Guidelines

Clinical question: What is the association between cerebrospinal fluid (CSF) red blood cell (RBC) counts and protein concentrations in infants younger than 57 days of age?

Background: Lumbar puncture (LP) is commonly performed in young infants to evaluate for meningitis in the clinical scenario of fever without source. Traumatic LP is common in children, and higher RBC counts are associated with increased CSF protein concentrations. The dynamic nature of CSF composition in young infants makes determination of the exact relationship between RBC counts and protein concentration challenging, which then complicates interpretation of CSF.

Study design: Retrospective, cross-sectional study.

Setting: Tertiary-care children's hospital.

Synopsis: Over a four-year period, 1,241 infants younger than 57 days of age that underwent LP were studied, excluding infants with conditions known to increase CSF protein concentrations: ventricular shunt, serious bacterial infection, congenital infection, herpes simplex virus or enterovirus positive PCR in CSF, seizure, or elevated serum bilirubin. Grossly bloody specimens with RBC counts >150,000 cells/mm3 were also excluded. Linear regression was used to determine relationship between CSF RBCs and protein, with protein increasing at a rate of 1.9 mg/dL per 1,000 CSF RBCs.

This ratio is different from a more traditional correction factor of approximately 1 mg/dL CSF protein increase per 1,000 CSF RBCs, which is derived from older populations of children.

However, this study is limited by the exclusion of grossly bloody specimens, which if included would have resulted in a ratio similar to the more traditional values. Additionally, application of this specific correction factor to prediction rules for bacterial meningitis has not been studied. Nonetheless, this study provides a baseline by which clinicians may interpret protein concentrations in traumatically bloody CSF specimens in young infants.

Bottom line: CSF protein concentrations increase at roughly 2 mg/dL per 1,000 CSF RBCs.

Citation: Hines BA, Nigrovic LE, Neuman MI, Shah SS. Adjustment of cerebrospinal fluid protein for red blood cells in neonates and young infants. J Hosp Med. 2012;7:325-328.

Reviewed by Pediatric Editor Mark Shen, MD, SFHM, medical director of hospital medicine at Dell Children's Medical Center, Austin, Texas.

Clinical question: What is the association between cerebrospinal fluid (CSF) red blood cell (RBC) counts and protein concentrations in infants younger than 57 days of age?

Background: Lumbar puncture (LP) is commonly performed in young infants to evaluate for meningitis in the clinical scenario of fever without source. Traumatic LP is common in children, and higher RBC counts are associated with increased CSF protein concentrations. The dynamic nature of CSF composition in young infants makes determination of the exact relationship between RBC counts and protein concentration challenging, which then complicates interpretation of CSF.

Study design: Retrospective, cross-sectional study.

Setting: Tertiary-care children's hospital.

Synopsis: Over a four-year period, 1,241 infants younger than 57 days of age that underwent LP were studied, excluding infants with conditions known to increase CSF protein concentrations: ventricular shunt, serious bacterial infection, congenital infection, herpes simplex virus or enterovirus positive PCR in CSF, seizure, or elevated serum bilirubin. Grossly bloody specimens with RBC counts >150,000 cells/mm3 were also excluded. Linear regression was used to determine relationship between CSF RBCs and protein, with protein increasing at a rate of 1.9 mg/dL per 1,000 CSF RBCs.

This ratio is different from a more traditional correction factor of approximately 1 mg/dL CSF protein increase per 1,000 CSF RBCs, which is derived from older populations of children.

However, this study is limited by the exclusion of grossly bloody specimens, which if included would have resulted in a ratio similar to the more traditional values. Additionally, application of this specific correction factor to prediction rules for bacterial meningitis has not been studied. Nonetheless, this study provides a baseline by which clinicians may interpret protein concentrations in traumatically bloody CSF specimens in young infants.

Bottom line: CSF protein concentrations increase at roughly 2 mg/dL per 1,000 CSF RBCs.

Citation: Hines BA, Nigrovic LE, Neuman MI, Shah SS. Adjustment of cerebrospinal fluid protein for red blood cells in neonates and young infants. J Hosp Med. 2012;7:325-328.

Reviewed by Pediatric Editor Mark Shen, MD, SFHM, medical director of hospital medicine at Dell Children's Medical Center, Austin, Texas.

Clinical question: What is the association between cerebrospinal fluid (CSF) red blood cell (RBC) counts and protein concentrations in infants younger than 57 days of age?

Background: Lumbar puncture (LP) is commonly performed in young infants to evaluate for meningitis in the clinical scenario of fever without source. Traumatic LP is common in children, and higher RBC counts are associated with increased CSF protein concentrations. The dynamic nature of CSF composition in young infants makes determination of the exact relationship between RBC counts and protein concentration challenging, which then complicates interpretation of CSF.

Study design: Retrospective, cross-sectional study.

Setting: Tertiary-care children's hospital.

Synopsis: Over a four-year period, 1,241 infants younger than 57 days of age that underwent LP were studied, excluding infants with conditions known to increase CSF protein concentrations: ventricular shunt, serious bacterial infection, congenital infection, herpes simplex virus or enterovirus positive PCR in CSF, seizure, or elevated serum bilirubin. Grossly bloody specimens with RBC counts >150,000 cells/mm3 were also excluded. Linear regression was used to determine relationship between CSF RBCs and protein, with protein increasing at a rate of 1.9 mg/dL per 1,000 CSF RBCs.

This ratio is different from a more traditional correction factor of approximately 1 mg/dL CSF protein increase per 1,000 CSF RBCs, which is derived from older populations of children.

However, this study is limited by the exclusion of grossly bloody specimens, which if included would have resulted in a ratio similar to the more traditional values. Additionally, application of this specific correction factor to prediction rules for bacterial meningitis has not been studied. Nonetheless, this study provides a baseline by which clinicians may interpret protein concentrations in traumatically bloody CSF specimens in young infants.

Bottom line: CSF protein concentrations increase at roughly 2 mg/dL per 1,000 CSF RBCs.

Citation: Hines BA, Nigrovic LE, Neuman MI, Shah SS. Adjustment of cerebrospinal fluid protein for red blood cells in neonates and young infants. J Hosp Med. 2012;7:325-328.

Reviewed by Pediatric Editor Mark Shen, MD, SFHM, medical director of hospital medicine at Dell Children's Medical Center, Austin, Texas.

A national outbreak of fungal meningitis tied to contaminated steroids in epidural injections should make hospitalists vigilant with patients who present potential symptoms, says an infectious-disease (ID) specialist.

