Fellows journal Club
Fellow: Sonya Tang Girdwood, MD, Ph.D. | Hospital Medicine Fellow and NICHD Clinical Pharmacology Fellow, Cincinnati Children’s Hospital Medical Center
Article: Shein S, Kong M, McKee B, O’Riordan M, Toltzis P, Randolph A. Antibiotic Prescription in Young Children with Respiratory Syncytial Virus-Associated Respiratory Failure and Associated Outcomes Pediatric Critical Care Medicine. 2019; 20 (2): 101-109.
Summary: This is a retrospective cohort study in previously healthy children less than 2 years old who were diagnosed with respiratory syncytial-virus (RSV) associated lower respiratory tract infection (LRTI) and received mechanical ventilation (MV). The authors sought to determine associations between antibiotic prescriptions on the first 2 MV days (i.e. early antibiotic prescription) and clinical outcomes. They found that 82% of the 2,107 patients included in the study received antibiotics on both of the first 2 MV days, with the antibiotic prescription proportion varying from 36% to 100% across centers. To the authors’ surprise, despite being younger and having a higher percentage of patients receive vasoactive medications, the cohort with early antibiotic prescription had a shorter duration of MV and length of stay compared with the patients who received no antibiotics on the first 2 MV days.
What are the key strengths of the article?
A key strength of this study is that it includes 46 tertiary care children’s hospital in the United States through the Pediatric Health Information System (PHIS) database and over 2,000 patients. The findings of shorter duration of MV and length of stay when antibiotics are prescribed on the first 2 MV days are consistent even when controlling for age, race, gender, vasoactive medication use, insurance type and treatment center in the multivariate model, when stratifying the cohort by presence or absence of a diagnosis code for bacterial pneumonia, and when including non-RSV LRTI patients.
Are there any limitations or flaws in the article?
Using an administratative database has its inherent limitation, but the authors utilized multiple measures to optimize the quality of data, such as requiring both a MV flag and prescription of a neuromuscular antagonist to meet MV criteria. The study excluded patients who received antibiotics on only 1 of the first 2 MV days (~17% patients screened), so it is unknown if findings would be similar in this group. In addition, prescription and billing of an antibiotic does not necessarily equate to receipt of antibiotics.
While not a flaw or limitation, it remains uncertain why there is an association between early antibiotic prescription and clinical outcomes. The authors propose two explanations. There may be an anti-inflammatory effect of antibiotics, but many of those used in thsi study patient popoulation do not have significant anti-inflammatory properties. The antibiotics may be treating bacterial pneumonia, although nearly ¾ of the patients did not have a diagnosis code of bacterial pneumonia, a finding that may be due to limited sensitivities of current diagnostic methods.
What is the major takeaway message?
A large proportion of young children who are mechanically ventilated for LRTI are prescribed antibiotics on the first 2 MV days, though there is variability across centers. Early antibiotic prescription on both of the first 2 MV days is associated with shorter duration of MV by 1.21 days and length of stay by 2.07 days.
Describe how this article should impact our practice:
Although this article focused on a population admitted to the pediatric intensive care unit (PICU), I selected this article because these patients are often transferred to the hospitalist service after extubation and stabilization. With this study, our colleagues in the PICU may prescribe antibiotics for patients intubated for viral LRTI with increasing frequency and we will need to decide whether or not to continue antibiotics at the time of transfer. Interestingly, in this study, patients were intubated for a median of 6 days, and therefore likely completed a full course (assuming 7 days) of antibiotics while in the PICU. However, there will be patients who transfer after only a few days of antibiotics and we must ask ourselves, do we continue the antibiotics even if endotracheal cultures and chest X-rays appear to be negative for pneumonia? If so, how long do we continue antibiotics and when do we transition to enteral options? If we choose to discontinue antibiotics, should we observe patients off antibiotics for a period of time to ensure they do not decompensate? Further studies, ideally prospective, will be needed to help guide our antibiotic management of these patients who transfer to our service.
