Pulmonary Health Hub

Data consistently support the negative impact of tobacco use in pregnancy with respect to pregnancy outcome, and the benefits of discontinuation or reduction as early as possible.

Recent analyses by investigators at the National Center on Birth Defects and Developmental Disabilities at the Centers for Disease Control and Prevention suggest that more than 6% of oral clefts, or 430 affected infants per year in the United States, could be prevented annually if women can discontinue tobacco use prior to conception (Birth Defects Res A Clin Mol Teratol. 2014 Nov;100[11]:822-5). Similarly, preconception smoking cessation could prevent the 1.4% of nonsyndromic congenital heart defects that are attributable to maternal smoking in the first trimester (J Pediatr. 2015 Apr;166[4]:978-984.e2).

With respect to the risk for adverse outcomes beyond the first trimester, recent data also show clearly that the trimester of discontinuation is related to intrauterine growth restriction in a dose-response fashion (Obstet Gynecol. 2015 Jun;125[6]:1452-9).

In a recent population-based retrospective cohort study of 927,424 singleton births 2006-2012 in Ohio, the adjusted relative risk of infant birth weight less than the 5th percentile for those women who discontinued smoking after the first trimester compared with nonsmokers was 1.25 (95% confidence interval, 1.17-1.33); for those who discontinued after the second trimester the relative risk was 1.83 (95% CI, 1.68-1.99); and for those who smoked throughout pregnancy the relative risk was 2.44 (95% CI, 2.37-2.51).

Given the compelling reasons to encourage women to stop smoking or at least to reduce harm during pregnancy, options for assistance with smoking cessation are of high interest. Beyond simple screening and advice to quit, cognitive behavioral therapy has been shown to provide some benefit. The addition of pharmacologic treatment with nicotine replacement therapy (NRT) has been studied in six randomized clinical trials (RCTs) conducted in pregnant women, four of which compared NRT plus advice/behavioral support to placebo plus advice/behavioral support, and two of which compared NRT plus advice/behavioral support to advice/behavioral support alone.

In a recent Cochrane systematic review of these studies, no statistically significant evidence of effectiveness was demonstrated for NRT versus placebo/control in a pooled sample of 1,745 pregnant patients (risk ratio, 1.33, 95% CI, 0.93-1.91). However, there was high heterogeneity in the dose of NRT and the delivery method (e.g., gum, patch) across studies, and poor adherence to the NRT treatment in all trials (Cochrane Database Syst Rev. 2012 Sep 12;9:CD010078).

With respect to safety, in the same Cochrane review there were no statistically significant differences in rates of miscarriage, stillbirth, premature birth, birth weight, low birth weight, admissions to neonatal intensive care, or neonatal death between NRT and control groups. However, small sample sizes and adherence issues across these trials hampered the interpretability of these data.

One relatively large claims database study from the United Kingdom, which was published recently, examined major congenital anomalies following prescription of NRT. The investigators found no increased risks for most major defects following NRT prescription; the only significant association was with respiratory defects (Pediatrics. 2015 May;135[5]:859-67).

The general thinking has been that for a woman who is unable to quit smoking without pharmacological assistance, NRT that delivers nicotine alone to the developing fetus may be a better option than exposure to the multiple toxins that are contained in tobacco smoke. However, there is considerable controversy over the potential adverse neurotoxic effects of nicotine itself and long-term neurodevelopmental studies on children prenatally exposed to NRT are lacking.

Catherine Harrell/Frontline Medical News

Other options include bupropion and varenicline, neither of which have been studied in RCTs in pregnancy. Bupropion has been evaluated in a small controlled cohort study, a claims database study (n = 1,236 first-trimester exposed), and two case-control studies. None of these studies was focused on use of bupropion exclusively for smoking cessation, but rather for the more common indication of maternal depression. The first two studies suggested no increased risks for adverse pregnancy outcomes compared to women the same underlying conditions; the case control studies suggested small increased risks for heart defects but not the same ones in both studies (Expert Opin Drug Saf. 2014 Dec;13[12]:1721-31). The limited data on varenicline are too sparse to make any inferences.

Another possible alternative that has been gaining in popularity are e-cigarettes or related vapor products, which are touted to have advantages with respect to harm reduction, primarily because of possible improved adherence due to their similarity to conventional smoking. However, there is large variability in the amount of nicotine in the vapor of various e-cigarette brands, and some have suggested that e-cigarette users engage in longer puff duration than do those who smoke conventional cigarettes. To my knowledge, there are no controlled studies of e-cigarette use in pregnancy, but the concerns previously raised regarding nicotine exposure in any form likely apply to this delivery method (Birth Defects Res A Clin Mol Teratol. 2015 Mar;103[3]:186-95).

What is the role of the obstetrician in identifying nicotine and tobacco exposure in their patients and encouraging cessation or reduction prior to and during pregnancy?

The first responsibility is to screen pregnant women. A recent survey study suggests that 40% of the responding ob.gyns. never screened pregnant patients for use of noncombustible tobacco products such as e-cigarettes (Am J Obstet Gynecol. 2014 Dec;211[6]:695.e1-7). In the United States, an analysis of the Pregnancy Risk Assessment Monitoring System data collected across several states from 2009 to 2010 suggests that about a quarter of 3,559 pregnant women who reported smoking in the 3 months before pregnancy did not receive any interventions to stop smoking (Prev Med. 2015 Sep;78:92-100). In addition, four out of five ob.gyns. surveyed in 2012 were unaware of the Affordable Care Act provision that requires states to provide tobacco cessation coverage for pregnant Medicaid beneficiaries (Prev Med Rep. 2015;2:686-88).

Dr. Chambers is professor of pediatrics and director of clinical research at Rady Children’s Hospital, and associate director of the Clinical and Translational Research Institute at the University of California, San Diego. She is director of MotherToBaby California, past president of the Organization of Teratology Information Specialists, and past president of the Teratology Society. She reported having no financial disclosures relevant to this column, but has received research funding from GlaxoSmithKline and Pfizer for unrelated products.

Data consistently support the negative impact of tobacco use in pregnancy with respect to pregnancy outcome, and the benefits of discontinuation or reduction as early as possible.

Recent analyses by investigators at the National Center on Birth Defects and Developmental Disabilities at the Centers for Disease Control and Prevention suggest that more than 6% of oral clefts, or 430 affected infants per year in the United States, could be prevented annually if women can discontinue tobacco use prior to conception (Birth Defects Res A Clin Mol Teratol. 2014 Nov;100[11]:822-5). Similarly, preconception smoking cessation could prevent the 1.4% of nonsyndromic congenital heart defects that are attributable to maternal smoking in the first trimester (J Pediatr. 2015 Apr;166[4]:978-984.e2).

With respect to the risk for adverse outcomes beyond the first trimester, recent data also show clearly that the trimester of discontinuation is related to intrauterine growth restriction in a dose-response fashion (Obstet Gynecol. 2015 Jun;125[6]:1452-9).

In a recent population-based retrospective cohort study of 927,424 singleton births 2006-2012 in Ohio, the adjusted relative risk of infant birth weight less than the 5th percentile for those women who discontinued smoking after the first trimester compared with nonsmokers was 1.25 (95% confidence interval, 1.17-1.33); for those who discontinued after the second trimester the relative risk was 1.83 (95% CI, 1.68-1.99); and for those who smoked throughout pregnancy the relative risk was 2.44 (95% CI, 2.37-2.51).

Given the compelling reasons to encourage women to stop smoking or at least to reduce harm during pregnancy, options for assistance with smoking cessation are of high interest. Beyond simple screening and advice to quit, cognitive behavioral therapy has been shown to provide some benefit. The addition of pharmacologic treatment with nicotine replacement therapy (NRT) has been studied in six randomized clinical trials (RCTs) conducted in pregnant women, four of which compared NRT plus advice/behavioral support to placebo plus advice/behavioral support, and two of which compared NRT plus advice/behavioral support to advice/behavioral support alone.

In a recent Cochrane systematic review of these studies, no statistically significant evidence of effectiveness was demonstrated for NRT versus placebo/control in a pooled sample of 1,745 pregnant patients (risk ratio, 1.33, 95% CI, 0.93-1.91). However, there was high heterogeneity in the dose of NRT and the delivery method (e.g., gum, patch) across studies, and poor adherence to the NRT treatment in all trials (Cochrane Database Syst Rev. 2012 Sep 12;9:CD010078).

With respect to safety, in the same Cochrane review there were no statistically significant differences in rates of miscarriage, stillbirth, premature birth, birth weight, low birth weight, admissions to neonatal intensive care, or neonatal death between NRT and control groups. However, small sample sizes and adherence issues across these trials hampered the interpretability of these data.

One relatively large claims database study from the United Kingdom, which was published recently, examined major congenital anomalies following prescription of NRT. The investigators found no increased risks for most major defects following NRT prescription; the only significant association was with respiratory defects (Pediatrics. 2015 May;135[5]:859-67).

The general thinking has been that for a woman who is unable to quit smoking without pharmacological assistance, NRT that delivers nicotine alone to the developing fetus may be a better option than exposure to the multiple toxins that are contained in tobacco smoke. However, there is considerable controversy over the potential adverse neurotoxic effects of nicotine itself and long-term neurodevelopmental studies on children prenatally exposed to NRT are lacking.

Catherine Harrell/Frontline Medical News

Other options include bupropion and varenicline, neither of which have been studied in RCTs in pregnancy. Bupropion has been evaluated in a small controlled cohort study, a claims database study (n = 1,236 first-trimester exposed), and two case-control studies. None of these studies was focused on use of bupropion exclusively for smoking cessation, but rather for the more common indication of maternal depression. The first two studies suggested no increased risks for adverse pregnancy outcomes compared to women the same underlying conditions; the case control studies suggested small increased risks for heart defects but not the same ones in both studies (Expert Opin Drug Saf. 2014 Dec;13[12]:1721-31). The limited data on varenicline are too sparse to make any inferences.