Earlier this month, health officials linked the outbreak to tainted batches of steroids used in spinal injections, and they say it could be weeks, or even months, before they know whether the incubation period for the disease is over, according to The New York Times.

"The key in my mind is that hospitalists ought to have a high index of suspicion for this right now," says hospitalist and ID expert James Pile, MD, FACP, SFHM, of the Cleveland Clinic. "If you encounter a patient you think may have meningitis, may have a brain stem stroke, may have an epidural abscess or vertebral osteomyelitis...at least think and ask the patient, or their family member, 'Did you receive an epidural steroid injection recently?'"

The answer to that question will help determine the best care delivery for hospitalists, and physicians should not rely on patients to relay the information without being asked for it, Dr. Pile says.

The outbreak has been traced to three contaminated batches of methylprednisolone produced by the New England Compounding Center in Framingham, Mass. The company, which is under criminal investigation, has been linked to at least 25 deaths and more than 317 infected patients. Although 14,000 people might have been injected with the contaminated compound, CDC officials say the likelihood of infection remains relatively low.

Dr. Pile says that while hospitalists might see only a handful of fungal meningitis cases in their careers, they still need to keep the possibility in mind when examining patients. It's a safe approach to take, particularly as the CDC continues to investigate the extent of the outbreak. The CDC has advised against antifungal prophylaxis or presumptive treatment of exposed asymptomatic patients without a diagnosed case of meningitis.

"This is just unfolding so quickly, it's a moving target," Dr. Pile adds. "How big it ends up being and what kinds of new or unusual manifestations present remain to be seen."

Visit our website for more information about infectious disease and hospital medicine.

A national outbreak of fungal meningitis tied to contaminated steroids in epidural injections should make hospitalists vigilant with patients who present potential symptoms, says an infectious-disease (ID) specialist.

Earlier this month, health officials linked the outbreak to tainted batches of steroids used in spinal injections, and they say it could be weeks, or even months, before they know whether the incubation period for the disease is over, according to The New York Times.

"The key in my mind is that hospitalists ought to have a high index of suspicion for this right now," says hospitalist and ID expert James Pile, MD, FACP, SFHM, of the Cleveland Clinic. "If you encounter a patient you think may have meningitis, may have a brain stem stroke, may have an epidural abscess or vertebral osteomyelitis...at least think and ask the patient, or their family member, 'Did you receive an epidural steroid injection recently?'"

The answer to that question will help determine the best care delivery for hospitalists, and physicians should not rely on patients to relay the information without being asked for it, Dr. Pile says.

The outbreak has been traced to three contaminated batches of methylprednisolone produced by the New England Compounding Center in Framingham, Mass. The company, which is under criminal investigation, has been linked to at least 25 deaths and more than 317 infected patients. Although 14,000 people might have been injected with the contaminated compound, CDC officials say the likelihood of infection remains relatively low.

Dr. Pile says that while hospitalists might see only a handful of fungal meningitis cases in their careers, they still need to keep the possibility in mind when examining patients. It's a safe approach to take, particularly as the CDC continues to investigate the extent of the outbreak. The CDC has advised against antifungal prophylaxis or presumptive treatment of exposed asymptomatic patients without a diagnosed case of meningitis.

"This is just unfolding so quickly, it's a moving target," Dr. Pile adds. "How big it ends up being and what kinds of new or unusual manifestations present remain to be seen."

Visit our website for more information about infectious disease and hospital medicine.

A national outbreak of fungal meningitis tied to contaminated steroids in epidural injections should make hospitalists vigilant with patients who present potential symptoms, says an infectious-disease (ID) specialist.

Earlier this month, health officials linked the outbreak to tainted batches of steroids used in spinal injections, and they say it could be weeks, or even months, before they know whether the incubation period for the disease is over, according to The New York Times.

"The key in my mind is that hospitalists ought to have a high index of suspicion for this right now," says hospitalist and ID expert James Pile, MD, FACP, SFHM, of the Cleveland Clinic. "If you encounter a patient you think may have meningitis, may have a brain stem stroke, may have an epidural abscess or vertebral osteomyelitis...at least think and ask the patient, or their family member, 'Did you receive an epidural steroid injection recently?'"

The answer to that question will help determine the best care delivery for hospitalists, and physicians should not rely on patients to relay the information without being asked for it, Dr. Pile says.

The outbreak has been traced to three contaminated batches of methylprednisolone produced by the New England Compounding Center in Framingham, Mass. The company, which is under criminal investigation, has been linked to at least 25 deaths and more than 317 infected patients. Although 14,000 people might have been injected with the contaminated compound, CDC officials say the likelihood of infection remains relatively low.

Dr. Pile says that while hospitalists might see only a handful of fungal meningitis cases in their careers, they still need to keep the possibility in mind when examining patients. It's a safe approach to take, particularly as the CDC continues to investigate the extent of the outbreak. The CDC has advised against antifungal prophylaxis or presumptive treatment of exposed asymptomatic patients without a diagnosed case of meningitis.

"This is just unfolding so quickly, it's a moving target," Dr. Pile adds. "How big it ends up being and what kinds of new or unusual manifestations present remain to be seen."

Visit our website for more information about infectious disease and hospital medicine.

The largest effort to date to tackle central-line-associated bloodstream infections (CLABSIs) has reduced infection rates in ICUs nationwide by 40%, according to preliminary findings from the federal Agency for Healthcare Research and Quality (AHRQ).

AHRQ attributes the decrease to a CLABSI safety checklist from the Comprehensive Unit-Based Safety Program (CUSP) that encourages hospital staff to wash their hands prior to inserting central lines, avoid the femoral site, remove lines when they are no longer needed, and use the antimicrobial agent chlorhexidine to clean the patient's insertion site.

The checklist was developed by Peter Pronovost, MD, PhD, FCCM, and colleagues at Johns Hopkins University in Baltimore, and originally implemented in ICUs statewide in Michigan as the Keystone Project. Since 2009, CUSP has recruited more than 1,000 participating hospitals in 44 states. CUSP collectively reported a decrease to 1.25 from 1.87 CLABSIs per 1,000 central-line days 10-12 months after implementing the program, according to AHRQ [PDF].

The real game-changer for CLABSIs has been the widespread adoption of chlorhexidine as an insertion site disinfectant, says Sanjay Saint, MD, MPH, director of the Veterans Administration at the University of Michigan Patient Safety Enhancement Program in Ann Arbor and professor of medicine at the University of Michigan. Dr. Saint is on the national leadership team of On the CUSP: Stop CAUTI (Catheter-Associated Urinary Tract Infections), an initiative that aims to reduce mean rates of CAUTI infections by 25% in hospitals nationwide.

