1. Amanda I. Messinger, MD*
2. Oren Kupfer, MD*
3. Amanda Hurst, PharmD†
4. Sarah Parker, MD‡


 

1. Divisions of *Pulmonary Medicine and

2. ‡Infectious Diseases, Department of Pediatrics, University of Colorado Denver School of Medicine, Aurora, CO

3. †Department of Pharmacy, Children’s Hospital Colorado, Aurora, CO

* Abbreviations:
 CAP: : community-acquired pneumonia
 CT: : computed tomography
 IV: : intravenous
 MIC: : minimum inhibitory concentration
 MRSA: : methicillin-resistant Staphylococcus aureus PCR: : polymerase chain reaction
 VATS: : video-assisted thorascopic surgery

Management of pediatric community-acquired pneumonia should focus on judicious use of antimicrobial medications, bacterial diagnostics, and surgical drainage when complicated by large effusion and empyema. Treatment in adherence to national guidelines produces favorable outcomes.

After completing this article, readers should be able to:

1. Reinforce rational antibiotic use for bacterial community-acquired pneumonia (CAP) in outpatient and inpatient settings.

2. Review and update techniques for microbial diagnosis of CAP.

3. Review medical and surgical management of complicated pneumonia.

4. Present specific considerations for CAP in patients with neuromuscular disease.

Community-acquired pneumonia (CAP) is the most common cause of death in children worldwide, accounting for 15% of deaths in children younger than 5 years of age. (1) Nearly 1 in 500 children will be hospitalized for CAP, which creates a substantial economic burden. CAP is thus important to diagnose and appropriately treat. While viral causes of CAP are most common, differentiating viral versus bacterial etiologies can be difficult. This leads to excessive use of antimicrobial medications or susceptibility to feeling a pressure to prescribe. (2) Overall, in the United States, 11.4 million antimicrobial prescriptions for pediatric respiratory tract infections per year are avoidable. (3) Furthermore, broad-spectrum but less effective antimicrobial agents are often prescribed when pharmacokinetically favorable narrow-spectrum agents are available. (4) Arguably, the untoward effects of overtreatment of CAP in those in whom treatment is unwarranted compounds the morbidity of this disease process. Because of mounting knowledge of antimicrobial side effects, resistance, and microbiome effects, practitioners must adhere to the principles of judicious use when treating CAP. In this regard, CAP, its epidemiology, various etiologic origins, clinical presentations, and general diagnosis and treatment were …

Management of Pediatric Community-acquired Bacterial Pneumonia

1. Susan F. Massengill, MD*
2. Maria Ferris, MD, MPH, PhD†


 

1. *Director, Pediatric Nephrology, Levine Children’s Hospital, Adjunct Associate Professor of Pediatrics, University of North Carolina School of Medicine, Charlotte, NC.

2. †Director, Pediatric Dialysis and Transplant Programs, UNC Kidney Center, Founder and Director, The UNC Children’s Hospital TRxANSITION Program, University of North Carolina at Chapel Hill, Chapel Hill, NC.

* Abbreviations:
 1,25(OH)2 D: : 1,25-dihydroxyvitamin D
 ACE: : angiotensin-converting enzyme
 CKD: : chronic kidney disease
 CKiD: : Chronic Kidney Disease in Children
 CVD: : cardiovascular disease
 eGFR: : estimated glomerular filtration rate
 ESKD: : end-stage kidney disease
 GFR: : glomerular filtration rate
 HCT: : health care transition
 MBD: : metabolic bone disease

Chronic kidney disease (CKD) is a devastating diagnosis with many co-morbidities, increasing the risk of mortality 30 to 150 times that of the general pediatric population. Recognition of at-risk children can lead to earlier screening and risk reduction. Primary care clinicians are often unaware of the comorbid conditions and long-term consequences of CKD, particularly with respect to cardiovascular disease, nutrition and growth, neurocognitive development, and burden of disease.

After completing this article, readers should be able to:

1. Be aware of the life course of CKD and its co-morbidities.

2. Recall the risk factors and complications of pediatric CKD.

3. Discuss measures to prevent or delay the progression of pediatric CKD.

4. Optimize the communication between the primary care clinician and nephrologist in treating children, adolescents, and young adults with CKD.