Another possible alternative that has been gaining in popularity are e-cigarettes or related vapor products, which are touted to have advantages with respect to harm reduction, primarily because of possible improved adherence due to their similarity to conventional smoking. However, there is large variability in the amount of nicotine in the vapor of various e-cigarette brands, and some have suggested that e-cigarette users engage in longer puff duration than do those who smoke conventional cigarettes. To my knowledge, there are no controlled studies of e-cigarette use in pregnancy, but the concerns previously raised regarding nicotine exposure in any form likely apply to this delivery method (Birth Defects Res A Clin Mol Teratol. 2015 Mar;103[3]:186-95).

What is the role of the obstetrician in identifying nicotine and tobacco exposure in their patients and encouraging cessation or reduction prior to and during pregnancy?

The first responsibility is to screen pregnant women. A recent survey study suggests that 40% of the responding ob.gyns. never screened pregnant patients for use of noncombustible tobacco products such as e-cigarettes (Am J Obstet Gynecol. 2014 Dec;211[6]:695.e1-7). In the United States, an analysis of the Pregnancy Risk Assessment Monitoring System data collected across several states from 2009 to 2010 suggests that about a quarter of 3,559 pregnant women who reported smoking in the 3 months before pregnancy did not receive any interventions to stop smoking (Prev Med. 2015 Sep;78:92-100). In addition, four out of five ob.gyns. surveyed in 2012 were unaware of the Affordable Care Act provision that requires states to provide tobacco cessation coverage for pregnant Medicaid beneficiaries (Prev Med Rep. 2015;2:686-88).

Dr. Chambers is professor of pediatrics and director of clinical research at Rady Children’s Hospital, and associate director of the Clinical and Translational Research Institute at the University of California, San Diego. She is director of MotherToBaby California, past president of the Organization of Teratology Information Specialists, and past president of the Teratology Society. She reported having no financial disclosures relevant to this column, but has received research funding from GlaxoSmithKline and Pfizer for unrelated products.

Data consistently support the negative impact of tobacco use in pregnancy with respect to pregnancy outcome, and the benefits of discontinuation or reduction as early as possible.

Recent analyses by investigators at the National Center on Birth Defects and Developmental Disabilities at the Centers for Disease Control and Prevention suggest that more than 6% of oral clefts, or 430 affected infants per year in the United States, could be prevented annually if women can discontinue tobacco use prior to conception (Birth Defects Res A Clin Mol Teratol. 2014 Nov;100[11]:822-5). Similarly, preconception smoking cessation could prevent the 1.4% of nonsyndromic congenital heart defects that are attributable to maternal smoking in the first trimester (J Pediatr. 2015 Apr;166[4]:978-984.e2).

With respect to the risk for adverse outcomes beyond the first trimester, recent data also show clearly that the trimester of discontinuation is related to intrauterine growth restriction in a dose-response fashion (Obstet Gynecol. 2015 Jun;125[6]:1452-9).

In a recent population-based retrospective cohort study of 927,424 singleton births 2006-2012 in Ohio, the adjusted relative risk of infant birth weight less than the 5th percentile for those women who discontinued smoking after the first trimester compared with nonsmokers was 1.25 (95% confidence interval, 1.17-1.33); for those who discontinued after the second trimester the relative risk was 1.83 (95% CI, 1.68-1.99); and for those who smoked throughout pregnancy the relative risk was 2.44 (95% CI, 2.37-2.51).

Given the compelling reasons to encourage women to stop smoking or at least to reduce harm during pregnancy, options for assistance with smoking cessation are of high interest. Beyond simple screening and advice to quit, cognitive behavioral therapy has been shown to provide some benefit. The addition of pharmacologic treatment with nicotine replacement therapy (NRT) has been studied in six randomized clinical trials (RCTs) conducted in pregnant women, four of which compared NRT plus advice/behavioral support to placebo plus advice/behavioral support, and two of which compared NRT plus advice/behavioral support to advice/behavioral support alone.

In a recent Cochrane systematic review of these studies, no statistically significant evidence of effectiveness was demonstrated for NRT versus placebo/control in a pooled sample of 1,745 pregnant patients (risk ratio, 1.33, 95% CI, 0.93-1.91). However, there was high heterogeneity in the dose of NRT and the delivery method (e.g., gum, patch) across studies, and poor adherence to the NRT treatment in all trials (Cochrane Database Syst Rev. 2012 Sep 12;9:CD010078).

With respect to safety, in the same Cochrane review there were no statistically significant differences in rates of miscarriage, stillbirth, premature birth, birth weight, low birth weight, admissions to neonatal intensive care, or neonatal death between NRT and control groups. However, small sample sizes and adherence issues across these trials hampered the interpretability of these data.

One relatively large claims database study from the United Kingdom, which was published recently, examined major congenital anomalies following prescription of NRT. The investigators found no increased risks for most major defects following NRT prescription; the only significant association was with respiratory defects (Pediatrics. 2015 May;135[5]:859-67).

The general thinking has been that for a woman who is unable to quit smoking without pharmacological assistance, NRT that delivers nicotine alone to the developing fetus may be a better option than exposure to the multiple toxins that are contained in tobacco smoke. However, there is considerable controversy over the potential adverse neurotoxic effects of nicotine itself and long-term neurodevelopmental studies on children prenatally exposed to NRT are lacking.

Catherine Harrell/Frontline Medical News

Other options include bupropion and varenicline, neither of which have been studied in RCTs in pregnancy. Bupropion has been evaluated in a small controlled cohort study, a claims database study (n = 1,236 first-trimester exposed), and two case-control studies. None of these studies was focused on use of bupropion exclusively for smoking cessation, but rather for the more common indication of maternal depression. The first two studies suggested no increased risks for adverse pregnancy outcomes compared to women the same underlying conditions; the case control studies suggested small increased risks for heart defects but not the same ones in both studies (Expert Opin Drug Saf. 2014 Dec;13[12]:1721-31). The limited data on varenicline are too sparse to make any inferences.

Another possible alternative that has been gaining in popularity are e-cigarettes or related vapor products, which are touted to have advantages with respect to harm reduction, primarily because of possible improved adherence due to their similarity to conventional smoking. However, there is large variability in the amount of nicotine in the vapor of various e-cigarette brands, and some have suggested that e-cigarette users engage in longer puff duration than do those who smoke conventional cigarettes. To my knowledge, there are no controlled studies of e-cigarette use in pregnancy, but the concerns previously raised regarding nicotine exposure in any form likely apply to this delivery method (Birth Defects Res A Clin Mol Teratol. 2015 Mar;103[3]:186-95).

What is the role of the obstetrician in identifying nicotine and tobacco exposure in their patients and encouraging cessation or reduction prior to and during pregnancy?

The first responsibility is to screen pregnant women. A recent survey study suggests that 40% of the responding ob.gyns. never screened pregnant patients for use of noncombustible tobacco products such as e-cigarettes (Am J Obstet Gynecol. 2014 Dec;211[6]:695.e1-7). In the United States, an analysis of the Pregnancy Risk Assessment Monitoring System data collected across several states from 2009 to 2010 suggests that about a quarter of 3,559 pregnant women who reported smoking in the 3 months before pregnancy did not receive any interventions to stop smoking (Prev Med. 2015 Sep;78:92-100). In addition, four out of five ob.gyns. surveyed in 2012 were unaware of the Affordable Care Act provision that requires states to provide tobacco cessation coverage for pregnant Medicaid beneficiaries (Prev Med Rep. 2015;2:686-88).

Dr. Chambers is professor of pediatrics and director of clinical research at Rady Children’s Hospital, and associate director of the Clinical and Translational Research Institute at the University of California, San Diego. She is director of MotherToBaby California, past president of the Organization of Teratology Information Specialists, and past president of the Teratology Society. She reported having no financial disclosures relevant to this column, but has received research funding from GlaxoSmithKline and Pfizer for unrelated products.

SAN DIEGO – Enterovirus D68 appeared more virulent – but not more lethal – than rhinovirus and other strains of enterovirus among children, said the authors of a single-center study.

The pulmonary pathogen was linked to higher rates of respiratory distress, hospital admission, and magnesium sulfate therapy, but patients were no more likely to die or require critical care unit admission than were those infected with other EV genotypes or rhinovirus, said Dr. Dominik Mertz of the division of infectious diseases at McMaster University, in Hamilton, Ont.

Amy Karon/Frontline Medical News

The study also uncovered no evidence of EV-68 transmission at the hospital, Dr. Mertz and his associates said at an annual scientific meeting on infectious diseases.

In 2014, an outbreak of EV-D68 in the United States included more than 1,000 confirmed cases, almost all among children, and many of whom had comorbid asthma or a history of wheezing. Fourteen patients died, and the Centers for Disease Control and Prevention noted that millions more individuals probably had milder EV-D68 infections for which they were never tested.

Dr. Mertz and his associates studied children who presented consecutively to the hospital during the 3 months between Aug. 1 and Oct. 31, 2014. During that time, nasopharyngeal swabs that were positive for EV or rhinovirus were automatically tested for EV-D68. The researchers matched EV-D68–positive patients with children who were positive for rhinovirus or other EVs on the basis of sex, age, and date of presentation to the hospital.

Almost a third (93 of 297; 31%) of rhinovirus or EV samples were positive for EV-D68. Among 87 matched pairs, EV-D68 infection was associated with a threefold greater odds of respiratory distress (95% confidence interval, 1.47-6.14), and a more than twofold rise in the odds of needing magnesium sulfate therapy (odds ratio, 2.62; 95% CI, 1.06-6.47). There was a trend toward greater risk of hospital admission with EV-D68, although it was not statistically significant (OR, 2.29; 95% CI, 0.96-5.46; P = .06).

Notably, EV-68 did not increase the likelihood of death or CCU admission, while, influenza causes dozens of deaths among children in the United States every year, Dr. Mertz and his coinvestigator Dr. Jeffrey Pernica noted in an interview (MMWR. 2014 Jun 6:63[22];483-90). Studies have yet to compare the morbidity and mortality burdens of influenza, respiratory syncytial virus, and EV-D68, and they would like to do so, they said.

“There was a lot of fuss made about EV-D68,” said Dr. Mertz. “But we have flu every year, and many more kids get the flu and die of flu than EV-D68.”