Although hospitalists don't routinely place central lines, their role in this procedure is growing, both in nonacademic hospitals that lack intensivists and on hospitals' general medicine floors.

"My take-home message for hospitalists: if you are putting in central lines, if you only make one change in practice, is to use chlorhexidine as the site disinfectant," Dr. Saint says.

Visit our website for more information about central-line-associated bloodstream infections.

The largest effort to date to tackle central-line-associated bloodstream infections (CLABSIs) has reduced infection rates in ICUs nationwide by 40%, according to preliminary findings from the federal Agency for Healthcare Research and Quality (AHRQ).

AHRQ attributes the decrease to a CLABSI safety checklist from the Comprehensive Unit-Based Safety Program (CUSP) that encourages hospital staff to wash their hands prior to inserting central lines, avoid the femoral site, remove lines when they are no longer needed, and use the antimicrobial agent chlorhexidine to clean the patient's insertion site.

The checklist was developed by Peter Pronovost, MD, PhD, FCCM, and colleagues at Johns Hopkins University in Baltimore, and originally implemented in ICUs statewide in Michigan as the Keystone Project. Since 2009, CUSP has recruited more than 1,000 participating hospitals in 44 states. CUSP collectively reported a decrease to 1.25 from 1.87 CLABSIs per 1,000 central-line days 10-12 months after implementing the program, according to AHRQ [PDF].

The real game-changer for CLABSIs has been the widespread adoption of chlorhexidine as an insertion site disinfectant, says Sanjay Saint, MD, MPH, director of the Veterans Administration at the University of Michigan Patient Safety Enhancement Program in Ann Arbor and professor of medicine at the University of Michigan. Dr. Saint is on the national leadership team of On the CUSP: Stop CAUTI (Catheter-Associated Urinary Tract Infections), an initiative that aims to reduce mean rates of CAUTI infections by 25% in hospitals nationwide.

Although hospitalists don't routinely place central lines, their role in this procedure is growing, both in nonacademic hospitals that lack intensivists and on hospitals' general medicine floors.

"My take-home message for hospitalists: if you are putting in central lines, if you only make one change in practice, is to use chlorhexidine as the site disinfectant," Dr. Saint says.

Visit our website for more information about central-line-associated bloodstream infections.

The largest effort to date to tackle central-line-associated bloodstream infections (CLABSIs) has reduced infection rates in ICUs nationwide by 40%, according to preliminary findings from the federal Agency for Healthcare Research and Quality (AHRQ).

AHRQ attributes the decrease to a CLABSI safety checklist from the Comprehensive Unit-Based Safety Program (CUSP) that encourages hospital staff to wash their hands prior to inserting central lines, avoid the femoral site, remove lines when they are no longer needed, and use the antimicrobial agent chlorhexidine to clean the patient's insertion site.

The checklist was developed by Peter Pronovost, MD, PhD, FCCM, and colleagues at Johns Hopkins University in Baltimore, and originally implemented in ICUs statewide in Michigan as the Keystone Project. Since 2009, CUSP has recruited more than 1,000 participating hospitals in 44 states. CUSP collectively reported a decrease to 1.25 from 1.87 CLABSIs per 1,000 central-line days 10-12 months after implementing the program, according to AHRQ [PDF].

The real game-changer for CLABSIs has been the widespread adoption of chlorhexidine as an insertion site disinfectant, says Sanjay Saint, MD, MPH, director of the Veterans Administration at the University of Michigan Patient Safety Enhancement Program in Ann Arbor and professor of medicine at the University of Michigan. Dr. Saint is on the national leadership team of On the CUSP: Stop CAUTI (Catheter-Associated Urinary Tract Infections), an initiative that aims to reduce mean rates of CAUTI infections by 25% in hospitals nationwide.

Although hospitalists don't routinely place central lines, their role in this procedure is growing, both in nonacademic hospitals that lack intensivists and on hospitals' general medicine floors.

"My take-home message for hospitalists: if you are putting in central lines, if you only make one change in practice, is to use chlorhexidine as the site disinfectant," Dr. Saint says.

Visit our website for more information about central-line-associated bloodstream infections.

A dosage recommendation in the August 2012 article “What is the Optimal Therapy for Acute DVT” (p. 17) should have read: The 2012 American College of Chest Physicians (ACCP) guidelines on antithrombotic therapy for VTE recommends initial therapy with LMWH or fondaparinux (rather than IV or SC UFH). The guidelines suggest that LMWH once-daily dosing is favored over twice-daily dosing, based mainly on patient convenience, although this is a weak recommendation (2C) based on the overall quality of the data. The recommendation applies only if the daily dosing of the LMWH, including tinzaparin, dalteparin, and nadroparin, is equivalent to the twice-daily dosing (i.e. dalteparin may be dosed at 100 units/kg BID vs. 200 units/kg daily). Of importance, enoxaparin has not been studied at a once-daily dose (2 mg/kg), which is equivalent to the twice-daily dosing regimen (1 mg/kg twice daily). Additionally, one study suggests that once-daily dosing of enoxaparin 1.5 mg/kg might be inferior to 1 mg/kg twice daily dosing; therefore, caution must be exercised in applying this recommendation to the LMWH enoxaparin.^3,27,28

A dosage recommendation in the August 2012 article “What is the Optimal Therapy for Acute DVT” (p. 17) should have read: The 2012 American College of Chest Physicians (ACCP) guidelines on antithrombotic therapy for VTE recommends initial therapy with LMWH or fondaparinux (rather than IV or SC UFH). The guidelines suggest that LMWH once-daily dosing is favored over twice-daily dosing, based mainly on patient convenience, although this is a weak recommendation (2C) based on the overall quality of the data. The recommendation applies only if the daily dosing of the LMWH, including tinzaparin, dalteparin, and nadroparin, is equivalent to the twice-daily dosing (i.e. dalteparin may be dosed at 100 units/kg BID vs. 200 units/kg daily). Of importance, enoxaparin has not been studied at a once-daily dose (2 mg/kg), which is equivalent to the twice-daily dosing regimen (1 mg/kg twice daily). Additionally, one study suggests that once-daily dosing of enoxaparin 1.5 mg/kg might be inferior to 1 mg/kg twice daily dosing; therefore, caution must be exercised in applying this recommendation to the LMWH enoxaparin.^3,27,28

A dosage recommendation in the August 2012 article “What is the Optimal Therapy for Acute DVT” (p. 17) should have read: The 2012 American College of Chest Physicians (ACCP) guidelines on antithrombotic therapy for VTE recommends initial therapy with LMWH or fondaparinux (rather than IV or SC UFH). The guidelines suggest that LMWH once-daily dosing is favored over twice-daily dosing, based mainly on patient convenience, although this is a weak recommendation (2C) based on the overall quality of the data. The recommendation applies only if the daily dosing of the LMWH, including tinzaparin, dalteparin, and nadroparin, is equivalent to the twice-daily dosing (i.e. dalteparin may be dosed at 100 units/kg BID vs. 200 units/kg daily). Of importance, enoxaparin has not been studied at a once-daily dose (2 mg/kg), which is equivalent to the twice-daily dosing regimen (1 mg/kg twice daily). Additionally, one study suggests that once-daily dosing of enoxaparin 1.5 mg/kg might be inferior to 1 mg/kg twice daily dosing; therefore, caution must be exercised in applying this recommendation to the LMWH enoxaparin.^3,27,28

Dr. Hospitalist

One of our providers wants to use adult hospitalists for coverage of inpatient orthopedic surgery patients. Is this acceptable practice? Are there qualifiers?

