care, 6 for emergency departments – with a primary objective of mitigating length-of-stay, costs, inpatient admission, and readmission. Pathways were meant to guide clinicians with “evidence-based recommendations and flows based on patient assessments and clinical findings.” Adherence to these pathways was scored by medical record review on a scale of 0-100 for each of the 18 categories. Low adherence was classified as a score below 86, midlevel adherence as a score between 86 and 93, and high adherence as anything above 94.

Mean adherence scores were: ED 78.2 (standard deviation [SD] 18.3, n = 279), inpatient 94.7 (SD 6.6, n = 231).No difference was noted in care of patients based on patient gender and medical complexity, but higher adherence was noted for younger patients.

Higher adherence led to shorter length of stay in both inpatient and emergency departments: 2.7 days vs. 3.7 days (P < .05), and 191 minutes vs. 264 minutes (P < .01), respectively. Mean patient costs saw greater reductions in departments with high adherence; a difference of $3,045 was noted in high-adherence inpatient departments, compared to a difference of $1,564 in inpatient departments with lower adherence to the pathway (P < .05). Similarly, emergency departments with high adherence saw average costs per patient drop by $183, compared to $95 for emergency departments with lower adherence scores (P < .05). Admittance odds and 7-day readmissions to emergency departments also were lower when adherence to pathways was higher.

Dr. Bryan cautioned that because this was a single-center study and the results may be difficult to generalize across institutions, adding that she and her coinvestigators were limited by the amount of information they could cull from available electronic medical records.

Dr. Bryan did not report any relevant financial disclosures.

[email protected]

SAN DIEGO– Adoption of and strict adherence to a clinical pathway for diagnosis and treatment of bronchiolitis, especially in pediatric patients, can alleviate costs for both patients and hospitals in the ED and inpatient settings, and allow for shorter lengths of stay, according to a retrospective cohort study.

“This is an important topic because bronchiolitis is the leading cause of infant hospitalization in the U.S., and the cost of bronchiolitis hospitalization has been increasing,” Dr. Mersine A. Bryan of Seattle Children’s Hospital said at the annual meeting of the Pediatric Academic Societies.

“The care for bronchiolitis is supportive, meaning that testing and medical treatments are generally unnecessary, and can add to costs without improving outcomes. Because of that, bronchiolitis is a good candidate for clinical pathways and clinical practice guidelines,” Dr. Bryan said.

She and her coinvestigators looked at 282 children aged 0-24 months who presented at Seattle Children’s Hospital’s emergency department or inpatient setting with bronchiolitis between December 2009 and July 2012. A total of 18 process-of-care quality measures were instituted – 12 designed for inpatient care, 6 for emergency departments – with a primary objective of mitigating length-of-stay, costs, inpatient admission, and readmission. Pathways were meant to guide clinicians with “evidence-based recommendations and flows based on patient assessments and clinical findings.” Adherence to these pathways was scored by medical record review on a scale of 0-100 for each of the 18 categories. Low adherence was classified as a score below 86, midlevel adherence as a score between 86 and 93, and high adherence as anything above 94.

Mean adherence scores were: ED 78.2 (standard deviation [SD] 18.3, n = 279), inpatient 94.7 (SD 6.6, n = 231).No difference was noted in care of patients based on patient gender and medical complexity, but higher adherence was noted for younger patients.

Higher adherence led to shorter length of stay in both inpatient and emergency departments: 2.7 days vs. 3.7 days (P < .05), and 191 minutes vs. 264 minutes (P < .01), respectively. Mean patient costs saw greater reductions in departments with high adherence; a difference of $3,045 was noted in high-adherence inpatient departments, compared to a difference of $1,564 in inpatient departments with lower adherence to the pathway (P < .05). Similarly, emergency departments with high adherence saw average costs per patient drop by $183, compared to $95 for emergency departments with lower adherence scores (P < .05). Admittance odds and 7-day readmissions to emergency departments also were lower when adherence to pathways was higher.

Dr. Bryan cautioned that because this was a single-center study and the results may be difficult to generalize across institutions, adding that she and her coinvestigators were limited by the amount of information they could cull from available electronic medical records.

Dr. Bryan did not report any relevant financial disclosures.