Patients with EV-D68 infection were more likely than others to have a family history of atopy (OR, 2.25) and a personal history of asthma or wheezing (OR, 1.77), hay fever (1.22), and eosinophilia (4.5), although none of these associations reached statistical significance, the investigators reported. “It seems reasonable to hypothesize that EV-D68 is a more virulent pulmonary pathogen to those with preexisting atopic disease than other rhinoviruses and enteroviruses,” Dr. Mertz and his associates wrote in an associated article (CMAJ. 2015 Oct. 13. doi: 10.1503/cmaj.150619). “We can hypothesize that these children are more likely to have respiratory distress because of the combination of allergy and EV-D68, but why the same doesn’t hold true for rhinovirus or other enterovirus strains, we don’t know,” Dr. Mertz said.

The investigators received no funding for the study and reported no conflicts of interest.

SAN DIEGO – Enterovirus D68 appeared more virulent – but not more lethal – than rhinovirus and other strains of enterovirus among children, said the authors of a single-center study.

The pulmonary pathogen was linked to higher rates of respiratory distress, hospital admission, and magnesium sulfate therapy, but patients were no more likely to die or require critical care unit admission than were those infected with other EV genotypes or rhinovirus, said Dr. Dominik Mertz of the division of infectious diseases at McMaster University, in Hamilton, Ont.

Amy Karon/Frontline Medical News

The study also uncovered no evidence of EV-68 transmission at the hospital, Dr. Mertz and his associates said at an annual scientific meeting on infectious diseases.

In 2014, an outbreak of EV-D68 in the United States included more than 1,000 confirmed cases, almost all among children, and many of whom had comorbid asthma or a history of wheezing. Fourteen patients died, and the Centers for Disease Control and Prevention noted that millions more individuals probably had milder EV-D68 infections for which they were never tested.

Dr. Mertz and his associates studied children who presented consecutively to the hospital during the 3 months between Aug. 1 and Oct. 31, 2014. During that time, nasopharyngeal swabs that were positive for EV or rhinovirus were automatically tested for EV-D68. The researchers matched EV-D68–positive patients with children who were positive for rhinovirus or other EVs on the basis of sex, age, and date of presentation to the hospital.

Almost a third (93 of 297; 31%) of rhinovirus or EV samples were positive for EV-D68. Among 87 matched pairs, EV-D68 infection was associated with a threefold greater odds of respiratory distress (95% confidence interval, 1.47-6.14), and a more than twofold rise in the odds of needing magnesium sulfate therapy (odds ratio, 2.62; 95% CI, 1.06-6.47). There was a trend toward greater risk of hospital admission with EV-D68, although it was not statistically significant (OR, 2.29; 95% CI, 0.96-5.46; P = .06).

Notably, EV-68 did not increase the likelihood of death or CCU admission, while, influenza causes dozens of deaths among children in the United States every year, Dr. Mertz and his coinvestigator Dr. Jeffrey Pernica noted in an interview (MMWR. 2014 Jun 6:63[22];483-90). Studies have yet to compare the morbidity and mortality burdens of influenza, respiratory syncytial virus, and EV-D68, and they would like to do so, they said.

“There was a lot of fuss made about EV-D68,” said Dr. Mertz. “But we have flu every year, and many more kids get the flu and die of flu than EV-D68.”

Patients with EV-D68 infection were more likely than others to have a family history of atopy (OR, 2.25) and a personal history of asthma or wheezing (OR, 1.77), hay fever (1.22), and eosinophilia (4.5), although none of these associations reached statistical significance, the investigators reported. “It seems reasonable to hypothesize that EV-D68 is a more virulent pulmonary pathogen to those with preexisting atopic disease than other rhinoviruses and enteroviruses,” Dr. Mertz and his associates wrote in an associated article (CMAJ. 2015 Oct. 13. doi: 10.1503/cmaj.150619). “We can hypothesize that these children are more likely to have respiratory distress because of the combination of allergy and EV-D68, but why the same doesn’t hold true for rhinovirus or other enterovirus strains, we don’t know,” Dr. Mertz said.

The investigators received no funding for the study and reported no conflicts of interest.

SAN DIEGO – Enterovirus D68 appeared more virulent – but not more lethal – than rhinovirus and other strains of enterovirus among children, said the authors of a single-center study.

The pulmonary pathogen was linked to higher rates of respiratory distress, hospital admission, and magnesium sulfate therapy, but patients were no more likely to die or require critical care unit admission than were those infected with other EV genotypes or rhinovirus, said Dr. Dominik Mertz of the division of infectious diseases at McMaster University, in Hamilton, Ont.

Amy Karon/Frontline Medical News

The study also uncovered no evidence of EV-68 transmission at the hospital, Dr. Mertz and his associates said at an annual scientific meeting on infectious diseases.

In 2014, an outbreak of EV-D68 in the United States included more than 1,000 confirmed cases, almost all among children, and many of whom had comorbid asthma or a history of wheezing. Fourteen patients died, and the Centers for Disease Control and Prevention noted that millions more individuals probably had milder EV-D68 infections for which they were never tested.

Dr. Mertz and his associates studied children who presented consecutively to the hospital during the 3 months between Aug. 1 and Oct. 31, 2014. During that time, nasopharyngeal swabs that were positive for EV or rhinovirus were automatically tested for EV-D68. The researchers matched EV-D68–positive patients with children who were positive for rhinovirus or other EVs on the basis of sex, age, and date of presentation to the hospital.

Almost a third (93 of 297; 31%) of rhinovirus or EV samples were positive for EV-D68. Among 87 matched pairs, EV-D68 infection was associated with a threefold greater odds of respiratory distress (95% confidence interval, 1.47-6.14), and a more than twofold rise in the odds of needing magnesium sulfate therapy (odds ratio, 2.62; 95% CI, 1.06-6.47). There was a trend toward greater risk of hospital admission with EV-D68, although it was not statistically significant (OR, 2.29; 95% CI, 0.96-5.46; P = .06).

Notably, EV-68 did not increase the likelihood of death or CCU admission, while, influenza causes dozens of deaths among children in the United States every year, Dr. Mertz and his coinvestigator Dr. Jeffrey Pernica noted in an interview (MMWR. 2014 Jun 6:63[22];483-90). Studies have yet to compare the morbidity and mortality burdens of influenza, respiratory syncytial virus, and EV-D68, and they would like to do so, they said.

“There was a lot of fuss made about EV-D68,” said Dr. Mertz. “But we have flu every year, and many more kids get the flu and die of flu than EV-D68.”

Patients with EV-D68 infection were more likely than others to have a family history of atopy (OR, 2.25) and a personal history of asthma or wheezing (OR, 1.77), hay fever (1.22), and eosinophilia (4.5), although none of these associations reached statistical significance, the investigators reported. “It seems reasonable to hypothesize that EV-D68 is a more virulent pulmonary pathogen to those with preexisting atopic disease than other rhinoviruses and enteroviruses,” Dr. Mertz and his associates wrote in an associated article (CMAJ. 2015 Oct. 13. doi: 10.1503/cmaj.150619). “We can hypothesize that these children are more likely to have respiratory distress because of the combination of allergy and EV-D68, but why the same doesn’t hold true for rhinovirus or other enterovirus strains, we don’t know,” Dr. Mertz said.

The investigators received no funding for the study and reported no conflicts of interest.

NATIONAL HARBOR, MD – While Americans search high and low for solutions to their chronic pain problems, one of the simplest fixes may be right under their noses: getting a good night’s sleep.

Dr. Ashwin Mehta of the University of Miami spoke at length about the need for deep, restful sleep, and the relationship between circadian rhythms and chronic lower back pain, during a presentation at the annual meeting of the American Academy of Pain Medicine.

©JackF/thinkstockphotos.com

“REM [rapid eye movement] sleep [can] optimize regulation of physiological functions,” explained Dr. Mehta, adding that sleep loss can lead to altered immune responses, changes in circulating levels of leukocytes and cytokines, and decreased levels of antibodies.

Citing earlier research by another investigator, Dr. Mehta explained that there is evidence pain is directly correlated to fatigue, with sleep holding the key to solving problems with both (J Pain Symptom Manage. 2010 Jan;39[1]:126-38). Particularly in cancer patients, restfulness was shown to improve mood and well-being in a similar study (J Clin Oncol. 2012 Mar 19;30[12]:1335-42).

Dr. Mehta also reviewed known information that neuropeptides, specifically, serotonin, glutamate, gama-aminobutyric acid, and substance P, are linked to poor sleep, poor mood, and chronic pain. Multidisciplinary approaches should be considered by physicians and patients to find the most effective strategy for getting good sleep and mitigating chronic pain. These approaches can include, among other things, cognitive-behavioral interventions, increased exercise, breathing exercises, and yoga (Sleep. 2011 Dec 1;34[12]:1631-40).

Magnesium, vitamin D, and products with lavender (Am J Crit Care. 2014 Jan;23[1]:24-9) and passionflower (Phytother Res. 2011 Aug;25[8]:1153-9) – such as oil and tea – can help with achieving restful sleep on a consistent basis, and have been studied as recently as 2014 and 2011, respectively, said Dr. Mehta.

Naps can also be effective, although impractical for most patients. Finding time either in the middle of the day or after work for a nap can help improve sleep at night, while walking a mile after dinner is also highly recommended. Good “sleep hygiene” is also encouraged; this includes sleeping someplace that is both quiet and dark, without any bright lights – this includes the omnipresent cell phones, laptops, tablet computers, and televisions. Patients should also never eat while in bed, and refrain from alcohol and caffeine before going to bed.

Dr. Mehta did not report any relevant financial disclosures.

[email protected]

NATIONAL HARBOR, MD – While Americans search high and low for solutions to their chronic pain problems, one of the simplest fixes may be right under their noses: getting a good night’s sleep.

Dr. Ashwin Mehta of the University of Miami spoke at length about the need for deep, restful sleep, and the relationship between circadian rhythms and chronic lower back pain, during a presentation at the annual meeting of the American Academy of Pain Medicine.

©JackF/thinkstockphotos.com

“REM [rapid eye movement] sleep [can] optimize regulation of physiological functions,” explained Dr. Mehta, adding that sleep loss can lead to altered immune responses, changes in circulating levels of leukocytes and cytokines, and decreased levels of antibodies.