Article: Shein S, Kong M, McKee B, O’Riordan M, Toltzis P, Randolph A. Antibiotic Prescription in Young Children with Respiratory Syncytial Virus-Associated Respiratory Failure and Associated Outcomes Pediatric Critical Care Medicine. 2019; 20 (2): 101-109.
Summary: This is a retrospective cohort study in previously healthy children less than 2 years old who were diagnosed with respiratory syncytial-virus (RSV) associated lower respiratory tract infection (LRTI) and received mechanical ventilation (MV). The authors sought to determine associations between antibiotic prescriptions on the first 2 MV days (i.e. early antibiotic prescription) and clinical outcomes. They found that 82% of the 2,107 patients included in the study received antibiotics on both of the first 2 MV days, with the antibiotic prescription proportion varying from 36% to 100% across centers. To the authors’ surprise, despite being younger and having a higher percentage of patients receive vasoactive medications, the cohort with early antibiotic prescription had a shorter duration of MV and length of stay compared with the patients who received no antibiotics on the first 2 MV days.
What are the key strengths of the article?
A key strength of this study is that it includes 46 tertiary care children’s hospital in the United States through the Pediatric Health Information System (PHIS) database and over 2,000 patients. The findings of shorter duration of MV and length of stay when antibiotics are prescribed on the first 2 MV days are consistent even when controlling for age, race, gender, vasoactive medication use, insurance type and treatment center in the multivariate model, when stratifying the cohort by presence or absence of a diagnosis code for bacterial pneumonia, and when including non-RSV LRTI patients.
Are there any limitations or flaws in the article?
Using an administratative database has its inherent limitation, but the authors utilized multiple measures to optimize the quality of data, such as requiring both a MV flag and prescription of a neuromuscular antagonist to meet MV criteria. The study excluded patients who received antibiotics on only 1 of the first 2 MV days (~17% patients screened), so it is unknown if findings would be similar in this group. In addition, prescription and billing of an antibiotic does not necessarily equate to receipt of antibiotics.
While not a flaw or limitation, it remains uncertain why there is an association between early antibiotic prescription and clinical outcomes. The authors propose two explanations. There may be an anti-inflammatory effect of antibiotics, but many of those used in thsi study patient popoulation do not have significant anti-inflammatory properties. The antibiotics may be treating bacterial pneumonia, although nearly ¾ of the patients did not have a diagnosis code of bacterial pneumonia, a finding that may be due to limited sensitivities of current diagnostic methods.
What is the major takeaway message?
A large proportion of young children who are mechanically ventilated for LRTI are prescribed antibiotics on the first 2 MV days, though there is variability across centers. Early antibiotic prescription on both of the first 2 MV days is associated with shorter duration of MV by 1.21 days and length of stay by 2.07 days.
Describe how this article should impact our practice:
Although this article focused on a population admitted to the pediatric intensive care unit (PICU), I selected this article because these patients are often transferred to the hospitalist service after extubation and stabilization. With this study, our colleagues in the PICU may prescribe antibiotics for patients intubated for viral LRTI with increasing frequency and we will need to decide whether or not to continue antibiotics at the time of transfer. Interestingly, in this study, patients were intubated for a median of 6 days, and therefore likely completed a full course (assuming 7 days) of antibiotics while in the PICU. However, there will be patients who transfer after only a few days of antibiotics and we must ask ourselves, do we continue the antibiotics even if endotracheal cultures and chest X-rays appear to be negative for pneumonia? If so, how long do we continue antibiotics and when do we transition to enteral options? If we choose to discontinue antibiotics, should we observe patients off antibiotics for a period of time to ensure they do not decompensate? Further studies, ideally prospective, will be needed to help guide our antibiotic management of these patients who transfer to our service.