A 13-month-old toddler new to your practice presents for his 1-year health maintenance visit with poor growth and developmental delay. He is just now sitting without support and appears to have occasional leg pain. He is pale, weighs 7.9 kg, and has a normal blood pressure. The results of laboratory studies are remarkable for anemia (hemoglobin, 9 g/dL [90 g/L]), profound acidosis (carbon dioxide, 12 mEq/L [12 mmol/L]), azotemia (urea nitrogen, 117 mg/dL [41.8 mmol/L]; creatinine, 2.44 mg/dL [216 μmol/L]), and profound hypocalcemia (calcium, 5.6 mg/dL [1.40 mmol/L]), prompting further evaluation where hypocalcemia was confirmed. Urinalysis revealed a specific gravity of 1.005 and proteinuria (1+). Renal ultrasonography revealed bilateral renal hypoplasia. Renal replacement therapy was initiated with peritoneal dialysis, and the patient is on the renal transplantation waiting list.

A previously healthy, 14-year-old, African American girl presents with a 3-month history of facial …

http://www.nccpeds.com/kidney/articles/CKD%20PIR.pdf

Chronic kidney disease in children and adolescents

1. Nathan Donaldson, DO*
2. Julia Sanders, MD*
3. Jason Child, PharmD†
4. Sarah Parker, MD‡


 

1. *Division of Orthopedic Surgery and

2. ‡Division of Infectious Diseases, Department of Pediatrics, University of Colorado Denver School of Medicine, Aurora, CO

3. †Department of Pharmacy, Children’s Hospital Colorado, Aurora, CO

* Abbreviations:
 ADE: : adverse drug event
 CRMO: : chronic recurrent multifocal osteomyelitis
 CRP: : C-reactive protein
 CT: : computed tomography
 ESR: : erythrocyte sedimentation rate
 MRI: : magnetic resonance imaging
 MRSA: : methicillin-resistant Staphylococcus aureus MSSA: : methicillin-susceptible Staphylococcus aureus OAI: : osteoarticular infection
 WBC: : white blood cell

Management of pediatric acute hematogenous osteoarticular infections has changed in various ways during the past decade, including the description of new pathogens and updated diagnostic and treatment strategies (such as infected source sampling and an early switch to oral therapy).

After completing this article, readers should be able to:

1. Understand what predisposes children of different age groups to acute hematogenous osteoarticular infections (OAIs), particularly the role of anatomy and differing pathogenic susceptibilities.

2. Recognize the symptoms present in children with OAIs and their most common differential diagnoses.

3. Understand the most effective imaging techniques and laboratory tests/cultures to diagnose an OAI and how to interpret them.

4. Understand the benefits and limitations of therapeutic surgery and source sampling (biopsy/aspirate) and when to commence antimicrobial drug therapy.

5. Recognize the most common causative pathogens and the most effective antimicrobial drugs for their treatment.

6. Determine how long a patient should be taking intravenous and oral therapy and under what conditions they should switch from intravenous to oral antimicrobial agents.

7. Understand the recommended follow-up after diagnosis, including when to expect normalization of laboratory values in patients with uncomplicated OAIs.

8. Recognize complicated OAIs and their possible long-term sequelae.

Pediatric osteoarticular infections (OAIs) include infections of the bones (osteomyelitis) and joints (septic arthritis). Pathogenic organisms may be introduced into these normally sterile sites via direct inoculation (eg, trauma or surgery) or via erosion from a contiguously infected source (eg, chronic ulcer), but organisms are mostly hematogenously delivered. Bacteria are the most common pathogens to cause OAIs, but mycobacteria, fungi, and viruses can also infect these tissues. If diagnosed in the first 10 to 14 days, these infections are …

Acute Hematogenous Bacterial Osteoarticular Infections in Children.