Citing earlier research by another investigator, Dr. Mehta explained that there is evidence pain is directly correlated to fatigue, with sleep holding the key to solving problems with both (J Pain Symptom Manage. 2010 Jan;39[1]:126-38). Particularly in cancer patients, restfulness was shown to improve mood and well-being in a similar study (J Clin Oncol. 2012 Mar 19;30[12]:1335-42).

Dr. Mehta also reviewed known information that neuropeptides, specifically, serotonin, glutamate, gama-aminobutyric acid, and substance P, are linked to poor sleep, poor mood, and chronic pain. Multidisciplinary approaches should be considered by physicians and patients to find the most effective strategy for getting good sleep and mitigating chronic pain. These approaches can include, among other things, cognitive-behavioral interventions, increased exercise, breathing exercises, and yoga (Sleep. 2011 Dec 1;34[12]:1631-40).

Magnesium, vitamin D, and products with lavender (Am J Crit Care. 2014 Jan;23[1]:24-9) and passionflower (Phytother Res. 2011 Aug;25[8]:1153-9) – such as oil and tea – can help with achieving restful sleep on a consistent basis, and have been studied as recently as 2014 and 2011, respectively, said Dr. Mehta.

Naps can also be effective, although impractical for most patients. Finding time either in the middle of the day or after work for a nap can help improve sleep at night, while walking a mile after dinner is also highly recommended. Good “sleep hygiene” is also encouraged; this includes sleeping someplace that is both quiet and dark, without any bright lights – this includes the omnipresent cell phones, laptops, tablet computers, and televisions. Patients should also never eat while in bed, and refrain from alcohol and caffeine before going to bed.

Dr. Mehta did not report any relevant financial disclosures.

[email protected]

NATIONAL HARBOR, MD – While Americans search high and low for solutions to their chronic pain problems, one of the simplest fixes may be right under their noses: getting a good night’s sleep.

Dr. Ashwin Mehta of the University of Miami spoke at length about the need for deep, restful sleep, and the relationship between circadian rhythms and chronic lower back pain, during a presentation at the annual meeting of the American Academy of Pain Medicine.

©JackF/thinkstockphotos.com

“REM [rapid eye movement] sleep [can] optimize regulation of physiological functions,” explained Dr. Mehta, adding that sleep loss can lead to altered immune responses, changes in circulating levels of leukocytes and cytokines, and decreased levels of antibodies.

Citing earlier research by another investigator, Dr. Mehta explained that there is evidence pain is directly correlated to fatigue, with sleep holding the key to solving problems with both (J Pain Symptom Manage. 2010 Jan;39[1]:126-38). Particularly in cancer patients, restfulness was shown to improve mood and well-being in a similar study (J Clin Oncol. 2012 Mar 19;30[12]:1335-42).

Dr. Mehta also reviewed known information that neuropeptides, specifically, serotonin, glutamate, gama-aminobutyric acid, and substance P, are linked to poor sleep, poor mood, and chronic pain. Multidisciplinary approaches should be considered by physicians and patients to find the most effective strategy for getting good sleep and mitigating chronic pain. These approaches can include, among other things, cognitive-behavioral interventions, increased exercise, breathing exercises, and yoga (Sleep. 2011 Dec 1;34[12]:1631-40).

Magnesium, vitamin D, and products with lavender (Am J Crit Care. 2014 Jan;23[1]:24-9) and passionflower (Phytother Res. 2011 Aug;25[8]:1153-9) – such as oil and tea – can help with achieving restful sleep on a consistent basis, and have been studied as recently as 2014 and 2011, respectively, said Dr. Mehta.

Naps can also be effective, although impractical for most patients. Finding time either in the middle of the day or after work for a nap can help improve sleep at night, while walking a mile after dinner is also highly recommended. Good “sleep hygiene” is also encouraged; this includes sleeping someplace that is both quiet and dark, without any bright lights – this includes the omnipresent cell phones, laptops, tablet computers, and televisions. Patients should also never eat while in bed, and refrain from alcohol and caffeine before going to bed.

Dr. Mehta did not report any relevant financial disclosures.

[email protected]

SAN DIEGO – Prophylactic palivizumab cut the odds of hospitalization for severe respiratory syncytial virus (RSV) infection by about 75% among preterm infants born at more than 29 weeks’ gestational age – even those without congenital heart disease or chronic lung disease, investigators reported.

The finding belies the American Academy of Pediatrics’ recommendation to limit use of the humanized monoclonal antibody to infants born before 29 weeks’ gestation and to children who have other risk factors for severe RSV infection, Dr. Ram Yogev of Ann and Robert H. Lurie Children’s Hospital, Chicago, said in an interview.

“Our results validate the older studies, except this was done in real life,” added lead investigator Dr. Eric Simões of Children’s Hospital Colorado, Aurora, who presented the findings at an annual scientific meeting on infectious diseases.

RSV usually causes mild upper respiratory tract infections, but premature infants and children who have comorbid cardiac or pulmonary disease can develop severe infections of the lower respiratory tract. Weekly palivizumab dosing was 45%-80% effective in preventing RSV-related hospitalizations in clinical trials of these high-risk patients, noted Dr. Simões and his associates.

But in 2014, the American Academy of Pediatrics reviewed the literature and revised its guidance to limit palivizumab to preterm infants born before 29 weeks’ gestation and to infants with comorbid risk conditions. The biologic “has been shown to have a limited effect on reducing RSV hospitalization,” the academy concluded. The update drew criticism from some pediatric infectious disease experts, who contended that AAP cited observational studies that actually contradicted its conclusions.

To further examine the issue, Dr. Simões and associates analyzed data from a multicenter study of high-risk infants and children under the age of 2 years who had been hospitalized with lower respiratory tract infections. Between 2002 and 2006, 849 of these patients had a nasopharyngeal wash or endotracheal aspirate tested for RSV, and 403 were positive. The investigators determined that the odds of a positive RSV test were 58% lower for patients who had received prophylactic palivizumab, compared with patients who had not (95% confidence interval for efficacy, 43%-69%; P less than .0001).

Furthermore, palivizumab was 75% effective against severe RSV disease in preterm patients born at 29-35 weeks’ gestation who were chronologically younger than 6 months and had no congenital heart disease or chronic lung disease, said the investigators. Based on that finding, AAP should reconsider its recommendations on palivizumab, said Dr. Yogev.

“This study should answer some of the issues raised in the AAP recommendations,” added Dr. Simões.

Palivizumab did not prevent hospitalizations for human metapneumovirus (hMPV) infection, which further validated the results on RSV, said Dr. Simões. The test-negative case-control design of the study “cuts out the whole issue of [bias due to] care-seeking behavior,” he added. “But children on palivizumab would be more seriously ill, so how do you correct for that? Traditional methods are based on multivariate analysis, but we used propensity scores.” A goodness-of-fit test showed that this approach controlled for all variables except palivizumab exposure and age greater than 6 months, meaning that only these two factors were significantly protective against RSV infection, he said.

IDWeek marked the combined annual meetings of the Infectious Diseases Society of America, the Society for Healthcare Epidemiology of America, the HIV Medicine Association, and the Pediatric Infectious Diseases Society.

MedImmune sponsored the original study of hMPV tract infections, from which these data were obtained. Dr. Simões reported having received funding support and consulting fees from MedImmune.

SAN DIEGO – Prophylactic palivizumab cut the odds of hospitalization for severe respiratory syncytial virus (RSV) infection by about 75% among preterm infants born at more than 29 weeks’ gestational age – even those without congenital heart disease or chronic lung disease, investigators reported.

The finding belies the American Academy of Pediatrics’ recommendation to limit use of the humanized monoclonal antibody to infants born before 29 weeks’ gestation and to children who have other risk factors for severe RSV infection, Dr. Ram Yogev of Ann and Robert H. Lurie Children’s Hospital, Chicago, said in an interview.

“Our results validate the older studies, except this was done in real life,” added lead investigator Dr. Eric Simões of Children’s Hospital Colorado, Aurora, who presented the findings at an annual scientific meeting on infectious diseases.

RSV usually causes mild upper respiratory tract infections, but premature infants and children who have comorbid cardiac or pulmonary disease can develop severe infections of the lower respiratory tract. Weekly palivizumab dosing was 45%-80% effective in preventing RSV-related hospitalizations in clinical trials of these high-risk patients, noted Dr. Simões and his associates.

But in 2014, the American Academy of Pediatrics reviewed the literature and revised its guidance to limit palivizumab to preterm infants born before 29 weeks’ gestation and to infants with comorbid risk conditions. The biologic “has been shown to have a limited effect on reducing RSV hospitalization,” the academy concluded. The update drew criticism from some pediatric infectious disease experts, who contended that AAP cited observational studies that actually contradicted its conclusions.

To further examine the issue, Dr. Simões and associates analyzed data from a multicenter study of high-risk infants and children under the age of 2 years who had been hospitalized with lower respiratory tract infections. Between 2002 and 2006, 849 of these patients had a nasopharyngeal wash or endotracheal aspirate tested for RSV, and 403 were positive. The investigators determined that the odds of a positive RSV test were 58% lower for patients who had received prophylactic palivizumab, compared with patients who had not (95% confidence interval for efficacy, 43%-69%; P less than .0001).

Furthermore, palivizumab was 75% effective against severe RSV disease in preterm patients born at 29-35 weeks’ gestation who were chronologically younger than 6 months and had no congenital heart disease or chronic lung disease, said the investigators. Based on that finding, AAP should reconsider its recommendations on palivizumab, said Dr. Yogev.

“This study should answer some of the issues raised in the AAP recommendations,” added Dr. Simões.

Palivizumab did not prevent hospitalizations for human metapneumovirus (hMPV) infection, which further validated the results on RSV, said Dr. Simões. The test-negative case-control design of the study “cuts out the whole issue of [bias due to] care-seeking behavior,” he added. “But children on palivizumab would be more seriously ill, so how do you correct for that? Traditional methods are based on multivariate analysis, but we used propensity scores.” A goodness-of-fit test showed that this approach controlled for all variables except palivizumab exposure and age greater than 6 months, meaning that only these two factors were significantly protective against RSV infection, he said.

IDWeek marked the combined annual meetings of the Infectious Diseases Society of America, the Society for Healthcare Epidemiology of America, the HIV Medicine Association, and the Pediatric Infectious Diseases Society.