[email protected]

SAN DIEGO– Adoption of and strict adherence to a clinical pathway for diagnosis and treatment of bronchiolitis, especially in pediatric patients, can alleviate costs for both patients and hospitals in the ED and inpatient settings, and allow for shorter lengths of stay, according to a retrospective cohort study.

“This is an important topic because bronchiolitis is the leading cause of infant hospitalization in the U.S., and the cost of bronchiolitis hospitalization has been increasing,” Dr. Mersine A. Bryan of Seattle Children’s Hospital said at the annual meeting of the Pediatric Academic Societies.

“The care for bronchiolitis is supportive, meaning that testing and medical treatments are generally unnecessary, and can add to costs without improving outcomes. Because of that, bronchiolitis is a good candidate for clinical pathways and clinical practice guidelines,” Dr. Bryan said.

She and her coinvestigators looked at 282 children aged 0-24 months who presented at Seattle Children’s Hospital’s emergency department or inpatient setting with bronchiolitis between December 2009 and July 2012. A total of 18 process-of-care quality measures were instituted – 12 designed for inpatient care, 6 for emergency departments – with a primary objective of mitigating length-of-stay, costs, inpatient admission, and readmission. Pathways were meant to guide clinicians with “evidence-based recommendations and flows based on patient assessments and clinical findings.” Adherence to these pathways was scored by medical record review on a scale of 0-100 for each of the 18 categories. Low adherence was classified as a score below 86, midlevel adherence as a score between 86 and 93, and high adherence as anything above 94.

Mean adherence scores were: ED 78.2 (standard deviation [SD] 18.3, n = 279), inpatient 94.7 (SD 6.6, n = 231).No difference was noted in care of patients based on patient gender and medical complexity, but higher adherence was noted for younger patients.

Higher adherence led to shorter length of stay in both inpatient and emergency departments: 2.7 days vs. 3.7 days (P < .05), and 191 minutes vs. 264 minutes (P < .01), respectively. Mean patient costs saw greater reductions in departments with high adherence; a difference of $3,045 was noted in high-adherence inpatient departments, compared to a difference of $1,564 in inpatient departments with lower adherence to the pathway (P < .05). Similarly, emergency departments with high adherence saw average costs per patient drop by $183, compared to $95 for emergency departments with lower adherence scores (P < .05). Admittance odds and 7-day readmissions to emergency departments also were lower when adherence to pathways was higher.

Dr. Bryan cautioned that because this was a single-center study and the results may be difficult to generalize across institutions, adding that she and her coinvestigators were limited by the amount of information they could cull from available electronic medical records.

Dr. Bryan did not report any relevant financial disclosures.

[email protected]

SAN DIEGO– There is no clear clinical benefit to diagnosing and treating infants with abnormal swallowing, according to the results of a video fluoroscopic swallow study (VFSS), and in certain cases, the study could be associated with an increased risk of developing acute respiratory infections (ARI) in these populations.

In a retrospective cohort study, Dr. Eric R. Coon of the University of Utah, Salt Lake City, and his colleagues examined data on all infants aged 12 months or younger who underwent VFSS from 2010 to 2012 at Primary Children’s Hospital in Salt Lake City.

“Providers implicitly believe that infant swallowing abnormalities lead to future respiratory illness,” Dr. Coon said at the annual meeting of the Pediatric Academic Societies. “However, data for that link is limited to descriptive case series, and studies relying on subjective definitions of aspiration that don’t include radiographic confirmation [and] interventions for swallowing abnormalities have not been shown to improve important clinical outcomes.”

The investigators looked at all inpatient, outpatient, and emergency department ARI cases in the Intermountain Healthcare system, a network of 22 hospital centers servicing five states, over the same time period in patients who experienced ARI between their first VFSS and age 3 years. ARI was defined as either bronchiolitis, asthma, pneumonia, or aspiration pneumonia, and was identified via IDC-9 codes.

Out of 576 infants, 199 (34%) exhibited oropharyngeal aspiration, 79 (14%) showed penetration, and 298 (52%)were classified as “normal.” Of the 199 with aspiration, 38 (19%) had thin aspiration and cough, 11 (6%) had thick aspiration and cough, 93 (47%) had thin aspiration and were silent, and 57 (28%) had thick aspiration and were silent.

