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Studies that just may change your practice

December 2008

Published in the December 2008 issue of Today’s Hospitalist

When pediatric hospitalists Lisa B. Zaoutis, MD, and Matthew Garber, MD, set out to present their take on the most influential studies of the past year, they had to wade through 1,100 abstracts that pertained to pediatric hospital medicine.

Dr. Garber “who directs the University of South Carolina’s pediatric hospitalist program at Palmetto Health Richland’s Children’s Hospital in Columbia, S.C. “and Dr. Zaoutis, inpatient section chief at Children’s Hospital of Philadelphia, whittled that pile down to less than a dozen studies they deemed to be the most compelling. They identified the following 10 practice-changing studies at this summer’s pediatric hospital medicine conference sponsored by the American Academy of Pediatrics.

Life-savers: rapid response teams
Researchers studied the effects of rapid response teams (RRTs) on hospital-wide mortality and code rates outside the ICU. They estimated that the presence of an RRT saved 33 lives over 19 months at one large academic children’s hospital.

The study’s multidisciplinary RRT team, which consisted of ICU-trained personnel available 24/7 for patient evaluation outside of the ICU, assessed children within five minutes of being called by a staff member. Staff were worried about a change in respiratory function or another problem.

While many patients ended up being transferred to the ICU, the most common action taken by the team was basic airway support. The hospital’s mean mortality rate decreased 18%, while code rates outside the ICU fell 72%. The study was published in the Nov. 21, 2007, Journal of the American Medical Association.

“When a kid codes, the outcome is pretty poor, so evaluation and intervention at the time of clinical deterioration but before arrest is key,” said Dr. Zaoutis. While RRTs need to be evaluated in other settings and cost-effectiveness has yet to be determined, she concluded that the teams do save lives in academic children’s hospitals.

New evidence on treating UTIs
Two percent of infants experience a urinary tract infection (UTI) during their first year of life. Doctors routinely recommend ultrasounds and voiding cystourethrograms (VCUGs), which are invasive, unpleasant and carry a risk of radiation exposure.

Authors of a study published in the December 2007 Journal of Pediatrics hypothesized that dilating vesicoureteral reflux (VUR), which corresponds to VUR grades 3 through 5, rarely occurs if a dimercaptosuccinic acid (DMSA) scan done within the first two weeks of the first UTI is normal.

“This could help avoid that dreaded VCUG in children with a normal DMSA scan,” Dr. Zaoutis explained, “given that there is little concern about renal injury when the grade of reflux is low.”

According to the study results, dilating VUR is found almost exclusively (96%) in children with abnormal DMSA scans. About 17% of those with an abnormal DMSA will have dilating VUR compared to only 0.7% of children with a normal DMSA scan.

Dr. Zaoutis recommended considering a DMSA scan within two weeks of a first UTI. “If it’s normal,” she said, “you can reassure the parents that the child likely does not have dilating VUR and may possibly skip the VCUG.” This would spare about half the children who currently get a VCUG after a first UTI.

If the DMSA scan is abnormal, she said, physicians should follow routine guidelines for imaging after first UTI. Those guidelines currently include VCUG and renal ultrasound.

Oral therapy for acute pyelonephritis
Which is the better approach to treating acute pyelonephritis in children: oral antibiotics or IV therapy? Previous studies have found no difference between the two in regard to renal damage. However, treating children with only oral antibiotics is less expensive and easier.

A group of physicians took this issue further by comparing the outcomes of patients treated with IV therapy to patients treated with only oral therapy at 28 pediatric hospitals in northeast Italy. They wanted to see if oral amoxicillin alone was as effective as IV ceftriaxone followed by oral therapy.

During the study, which was published in the July 4, 2007, British Medical Journal, pediatricians did a renal ultrasound and a DMSA scan within 10 days and continued antibiotic prophylaxis until they disproved reflux. They also looked at the DMSA scan one year later for children whose initial DMSA scan was abnormal.

They concluded that acute pyelonephritis can be safely and effectively treated exclusively with oral therapy, avoiding hospitalization, reducing cost and easing discomfort. Dr. Zaoutis added that “doctors need to choose an empiric drug that would have a low likelihood of resistance based on susceptibility profiles in their community.”

The controversy over pediatric empyema
Treating empyema is controversial because there are so many ways to approach it, including antibiotic therapy, thoracentesis, chest tube placement, fibrinolytic therapy, video assisted thorascopic surgery (VATS) and thoracotomy.

In a retrospective study published in the January 2008 issue of Archives of Pediatrics & Adolescent Medicine, doctors compared outcomes between primary operative management “defined as antibiotics and early decortication with VATS or thoracotomy “and non-operative management, which consisted of antibiotic therapy with or without thoracentesis or chest tube drainage. In primary operative management, the patient had a decortication procedure within the first two days, while in non-operative management, the patient had no decortication procedure or it was done after day two.

Doctors found that children with primary operative management were more likely to have a shorter length of stay, despite going to surgery, and total charges that were about $20,000 less than those in the non-operative management group. Further, children with primary operative management were less likely to have therapeutic failure (5.5% vs. 39%), with no difference in complication rates.

This study confirms, said Dr. Zaoutis, that the medical community should consider moving toward primary operative management for these patients.