MedImmune sponsored the original study of hMPV tract infections, from which these data were obtained. Dr. Simões reported having received funding support and consulting fees from MedImmune.

SAN DIEGO – Prophylactic palivizumab cut the odds of hospitalization for severe respiratory syncytial virus (RSV) infection by about 75% among preterm infants born at more than 29 weeks’ gestational age – even those without congenital heart disease or chronic lung disease, investigators reported.

The finding belies the American Academy of Pediatrics’ recommendation to limit use of the humanized monoclonal antibody to infants born before 29 weeks’ gestation and to children who have other risk factors for severe RSV infection, Dr. Ram Yogev of Ann and Robert H. Lurie Children’s Hospital, Chicago, said in an interview.

“Our results validate the older studies, except this was done in real life,” added lead investigator Dr. Eric Simões of Children’s Hospital Colorado, Aurora, who presented the findings at an annual scientific meeting on infectious diseases.

RSV usually causes mild upper respiratory tract infections, but premature infants and children who have comorbid cardiac or pulmonary disease can develop severe infections of the lower respiratory tract. Weekly palivizumab dosing was 45%-80% effective in preventing RSV-related hospitalizations in clinical trials of these high-risk patients, noted Dr. Simões and his associates.

But in 2014, the American Academy of Pediatrics reviewed the literature and revised its guidance to limit palivizumab to preterm infants born before 29 weeks’ gestation and to infants with comorbid risk conditions. The biologic “has been shown to have a limited effect on reducing RSV hospitalization,” the academy concluded. The update drew criticism from some pediatric infectious disease experts, who contended that AAP cited observational studies that actually contradicted its conclusions.

To further examine the issue, Dr. Simões and associates analyzed data from a multicenter study of high-risk infants and children under the age of 2 years who had been hospitalized with lower respiratory tract infections. Between 2002 and 2006, 849 of these patients had a nasopharyngeal wash or endotracheal aspirate tested for RSV, and 403 were positive. The investigators determined that the odds of a positive RSV test were 58% lower for patients who had received prophylactic palivizumab, compared with patients who had not (95% confidence interval for efficacy, 43%-69%; P less than .0001).

Furthermore, palivizumab was 75% effective against severe RSV disease in preterm patients born at 29-35 weeks’ gestation who were chronologically younger than 6 months and had no congenital heart disease or chronic lung disease, said the investigators. Based on that finding, AAP should reconsider its recommendations on palivizumab, said Dr. Yogev.

“This study should answer some of the issues raised in the AAP recommendations,” added Dr. Simões.

Palivizumab did not prevent hospitalizations for human metapneumovirus (hMPV) infection, which further validated the results on RSV, said Dr. Simões. The test-negative case-control design of the study “cuts out the whole issue of [bias due to] care-seeking behavior,” he added. “But children on palivizumab would be more seriously ill, so how do you correct for that? Traditional methods are based on multivariate analysis, but we used propensity scores.” A goodness-of-fit test showed that this approach controlled for all variables except palivizumab exposure and age greater than 6 months, meaning that only these two factors were significantly protective against RSV infection, he said.

IDWeek marked the combined annual meetings of the Infectious Diseases Society of America, the Society for Healthcare Epidemiology of America, the HIV Medicine Association, and the Pediatric Infectious Diseases Society.

MedImmune sponsored the original study of hMPV tract infections, from which these data were obtained. Dr. Simões reported having received funding support and consulting fees from MedImmune.

Receiving the tetanus, diphtheria, acellular pertussis vaccine during pregnancy does not increase the risk of adverse events for mother or baby, even if the mother has previously received the vaccine within the past 2 years, according to a report published Oct. 20 in JAMA.

Women should receive a Tdap vaccination during each pregnancy – preferably in the third trimester – so that the fetus receives some maternal antibodies against pertussis for limited protection until the first DTaP vaccine at age 2 months, according to 2012 recommendation from the Advisory Committee on Immunization Practices (ACIP). Yet previous research has not clarified the safety of repeated doses of maternal Tdap immunization.

©AvailableLight/istockphoto.com

“These findings suggest that relatively recent receipt of a prior tetanus-containing vaccination does not increase risk after Tdap vaccination in pregnancy,” wrote Dr. Lakshmi Sukumaran of the Centers for Disease Control and Prevention Immunization Safety Office, and colleagues. “Our findings should reassure patients and clinicians who might be hesitant to give Tdap vaccine to pregnant women who recently received a Tdap or other tetanus-containing vaccination.”

In the retrospective cohort study involving pregnancies between Jan. 1, 2007, through Nov. 15, 2013, the researchers examined data from 29,155 pregnant women, aged 14-49, who enrolled in seven Vaccine Safety Datalink sites in California, Colorado, Minnesota, Oregon, Washington, and Wisconsin.

The researchers compared the 49% of women who had received a tetanus-containing vaccine more than 5 years before their current pregnancy (controls) with the 17% of women who had received a tetanus-containing vaccine less than 2 years before, and the 34% of women who had been vaccinated 2-5 years earlier. More than two-thirds of the women (67.4%) received the Tdap during the third trimester, compared with 27.5% in the second trimester, and 5.1% in the first trimester (JAMA. 2015;314[15]:1581-7. doi: 10.1001/jama.2015.12790).

The researchers evaluated several adverse events including fever, allergy, and local reactions in mothers in the week following immunization, as well as preterm birth, low birth weight and small for gestational age in newborns. Local reactions included limb pain, limb swelling, cellulitis, lymphadenitis, and Arthus reaction. The researchers also looked for Guillain-Barré syndrome through day 42 after vaccination.

Few acute adverse events occurred after vaccination, and no statistically significant differences occurred across the three groups in terms of fever, allergic reactions, and local reactions.

Women who had received a tetanus-containing vaccine less than 2 years earlier had fevers at a rate of 2.1 per 10,000 women, compared with 3.5 per 10,000 women among controls (adjusted relative rate: 0.66; P = .70). Similarly, allergic reactions occurred at a rate of 2.1 per 10,000 women for those who had a vaccine less than 2 years prior, compared to 1 per 10,000 women who had the vaccine 2-5 years earlier, and 1.4 per 10,000 women among controls.

Local reactions occurred at a rate of 4.2, 7.0 and 11.2 per 10,000 women for those who had the vaccine less than 2 years prior, between 2-5 years prior, and more than 5 years prior, respectively. Preterm delivery rates, low birth weight, and small for gestation age were all similar across the three groups.

The Centers for Disease Control and Prevention and the National Institute of Allergy and Infectious Diseases funded the study. Dr. Sukumaran reported receiving research support from the National Institutes of Health. The other researchers reported receiving research support from GlaxoSmithKline, Sanofi Pasteur, Merck, Pfizer, Nuron Biotech, MedImmune, Novartis, and Protein Science.

Receiving the tetanus, diphtheria, acellular pertussis vaccine during pregnancy does not increase the risk of adverse events for mother or baby, even if the mother has previously received the vaccine within the past 2 years, according to a report published Oct. 20 in JAMA.

Women should receive a Tdap vaccination during each pregnancy – preferably in the third trimester – so that the fetus receives some maternal antibodies against pertussis for limited protection until the first DTaP vaccine at age 2 months, according to 2012 recommendation from the Advisory Committee on Immunization Practices (ACIP). Yet previous research has not clarified the safety of repeated doses of maternal Tdap immunization.

©AvailableLight/istockphoto.com

“These findings suggest that relatively recent receipt of a prior tetanus-containing vaccination does not increase risk after Tdap vaccination in pregnancy,” wrote Dr. Lakshmi Sukumaran of the Centers for Disease Control and Prevention Immunization Safety Office, and colleagues. “Our findings should reassure patients and clinicians who might be hesitant to give Tdap vaccine to pregnant women who recently received a Tdap or other tetanus-containing vaccination.”

In the retrospective cohort study involving pregnancies between Jan. 1, 2007, through Nov. 15, 2013, the researchers examined data from 29,155 pregnant women, aged 14-49, who enrolled in seven Vaccine Safety Datalink sites in California, Colorado, Minnesota, Oregon, Washington, and Wisconsin.

The researchers compared the 49% of women who had received a tetanus-containing vaccine more than 5 years before their current pregnancy (controls) with the 17% of women who had received a tetanus-containing vaccine less than 2 years before, and the 34% of women who had been vaccinated 2-5 years earlier. More than two-thirds of the women (67.4%) received the Tdap during the third trimester, compared with 27.5% in the second trimester, and 5.1% in the first trimester (JAMA. 2015;314[15]:1581-7. doi: 10.1001/jama.2015.12790).

The researchers evaluated several adverse events including fever, allergy, and local reactions in mothers in the week following immunization, as well as preterm birth, low birth weight and small for gestational age in newborns. Local reactions included limb pain, limb swelling, cellulitis, lymphadenitis, and Arthus reaction. The researchers also looked for Guillain-Barré syndrome through day 42 after vaccination.

Few acute adverse events occurred after vaccination, and no statistically significant differences occurred across the three groups in terms of fever, allergic reactions, and local reactions.

Women who had received a tetanus-containing vaccine less than 2 years earlier had fevers at a rate of 2.1 per 10,000 women, compared with 3.5 per 10,000 women among controls (adjusted relative rate: 0.66; P = .70). Similarly, allergic reactions occurred at a rate of 2.1 per 10,000 women for those who had a vaccine less than 2 years prior, compared to 1 per 10,000 women who had the vaccine 2-5 years earlier, and 1.4 per 10,000 women among controls.

Local reactions occurred at a rate of 4.2, 7.0 and 11.2 per 10,000 women for those who had the vaccine less than 2 years prior, between 2-5 years prior, and more than 5 years prior, respectively. Preterm delivery rates, low birth weight, and small for gestation age were all similar across the three groups.

The Centers for Disease Control and Prevention and the National Institute of Allergy and Infectious Diseases funded the study. Dr. Sukumaran reported receiving research support from the National Institutes of Health. The other researchers reported receiving research support from GlaxoSmithKline, Sanofi Pasteur, Merck, Pfizer, Nuron Biotech, MedImmune, Novartis, and Protein Science.

