Fellows journal Club
Article: Thomson J, Hall M, Ambroggio L, Berry JG, Stone B, Srivastava R, Shah SS. Antibiotics for Aspiration Pneumonia in Neurologically Impaired Children. Journal Hospital Medicine. 2020 Jul 1;15(7):395-402.
Fellow: Rachel “Danielle” Fisher, MD; Helen DeVos Children’s Hospital, Spectrum Health, Grand Rapids, MI.
Summary: In neurologically impaired children, types of antibiotic coverage for aspiration pneumonia (anaerobes, gram negative, and antipseudomonal) were compared to find the relative impact of antibiotic choice on length of stay, ICU transfer, and acute respiratory failure. Investigators used the Pediatric Health Information System (PHIS) database and used diagnosis codes to identify patients who had diagnosis of neurologic impairment, aspiration pneumonia, and received antibiotics in the first 2 days of admission, but also excluded tracheostomy dependent patients. Children who received only anaerobic coverage and those who received anaerobic plus gram negative coverage had similar outcomes for ICU transfer and length of stay, but anaerobic plus gram negative coverage increased the risk of respiratory failure compared to anaerobic coverage alone. Those receiving gram negative coverage alone had statistically significantly worse outcomes on all 3 measures compared to anaerobic coverage alone, and those receiving antipseudomonal coverage had a shorter length of stay.
Key Strengths: This was a large-scale study including n=4733 patients in multiple children’s hospitals, which is the setting where the majority of acute care for neurologically impaired children occurs. The study highlights the variability of prescribing practices between different hospitals. The selected outcome criteria of respiratory failure and ICU transfer were both relatively common (25%, 29%) and clinically significant events. The authors used adjusted outcomes through a generalized linear mixed effects model to account for several markers of severity including age, presence and number of complex chronic conditions, technology dependence, diagnostic testing on admission, and illness severity on presentation.
Limitations: The most prevalent regimen used was anaerobic plus gram negative, but the reference group was set to be anaerobic coverage alone. Despite attempts to control for complexity, the measures are not comprehensive and do not use a validated scoring system. There is no way to control how physician choice of antibiotic may be influenced by that complexity in a retrospective observational study. The study did not examine correlation to causative organisms of the pneumonias, which will influence treatment success.
Main Takeaway: Anaerobic coverage inclusion is important to the treatment of aspiration pneumonia in neurologically impaired children. Gram negative coverage alone was inferior in all clinical outcomes to regimens that included anaerobic coverage and doubled the rate of acute respiratory failure.
Impact to practice: This study shows that anaerobic coverage is crucial for prevention of negative outcomes in neurologically impaired children with aspiration pneumonia. Anaerobic coverage inclusion can be increased, as currently institutions are prescribing gram negative coverage alone for 3-26% of patients. Because anaerobic alone and anaerobic plus gram negative coverage performed similarly in length of stay and ICU transfer but had differences in acute respiratory failure, further study should elucidate the role of gram negative coverage before narrowing the spectrum to anaerobic coverage alone.
Fellow: Rachel “Danielle” Fisher, MD; Helen DeVos Children’s Hospital, Spectrum Health, Grand Rapids, MI.
Summary: In neurologically impaired children, types of antibiotic coverage for aspiration pneumonia (anaerobes, gram negative, and antipseudomonal) were compared to find the relative impact of antibiotic choice on length of stay, ICU transfer, and acute respiratory failure. Investigators used the Pediatric Health Information System (PHIS) database and used diagnosis codes to identify patients who had diagnosis of neurologic impairment, aspiration pneumonia, and received antibiotics in the first 2 days of admission, but also excluded tracheostomy dependent patients. Children who received only anaerobic coverage and those who received anaerobic plus gram negative coverage had similar outcomes for ICU transfer and length of stay, but anaerobic plus gram negative coverage increased the risk of respiratory failure compared to anaerobic coverage alone. Those receiving gram negative coverage alone had statistically significantly worse outcomes on all 3 measures compared to anaerobic coverage alone, and those receiving antipseudomonal coverage had a shorter length of stay.