Dexamethasone for bronchiolitis?
"I think we can stop using dexamethasone for infants with first-time wheezing,” Dr. Zaoutis concluded after analyzing a study published in the July 26, 2007, issue of New England Journal of Medicine. The study looked at the effectiveness of dexamethasone in treating bronchiolitis, a leading cause of hospitalization in children.

Researchers followed 600 infants between two and 12 months of age who were brought to one of 20 emergency departments with their first episode of moderate to severe wheezing.

Each child received an equivalent volume of oral dexamethasone or placebo. Researchers found that dexamethasone did not reduce hospital admissions or length of stay, did not improve respiratory status after four hours of observation, and did not decrease the number of subsequent medical visits. This was true even among the subset of patients who had an increased risk of atopy because of factors like eczema or family history of asthma.

High-dose oral amoxicillin for severe pneumonia
Pneumonia is the leading cause of death in children in developing countries, taking more than 2 million lives each year. While mild cases are treated with oral antibiotics at home, doctors typically recommend hospitalization for severe pneumonia (defined as lower chest indrawing) and IV benzo-penicillin or IV ampicillin.

A study published in the Jan. 5, 2008, issue of The Lancet, however, found that a high dose (80-90 mg/kg per day) of oral amoxicillin administered at home was just as effective as IV ampicillin for severe pneumonia.

Can these results be applied to patients in the U.S.? Maybe, according to Dr. Garber. American children who don’t have certain risk factors can probably be discharged and treated at home. But the bottom line, said Dr. Garber, is to treat severe pneumonia with ampicillin (not ceftriaxone) and to treat severe pneumonia in patients older than five months who do not have very fast outpatients with high dose amoxicillin.

ALTEs admissions
Should all infants presenting with an apparent life-threatening event (ALTE) be admitted? Maybe not. A study published in the April 2007 issue of Pediatrics found that 51 out of 64 children under one year old admitted to the hospital after arriving in the ED with an ALTE could have been safely discharged.

With ALTEs, it’s difficult to predict if the child will go on to have additional events or problems, or if tests done in the hospital are worthwhile. “When a child has a normal physical exam after a suspected ALTE, are there any criteria that can predict safe discharge from the ED?” Dr. Garber asked.

To find out, researchers enrolled 64 children under one year old for a prospective observational analysis in the ED of Children’s Hospital of Los Angeles. They analyzed how many of those patients experienced subsequent events requiring resuscitation, needed treatment for something else, or developed life-threatening conditions during hospitalization.

The authors concluded that the highest-risk criteria for a child requiring treatment after an ALTE included age (patients younger than a month old were most at risk) and whether multiple ALTEs occurred in the 24 hours before the child was brought to the ED.

Steroids in Henoch-Schonlein Purpura (HSP)
The conflicting evidence about the use of steroids for HSP, the most common childhood vasculitis, prompted researchers to launch a systematic review that was published in the November 2007 issue of Pediatrics. Currently, steroids may be used to treat abdominal pain, arthritis and nephritis. The authors looked at 15 studies to determine if early treatment with steroids shortened the duration of abdominal symptoms, decreased the odds of HSP recurrence and lowered the odds of developing persistent renal abnormalities.

They found that steroids did decrease the duration of abdominal symptoms. As for decreasing the odds of HSP recurrence, two prospective studies were affirmative, but other studies were too heterogenous, so researchers found no definite answer.

Most studies pointed to steroids decreasing the odds of developing persistent renal abnormalities. In three prospective studies, early treatment significantly reduced the odds of developing persistent renal disease, although one retrospective study did not reach that conclusion.

Overall, the Pediatrics study confirmed that early steroid treatment may improve the odds of abdominal pain resolution within 24 hours and reduced odds of persistent renal disease.

Triple therapy vs. monotherapy for appendicitis
Evidence is growing to support changing the standard of care for ruptured appendicitis from aminoglycoside-based triple antibiotic therapy to monotherapy.

A study in the May 2007 issue of Pediatrics found that almost half of surgeons use monotherapy for ruptured appendicitis. The study also found that cefoxitin and piperacillin/tazobactam may be just as effective as traditional therapy, Dr. Garber said, and that those therapies may decrease cost, length of stay and possibly even morbidity.

He recommended that physicians consider treating appendicitis with perforation with cefoxitin or an extended spectrum penicillin/beta-lactamase inhibitor.

Childhood bacterial meningitis
Despite vaccines, bacterial meningitis affects more than 1 million people annually. A prospective, randomized, double-blind, placebo-controlled trial published in the November 2007 issue of Clinical Infectious Diseases looked at the use of adjuvant glycerol and/or dexamethasone to improve outcomes.

The authors questioned whether oral glycerol, IV dex or a combination would reduce death, severe neurologic sequelae and profound hearing loss in children treated with ceftriaxone. The study included children two months through age 16 with bacterial meningitis in 10 institutions throughout Latin America.

One significant finding was that the glycerol group had less neurologic sequelae, Dr. Garber said. Glycerol combined with dex reduced neurologic sequelae as well. Neither really improved mortality, he added, although there was a trend toward decreased mortality with glycerol. And nothing helped the profound hearing loss.

His conclusion? Glycerol is cheap, oral, easily available and requires no special storage requirements.

Ingrid Palmer is a freelance writer based in West Chester, Ohio.