Receiving the tetanus, diphtheria, acellular pertussis vaccine during pregnancy does not increase the risk of adverse events for mother or baby, even if the mother has previously received the vaccine within the past 2 years, according to a report published Oct. 20 in JAMA.

Women should receive a Tdap vaccination during each pregnancy – preferably in the third trimester – so that the fetus receives some maternal antibodies against pertussis for limited protection until the first DTaP vaccine at age 2 months, according to 2012 recommendation from the Advisory Committee on Immunization Practices (ACIP). Yet previous research has not clarified the safety of repeated doses of maternal Tdap immunization.

©AvailableLight/istockphoto.com

“These findings suggest that relatively recent receipt of a prior tetanus-containing vaccination does not increase risk after Tdap vaccination in pregnancy,” wrote Dr. Lakshmi Sukumaran of the Centers for Disease Control and Prevention Immunization Safety Office, and colleagues. “Our findings should reassure patients and clinicians who might be hesitant to give Tdap vaccine to pregnant women who recently received a Tdap or other tetanus-containing vaccination.”

In the retrospective cohort study involving pregnancies between Jan. 1, 2007, through Nov. 15, 2013, the researchers examined data from 29,155 pregnant women, aged 14-49, who enrolled in seven Vaccine Safety Datalink sites in California, Colorado, Minnesota, Oregon, Washington, and Wisconsin.

The researchers compared the 49% of women who had received a tetanus-containing vaccine more than 5 years before their current pregnancy (controls) with the 17% of women who had received a tetanus-containing vaccine less than 2 years before, and the 34% of women who had been vaccinated 2-5 years earlier. More than two-thirds of the women (67.4%) received the Tdap during the third trimester, compared with 27.5% in the second trimester, and 5.1% in the first trimester (JAMA. 2015;314[15]:1581-7. doi: 10.1001/jama.2015.12790).

The researchers evaluated several adverse events including fever, allergy, and local reactions in mothers in the week following immunization, as well as preterm birth, low birth weight and small for gestational age in newborns. Local reactions included limb pain, limb swelling, cellulitis, lymphadenitis, and Arthus reaction. The researchers also looked for Guillain-Barré syndrome through day 42 after vaccination.

Few acute adverse events occurred after vaccination, and no statistically significant differences occurred across the three groups in terms of fever, allergic reactions, and local reactions.

Women who had received a tetanus-containing vaccine less than 2 years earlier had fevers at a rate of 2.1 per 10,000 women, compared with 3.5 per 10,000 women among controls (adjusted relative rate: 0.66; P = .70). Similarly, allergic reactions occurred at a rate of 2.1 per 10,000 women for those who had a vaccine less than 2 years prior, compared to 1 per 10,000 women who had the vaccine 2-5 years earlier, and 1.4 per 10,000 women among controls.

Local reactions occurred at a rate of 4.2, 7.0 and 11.2 per 10,000 women for those who had the vaccine less than 2 years prior, between 2-5 years prior, and more than 5 years prior, respectively. Preterm delivery rates, low birth weight, and small for gestation age were all similar across the three groups.

The Centers for Disease Control and Prevention and the National Institute of Allergy and Infectious Diseases funded the study. Dr. Sukumaran reported receiving research support from the National Institutes of Health. The other researchers reported receiving research support from GlaxoSmithKline, Sanofi Pasteur, Merck, Pfizer, Nuron Biotech, MedImmune, Novartis, and Protein Science.

SAN DIEGO – Only 39% of patients hospitalized for pneumonia underwent HIV testing, even though federal recommendations for universal HIV screening in all health care settings have been in place since 2006, according to the results of a retrospective, single-center study.

“Despite universal recommendations for HIV screening in all health care settings, HIV testing rates remain low among patients hospitalized with pneumonia,” Dr. Dana C. Clifton said at an annual scientific meeting on infectious diseases. “A number of patients were subsequently diagnosed with HIV after a prolonged delay.”

Of patients newly diagnosed with HIV in the United States, 41% report no prior HIV testing and an estimated 14%-25% of those living with HIV are undiagnosed, said Dr. Clifton, an internist at Duke University Medical Center, Durham, N.C. In 2006, the Centers for Disease Control and Prevention recommended routine HIV screening in all health care settings for all patients aged between 13 and 64 years old. “Multiple studies have shown that routine screening is cost effective, compared with screening tests for colon cancer, diabetes, and breast cancer,” Dr. Clifton said. In addition, bacterial pneumonia “is a predictor of HIV infection, and the clinical manifestations of bacterial pneumonia are similar whether one has HIV or not. So the question is, how do you decide whom to screen for HIV at hospital admission for pneumonia?”

Dr. Clifton and her associates retrospectively evaluated patients admitted to Duke University Health System between Jan. 1, 1996 and Dec. 31, 2014 with a first primary diagnosis of pneumonia. They used ICD-9 codes for primary diagnosis of pneumonia at time of hospital admission, reviewed a subset of charts to validate the diagnosis, and conducted a random sample of those without prior HIV diagnosis to evaluate HIV testing. The primary outcome was HIV testing during pneumonia admission. Secondary outcomes were documented prior HIV testing in the electronic medical record and subsequent new HIV diagnosis following pneumonia admission.

During the time period studied, 6,858 patients were admitted with a primary diagnosis of pneumonia. Their median age was 50 years, 49% were male, 53% were white, 41% were African American, and the rest were from other ethnic groups. In all, 5,133 (75%) were discharged by general medicine or pulmonary service.

Of the 6,858 patients, 6,513 (95%) were not previously known to be HIV positive (95%), while 345 (5%) were previously known to be HIV positive. Of the 6,513 not previously known to be HIV positive, 19 (0.3%) were diagnosed with HIV during hospital admission and 46 (0.7%) were diagnosed with HIV a median of 807 days after admission.

When the researchers evaluated a random sample of 207 patients not previously known to be HIV positive, the researchers found that only 69 (33%) had an HIV test result ever documented before or during admission, while 16 (8%) were tested for HIV sometime after discharge.

The researchers noted a slight but nonsignificant improvement in the proportion of patients with pneumonia who were ever tested for HIV before or during admission, before and after implementation of the CDC guidelines in 2006 (from 28% to 39%; P = .09). Dr. Clifton pointed out that the 5% prevalence of HIV observed in patients admitted with pneumonia is 10 times higher than the prevalence of HIV in the general population (.47%).

Limitations of the study, she said, include its retrospective, single-center design and the fact that it relied on an administrative database. “There’s also potential for coding bias using ICD-9 codes,” she said. “However, prior studies using ICD-9 codes for diagnosis of pneumonia show reasonably good specificity.”

She concluded her presentation by calling for “more studies to evaluate HIV testing and diagnosis in this higher-risk population of patients admitted with pneumonia. Opt-out HIV testing among pneumonia inpatients should be implemented for earlier HIV diagnosis and improved outcomes.”

IDWeek marks the combined annual meetings of the Infectious Diseases Society of America, the Society for Healthcare Epidemiology of America, the HIV Medicine Association, and the Pediatric Infectious Diseases Society. The researchers reported having no financial disclosures.

The researchers reported having no financial disclosures.

[email protected]

SAN DIEGO – Only 39% of patients hospitalized for pneumonia underwent HIV testing, even though federal recommendations for universal HIV screening in all health care settings have been in place since 2006, according to the results of a retrospective, single-center study.

“Despite universal recommendations for HIV screening in all health care settings, HIV testing rates remain low among patients hospitalized with pneumonia,” Dr. Dana C. Clifton said at an annual scientific meeting on infectious diseases. “A number of patients were subsequently diagnosed with HIV after a prolonged delay.”

Of patients newly diagnosed with HIV in the United States, 41% report no prior HIV testing and an estimated 14%-25% of those living with HIV are undiagnosed, said Dr. Clifton, an internist at Duke University Medical Center, Durham, N.C. In 2006, the Centers for Disease Control and Prevention recommended routine HIV screening in all health care settings for all patients aged between 13 and 64 years old. “Multiple studies have shown that routine screening is cost effective, compared with screening tests for colon cancer, diabetes, and breast cancer,” Dr. Clifton said. In addition, bacterial pneumonia “is a predictor of HIV infection, and the clinical manifestations of bacterial pneumonia are similar whether one has HIV or not. So the question is, how do you decide whom to screen for HIV at hospital admission for pneumonia?”

Dr. Clifton and her associates retrospectively evaluated patients admitted to Duke University Health System between Jan. 1, 1996 and Dec. 31, 2014 with a first primary diagnosis of pneumonia. They used ICD-9 codes for primary diagnosis of pneumonia at time of hospital admission, reviewed a subset of charts to validate the diagnosis, and conducted a random sample of those without prior HIV diagnosis to evaluate HIV testing. The primary outcome was HIV testing during pneumonia admission. Secondary outcomes were documented prior HIV testing in the electronic medical record and subsequent new HIV diagnosis following pneumonia admission.

During the time period studied, 6,858 patients were admitted with a primary diagnosis of pneumonia. Their median age was 50 years, 49% were male, 53% were white, 41% were African American, and the rest were from other ethnic groups. In all, 5,133 (75%) were discharged by general medicine or pulmonary service.

Of the 6,858 patients, 6,513 (95%) were not previously known to be HIV positive (95%), while 345 (5%) were previously known to be HIV positive. Of the 6,513 not previously known to be HIV positive, 19 (0.3%) were diagnosed with HIV during hospital admission and 46 (0.7%) were diagnosed with HIV a median of 807 days after admission.

When the researchers evaluated a random sample of 207 patients not previously known to be HIV positive, the researchers found that only 69 (33%) had an HIV test result ever documented before or during admission, while 16 (8%) were tested for HIV sometime after discharge.

The researchers noted a slight but nonsignificant improvement in the proportion of patients with pneumonia who were ever tested for HIV before or during admission, before and after implementation of the CDC guidelines in 2006 (from 28% to 39%; P = .09). Dr. Clifton pointed out that the 5% prevalence of HIV observed in patients admitted with pneumonia is 10 times higher than the prevalence of HIV in the general population (.47%).

Limitations of the study, she said, include its retrospective, single-center design and the fact that it relied on an administrative database. “There’s also potential for coding bias using ICD-9 codes,” she said. “However, prior studies using ICD-9 codes for diagnosis of pneumonia show reasonably good specificity.”