–Libby Gardner

Dr. Hospitalist responds:

Let’s see how far we can tackle this open-ended question. There has been lots of discussion on the topic of comanagement in the past by people eminently more qualified than I am. Still, it never hurts to take a fresh look at things.

For one, on the subject of admissions, I am a firm believer that hospitalists should admit all adult hip fractures. The overwhelming majority of the time, these patients are elderly with comorbid conditions. Sure, they are going to get their hip fixed, because the alternative is usually unacceptable, but some thought needs to go into the process. The orthopedic surgeon sees a hip that needs fixing and not much else. When issues like renal failure, afib, CHF, prior DVT, or dementia are present, hospitalists should take charge of the case. It is the best way to ensure that the patient receives optimal medical care and the documentation that goes along with it. I love our orthopedic surgeons, but I don’t want them primarily admitting, managing, and discharging my elderly patients. Let the surgeon do what they do best, which is operate, and leave the rest to us.

On the subject of orthopedic trauma, I take the exact opposite tack—this is not something for which I or most of my colleagues have expertise. A young, healthy patient with trauma should be admitted by the orthopedic service; that patient population’s complications are much more likely to be directly related to their trauma.

When it comes to elective surgery, when the admitting surgeon (orthopedic or otherwise) wants the help of a hospitalist, then I think it is of paramount importance to have clear “rules of engagement.” I think with good expectations, you can have a fantastic working relationship with your surgeons. Without them, it becomes a nightmare.

Here are my HM group’s rules for elective orthopedic surgery:

• Orthopedics handles all pain medications and VTE prophylaxis, including discharge prescriptions.
• Medicine handles all admit and discharge medication reconciliation (“med rec”).
• There is shared discussion on:

  • Need for transfusion; and
  • The VTE prophylaxis when a patient already is on chronic anticoagulation.

We do not vary from this protocol. I never adjust a patient’s pain medications. Even the floor nurses know this. Because I’m doing the admit med rec, it also means that the patient doesn’t have their HCTZ continued after 600cc of EBL and spinal anesthesia.

The system works because the rules are clear and the communication is consistent. This does not mean that we cover the orthopedic service at night. They are equally responsible for their patients under the items outlined above. In my view—and this might sound simplistic—the surgeon caused the post-op pain, so they should be responsible for managing it. On VTE prophylaxis, I might take a more nuanced view, but for our surgeons, they own the wound and the post-op follow-up, so they get the choice on what agent to use.

Would I accept an arrangement in which I covered all the orthopedic issues out of regular hours? Nope—not when they have primary responsibility for the case; they should always be directly available to the nurse. I think that anything else would be a system ripe for abuse.

Our exact rules will not work for every situation, but I would strongly encourage the two basic tenets from above: No. 1, the hospitalist should primarily admit and manage elderly hip fractures, and No. 2, clear rules of engagement should be established with your orthopedic or surgery group. It’s a discussion worth having during daylight hours, because trying to figure out the rules at 3 in the morning rarely ends well.

Dr. Hospitalist

One of our providers wants to use adult hospitalists for coverage of inpatient orthopedic surgery patients. Is this acceptable practice? Are there qualifiers?

–Libby Gardner

Dr. Hospitalist responds:

Let’s see how far we can tackle this open-ended question. There has been lots of discussion on the topic of comanagement in the past by people eminently more qualified than I am. Still, it never hurts to take a fresh look at things.

For one, on the subject of admissions, I am a firm believer that hospitalists should admit all adult hip fractures. The overwhelming majority of the time, these patients are elderly with comorbid conditions. Sure, they are going to get their hip fixed, because the alternative is usually unacceptable, but some thought needs to go into the process. The orthopedic surgeon sees a hip that needs fixing and not much else. When issues like renal failure, afib, CHF, prior DVT, or dementia are present, hospitalists should take charge of the case. It is the best way to ensure that the patient receives optimal medical care and the documentation that goes along with it. I love our orthopedic surgeons, but I don’t want them primarily admitting, managing, and discharging my elderly patients. Let the surgeon do what they do best, which is operate, and leave the rest to us.

On the subject of orthopedic trauma, I take the exact opposite tack—this is not something for which I or most of my colleagues have expertise. A young, healthy patient with trauma should be admitted by the orthopedic service; that patient population’s complications are much more likely to be directly related to their trauma.

When it comes to elective surgery, when the admitting surgeon (orthopedic or otherwise) wants the help of a hospitalist, then I think it is of paramount importance to have clear “rules of engagement.” I think with good expectations, you can have a fantastic working relationship with your surgeons. Without them, it becomes a nightmare.

Here are my HM group’s rules for elective orthopedic surgery:

• Orthopedics handles all pain medications and VTE prophylaxis, including discharge prescriptions.
• Medicine handles all admit and discharge medication reconciliation (“med rec”).
• There is shared discussion on:

  • Need for transfusion; and
  • The VTE prophylaxis when a patient already is on chronic anticoagulation.

We do not vary from this protocol. I never adjust a patient’s pain medications. Even the floor nurses know this. Because I’m doing the admit med rec, it also means that the patient doesn’t have their HCTZ continued after 600cc of EBL and spinal anesthesia.

The system works because the rules are clear and the communication is consistent. This does not mean that we cover the orthopedic service at night. They are equally responsible for their patients under the items outlined above. In my view—and this might sound simplistic—the surgeon caused the post-op pain, so they should be responsible for managing it. On VTE prophylaxis, I might take a more nuanced view, but for our surgeons, they own the wound and the post-op follow-up, so they get the choice on what agent to use.