Those deemed “thick aspiration, silent,” however, averaged 581 days to ARI, the shortest of any cohort, and a mean of 2.39 ARIs per subject. “Thin aspiration, cough” subjects had 638 mean days to ARI and a mean of 1.63 ARIs; “thick aspiration, cough” subjects had a mean of 750 days to ARI and 0.55 mean number of ARIs; and “thin aspiration, silent” had an average of 669 days to ARI and a mean of 1.69 ARIs (P < .05).

Those in the normal, or control, cohort averaged 715 days to ARI and 1.36 ARIs, while those with just penetration averaged 681 days to ARIs and 1.53 ARIs per subject (P < .05).

Cox regression models were used to calculate data time to first ARI, and Poisson regression was used for data on total number of ARIs experienced. Taking into account subject’s age at initial test, presence of complex chronic conditions in each subject, result of VFSS and type of aspiration intervention, silent aspiration with thickened feed yielded a Cox hazard ratio of 1.30 and a Poisson hazard ratio of 1.47, higher than all the others.

“The clinical importance of [VFSS]-detected abnormalities remains unclear, making them high-risk for overdiagnosis,” concluded Dr. Coon, adding that “patients may not experience net benefit, but may in fact be harmed.”

Dr. Coon did not report any relevant financial disclosures.

[email protected]

SAN DIEGO– There is no clear clinical benefit to diagnosing and treating infants with abnormal swallowing, according to the results of a video fluoroscopic swallow study (VFSS), and in certain cases, the study could be associated with an increased risk of developing acute respiratory infections (ARI) in these populations.

In a retrospective cohort study, Dr. Eric R. Coon of the University of Utah, Salt Lake City, and his colleagues examined data on all infants aged 12 months or younger who underwent VFSS from 2010 to 2012 at Primary Children’s Hospital in Salt Lake City.

“Providers implicitly believe that infant swallowing abnormalities lead to future respiratory illness,” Dr. Coon said at the annual meeting of the Pediatric Academic Societies. “However, data for that link is limited to descriptive case series, and studies relying on subjective definitions of aspiration that don’t include radiographic confirmation [and] interventions for swallowing abnormalities have not been shown to improve important clinical outcomes.”

The investigators looked at all inpatient, outpatient, and emergency department ARI cases in the Intermountain Healthcare system, a network of 22 hospital centers servicing five states, over the same time period in patients who experienced ARI between their first VFSS and age 3 years. ARI was defined as either bronchiolitis, asthma, pneumonia, or aspiration pneumonia, and was identified via IDC-9 codes.

Out of 576 infants, 199 (34%) exhibited oropharyngeal aspiration, 79 (14%) showed penetration, and 298 (52%)were classified as “normal.” Of the 199 with aspiration, 38 (19%) had thin aspiration and cough, 11 (6%) had thick aspiration and cough, 93 (47%) had thin aspiration and were silent, and 57 (28%) had thick aspiration and were silent.

Those deemed “thick aspiration, silent,” however, averaged 581 days to ARI, the shortest of any cohort, and a mean of 2.39 ARIs per subject. “Thin aspiration, cough” subjects had 638 mean days to ARI and a mean of 1.63 ARIs; “thick aspiration, cough” subjects had a mean of 750 days to ARI and 0.55 mean number of ARIs; and “thin aspiration, silent” had an average of 669 days to ARI and a mean of 1.69 ARIs (P < .05).

Those in the normal, or control, cohort averaged 715 days to ARI and 1.36 ARIs, while those with just penetration averaged 681 days to ARIs and 1.53 ARIs per subject (P < .05).

Cox regression models were used to calculate data time to first ARI, and Poisson regression was used for data on total number of ARIs experienced. Taking into account subject’s age at initial test, presence of complex chronic conditions in each subject, result of VFSS and type of aspiration intervention, silent aspiration with thickened feed yielded a Cox hazard ratio of 1.30 and a Poisson hazard ratio of 1.47, higher than all the others.

“The clinical importance of [VFSS]-detected abnormalities remains unclear, making them high-risk for overdiagnosis,” concluded Dr. Coon, adding that “patients may not experience net benefit, but may in fact be harmed.”

Dr. Coon did not report any relevant financial disclosures.

[email protected]

SAN DIEGO– There is no clear clinical benefit to diagnosing and treating infants with abnormal swallowing, according to the results of a video fluoroscopic swallow study (VFSS), and in certain cases, the study could be associated with an increased risk of developing acute respiratory infections (ARI) in these populations.