She concluded her presentation by calling for “more studies to evaluate HIV testing and diagnosis in this higher-risk population of patients admitted with pneumonia. Opt-out HIV testing among pneumonia inpatients should be implemented for earlier HIV diagnosis and improved outcomes.”

IDWeek marks the combined annual meetings of the Infectious Diseases Society of America, the Society for Healthcare Epidemiology of America, the HIV Medicine Association, and the Pediatric Infectious Diseases Society. The researchers reported having no financial disclosures.

The researchers reported having no financial disclosures.

[email protected]

SAN DIEGO – Only 39% of patients hospitalized for pneumonia underwent HIV testing, even though federal recommendations for universal HIV screening in all health care settings have been in place since 2006, according to the results of a retrospective, single-center study.

“Despite universal recommendations for HIV screening in all health care settings, HIV testing rates remain low among patients hospitalized with pneumonia,” Dr. Dana C. Clifton said at an annual scientific meeting on infectious diseases. “A number of patients were subsequently diagnosed with HIV after a prolonged delay.”

Of patients newly diagnosed with HIV in the United States, 41% report no prior HIV testing and an estimated 14%-25% of those living with HIV are undiagnosed, said Dr. Clifton, an internist at Duke University Medical Center, Durham, N.C. In 2006, the Centers for Disease Control and Prevention recommended routine HIV screening in all health care settings for all patients aged between 13 and 64 years old. “Multiple studies have shown that routine screening is cost effective, compared with screening tests for colon cancer, diabetes, and breast cancer,” Dr. Clifton said. In addition, bacterial pneumonia “is a predictor of HIV infection, and the clinical manifestations of bacterial pneumonia are similar whether one has HIV or not. So the question is, how do you decide whom to screen for HIV at hospital admission for pneumonia?”

Dr. Clifton and her associates retrospectively evaluated patients admitted to Duke University Health System between Jan. 1, 1996 and Dec. 31, 2014 with a first primary diagnosis of pneumonia. They used ICD-9 codes for primary diagnosis of pneumonia at time of hospital admission, reviewed a subset of charts to validate the diagnosis, and conducted a random sample of those without prior HIV diagnosis to evaluate HIV testing. The primary outcome was HIV testing during pneumonia admission. Secondary outcomes were documented prior HIV testing in the electronic medical record and subsequent new HIV diagnosis following pneumonia admission.

During the time period studied, 6,858 patients were admitted with a primary diagnosis of pneumonia. Their median age was 50 years, 49% were male, 53% were white, 41% were African American, and the rest were from other ethnic groups. In all, 5,133 (75%) were discharged by general medicine or pulmonary service.

Of the 6,858 patients, 6,513 (95%) were not previously known to be HIV positive (95%), while 345 (5%) were previously known to be HIV positive. Of the 6,513 not previously known to be HIV positive, 19 (0.3%) were diagnosed with HIV during hospital admission and 46 (0.7%) were diagnosed with HIV a median of 807 days after admission.

When the researchers evaluated a random sample of 207 patients not previously known to be HIV positive, the researchers found that only 69 (33%) had an HIV test result ever documented before or during admission, while 16 (8%) were tested for HIV sometime after discharge.

The researchers noted a slight but nonsignificant improvement in the proportion of patients with pneumonia who were ever tested for HIV before or during admission, before and after implementation of the CDC guidelines in 2006 (from 28% to 39%; P = .09). Dr. Clifton pointed out that the 5% prevalence of HIV observed in patients admitted with pneumonia is 10 times higher than the prevalence of HIV in the general population (.47%).

Limitations of the study, she said, include its retrospective, single-center design and the fact that it relied on an administrative database. “There’s also potential for coding bias using ICD-9 codes,” she said. “However, prior studies using ICD-9 codes for diagnosis of pneumonia show reasonably good specificity.”

She concluded her presentation by calling for “more studies to evaluate HIV testing and diagnosis in this higher-risk population of patients admitted with pneumonia. Opt-out HIV testing among pneumonia inpatients should be implemented for earlier HIV diagnosis and improved outcomes.”

IDWeek marks the combined annual meetings of the Infectious Diseases Society of America, the Society for Healthcare Epidemiology of America, the HIV Medicine Association, and the Pediatric Infectious Diseases Society. The researchers reported having no financial disclosures.

The researchers reported having no financial disclosures.

[email protected]

Joyce Ross explains the role of triglycerides in cardiovascular health and how to manage high levels.

This video provides three takeaways in less than three minutes from the presentation at the 2015 MEDS conference, entitled “Triglycerides on the Rise: Confronting Residual Cardiometabolic Risk,” co-presented with Gregory S. Pokrywka, MD, CACP, FNLA, NCMP, jointly provided by Postgraduate Institute for Medicine and Medtelligence, and supported by an educational grant from Amarin Pharma Inc.

Joyce Ross explains the role of triglycerides in cardiovascular health and how to manage high levels.

This video provides three takeaways in less than three minutes from the presentation at the 2015 MEDS conference, entitled “Triglycerides on the Rise: Confronting Residual Cardiometabolic Risk,” co-presented with Gregory S. Pokrywka, MD, CACP, FNLA, NCMP, jointly provided by Postgraduate Institute for Medicine and Medtelligence, and supported by an educational grant from Amarin Pharma Inc.

Joyce Ross explains the role of triglycerides in cardiovascular health and how to manage high levels.

This video provides three takeaways in less than three minutes from the presentation at the 2015 MEDS conference, entitled “Triglycerides on the Rise: Confronting Residual Cardiometabolic Risk,” co-presented with Gregory S. Pokrywka, MD, CACP, FNLA, NCMP, jointly provided by Postgraduate Institute for Medicine and Medtelligence, and supported by an educational grant from Amarin Pharma Inc.

SAN DIEGO – Antibiotic prescribing patterns for pediatric community-acquired pneumonia vary substantially across both children’s hospitals and facilities that are not children’s hospitals, a large analysis found.

Specifically, children’s hospitals are far more likely to prescribe in accordance with national guidelines than are other hospitals.

“Moving forward, I think there’s a need for further study to understand these differences, so we can begin to narrow this gap between children’s and non–children’s hospitals,” lead study author Dr. Alison Tribble said at an annual scientific meeting on infectious diseases. “Across the board, we need to continue efforts to improve guideline adherence for all children hospitalized with community-acquired pneumonia.”

In 2012, community-acquired pneumonia (CAP) accounted for 120,000 known pneumonia admissions among children in the United States and about 7% of all pediatric hospitalizations, said Dr. Tribble, a pediatric infectious disease specialist at C.S. Mott Children’s Hospital and the University of Michigan Medical Center, both in Ann Arbor. “We also know that pneumonia accounts for more days of antibiotic therapy than any other indication for admission to U.S. children’s hospitals,” she said.

In 2011, the Infectious Diseases Society of America and Pediatric Infectious Diseases Society released guidelines for pediatric CAP, which recommend a first-line therapy with penicillin, ampicillin, or amoxicillin for most children who are immunized and healthy. “Only in situations where there’s a significant concern for an atypical organism should we be adding coverage for that – even in older children,” Dr. Tribble said. Following the release of the guidelines, she continued, multiple studies have shown that the use of first-line therapy is increasing in children’s hospitals. “However, a substantial proportion of children with pneumonia are admitted to non–children’s hospitals,” she said. “Prior to release of the guidelines, one study showed that use of first-line therapy for pediatric CAP was low in non–children’s hospitals (J Pediatr. 2014 165[3]:585-91), but postguideline CAP therapy in non–children’s hospitals has not yet been evaluated.”

For the current study, Dr. Tribble and her associates set out to evaluate antibiotic prescribing patterns for pediatric CAP in non–children’s hospitals and to compare prescribing patterns between children’s and non–children’s hospitals. They conducted a retrospective cross-sectional study of children aged 1-17 years admitted for CAP in 2013 to 323 hospitals, captured via the Pediatric Health Information System (PHIS) and Premier Perspective databases. PHIS is an administrative database that includes billing data, diagnosis codes, and procedure codes for about 44 freestanding children’s hospitals nationwide, while Premier Perspective encompasses data from 522 hospitals nationwide. The researchers used a validated ICD-9 code-based algorithm to identify patients with CAP and excluded those with complicated pneumonia or complex chronic conditions, those who received intensive care, and those with methicillin-resistant Staphylococcus aureus infection or colonization.

Children’s hospitals were defined as those with pediatric admissions accounting for more than 75% of all admissions. “This was after excluding newborns and admission for childbirth, because many community hospitals will have a birthing center or a NICU, but otherwise would not be considered a children’s hospital,” Dr. Tribble explained. Any other hospital was considered a non–children’s hospital.

Three different outcomes for antibiotic use were examined: those who ever received penicillin, amoxicillin, or ampicillin (guideline therapy); those who ever received a macrolide, fluoroquinolone, or tetracycline (atypical therapy); and those who received anything other than penicillin, amoxicillin, or ampicillin (nonguideline therapy). The standardized probability of exposure to select antibiotics was compared between children’s and non–children’s hospitals, adjusted for age, sex, and insurance provider.

In all, 323 hospitals contributed 15,495 CAP cases. Of the 323 hospitals, 49 were identified as children’s hospitals (44 from the PHIS database and 5 from the Premier database). Dr. Tribble reported results from 9,224 subjects admitted to children’s hospitals and 6,271 subjects admitted to non–children’s hospitals. The demographics between the two groups were similar: The patients’ mean age was 3 years, and 66% were younger than age 5 years.

After adjustment of data, patients admitted to children’s hospitals were found to be more likely to receive guideline therapy, compared with those admitted to non–children’s hospitals (46% vs. 15%, respectively), were less likely to received atypical therapy (36% vs. 51%), and were less likely to receive nonguideline therapy (78% vs. 94%; P less than .001 for all comparisons).

Dr. Tribble acknowledged certain limitations of the study, including the potential for misclassification of children’s hospitals in the Premier database, “although most likely I think we would have failed to identify a children’s hospital, and this would have biased us toward the null and made our difference less significant,” she said. “We are developing an absolute volume classification so we can look at this in another way.” Another limitation is that the study design did not account for the potential of combination therapy, “and you can’t account for change in therapy during hospitalization. Lastly, we compared data across different databases and across different hospital types.”