Would I accept an arrangement in which I covered all the orthopedic issues out of regular hours? Nope—not when they have primary responsibility for the case; they should always be directly available to the nurse. I think that anything else would be a system ripe for abuse.

Our exact rules will not work for every situation, but I would strongly encourage the two basic tenets from above: No. 1, the hospitalist should primarily admit and manage elderly hip fractures, and No. 2, clear rules of engagement should be established with your orthopedic or surgery group. It’s a discussion worth having during daylight hours, because trying to figure out the rules at 3 in the morning rarely ends well.

Dr. Hospitalist

One of our providers wants to use adult hospitalists for coverage of inpatient orthopedic surgery patients. Is this acceptable practice? Are there qualifiers?

–Libby Gardner

Dr. Hospitalist responds:

Let’s see how far we can tackle this open-ended question. There has been lots of discussion on the topic of comanagement in the past by people eminently more qualified than I am. Still, it never hurts to take a fresh look at things.

For one, on the subject of admissions, I am a firm believer that hospitalists should admit all adult hip fractures. The overwhelming majority of the time, these patients are elderly with comorbid conditions. Sure, they are going to get their hip fixed, because the alternative is usually unacceptable, but some thought needs to go into the process. The orthopedic surgeon sees a hip that needs fixing and not much else. When issues like renal failure, afib, CHF, prior DVT, or dementia are present, hospitalists should take charge of the case. It is the best way to ensure that the patient receives optimal medical care and the documentation that goes along with it. I love our orthopedic surgeons, but I don’t want them primarily admitting, managing, and discharging my elderly patients. Let the surgeon do what they do best, which is operate, and leave the rest to us.

On the subject of orthopedic trauma, I take the exact opposite tack—this is not something for which I or most of my colleagues have expertise. A young, healthy patient with trauma should be admitted by the orthopedic service; that patient population’s complications are much more likely to be directly related to their trauma.

When it comes to elective surgery, when the admitting surgeon (orthopedic or otherwise) wants the help of a hospitalist, then I think it is of paramount importance to have clear “rules of engagement.” I think with good expectations, you can have a fantastic working relationship with your surgeons. Without them, it becomes a nightmare.

Here are my HM group’s rules for elective orthopedic surgery:

• Orthopedics handles all pain medications and VTE prophylaxis, including discharge prescriptions.
• Medicine handles all admit and discharge medication reconciliation (“med rec”).
• There is shared discussion on:

  • Need for transfusion; and
  • The VTE prophylaxis when a patient already is on chronic anticoagulation.

We do not vary from this protocol. I never adjust a patient’s pain medications. Even the floor nurses know this. Because I’m doing the admit med rec, it also means that the patient doesn’t have their HCTZ continued after 600cc of EBL and spinal anesthesia.

The system works because the rules are clear and the communication is consistent. This does not mean that we cover the orthopedic service at night. They are equally responsible for their patients under the items outlined above. In my view—and this might sound simplistic—the surgeon caused the post-op pain, so they should be responsible for managing it. On VTE prophylaxis, I might take a more nuanced view, but for our surgeons, they own the wound and the post-op follow-up, so they get the choice on what agent to use.

Would I accept an arrangement in which I covered all the orthopedic issues out of regular hours? Nope—not when they have primary responsibility for the case; they should always be directly available to the nurse. I think that anything else would be a system ripe for abuse.

Our exact rules will not work for every situation, but I would strongly encourage the two basic tenets from above: No. 1, the hospitalist should primarily admit and manage elderly hip fractures, and No. 2, clear rules of engagement should be established with your orthopedic or surgery group. It’s a discussion worth having during daylight hours, because trying to figure out the rules at 3 in the morning rarely ends well.

Cardiologists aren’t shy about repeating it: guidelines, guidelines, guidelines. That is, follow them.

“Evidence-based, guideline-driven optimal care for heart failure truly is beneficial,” Dr. Yancy says. “Every effort should be made to strive to achieve ideal thresholds and meeting best practices.”

There is now compelling evidence that, for patients with heart failure, the higher the degree of adherence to Class I-recommended therapies, the greater the reduction in 24-month mortality risk.⁵

“It would seem as if practicing best quality is almost a perfunctory statement, but consistently, when we look at surveys of quality improvement and adherence to evidence-based strategies, persistent gaps remain in the broader community,” Dr. Yancy says. “We know what we need to do. We’re still striving to get closer and closer to optimal care.”

Dr. Harold says the guidelines are there to make things simpler. So take advantage of them.

“If anything, hospitalists tend to be ahead of most other groups in terms of knowing evidence-based pathways and really tracking very specific protocols,” he says. “I think one of the advantages of hospitalist care is very often, it is guideline-driven. You have less variation in terms of care and quality outcomes.”

Cardiologists aren’t shy about repeating it: guidelines, guidelines, guidelines. That is, follow them.

“Evidence-based, guideline-driven optimal care for heart failure truly is beneficial,” Dr. Yancy says. “Every effort should be made to strive to achieve ideal thresholds and meeting best practices.”

There is now compelling evidence that, for patients with heart failure, the higher the degree of adherence to Class I-recommended therapies, the greater the reduction in 24-month mortality risk.⁵

“It would seem as if practicing best quality is almost a perfunctory statement, but consistently, when we look at surveys of quality improvement and adherence to evidence-based strategies, persistent gaps remain in the broader community,” Dr. Yancy says. “We know what we need to do. We’re still striving to get closer and closer to optimal care.”

Dr. Harold says the guidelines are there to make things simpler. So take advantage of them.

“If anything, hospitalists tend to be ahead of most other groups in terms of knowing evidence-based pathways and really tracking very specific protocols,” he says. “I think one of the advantages of hospitalist care is very often, it is guideline-driven. You have less variation in terms of care and quality outcomes.”

Cardiologists aren’t shy about repeating it: guidelines, guidelines, guidelines. That is, follow them.

“Evidence-based, guideline-driven optimal care for heart failure truly is beneficial,” Dr. Yancy says. “Every effort should be made to strive to achieve ideal thresholds and meeting best practices.”

There is now compelling evidence that, for patients with heart failure, the higher the degree of adherence to Class I-recommended therapies, the greater the reduction in 24-month mortality risk.⁵

“It would seem as if practicing best quality is almost a perfunctory statement, but consistently, when we look at surveys of quality improvement and adherence to evidence-based strategies, persistent gaps remain in the broader community,” Dr. Yancy says. “We know what we need to do. We’re still striving to get closer and closer to optimal care.”

Dr. Harold says the guidelines are there to make things simpler. So take advantage of them.