The aim of this study was to describe the variation in antibiotic prescribing practices for uncomplicated community-acquired pneumonia across the continuum of care for hospitalized pediatric patients to better inform future efforts at standardizing antibiotic therapy throughout a single hospitalization.
This is a retrospective cohort study involving 4 hospitals caring for children aged 3 months to 18 years, hospitalized between January 1, 2011, and December 31, 2012, with diagnosis of uncomplicated pneumonia and without complex chronic medical conditions.
Data collected include antibiotics prescribed before hospitalization, at the emergency department (ED) encounter, during hospitalization, and at hospital discharge.
Six hundred nine children met inclusion criteria, with a mean age of 5.3 years and median length of stay of 2 days. Emergency department providers prescribed narrow-spectrum therapy 27% of the time, whereas discharging providers prescribed narrow-spectrum therapy 56% of the time. Third- and fourth-generation cephalosporins were less often prescribed in the preadmission setting and at discharge but were more often prescribed in the ED and inpatient setting. There was an association between inpatient prescription of broad-spectrum antibiotics when a blood culture was obtained, when broad-spectrum antibiotics were prescribed in the ED, and with increasing length of stay.
Broad-spectrum antibiotic therapy for community-acquired pneumonia, especially third- and fourth-generation cephalosporins, often originates in the ED. When initiated in this setting, it is likely to be continued in the inpatient setting.

Antibiotic Prescribing Patterns Across the Continuum of Care for Children Hospitalized With Community-acquired Pneumonia

Orbital and preseptal cellulitis are most commonly caused by organisms that originate in the upper respiratory tract or from the skin. There is significant variation in antibiotics used, but ampicillin–sulbactam, ceftriaxone, metronidazole, clindamycin, amoxicillin, amoxicillin–clavulanate, cefuroxime, and vancomycin are often used in the treatment of these infections. The choice of antibiotic, however, is only one consideration. It is also important that antibiotics are dosed to optimize their pharmacodynamic target attainment. Like other serious infections, therapy can be transitioned from initial intravenous therapy to an oral regimen when there are clear signs of clinical and laboratory improvement. The total duration of therapy for these infections have also been decreasing in recent years with durations of approximately 2 weeks becoming more common, even for orbital or subperiosteal infections. Antimicrobial stewardship programs can work closely with providers who manage these infections to create pathways, choose optimal antibiotics and dosage, transition from intravenous to oral therapy, and provide shortest effective durations.

Applying Pharmacodynamics and Antimicrobial Stewardship to Pediatric Preseptal and Orbital Cellulitis.

1. Sarah Parker, MD*,†
2. Michelle Mitchell, MD*
3. Jason Child, PharmD†‡


 

1. *Division of Pediatric Infectious Diseases, University of Colorado School of Medicine/Children’s Hospital Colorado, Aurora, CO.

2. †Antimicrobial Stewardship Program, Children’s Hospital Colorado, Aurora, CO.

3. ‡Department of Pharmacy, Children’s Hospital Colorado, Aurora, CO.

* Abbreviations:
 CAP: : community-acquired pneumonia
 CLSI: : Clinical Laboratory Standards Institute
 CSF: : cerebrospinal fluid
 FDA: : Food and Drug Administration
 GAS: : group A streptococcus
 IM: : intramuscular
 IV: : intravenous
 MIC: : mean inhibitory concentration
 MRSA: : methicillin-resistant Staphylococcus aureus MSSA: : methicillin-susceptible Staphylococcus aureus PBP: : penicillin-binding protein
 PD: : pharmacodynamic
 PK: : pharmacokinetic
 PRSP: : penicillin-resistant Streptococcus pneumoniae UTI: : urinary tract infection

 In the spirit of last month’s issue emphasizing “Doing Less” and using evidenced-based guidelines for treating pneumonia and sinusitis, we present the following feature on the judicious use of cephalosporins. Joseph A. Zenel, MD Editor-in-Chief 

Although cephem antibiotics are important in a pediatrician’s armamentarium, they are overused to the detriment of patients, hospitals, and communities, despite the availability of sound alternatives. Going back to the basics on mechanisms of action, resistance, and pharmacokinetic and pharmacodynamic principles facilitates smarter use and preserves cures for tomorrow.

After reading this article, readers should be able to:

1. Describe in a general manner the mechanism of action, resistance, and pharmacokinetic and pharmacodynamic principles of cephem antibiotics.

2. Describe the advantages and disadvantages of oral cephem antibiotics compared with amoxicillin and amoxicillin–clavulanic acid.

3. Describe appropriate clinical situations in which to use cephem antibiotics.

4. Describe appropriate clinical situations where cephems are commonly used but could reasonably be replaced with an alternative, non-cephem antimicrobial.

