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Complex chronic conditions increased pneumonia disease severity
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Children with complex chronic conditions who presented with pneumonia had greater disease severity and were more likely to receive broad-spectrum antibiotics than children without complex chronic conditions, according to recent study findings published in The Pediatric Infectious Disease Journal.
JoAnna K. Leyenaar, MD, MPH, MSc, of the division of pediatric hospital medicine, department of pediatrics at Tufts-Medical Center, and colleagues evaluated 31,684 children younger than 18 years who were admitted to 284 hospitals using highly-detailed administrative data to determine the effect of complex chronic conditions (CCCs) on pneumonia. Of all participants, 11.9% had a CCC and were more likely to be older and have public health insurance compared with participants without a CCC.
JoAnna K. Leyenaar
CCCs included congenital or genetic defects (27.7%); neuromuscular disorders (22.8%); cardiovascular malformations (20.8%); hematologic or immunologic conditions (19.5%); chronic respiratory conditions (15.1%); malignant neoplasms (5.9%); metabolic conditions (3.6%); renal conditions (2.5%); and gastrointestinal conditions (1.7%). Two or more CCCs were present in 16.9% of patients in the retrospective cohort study.
Approximately one-third of all participants had asthma. Diagnostic testing, intensive therapies including inotropes, mechanical and noninvasive ventilation, and blood transfusions were more common among participants with CCCs compared with those without.
Typical Streptococcus pneumoniae was less likely among participants with CCCs, except for cardiovascular malformations. However, initial antibiotic coverage against MRSA, anaerobic organisms and Pseudomonas was two to five times more likely among participants with CCCs, except for cardiovascular malformations. On or after the second day of hospitalization, participants with CCCs were more likely to have antibiotic coverage expanded. Broad-spectrum antibiotics also were more common among participants with neuromuscular disorders, a single CCC or two or more CCCs.
More than 10% of participants with CCCs had pneumonia complications (adjusted OR=1.47; 95% CI, 1.24-1.75). There also was an increased length of hospital stay (adjusted RR=1.43; 95% CI, 1.39-1.48) and an increased risk of readmission within 30 days of discharge (adjusted OR=4; 95% CI, 3.2-5) compared to participants without CCC.
“Our study has important implications for the care of children with CCCs who are admitted to the hospital with pneumonia and established several important areas for future studies,” the researchers wrote. “Children with CCC presented to the hospital with greater disease severity, were more likely to receive broad-spectrum antibiotics at the time of hospitalization, and had considerably increased likelihood of antibiotic escalation during their hospital stay. … This research is an essential prerequisite to inform future treatment guidelines to optimize processes of care and outcomes among this population of children while minimizing potential adverse effects of unnecessary broad-spectrum antibiotic coverage.”
JoAnna K. Leyenaar, MD, MPH, MSc, can be reached at jleyenaar@tuftsmedicalcenter.org.
Disclosure: The study was funded in part by the National Center for Advancing Translational Sciences, NIH, and the National Center for Research Resources.
Perspective
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Samir S. Shah, MD, MSCE
There is a paucity of evidence to inform the diagnosis and management of pneumonia in children with complex chronic conditions (CCC), such as those with neuromuscular impairment or cardiovascular malformations. National guidelines such as those jointly published by the Pediatric Infectious Diseases Society and the Infectious Diseases Society of America focus on children without underlying medical conditions which might predispose to severe or recurrent pneumonia. Leyenaar and colleagues use data from the Perspective Data Warehouse (Premier Healthcare Informatics, Charlotte, NC), an administrative database, to describe the management and outcomes of children with complex chronic conditions who were hospitalized with pneumonia.
A total of 31,684 children from 284 hospitals were included; neuromuscular disorders and cardiovascular malformations were the most common types of complex chronic conditions, occurring in 22.8% and 20.8% of children with a CCC, respectively. Children with CCCs were less likely to receive typical pneumococcal coverage and more likely to receive broadspectrum antibiotics with coverage against MRSA, anaerobes, and Pseudomonas aeruginosa. Adjunct therapies such as corticosteroids and beta-agonists were also commonly administered. Pneumonia-associated complications occurred in >10% of children with a CCC; double the rate of complications in children without a CCC. Readmission and changes in antibiotic therapy were also common among children with CCCs. This study represents an important first step in improving the care and outcomes of children with CCCs who develop pneumonia. Subsequent studies should focus on determining which tests and treatments are associated with improved outcomes and which are unnecessary.
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