IDWeek marks the combined annual meetings of the Infectious Diseases Society of America, the Society for Healthcare Epidemiology of America, the HIV Medicine Association, and the Pediatric Infectious Diseases Society. The study was supported by a training grant from the National Institute of Child Health and Human Development. The researchers reported having no relevant financial disclosures.

SAN DIEGO – Antibiotic prescribing patterns for pediatric community-acquired pneumonia vary substantially across both children’s hospitals and facilities that are not children’s hospitals, a large analysis found.

Specifically, children’s hospitals are far more likely to prescribe in accordance with national guidelines than are other hospitals.

“Moving forward, I think there’s a need for further study to understand these differences, so we can begin to narrow this gap between children’s and non–children’s hospitals,” lead study author Dr. Alison Tribble said at an annual scientific meeting on infectious diseases. “Across the board, we need to continue efforts to improve guideline adherence for all children hospitalized with community-acquired pneumonia.”

In 2012, community-acquired pneumonia (CAP) accounted for 120,000 known pneumonia admissions among children in the United States and about 7% of all pediatric hospitalizations, said Dr. Tribble, a pediatric infectious disease specialist at C.S. Mott Children’s Hospital and the University of Michigan Medical Center, both in Ann Arbor. “We also know that pneumonia accounts for more days of antibiotic therapy than any other indication for admission to U.S. children’s hospitals,” she said.

In 2011, the Infectious Diseases Society of America and Pediatric Infectious Diseases Society released guidelines for pediatric CAP, which recommend a first-line therapy with penicillin, ampicillin, or amoxicillin for most children who are immunized and healthy. “Only in situations where there’s a significant concern for an atypical organism should we be adding coverage for that – even in older children,” Dr. Tribble said. Following the release of the guidelines, she continued, multiple studies have shown that the use of first-line therapy is increasing in children’s hospitals. “However, a substantial proportion of children with pneumonia are admitted to non–children’s hospitals,” she said. “Prior to release of the guidelines, one study showed that use of first-line therapy for pediatric CAP was low in non–children’s hospitals (J Pediatr. 2014 165[3]:585-91), but postguideline CAP therapy in non–children’s hospitals has not yet been evaluated.”

For the current study, Dr. Tribble and her associates set out to evaluate antibiotic prescribing patterns for pediatric CAP in non–children’s hospitals and to compare prescribing patterns between children’s and non–children’s hospitals. They conducted a retrospective cross-sectional study of children aged 1-17 years admitted for CAP in 2013 to 323 hospitals, captured via the Pediatric Health Information System (PHIS) and Premier Perspective databases. PHIS is an administrative database that includes billing data, diagnosis codes, and procedure codes for about 44 freestanding children’s hospitals nationwide, while Premier Perspective encompasses data from 522 hospitals nationwide. The researchers used a validated ICD-9 code-based algorithm to identify patients with CAP and excluded those with complicated pneumonia or complex chronic conditions, those who received intensive care, and those with methicillin-resistant Staphylococcus aureus infection or colonization.

Children’s hospitals were defined as those with pediatric admissions accounting for more than 75% of all admissions. “This was after excluding newborns and admission for childbirth, because many community hospitals will have a birthing center or a NICU, but otherwise would not be considered a children’s hospital,” Dr. Tribble explained. Any other hospital was considered a non–children’s hospital.

Three different outcomes for antibiotic use were examined: those who ever received penicillin, amoxicillin, or ampicillin (guideline therapy); those who ever received a macrolide, fluoroquinolone, or tetracycline (atypical therapy); and those who received anything other than penicillin, amoxicillin, or ampicillin (nonguideline therapy). The standardized probability of exposure to select antibiotics was compared between children’s and non–children’s hospitals, adjusted for age, sex, and insurance provider.

In all, 323 hospitals contributed 15,495 CAP cases. Of the 323 hospitals, 49 were identified as children’s hospitals (44 from the PHIS database and 5 from the Premier database). Dr. Tribble reported results from 9,224 subjects admitted to children’s hospitals and 6,271 subjects admitted to non–children’s hospitals. The demographics between the two groups were similar: The patients’ mean age was 3 years, and 66% were younger than age 5 years.

After adjustment of data, patients admitted to children’s hospitals were found to be more likely to receive guideline therapy, compared with those admitted to non–children’s hospitals (46% vs. 15%, respectively), were less likely to received atypical therapy (36% vs. 51%), and were less likely to receive nonguideline therapy (78% vs. 94%; P less than .001 for all comparisons).

Dr. Tribble acknowledged certain limitations of the study, including the potential for misclassification of children’s hospitals in the Premier database, “although most likely I think we would have failed to identify a children’s hospital, and this would have biased us toward the null and made our difference less significant,” she said. “We are developing an absolute volume classification so we can look at this in another way.” Another limitation is that the study design did not account for the potential of combination therapy, “and you can’t account for change in therapy during hospitalization. Lastly, we compared data across different databases and across different hospital types.”

IDWeek marks the combined annual meetings of the Infectious Diseases Society of America, the Society for Healthcare Epidemiology of America, the HIV Medicine Association, and the Pediatric Infectious Diseases Society. The study was supported by a training grant from the National Institute of Child Health and Human Development. The researchers reported having no relevant financial disclosures.

SAN DIEGO – Antibiotic prescribing patterns for pediatric community-acquired pneumonia vary substantially across both children’s hospitals and facilities that are not children’s hospitals, a large analysis found.

Specifically, children’s hospitals are far more likely to prescribe in accordance with national guidelines than are other hospitals.

“Moving forward, I think there’s a need for further study to understand these differences, so we can begin to narrow this gap between children’s and non–children’s hospitals,” lead study author Dr. Alison Tribble said at an annual scientific meeting on infectious diseases. “Across the board, we need to continue efforts to improve guideline adherence for all children hospitalized with community-acquired pneumonia.”

In 2012, community-acquired pneumonia (CAP) accounted for 120,000 known pneumonia admissions among children in the United States and about 7% of all pediatric hospitalizations, said Dr. Tribble, a pediatric infectious disease specialist at C.S. Mott Children’s Hospital and the University of Michigan Medical Center, both in Ann Arbor. “We also know that pneumonia accounts for more days of antibiotic therapy than any other indication for admission to U.S. children’s hospitals,” she said.

In 2011, the Infectious Diseases Society of America and Pediatric Infectious Diseases Society released guidelines for pediatric CAP, which recommend a first-line therapy with penicillin, ampicillin, or amoxicillin for most children who are immunized and healthy. “Only in situations where there’s a significant concern for an atypical organism should we be adding coverage for that – even in older children,” Dr. Tribble said. Following the release of the guidelines, she continued, multiple studies have shown that the use of first-line therapy is increasing in children’s hospitals. “However, a substantial proportion of children with pneumonia are admitted to non–children’s hospitals,” she said. “Prior to release of the guidelines, one study showed that use of first-line therapy for pediatric CAP was low in non–children’s hospitals (J Pediatr. 2014 165[3]:585-91), but postguideline CAP therapy in non–children’s hospitals has not yet been evaluated.”

For the current study, Dr. Tribble and her associates set out to evaluate antibiotic prescribing patterns for pediatric CAP in non–children’s hospitals and to compare prescribing patterns between children’s and non–children’s hospitals. They conducted a retrospective cross-sectional study of children aged 1-17 years admitted for CAP in 2013 to 323 hospitals, captured via the Pediatric Health Information System (PHIS) and Premier Perspective databases. PHIS is an administrative database that includes billing data, diagnosis codes, and procedure codes for about 44 freestanding children’s hospitals nationwide, while Premier Perspective encompasses data from 522 hospitals nationwide. The researchers used a validated ICD-9 code-based algorithm to identify patients with CAP and excluded those with complicated pneumonia or complex chronic conditions, those who received intensive care, and those with methicillin-resistant Staphylococcus aureus infection or colonization.

Children’s hospitals were defined as those with pediatric admissions accounting for more than 75% of all admissions. “This was after excluding newborns and admission for childbirth, because many community hospitals will have a birthing center or a NICU, but otherwise would not be considered a children’s hospital,” Dr. Tribble explained. Any other hospital was considered a non–children’s hospital.

Three different outcomes for antibiotic use were examined: those who ever received penicillin, amoxicillin, or ampicillin (guideline therapy); those who ever received a macrolide, fluoroquinolone, or tetracycline (atypical therapy); and those who received anything other than penicillin, amoxicillin, or ampicillin (nonguideline therapy). The standardized probability of exposure to select antibiotics was compared between children’s and non–children’s hospitals, adjusted for age, sex, and insurance provider.

In all, 323 hospitals contributed 15,495 CAP cases. Of the 323 hospitals, 49 were identified as children’s hospitals (44 from the PHIS database and 5 from the Premier database). Dr. Tribble reported results from 9,224 subjects admitted to children’s hospitals and 6,271 subjects admitted to non–children’s hospitals. The demographics between the two groups were similar: The patients’ mean age was 3 years, and 66% were younger than age 5 years.

After adjustment of data, patients admitted to children’s hospitals were found to be more likely to receive guideline therapy, compared with those admitted to non–children’s hospitals (46% vs. 15%, respectively), were less likely to received atypical therapy (36% vs. 51%), and were less likely to receive nonguideline therapy (78% vs. 94%; P less than .001 for all comparisons).

Dr. Tribble acknowledged certain limitations of the study, including the potential for misclassification of children’s hospitals in the Premier database, “although most likely I think we would have failed to identify a children’s hospital, and this would have biased us toward the null and made our difference less significant,” she said. “We are developing an absolute volume classification so we can look at this in another way.” Another limitation is that the study design did not account for the potential of combination therapy, “and you can’t account for change in therapy during hospitalization. Lastly, we compared data across different databases and across different hospital types.”

IDWeek marks the combined annual meetings of the Infectious Diseases Society of America, the Society for Healthcare Epidemiology of America, the HIV Medicine Association, and the Pediatric Infectious Diseases Society. The study was supported by a training grant from the National Institute of Child Health and Human Development. The researchers reported having no relevant financial disclosures.