The cephem antibiotics were first deployed in the 1960s but did not expand into broad use until the 1970s with the development of useful semisynthetic derivatives. The cephem class includes the cephalosporins and the cephamycins, of which more than 22 antibiotics are now in clinical use (Table 1). There is no doubt that the cephem antibiotics are important weapons in a practitioner’s armamentarium; they are the most widely prescribed and largest selling class of antibiotics, with $8.5 billion spent yearly worldwide. (1)

View this table:

Table 1. 
Compiled Cephem and Comparative Penicillin Agent Pharmacokinetic and Pharmacodynamic Data



That said, cephems are also arguably the most inappropriately used antibiotics in pediatrics. Approximately 40% of pediatric antibiotic use is inappropriate. This …

Cephem Antibiotics: Wise Use Today Preserves Cure for Tomorrow

Objective The pharmacokinetics of beta-lactam antibiotics favor administration via an extended infusion. Although literature supporting extended infusion beta-lactams exists in adults, few data are available to guide the practice in pediatrics. The purpose of this study was to compare clinical outcomes between extended and standard infusions in children. Methods This retrospective chart analysis included hospitalized patients 0 to 18 years old who received at least 72 hours of cefepime, piperacillin-tazobactam, or meropenem between October 1, 2017, and March 31, 2019. Clinical outcomes of care included hospital length of stay, readmission within 30 days, and all-cause mortality. Results A total of 551 patients (258 extended infusion, 293 standard infusion) met criteria for evaluation. Clinical outcomes among the entire population were similar. A subanalysis of select populations demonstrated decreased mortality in critical care patients (2.1% vs 19.6%, p = 0.006) and decreased 30-day readmission rates in bone marrow transplant patients (0% vs 50%, p = 0.012) who received the extended infusion compared with a standard infusion. Conclusions Outcomes were similar between extended and standard infusions in children. Subgroup analyses suggest a possible mortality benefit in the critically ill and decreased readmission rate in bone marrow transplant patients.

Extended Infusion of Beta-Lactams Is Associated With Improved Outcomes in Pediatric Patients.

Lessons Learned from Virtual Handshake Stewardship During a Pandemic.


 
 
 Decisions to discontinue antibiotics in infants undergoing evaluation for central nervous system (CNS) infection can be difficult. Previous reports have associated the use of the meningoencephalitis (ME) PCR panel with decreased hospital stay and antimicrobial use in pediatric and adult patients. However, limited focus has been on infants ≤60-days-old with temperature instability (TI) who undergo evaluation for serious bacterial infection based on age and risk-stratification. We hypothesize use of the ME panel will decrease the duration of antimicrobial use in infants with TI and negative bacterial cultures undergoing evaluation for CNS infection.
 
 
 
 The electronic medical record was queried for patients that met inclusion criteria. Infants ≤60-days-old evaluated for CNS infection due to TI between 1/1/12 – 1/31/22 were included. Exclusion criteria were history of intracranial (IC) devices, previous IC surgery, IC structural or neurovascular abnormalities, or head trauma. A retrospective chart review was performed. We compared length of stay and antimicrobial duration for the groups of patients with the ME panel done versus not done.
 
 
 
 A total of 1808 patients with negative bacterial cultures were identified, 96 of whom had the ME panel performed. Patient age, sex, and race were similar between groups. The median hospital length of stay for the patients that had the ME panel done was 64.7 hours as compared to 47.8 hours for those that did not have the ME panel done. The duration of antibacterial therapy was similar when the ME panel was done versus not done. The median duration of therapy for acyclovir was 8.5 when the ME panel was done versus 14.8 hours when it was not done.
 
 
 
 When including all patients ≤60-days-old evaluated for TI, use of the ME panel did not lead to a shorter length of hospital stay or duration of empiric antibiotics. However, use of the ME panel decreased duration of therapy in the subset of patients empirically started on acyclovir. Further data analysis will seek to identify patient populations that may most benefit from the use of the ME panel.
 
 
 
 All Authors: No reported disclosures.


Michelle L. Mitchell

Papers

Cephem Antibiotics: Wise Use Today Preserves Cure for Tomorrow

Extended Infusion of Beta-Lactams Is Associated With Improved Outcomes in Pediatric Patients.

Lessons Learned from Virtual Handshake Stewardship During a Pandemic.

569. Utility of the Meningoencephalitis Panel in Modifying Antimicrobial Use in Neonates with Temperature Instability

Review: Levofloxacin Prophylaxis in Pediatric Oncology Patients