In a retrospective cohort study, Dr. Eric R. Coon of the University of Utah, Salt Lake City, and his colleagues examined data on all infants aged 12 months or younger who underwent VFSS from 2010 to 2012 at Primary Children’s Hospital in Salt Lake City.

“Providers implicitly believe that infant swallowing abnormalities lead to future respiratory illness,” Dr. Coon said at the annual meeting of the Pediatric Academic Societies. “However, data for that link is limited to descriptive case series, and studies relying on subjective definitions of aspiration that don’t include radiographic confirmation [and] interventions for swallowing abnormalities have not been shown to improve important clinical outcomes.”

The investigators looked at all inpatient, outpatient, and emergency department ARI cases in the Intermountain Healthcare system, a network of 22 hospital centers servicing five states, over the same time period in patients who experienced ARI between their first VFSS and age 3 years. ARI was defined as either bronchiolitis, asthma, pneumonia, or aspiration pneumonia, and was identified via IDC-9 codes.

Out of 576 infants, 199 (34%) exhibited oropharyngeal aspiration, 79 (14%) showed penetration, and 298 (52%)were classified as “normal.” Of the 199 with aspiration, 38 (19%) had thin aspiration and cough, 11 (6%) had thick aspiration and cough, 93 (47%) had thin aspiration and were silent, and 57 (28%) had thick aspiration and were silent.

Those deemed “thick aspiration, silent,” however, averaged 581 days to ARI, the shortest of any cohort, and a mean of 2.39 ARIs per subject. “Thin aspiration, cough” subjects had 638 mean days to ARI and a mean of 1.63 ARIs; “thick aspiration, cough” subjects had a mean of 750 days to ARI and 0.55 mean number of ARIs; and “thin aspiration, silent” had an average of 669 days to ARI and a mean of 1.69 ARIs (P < .05).

Those in the normal, or control, cohort averaged 715 days to ARI and 1.36 ARIs, while those with just penetration averaged 681 days to ARIs and 1.53 ARIs per subject (P < .05).

Cox regression models were used to calculate data time to first ARI, and Poisson regression was used for data on total number of ARIs experienced. Taking into account subject’s age at initial test, presence of complex chronic conditions in each subject, result of VFSS and type of aspiration intervention, silent aspiration with thickened feed yielded a Cox hazard ratio of 1.30 and a Poisson hazard ratio of 1.47, higher than all the others.

“The clinical importance of [VFSS]-detected abnormalities remains unclear, making them high-risk for overdiagnosis,” concluded Dr. Coon, adding that “patients may not experience net benefit, but may in fact be harmed.”

Dr. Coon did not report any relevant financial disclosures.

[email protected]

SAN DIEGO– Children exposed to antibiotics are at a significantly heightened risk to develop extended-spectrum cephalosporin-resistant (ESC-R) and carbapenem-resistant (CR) Enterobacteriaceae infections within 30 days of said exposure, according to a prospective, case-controlled study.

Dr. Matthew P. Kronman, a pediatric infectious disease specialist at Seattle Children’s Hospital, and several coinvestigators examined data on 1,263 children from four hospital centers in the United States – Seattle Children’s Hospital; Washington University, St. Louis; Children’s Mercy Hospital, Kansas City, Mo.; and Children’s Hospital of Philadelphia – from Oct. 1, 2009, through Sept. 30, 2013.

“The CDC [Centers for Disease Control and Prevention] estimates that 2 million Americans get multidrug resistant organism [MDRO] infections each year, and 23,000 die,” said Dr. Kronman, adding that while it’s known that prior exposure to antibiotics is a key risk factor for colonization and development of an infection in adults, similar data among children with respect to ampC and extended-spectrum beta-lactamase (ESBL) are conflicting.

The study population included 95 subjects with ampC infections, 213 with ESBL infections, and 955 controls, for a total of 1,263 children. Prior exposure to antibiotics within the previous month or 3 months before infection was associated with infection of either ESC-R or CR Enterobacteriaceae (P < .01). A cumulative effect was noted, with increased exposure to antibiotics increasing the likelihood of developing an MDRO infection within 3 months (odds ratio 1.28 per month, P < .01), Dr. Kronman reported at the annual meeting of the Pediatric Academic Societies.

