BACKGROUND: In our institution's pediatric emergency department, adherence to evidencebased asthma guidelines was noted to be suboptimal for patients with asthma exacerbations. We hypothesized that an evidence-based asthma protocol would improve time to treatment and adherence to National Institutes of Health guidelines for patients presenting to the emergency department with status asthmaticus. METHODS: Subjects at our institution were retrospectively identified through an electronic medical record search following institutional review board approval. The asthma protocol was initiated in February 2012. All pediatric subjects who received continuous albuterol in the emergency department before (February 26, 2009, to February 22, 2012, n ‫؍‬ 193) and after (February 23, 2012, to December 31, 2012, n ‫؍‬ 68) protocol initiation were analyzed. The post-protocol data were collected as part of routine quality assurance monitoring with a target of 60 post-protocol subjects. Subjects were identified at the end of each month, which resulted in a total of 68 subjects being included. Primary outcomes measured included time to initial treatment with inhaled bronchodilator therapy, time to treatment with systemic corticosteroids, and total number of ipratropium bromide treatments delivered. RESULTS: Two-hundred sixty-one subjects (7.1 ؎ 4.6 y of age, 66% male) were included. Demographics were similar in the pre-and postprotocol groups. Compared with the pre-protocol group, more subjects in the post-protocol group received bronchodilators within 30 min (60% vs 77%, P ‫؍‬ .02), at least one dose of ipratropium bromide (55% vs 87%, P < .001), 3 doses of ipratropium bromide (14% vs 54%, P < .001), and corticosteroids within 60 min (62% vs 77%, P ‫؍‬ .04). There were no statistically significant differences between the pre-and post-protocol cohorts in the mean time to first bronchodilator treatment (32 ؎ 41 vs 26 ؎ 52 min, P ‫؍‬ .34), mean time to corticosteroid administration (74 ؎ 68 vs 54 ؎ 63 min, P ‫؍‬ .06), or mean emergency department length of stay (342 ؎ 143 vs 364 ؎ 183 min, P ‫؍‬ .31). CONCLUSIONS: An asthma protocol resulted in improved adherence to National Institutes of Health guidelines in children with status asthmaticus and improved efficiency in the administration of rescue bronchodilator and systemic corticosteroid therapy.

Objective We used a large research database to examine the association between urinary tract infections and necrotizing enterocolitis (NEC) in premature infants. Methods This retrospective data analysis included infants ≤32 weeks gestational age and ≤1500 g at birth who had urine cultures obtained at one of 322 neonatal intensive care units managed by the Pediatrix Medical Group from 1997–2012. The primary outcome was a diagnosis of NEC within 7 days after urine culture. We used multivariable conditional logistic regression conditioned on postnatal age and controlling for gestational age, inotropic support on the day of culture, and mechanical ventilation on the day of culture to evaluate the association between urine culture result and NEC. Results We identified 25,816 infants who had 43,556 urine cultures obtained; 6586 (15.1%) of the cultures were positive. A diagnosis of NEC within 7 days after culture was made in 334 (5.1%) of the 6586 positive cultures versus 1582 (4.3%) of the 36,970 negative cultures (p<0.01). On multivariable analysis, infants with any positive urine culture had increased risk of NEC (odds ratio [OR] 1.16, 95% confidence interval [CI] 1.02–1.31); the risk was higher when limited to Gram-negative organisms (OR 1.37, 95% CI 1.17–1.59). The risk of surgical NEC was increased in infants with any positive urine culture (OR 1.46, 95% CI 1.18–1.81) and was also higher when limited to Gram-negative organisms (OR 1.99, 95% CI 1.53–2.59). Conclusion Positive urine cultures were associated with increased risk of NEC within 7 days of culture.

Infection is common in premature infants and can cause significant morbidity and mortality. To prevent these devastating consequences, most infants admitted to the neonatal intensive care unit (NICU) are exposed to antibiotics. However, dosing regimens are often extrapolated from data in adults and older children, increasing the risk for drug toxicity and lack of clinical efficacy because they fail to account for developmental changes in infant physiology. Despite legislation promoting and, in some cases, requiring pediatric drug studies, infants remain therapeutic orphans who often receive drugs "off-label" without data from clinical trials. Pharmacokinetic (PK) studies in premature infants have been scarce due to low study consent rates; limited blood volume available to conduct PK studies; difficulty in obtaining blood from infants; limited use of sensitive, low-volume drug concentration assays; and a lack of expertise in pediatric modeling and simulation. However, newer technologies are emerging with minimal-risk study designs, including ultra-low-volume assays, PK modeling and simulation, and opportunistic drug protocols. With minimal-risk study designs, PK data and dosing regimens for infants are now available for antibiotics commonly used in the NICU, including ampicillin, clindamycin, meropenem, metronidazole, and piperacillin/tazobactam. The discrepancy between previous dosing recommendations extrapolated from adult data and newer dosing regimens based on infant PK studies highlights the need to conduct PK studies in premature infants.