RESUMO
OBJECTIVE: To identify practice patterns in the duration of prescribed antibiotics for the treatment of ambulatory children with community-acquired pneumonia (CAP) and to compare the frequency of adverse clinical outcomes between children prescribed short-vs prolonged-duration antibiotics. STUDY DESIGN: We performed a retrospective cohort study from 2010-2016 using the IBM Watson MarketScan Medicaid Database, a claims database of publicly insured patients from 11 states. We included children 1-18 years old with outpatient CAP who filled a prescription for oral antibiotics (n = 121 846 encounters). We used multivariable logistic regression to determine associations between the duration of prescribed antibiotics (5-9 days vs 10-14 days) and subsequent hospitalizations, new antibiotic prescriptions, and acute care visits. Outcomes were measured during the 14 days following the end of the dispensed antibiotic course. RESULTS: The most commonly prescribed duration of antibiotics was 10 days (82.8% of prescriptions), and 10.5% of patients received short-duration therapy. During the follow-up period, 0.2% of patients were hospitalized, 6.2% filled a new antibiotic prescription, and 5.1% had an acute care visit. Compared with the prolonged-duration group, the aORs for hospitalization, new antibiotic prescriptions, and acute care visits in the short-duration group were 1.16 (95% CI 0.80-1.66), 0.93 (95% CI 0.85-1.01), and 1.06 (95% CI 0.98-1.15), respectively. CONCLUSIONS: Most children treated for CAP as outpatients are prescribed at least 10 days of antibiotic therapy. Among pediatric outpatients with CAP, no significant differences were found in rates of adverse clinical outcomes between patients prescribed short-vs prolonged-duration antibiotics.
Assuntos
Assistência Ambulatorial/métodos , Antibacterianos/administração & dosagem , Pneumonia/tratamento farmacológico , Administração Oral , Adolescente , Antibacterianos/uso terapêutico , Criança , Pré-Escolar , Infecções Comunitárias Adquiridas/tratamento farmacológico , Esquema de Medicação , Feminino , Seguimentos , Humanos , Lactente , Modelos Logísticos , Masculino , Estudos Retrospectivos , Resultado do TratamentoRESUMO
OBJECTIVES: To describe antibiotic prescribing patterns in ambulatory children with community-acquired pneumonia and to assess the relationship between antibiotic selection and clinical outcomes. STUDY DESIGN: This was a retrospective cohort study of ambulatory Medicaid-enrolled children 0-18 years of age diagnosed with community-acquired pneumonia from 2010 to 2016. The exposure was antibiotic class: narrow-spectrum (aminopenicillins), broad-spectrum (amoxicillin/clavulanate and cephalosporins), macrolide monotherapy, macrolides with narrow-spectrum antibiotics, or macrolides with broad-spectrum antibiotics. The associations between antibiotic selection and the outcomes of subsequent hospitalization and development of severe pneumonia (chest drainage procedure, intensive care admission, mechanical ventilation) were assessed, controlling for measures of illness severity. RESULTS: Among 252 177 outpatient pneumonia visits, macrolide monotherapy was used in 43.2%, narrow-spectrum antibiotics in 26.1%, and broad-spectrum antibiotics in 24.7%. A total of 1488 children (0.59%) were subsequently hospitalized and 117 (0.05%) developed severe pneumonia. Compared with children receiving narrow-spectrum antibiotics, the odds of subsequent hospitalization were higher in children receiving broad-spectrum antibiotics (aOR, 1.34; 95% CI, 1.17-1.52) and lower in children receiving macrolide monotherapy (aOR, 0.64; 95% CI, 0.55-0.73) and macrolides with narrow-spectrum antibiotics (aOR, 0.62; 95% CI, 0.39-0.97). Children receiving macrolide monotherapy had lower odds of developing severe pneumonia than children receiving narrow-spectrum antibiotics (aOR, 0.56; 95% CI, 0.33-0.93). However, the absolute risk difference was <0.5% for all analyses. CONCLUSIONS: Macrolides are the most commonly prescribed antibiotic for ambulatory children with community-acquired pneumonia. Subsequent hospitalization and severe pneumonia are rare. Future efforts should focus on reducing broad-spectrum and macrolide antibiotic prescribing.