Those with ESBL infections were more likely to have any antibiotic exposure in the 30 days prior to their infection than were their control counterparts (OR > 2), but a similar, statistically significant relationship among those with ampC infections was not observed. When the researchers looked at broad-spectrum antibiotic exposures – defined as “carbapenems, beta-lactams, beta-lactase inhibitors, tetracyclines, and so on” – those with ESBL infections were more likely to have broad-spectrum antibiotic exposures in the month prior to their infection, which was not the case for those with ampC infections.

Both ESBL and ampC subjects were more likely to have been exposed to extended-spectrum cephalosporin use in the month prior to infection than controls. “When we looked just the use of antibiotics with anaerobic activity only, neither ESBL nor ampC infections were more likely than their control counterparts to have had exposure to anaerobic antibiotics in the month prior to infection,” Dr. Kronman said.

Patients had Escherichia coli and Klebsiella pneumoniae isolates collected from normally sterile sites; 91% were isolated from urine, and 46% were found to be associated with “community onset infection.” Samples were phenotypically resistant to extended spectrum cephalosporins, but were genotyped at Seattle Children’s Hospital to determine if the resistant strain was ampC or an ESBL. E. coli cases dominated the study population (85%), compared with cases of K. pneumoniae (15%). Results were adjusted for age, gender, prior hospitalization, underlying medical conditions, immunosuppression, and presence of indwelling devices. Median age of subjects was 5 years.

Those with resistant infections were more likely to have a “significant past medical history” of urologic conditions or malignancies; to have had hospitalization within the previous year; to be on immunosuppression at the time of the infection; or to have an indwelling device at the time of the infection. Resistant infections were less likely to originate in the community and were more commonly health care associated.

Dr. Kronman did not report any relevant financial disclosures.

[email protected]

SAN DIEGO– Children exposed to antibiotics are at a significantly heightened risk to develop extended-spectrum cephalosporin-resistant (ESC-R) and carbapenem-resistant (CR) Enterobacteriaceae infections within 30 days of said exposure, according to a prospective, case-controlled study.

Dr. Matthew P. Kronman, a pediatric infectious disease specialist at Seattle Children’s Hospital, and several coinvestigators examined data on 1,263 children from four hospital centers in the United States – Seattle Children’s Hospital; Washington University, St. Louis; Children’s Mercy Hospital, Kansas City, Mo.; and Children’s Hospital of Philadelphia – from Oct. 1, 2009, through Sept. 30, 2013.

“The CDC [Centers for Disease Control and Prevention] estimates that 2 million Americans get multidrug resistant organism [MDRO] infections each year, and 23,000 die,” said Dr. Kronman, adding that while it’s known that prior exposure to antibiotics is a key risk factor for colonization and development of an infection in adults, similar data among children with respect to ampC and extended-spectrum beta-lactamase (ESBL) are conflicting.

The study population included 95 subjects with ampC infections, 213 with ESBL infections, and 955 controls, for a total of 1,263 children. Prior exposure to antibiotics within the previous month or 3 months before infection was associated with infection of either ESC-R or CR Enterobacteriaceae (P < .01). A cumulative effect was noted, with increased exposure to antibiotics increasing the likelihood of developing an MDRO infection within 3 months (odds ratio 1.28 per month, P < .01), Dr. Kronman reported at the annual meeting of the Pediatric Academic Societies.

Those with ESBL infections were more likely to have any antibiotic exposure in the 30 days prior to their infection than were their control counterparts (OR > 2), but a similar, statistically significant relationship among those with ampC infections was not observed. When the researchers looked at broad-spectrum antibiotic exposures – defined as “carbapenems, beta-lactams, beta-lactase inhibitors, tetracyclines, and so on” – those with ESBL infections were more likely to have broad-spectrum antibiotic exposures in the month prior to their infection, which was not the case for those with ampC infections.

Both ESBL and ampC subjects were more likely to have been exposed to extended-spectrum cephalosporin use in the month prior to infection than controls. “When we looked just the use of antibiotics with anaerobic activity only, neither ESBL nor ampC infections were more likely than their control counterparts to have had exposure to anaerobic antibiotics in the month prior to infection,” Dr. Kronman said.