“If anything, hospitalists tend to be ahead of most other groups in terms of knowing evidence-based pathways and really tracking very specific protocols,” he says. “I think one of the advantages of hospitalist care is very often, it is guideline-driven. You have less variation in terms of care and quality outcomes.”

Clinical question: What is the epidemiology of bacteremia in one-week to three-month-old infants?

Background: Large studies of bacteremia in infants <90 days of age were largely performed before the era of routine prenatal screening and prophylaxis for Group B Streptococcus (GBS). Additionally, these studies have focused on febrile infants, which might not allow for characterization of the incidence of bacteremia when nonfebrile infants are considered.

Study design: Retrospective review.

Setting: Large HMO database.

Synopsis: Of 160,818 full-term infants born at Kaiser Permanente Northern California from 2005 to 2009, 4,255 blood cultures were obtained from 4,122 infants in outpatient clinics, the ED, or in an inpatient setting within 24 hours of birth. Preterm infants <37 weeks, infants with underlying medical conditions, and infants with cultures drawn within three days of an original culture were excluded.

A total of 8% of the blood cultures were positive, with 2.2% deemed true positives and 5.8% due to contaminants. The incidence rate of true bacteremia was 0.57 per 1,000 full-term births, with gram-negative organisms (predominantly Escherichia coli) representing the majority (63%) of pathogens, followed by GBS (21%), Staphylococcus aureus (8%), and Streptococcus pneumoniae (3%). There were no cases of Listeria monocytogenes or Neisseria meningitidis bacteremia, and there was one case of enterococcal bacteremia. Fever was absent in 7% of cases.

The authors conclude that ampicillin may no longer be necessary for empiric antibiotic coverage in this age group given that 36% of pathogens were resistant to ampicillin, there were no cases of Listeria, and there was only one case of enterococcus. However, these recommendations should be considered in light of the specific study setting, and might not be applicable to all areas.

Bottom line: E. coli, GBS, and S. aureus, in that order, are the most common causes of bacteremia in infants aged one week to three months.

Citation: Greenhow TL, Hung YY, Herz AM. Changing epidemiology of bacteremia in infants aged 1 week to 3 months. Pediatrics. 2012;129(3):e590-e596.

Reviewed by Pediatric Editor Mark Shen, MD, SFHM, medical director of hospital medicine at Dell Children's Medical Center, Austin, Texas.

Clinical question: What is the epidemiology of bacteremia in one-week to three-month-old infants?

Background: Large studies of bacteremia in infants <90 days of age were largely performed before the era of routine prenatal screening and prophylaxis for Group B Streptococcus (GBS). Additionally, these studies have focused on febrile infants, which might not allow for characterization of the incidence of bacteremia when nonfebrile infants are considered.

Study design: Retrospective review.

Setting: Large HMO database.

Synopsis: Of 160,818 full-term infants born at Kaiser Permanente Northern California from 2005 to 2009, 4,255 blood cultures were obtained from 4,122 infants in outpatient clinics, the ED, or in an inpatient setting within 24 hours of birth. Preterm infants <37 weeks, infants with underlying medical conditions, and infants with cultures drawn within three days of an original culture were excluded.

A total of 8% of the blood cultures were positive, with 2.2% deemed true positives and 5.8% due to contaminants. The incidence rate of true bacteremia was 0.57 per 1,000 full-term births, with gram-negative organisms (predominantly Escherichia coli) representing the majority (63%) of pathogens, followed by GBS (21%), Staphylococcus aureus (8%), and Streptococcus pneumoniae (3%). There were no cases of Listeria monocytogenes or Neisseria meningitidis bacteremia, and there was one case of enterococcal bacteremia. Fever was absent in 7% of cases.

The authors conclude that ampicillin may no longer be necessary for empiric antibiotic coverage in this age group given that 36% of pathogens were resistant to ampicillin, there were no cases of Listeria, and there was only one case of enterococcus. However, these recommendations should be considered in light of the specific study setting, and might not be applicable to all areas.

Bottom line: E. coli, GBS, and S. aureus, in that order, are the most common causes of bacteremia in infants aged one week to three months.

Citation: Greenhow TL, Hung YY, Herz AM. Changing epidemiology of bacteremia in infants aged 1 week to 3 months. Pediatrics. 2012;129(3):e590-e596.

Reviewed by Pediatric Editor Mark Shen, MD, SFHM, medical director of hospital medicine at Dell Children's Medical Center, Austin, Texas.

Clinical question: What is the epidemiology of bacteremia in one-week to three-month-old infants?

Background: Large studies of bacteremia in infants <90 days of age were largely performed before the era of routine prenatal screening and prophylaxis for Group B Streptococcus (GBS). Additionally, these studies have focused on febrile infants, which might not allow for characterization of the incidence of bacteremia when nonfebrile infants are considered.

Study design: Retrospective review.

Setting: Large HMO database.

Synopsis: Of 160,818 full-term infants born at Kaiser Permanente Northern California from 2005 to 2009, 4,255 blood cultures were obtained from 4,122 infants in outpatient clinics, the ED, or in an inpatient setting within 24 hours of birth. Preterm infants <37 weeks, infants with underlying medical conditions, and infants with cultures drawn within three days of an original culture were excluded.

A total of 8% of the blood cultures were positive, with 2.2% deemed true positives and 5.8% due to contaminants. The incidence rate of true bacteremia was 0.57 per 1,000 full-term births, with gram-negative organisms (predominantly Escherichia coli) representing the majority (63%) of pathogens, followed by GBS (21%), Staphylococcus aureus (8%), and Streptococcus pneumoniae (3%). There were no cases of Listeria monocytogenes or Neisseria meningitidis bacteremia, and there was one case of enterococcal bacteremia. Fever was absent in 7% of cases.

The authors conclude that ampicillin may no longer be necessary for empiric antibiotic coverage in this age group given that 36% of pathogens were resistant to ampicillin, there were no cases of Listeria, and there was only one case of enterococcus. However, these recommendations should be considered in light of the specific study setting, and might not be applicable to all areas.

Bottom line: E. coli, GBS, and S. aureus, in that order, are the most common causes of bacteremia in infants aged one week to three months.

Citation: Greenhow TL, Hung YY, Herz AM. Changing epidemiology of bacteremia in infants aged 1 week to 3 months. Pediatrics. 2012;129(3):e590-e596.

Reviewed by Pediatric Editor Mark Shen, MD, SFHM, medical director of hospital medicine at Dell Children's Medical Center, Austin, Texas.

Dr. Hospitalist

One of our providers wants to use adult hospitalists for coverage of inpatient orthopedic surgery patients. Is this acceptable practice? Are there qualifiers?