Assuntos
Antibacterianos/uso terapêutico , Prescrições de Medicamentos/estatística & dados numéricos , Pneumonia Bacteriana/tratamento farmacológico , Adolescente , Assistência Ambulatorial , Criança , Pré-Escolar , Estudos de Coortes , Infecções Comunitárias Adquiridas/tratamento farmacológico , Feminino , Humanos , Lactente , Masculino , Estudos Retrospectivos , Resultado do TratamentoRESUMO
OBJECTIVES: To update previously described trends for neonates with congenital diaphragmatic hernia (CDH) receiving ECMO with changes in recommendations for care, and to determine how recent advancements in respiratory care have affected this patient population. STUDY DESIGN: This study is a retrospective review of more than 2500 neonates with CDH who received ECMO listed in the Extracorporeal Life Support Organization (ELSO) registry. Cochran-Armitage and multivariate regression analyses were used to analyze changes in the patient population over time and in mortality-related risk factors. RESULTS: Almost one-half (48.1%) of the term neonates survived to discharge, representing a 13.8% decline in survival over the past 25 years (P < .0001). Over the past 10 years, the prevalence of respiratory acidosis more than doubled (P < .0001) and the prevalence of major complications increased (P < .001). During the same period, the number of ECMO courses longer than 1 week increased (P < .001), whereas the prevalence of multiple complications (>4) decreased (P < .0001). Surgeries performed on ECMO were associated with worse outcomes than those performed off ECMO. ECMO duration no longer represents a mortality-related risk factor. CONCLUSIONS: Survival rates for neonates with CDH receiving ECMO have continued to drop in the modern era. Although the safety of ECMO has improved over the last decade, the number of patients experiencing significant respiratory acidosis has more than doubled-increasing the risk of intracranial hemorrhage and overall mortality. The evidence for permissive hypercapnia remains mixed; nonetheless, we believe that the risks outweigh the rewards in this patient population.
Assuntos
Oxigenação por Membrana Extracorpórea , Hérnias Diafragmáticas Congênitas/terapia , Oxigenação por Membrana Extracorpórea/efeitos adversos , Feminino , Hérnias Diafragmáticas Congênitas/mortalidade , Humanos , Recém-Nascido , Modelos Logísticos , Masculino , Análise Multivariada , Sistema de Registros , Estudos Retrospectivos , Fatores de Risco , Análise de Sobrevida , Resultado do TratamentoRESUMO
OBJECTIVE: To describe the off-label use of antithrombin concentrate in tertiary care pediatric hospitals across the US. STUDY DESIGN: This is a retrospective, multicenter, cohort study of 4210 admissions of children younger than 18 years of age who received antithrombin concentrate between 2002 and 2011 within the Pediatric Health Information System administrative database. An on-label admission was defined as an admission with an International Classification of Diseases diagnostic code for a primary hypercoagulable state; admissions without this code were classified as off-label. RESULTS: During the 10-year study period, off-label use of antithrombin concentrate increased 5-fold. Overall, 97% of study subjects received antithrombin off-label. Neonates younger than 30 days of age comprised the largest age group (45.7%) of use; 87% of patients had at least one complex chronic condition, with congenital heart/lung defects being the most prevalent primary diagnosis (36.3%). Extracorporeal membrane oxygenation was the most common procedure associated with antithrombin use (43.7%). CONCLUSIONS: The off-label use of antithrombin concentrate is increasing rapidly, particularly in critically ill children receiving extracorporeal membrane oxygenation, with few parallel studies to substantiate its safety or efficacy. Further preclinical and controlled clinical studies are critical to expanding our knowledge of this drug. In the meantime, antithrombin concentrate should be used judiciously by clinicians and following guidelines instated by hospitals.
Assuntos
Antitrombinas/uso terapêutico , Uso Off-Label , Adolescente , Criança , Pré-Escolar , Estudos de Coortes , Feminino , Cardiopatias Congênitas/tratamento farmacológico , Hospitais Pediátricos , Humanos , Lactente , Recém-Nascido , Pneumopatias/congênito , Pneumopatias/tratamento farmacológico , Masculino , Estudos Retrospectivos , Centros de Atenção TerciáriaRESUMO
OBJECTIVE: To describe a unique experience providing critical care to infants and children in Haiti 3 months after a major earthquake. DESIGN: Observational. SETTING: Field medical facility in a developing country. PATIENTS: Infants and children admitted to a combined neonatal and pediatric intensive care unit between April 17 and 24, 2010. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Nine infants and 20 children were admitted to an intensive care unit with eight cots and ten infant beds over a 1-wk period. Central nervous system and infectious diseases were the most common reasons for intensive care unit admission. Nine of 20 (45%) children died before hospital discharge. Survivors represented a cohort of children with acute, reversible disease. CONCLUSIONS: Pediatric critical care can be implemented in low-income countries but requires significant resource use and careful patient selection. Consideration should be paid to the costs of delivering critical care in developing countries, which can inadvertently appropriate resources that have a larger impact on pediatric public health.