Factors Associated With Antibiotic Use for Children Hospitalized With Pneumonia

Abstract

BACKGROUND: Antibiotics are frequently used for community-acquired pneumonia (CAP), although viral etiologies predominate. We sought to determine factors associated with antibiotic use among children hospitalized with suspected CAP. METHODS: We conducted a prospective cohort study of children who presented to the emergency department (ED) and were hospitalized for suspected CAP. We estimated risk factors associated with receipt of ≥1 dose of inpatient antibiotics and a full treatment course using multivariable Poisson regression with an interaction term between chest radiograph (CXR) findings and ED antibiotic use. We performed a subgroup analysis of children with nonradiographic CAP. RESULTS: Among 477 children, 60% received inpatient antibiotics and 53% received a full course. Factors associated with inpatient antibiotics included antibiotic receipt in the ED (relative risk 4.33 [95% confidence interval, 2.63–7.13]), fever (1.66 [1.22–2.27]), and use of supplemental oxygen (1.29 [1.11–1.50]). Children with radiographic CAP and equivocal CXRs had an increased risk of inpatient antibiotics compared with those with normal CXRs, but the increased risk was modest when antibiotics were given in the ED. Factors associated with a full course were similar. Among patients with nonradiographic CAP, 29% received inpatient antibiotics, 21% received a full course, and ED antibiotics increased the risk of inpatient antibiotics. CONCLUSIONS: Inpatient antibiotic utilization was associated with ED antibiotic decisions, CXR findings, and clinical factors. Nearly one-third of children with nonradiographic CAP received antibiotics, highlighting the need to reduce likely overuse. Antibiotic decisions in the ED were strongly associated with decisions in the inpatient setting, representing a modifiable target for future interventions.

Variation in bacterial pneumonia diagnoses and outcomes among children hospitalized with lower respiratory tract infections

“…Given rising rates of antibiotic resistance, it is critical that we develop and implement evidenced-based practices for the diagnosis and management of pediatric CAP. 29,32,33 We found that hospitals that diagnosed bacterial CAP more there is potential for misclassification bias for patients with an LRTI or bacterial CAP. However, we used definitions derived from prior literature to minimize this limitation.…”

“…It is also important to evaluate how hospital culture may drive some of these practice differences. Given rising rates of antibiotic resistance, it is critical that we develop and implement evidenced‐based practices for the diagnosis and management of pediatric CAP 29,32,33 …”

Antibiotic use and outcomes among children hospitalized with suspected pneumonia

“…We included a practical cohort of children managed in the ED for suspected CAP, regardless of radiographic findings. This is supported by multiple studies demonstrating that CXR interpretation is subjective, antibiotic decisions are made a priori of CXR results, and children can be diagnosed with CAP based on clinical findings even in the absence of radiographic confirmation 13,15–18 . CXRs were initially interpreted based on pediatric radiologists' impressions as part of clinical care.…”

“…In a sensitivity analysis, we redefined the exposure as a full antibiotic course (≥5 days inpatient or prescription at discharge), regardless of antibiotic receipt in the ED 19 . We evaluated ED antibiotics as our primary exposure because data suggest that antibiotics started in the ED are frequently continued for a full course 17 and timing between exposure and outcomes. While antibiotic decisions in the ED are typically influenced by a child's initial presentation in the ED, decisions about a full course may be influenced by additional factors that occur after hospital admission (e.g., escalated respiratory support), which were secondary outcomes.…”

“…This is supported by multiple studies demonstrating that CXR interpretation is subjective, antibiotic decisions are made a priori of CXR results, and children can be diagnosed with CAP based on clinical findings even in the absence of radiographic confirmation. 13,[15][16][17][18] CXRs were initially interpreted based on pediatric radiologists' impressions as part of clinical care. Results were categorized into two groups: (1) radiographic CAP (findings such as "infiltrate," "consolidation," "pneumonia," "atelectasis vs. pneumonia") and (2) nonradiographic CAP ("normal," "atelectasis," "peribronchial thickening" only).…”