—Libby Gardner

Dr. Hospitalist responds:

Let’s see how far we can tackle this open-ended question. There has been lots of discussion on the topic of comanagement in the past by people eminently more qualified than I am. Still, it never hurts to take a fresh look at things.

For one, on the subject of admissions, I am a firm believer that hospitalists should admit all adult hip fractures. The overwhelming majority of the time, these patients are elderly with comorbid conditions. Sure, they are going to get their hip fixed, because the alternative usually is unacceptable, but some thought needs to go into the process.

The orthopedic surgeon sees a hip that needs fixing and not much else. When such issues as renal failure, afib, congestive heart failure, prior DVT, dementia, and all the other common conditions are present, we as adult hospitalists should take charge of the case. That is the best way to ensure that the patient receives optimal medical care and the documentation that goes along with it. I love our orthopedic surgeons, but I don’t want them primarily admitting, managing, and discharging my elderly patients. Let the surgeon do what they do best—operate—and leave the rest to us as hospitalists.

On the subject of orthopedic trauma, I take the exact opposite approach—this is not something where we have daily expertise. A young, healthy patient with trauma should be admitted by the orthopedic service; that patient population’s complications are much more likely to be directly related to their trauma.

When it comes to elective surgery when the admitting surgeon (orthopedic or otherwise) wants the help of a hospitalist, then I think it is of paramount importance to establish clear “rules of engagement” (see “The Comanagement Conundrum,” April 2011, p. 1). I think with good expectations, you can have a fantastic relationship with your surgeons. Without them, it becomes a nightmare. As a real-life example, here are my HM group’s rules for elective orthopedic surgery:

• Orthopedics handles all pain medications and VTE prophylaxis, including discharge prescriptions;
• Medicine does the admission and medication reconciliation (“med rec”) at discharge;
• There is shared discussion on the need for transfusion; and
• There is shared discussion on the need for VTE prophylaxis when a patient already is on chronic anticoagulation.

We do not vary from this protocol. I never adjust a patient’s pain medications—even the floor nurses know this. Because I’m doing the admit and med rec, it also means that the patient doesn’t have their HCTZ continued after 600cc of EBL and spinal anesthesia. It works because the rules are clear and the communication is consistent.

This does not mean that we cover the orthopedic service at night; they are equally responsible for their patients under the items outlined above. In my view—and this might sound simplistic—the surgeon caused the post-op pain, so they should be responsible for managing it. With regard to VTE prophylaxis, I might take a more nuanced view, but for our surgeons, they own the wound and the post-op follow-up, so they get the choice on what agent to use.

Would I accept an arrangement in which I covered all the orthopedic issues out of regular hours? Nope—not when they have primary responsibility for the case; they should always be directly available to the nurse. I think that anything else would be a system ripe for abuse.

Our exact rules will not work for every situation, but I would strongly encourage the two basic tenets from above: No. 1, the hospitalist should primarily admit and manage elderly hip fractures, and No. 2, there should be clear rules of engagement with your orthopedic or surgery group. It’s a discussion worth having during daylight hours, because trying to figure out the rules at 3 in the morning rarely ends well.

Dr. Hospitalist

One of our providers wants to use adult hospitalists for coverage of inpatient orthopedic surgery patients. Is this acceptable practice? Are there qualifiers?

—Libby Gardner

Dr. Hospitalist responds:

Let’s see how far we can tackle this open-ended question. There has been lots of discussion on the topic of comanagement in the past by people eminently more qualified than I am. Still, it never hurts to take a fresh look at things.

For one, on the subject of admissions, I am a firm believer that hospitalists should admit all adult hip fractures. The overwhelming majority of the time, these patients are elderly with comorbid conditions. Sure, they are going to get their hip fixed, because the alternative usually is unacceptable, but some thought needs to go into the process.

The orthopedic surgeon sees a hip that needs fixing and not much else. When such issues as renal failure, afib, congestive heart failure, prior DVT, dementia, and all the other common conditions are present, we as adult hospitalists should take charge of the case. That is the best way to ensure that the patient receives optimal medical care and the documentation that goes along with it. I love our orthopedic surgeons, but I don’t want them primarily admitting, managing, and discharging my elderly patients. Let the surgeon do what they do best—operate—and leave the rest to us as hospitalists.

On the subject of orthopedic trauma, I take the exact opposite approach—this is not something where we have daily expertise. A young, healthy patient with trauma should be admitted by the orthopedic service; that patient population’s complications are much more likely to be directly related to their trauma.

When it comes to elective surgery when the admitting surgeon (orthopedic or otherwise) wants the help of a hospitalist, then I think it is of paramount importance to establish clear “rules of engagement” (see “The Comanagement Conundrum,” April 2011, p. 1). I think with good expectations, you can have a fantastic relationship with your surgeons. Without them, it becomes a nightmare. As a real-life example, here are my HM group’s rules for elective orthopedic surgery:

• Orthopedics handles all pain medications and VTE prophylaxis, including discharge prescriptions;
• Medicine does the admission and medication reconciliation (“med rec”) at discharge;
• There is shared discussion on the need for transfusion; and
• There is shared discussion on the need for VTE prophylaxis when a patient already is on chronic anticoagulation.

We do not vary from this protocol. I never adjust a patient’s pain medications—even the floor nurses know this. Because I’m doing the admit and med rec, it also means that the patient doesn’t have their HCTZ continued after 600cc of EBL and spinal anesthesia. It works because the rules are clear and the communication is consistent.

This does not mean that we cover the orthopedic service at night; they are equally responsible for their patients under the items outlined above. In my view—and this might sound simplistic—the surgeon caused the post-op pain, so they should be responsible for managing it. With regard to VTE prophylaxis, I might take a more nuanced view, but for our surgeons, they own the wound and the post-op follow-up, so they get the choice on what agent to use.

Would I accept an arrangement in which I covered all the orthopedic issues out of regular hours? Nope—not when they have primary responsibility for the case; they should always be directly available to the nurse. I think that anything else would be a system ripe for abuse.

Our exact rules will not work for every situation, but I would strongly encourage the two basic tenets from above: No. 1, the hospitalist should primarily admit and manage elderly hip fractures, and No. 2, there should be clear rules of engagement with your orthopedic or surgery group. It’s a discussion worth having during daylight hours, because trying to figure out the rules at 3 in the morning rarely ends well.

Dr. Hospitalist

One of our providers wants to use adult hospitalists for coverage of inpatient orthopedic surgery patients. Is this acceptable practice? Are there qualifiers?