Patients had Escherichia coli and Klebsiella pneumoniae isolates collected from normally sterile sites; 91% were isolated from urine, and 46% were found to be associated with “community onset infection.” Samples were phenotypically resistant to extended spectrum cephalosporins, but were genotyped at Seattle Children’s Hospital to determine if the resistant strain was ampC or an ESBL. E. coli cases dominated the study population (85%), compared with cases of K. pneumoniae (15%). Results were adjusted for age, gender, prior hospitalization, underlying medical conditions, immunosuppression, and presence of indwelling devices. Median age of subjects was 5 years.

Those with resistant infections were more likely to have a “significant past medical history” of urologic conditions or malignancies; to have had hospitalization within the previous year; to be on immunosuppression at the time of the infection; or to have an indwelling device at the time of the infection. Resistant infections were less likely to originate in the community and were more commonly health care associated.

Dr. Kronman did not report any relevant financial disclosures.

[email protected]

SAN DIEGO– Children exposed to antibiotics are at a significantly heightened risk to develop extended-spectrum cephalosporin-resistant (ESC-R) and carbapenem-resistant (CR) Enterobacteriaceae infections within 30 days of said exposure, according to a prospective, case-controlled study.

Dr. Matthew P. Kronman, a pediatric infectious disease specialist at Seattle Children’s Hospital, and several coinvestigators examined data on 1,263 children from four hospital centers in the United States – Seattle Children’s Hospital; Washington University, St. Louis; Children’s Mercy Hospital, Kansas City, Mo.; and Children’s Hospital of Philadelphia – from Oct. 1, 2009, through Sept. 30, 2013.

“The CDC [Centers for Disease Control and Prevention] estimates that 2 million Americans get multidrug resistant organism [MDRO] infections each year, and 23,000 die,” said Dr. Kronman, adding that while it’s known that prior exposure to antibiotics is a key risk factor for colonization and development of an infection in adults, similar data among children with respect to ampC and extended-spectrum beta-lactamase (ESBL) are conflicting.

The study population included 95 subjects with ampC infections, 213 with ESBL infections, and 955 controls, for a total of 1,263 children. Prior exposure to antibiotics within the previous month or 3 months before infection was associated with infection of either ESC-R or CR Enterobacteriaceae (P < .01). A cumulative effect was noted, with increased exposure to antibiotics increasing the likelihood of developing an MDRO infection within 3 months (odds ratio 1.28 per month, P < .01), Dr. Kronman reported at the annual meeting of the Pediatric Academic Societies.

Those with ESBL infections were more likely to have any antibiotic exposure in the 30 days prior to their infection than were their control counterparts (OR > 2), but a similar, statistically significant relationship among those with ampC infections was not observed. When the researchers looked at broad-spectrum antibiotic exposures – defined as “carbapenems, beta-lactams, beta-lactase inhibitors, tetracyclines, and so on” – those with ESBL infections were more likely to have broad-spectrum antibiotic exposures in the month prior to their infection, which was not the case for those with ampC infections.

Both ESBL and ampC subjects were more likely to have been exposed to extended-spectrum cephalosporin use in the month prior to infection than controls. “When we looked just the use of antibiotics with anaerobic activity only, neither ESBL nor ampC infections were more likely than their control counterparts to have had exposure to anaerobic antibiotics in the month prior to infection,” Dr. Kronman said.

Patients had Escherichia coli and Klebsiella pneumoniae isolates collected from normally sterile sites; 91% were isolated from urine, and 46% were found to be associated with “community onset infection.” Samples were phenotypically resistant to extended spectrum cephalosporins, but were genotyped at Seattle Children’s Hospital to determine if the resistant strain was ampC or an ESBL. E. coli cases dominated the study population (85%), compared with cases of K. pneumoniae (15%). Results were adjusted for age, gender, prior hospitalization, underlying medical conditions, immunosuppression, and presence of indwelling devices. Median age of subjects was 5 years.

Those with resistant infections were more likely to have a “significant past medical history” of urologic conditions or malignancies; to have had hospitalization within the previous year; to be on immunosuppression at the time of the infection; or to have an indwelling device at the time of the infection. Resistant infections were less likely to originate in the community and were more commonly health care associated.

Dr. Kronman did not report any relevant financial disclosures.

[email protected]