Key Strengths: This was a large-scale study including n=4733 patients in multiple children’s hospitals, which is the setting where the majority of acute care for neurologically impaired children occurs. The study highlights the variability of prescribing practices between different hospitals. The selected outcome criteria of respiratory failure and ICU transfer were both relatively common (25%, 29%) and clinically significant events. The authors used adjusted outcomes through a generalized linear mixed effects model to account for several markers of severity including age, presence and number of complex chronic conditions, technology dependence, diagnostic testing on admission, and illness severity on presentation.
Limitations: The most prevalent regimen used was anaerobic plus gram negative, but the reference group was set to be anaerobic coverage alone. Despite attempts to control for complexity, the measures are not comprehensive and do not use a validated scoring system. There is no way to control how physician choice of antibiotic may be influenced by that complexity in a retrospective observational study. The study did not examine correlation to causative organisms of the pneumonias, which will influence treatment success.
Main Takeaway: Anaerobic coverage inclusion is important to the treatment of aspiration pneumonia in neurologically impaired children. Gram negative coverage alone was inferior in all clinical outcomes to regimens that included anaerobic coverage and doubled the rate of acute respiratory failure.
Impact to practice: This study shows that anaerobic coverage is crucial for prevention of negative outcomes in neurologically impaired children with aspiration pneumonia. Anaerobic coverage inclusion can be increased, as currently institutions are prescribing gram negative coverage alone for 3-26% of patients. Because anaerobic alone and anaerobic plus gram negative coverage performed similarly in length of stay and ICU transfer but had differences in acute respiratory failure, further study should elucidate the role of gram negative coverage before narrowing the spectrum to anaerobic coverage alone.
Fellow: Rachel “Danielle” Fisher, MD; Helen DeVos Children’s Hospital, Spectrum Health, Grand Rapids, MI
Fellowship accomplishments and current research or work: My primary fellowship work is the development and study of a co-management program between our pediatric hospital medicine and pediatric neurosurgical teams. We designed and implemented the new program, and I am now studying its effect on cost, length of stay, ICU time, and readmissions with a primary goal to reduce readmissions. At the 6 month mark, we successfully reduced readmissions from 13% to 8%, representing a projected 5% cost savings for the overall program. Another quality improvement project involves increasing communication and safety planning in the peri-operative period for complex pediatric patients by using a novel huddle system invented at Helen DeVos Children’s Hospital called “iSTOP©,” which stands for Introduction, Surgery, Tubes and Lines, Operative Plan, Postoperative Plan. I presented our work as an oral presentation in the July 2020 Pediatric Hospital Medicine virtual conference.
Goals for the Future: I hope to continue my learning through a Pediatric Palliative Care and Hospice fellowship next year. Caring for patients with complex needs and decision making, especially those with severe neurologic impairment, brings me joy when we can improve their symptoms, quality of life, and time at home. My career goal is to become the medical director of a post-acute care facility for children with the breadth to offer skilled nursing, rehabilitation, and hospice respite care. My future vision would be partnering with others and using my PHM fellowship skills to develop subacute care as a growing research field.
Fun Fact: I won the medical school Halloween costume competition one year with a home-sewn dinosaur costume.
Fellowship accomplishments and current research or work: My primary fellowship work is the development and study of a co-management program between our pediatric hospital medicine and pediatric neurosurgical teams. We designed and implemented the new program, and I am now studying its effect on cost, length of stay, ICU time, and readmissions with a primary goal to reduce readmissions. At the 6 month mark, we successfully reduced readmissions from 13% to 8%, representing a projected 5% cost savings for the overall program. Another quality improvement project involves increasing communication and safety planning in the peri-operative period for complex pediatric patients by using a novel huddle system invented at Helen DeVos Children’s Hospital called “iSTOP©,” which stands for Introduction, Surgery, Tubes and Lines, Operative Plan, Postoperative Plan. I presented our work as an oral presentation in the July 2020 Pediatric Hospital Medicine virtual conference.
Goals for the Future: I hope to continue my learning through a Pediatric Palliative Care and Hospice fellowship next year. Caring for patients with complex needs and decision making, especially those with severe neurologic impairment, brings me joy when we can improve their symptoms, quality of life, and time at home. My career goal is to become the medical director of a post-acute care facility for children with the breadth to offer skilled nursing, rehabilitation, and hospice respite care. My future vision would be partnering with others and using my PHM fellowship skills to develop subacute care as a growing research field.
Fun Fact: I won the medical school Halloween costume competition one year with a home-sewn dinosaur costume.
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