Fellow: Sonya Tang Girdwood, MD, Ph.D. | Hospital Medicine Fellow and NICHD Clinical Pharmacology Fellow, Cincinnati Children’s Hospital Medical Center
Fellow Accomplishments/Current Work: In addition to being a Hospital Medicine Fellow, I am a T32 NICHD Clinical Pharmacology Fellow and serve as the national Clinical Pharmacology Chief Fellow. My research interest is in optimizing antimicrobial regimens in hospitalized children and I am currently evaluating the variability of beta-lactam antibiotic concentrations in patients admitted to the PICU through population pharmacokinetic modeling. I recently completed a QI study whose aim was to improve the transition of IV to enteral antibiotics in hospitalized patients. I’ve also had the privilege of working with 3 other fellows from different programs to launch the Twitter Journal Club, #PHMFellowJC, generating inter-institutional discussion on articles relevant to our field. I’ll be serving as one of the social media co-chairs at PHM at the end of this month.
Future plans: My goals is to have a joint research faculty position in the divisions of Hospital Medicine and Clinical Pharmacology following the completion of fellowship, with plans to apply for an NIH career development award.
Fun fact about yourself: My husband and I have been busy this summer providing respite care on the weekends for foster children, as we wait for our 3rd foster placement. When I have time, I sing with the Cincinnati Young Professionals Choral Collective, with whom I recently performed at Carnegie Hall.
Fellow Accomplishments/Current Work: In addition to being a Hospital Medicine Fellow, I am a T32 NICHD Clinical Pharmacology Fellow and serve as the national Clinical Pharmacology Chief Fellow. My research interest is in optimizing antimicrobial regimens in hospitalized children and I am currently evaluating the variability of beta-lactam antibiotic concentrations in patients admitted to the PICU through population pharmacokinetic modeling. I recently completed a QI study whose aim was to improve the transition of IV to enteral antibiotics in hospitalized patients. I’ve also had the privilege of working with 3 other fellows from different programs to launch the Twitter Journal Club, #PHMFellowJC, generating inter-institutional discussion on articles relevant to our field. I’ll be serving as one of the social media co-chairs at PHM at the end of this month.
Future plans: My goals is to have a joint research faculty position in the divisions of Hospital Medicine and Clinical Pharmacology following the completion of fellowship, with plans to apply for an NIH career development award.
Fun fact about yourself: My husband and I have been busy this summer providing respite care on the weekends for foster children, as we wait for our 3rd foster placement. When I have time, I sing with the Cincinnati Young Professionals Choral Collective, with whom I recently performed at Carnegie Hall.
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- Amanda Messer - UTIs and renal scarring
- Christiane Lenzen - procalcitonin and CAP
- Melanie Rudnick - dexamethasone and parapneumonic effusions
- Jane Im - empiric antibiotic therapy in infants
- Ashley Jenkins - AKI with vancomycin and piperacillin/tazobactam therapy
- Fatuma Barqadle - US for LPs
- Marni Shear - Hypotonic IV fluids and bronchiolitis
- Ivy Tam - Ipratropium and IV magnesium in asthmatics
- Daniela Burger - HSV in Infants
- Lindsay Weiss - macrolides in pneumonia
- Tiranun Rungvivatjarus - High Flow Nasal Cannula
- Karisa Grizzle - Empiric Antibiotics in Osteomyelitis
- Mike Fenster - Bacterial meningitis in positive UA
- Courtney Charvat - CSF bioplex assay
- Audrey Uong - Complex Care Discharges
- Adam Cohen - Early Master Clinician Traits
- Alice Lee - Variation in Orbital Cellulitis Care
- Joy Solano - Family centered interventions to improve education
- Sunita Hemani - Discharging after q3 albuterol in asthma
- Jennifer Chen - Discharge Instruction Literacy
- John Morrison - Readmission Models for Complex Care
- Hanna Siddiqui - Fever, PEWS, and deterioration
- Kate Kyler - Reducing Safety Events in Suicidal Patients via QI