—Libby Gardner

Dr. Hospitalist responds:

Let’s see how far we can tackle this open-ended question. There has been lots of discussion on the topic of comanagement in the past by people eminently more qualified than I am. Still, it never hurts to take a fresh look at things.

For one, on the subject of admissions, I am a firm believer that hospitalists should admit all adult hip fractures. The overwhelming majority of the time, these patients are elderly with comorbid conditions. Sure, they are going to get their hip fixed, because the alternative usually is unacceptable, but some thought needs to go into the process.

The orthopedic surgeon sees a hip that needs fixing and not much else. When such issues as renal failure, afib, congestive heart failure, prior DVT, dementia, and all the other common conditions are present, we as adult hospitalists should take charge of the case. That is the best way to ensure that the patient receives optimal medical care and the documentation that goes along with it. I love our orthopedic surgeons, but I don’t want them primarily admitting, managing, and discharging my elderly patients. Let the surgeon do what they do best—operate—and leave the rest to us as hospitalists.

On the subject of orthopedic trauma, I take the exact opposite approach—this is not something where we have daily expertise. A young, healthy patient with trauma should be admitted by the orthopedic service; that patient population’s complications are much more likely to be directly related to their trauma.

When it comes to elective surgery when the admitting surgeon (orthopedic or otherwise) wants the help of a hospitalist, then I think it is of paramount importance to establish clear “rules of engagement” (see “The Comanagement Conundrum,” April 2011, p. 1). I think with good expectations, you can have a fantastic relationship with your surgeons. Without them, it becomes a nightmare. As a real-life example, here are my HM group’s rules for elective orthopedic surgery:

• Orthopedics handles all pain medications and VTE prophylaxis, including discharge prescriptions;
• Medicine does the admission and medication reconciliation (“med rec”) at discharge;
• There is shared discussion on the need for transfusion; and
• There is shared discussion on the need for VTE prophylaxis when a patient already is on chronic anticoagulation.

We do not vary from this protocol. I never adjust a patient’s pain medications—even the floor nurses know this. Because I’m doing the admit and med rec, it also means that the patient doesn’t have their HCTZ continued after 600cc of EBL and spinal anesthesia. It works because the rules are clear and the communication is consistent.

This does not mean that we cover the orthopedic service at night; they are equally responsible for their patients under the items outlined above. In my view—and this might sound simplistic—the surgeon caused the post-op pain, so they should be responsible for managing it. With regard to VTE prophylaxis, I might take a more nuanced view, but for our surgeons, they own the wound and the post-op follow-up, so they get the choice on what agent to use.

Would I accept an arrangement in which I covered all the orthopedic issues out of regular hours? Nope—not when they have primary responsibility for the case; they should always be directly available to the nurse. I think that anything else would be a system ripe for abuse.

Our exact rules will not work for every situation, but I would strongly encourage the two basic tenets from above: No. 1, the hospitalist should primarily admit and manage elderly hip fractures, and No. 2, there should be clear rules of engagement with your orthopedic or surgery group. It’s a discussion worth having during daylight hours, because trying to figure out the rules at 3 in the morning rarely ends well.

Clinical question: What is the impact of a clinical practice guideline for hospitalized children with community-acquired pneumonia (CAP) on antibiotic selection?

Background: CAP is one of the most common reasons for hospitalizations in children. Broad-spectrum antibiotics frequently are prescribed for presumed bacterial pneumonia in children. Recent guidelines for CAP in children have emphasized that ampicillin is an appropriate empiric inpatient treatment option.

Study design: Retrospective review.

Setting: Tertiary referral children’s hospital.

Synopsis: Patients older than two months old with acute, uncomplicated CAP and without significant secondary illness were identified in the 12-month periods preceding and following the implementation of a clinical practice guideline (CPG) that recommended empiric treatment with ampicillin upon admission, and amoxicillin upon discharge.

A total of 1,033 patients were identified, 530 pre-CPG and 503 post-CPG, and the groups were similar. After the CPG, there was a significant increase in empiric ampicillin use (13% to 63%) and concomitant decrease in ceftriaxone use (72% to 21%). Rates of outpatient narrow-spectrum antibiotic prescribing increased as well, and the rate of treatment failure was similar between the groups.

Complex regression analysis was used to analyze the impact of a concomitant antibiotic stewardship program (ASP), implemented three months prior to the initiation of the CPG and demonstrating a separate and additive effect of both initiatives. Thus, changes in antibiotic prescribing were multifactorial over this time period.

The outcomes remain impressive in the context of two increasingly popular QI efforts—CPGs and ASPs. This study represents a meaningful contribution toward demonstration of outcomes-based quality improvement (QI).

Bottom line: In the context of a CPG, antibiotic spectrum may be safely narrowed in pediatric CAP.

Citation: Newman RE, Hedican EB, Herigon JC, Williams DD, Williams AR, Newland JG. Impact of a guideline on management of children hospitalized with community-acquired pneumonia. Pediatrics. 2012;129(3):e597-604.

Reviewed by Pediatric Editor Mark Shen, MD, FHM, medical director of hospital medicine at Dell Children’s Medical Center, Austin, Texas.

Clinical question: What is the impact of a clinical practice guideline for hospitalized children with community-acquired pneumonia (CAP) on antibiotic selection?

Background: CAP is one of the most common reasons for hospitalizations in children. Broad-spectrum antibiotics frequently are prescribed for presumed bacterial pneumonia in children. Recent guidelines for CAP in children have emphasized that ampicillin is an appropriate empiric inpatient treatment option.

Study design: Retrospective review.

Setting: Tertiary referral children’s hospital.

Synopsis: Patients older than two months old with acute, uncomplicated CAP and without significant secondary illness were identified in the 12-month periods preceding and following the implementation of a clinical practice guideline (CPG) that recommended empiric treatment with ampicillin upon admission, and amoxicillin upon discharge.

A total of 1,033 patients were identified, 530 pre-CPG and 503 post-CPG, and the groups were similar. After the CPG, there was a significant increase in empiric ampicillin use (13% to 63%) and concomitant decrease in ceftriaxone use (72% to 21%). Rates of outpatient narrow-spectrum antibiotic prescribing increased as well, and the rate of treatment failure was similar between the groups.

Complex regression analysis was used to analyze the impact of a concomitant antibiotic stewardship program (ASP), implemented three months prior to the initiation of the CPG and demonstrating a separate and additive effect of both initiatives. Thus, changes in antibiotic prescribing were multifactorial over this time period.

The outcomes remain impressive in the context of two increasingly popular QI efforts—CPGs and ASPs. This study represents a meaningful contribution toward demonstration of outcomes-based quality improvement (QI).

Bottom line: In the context of a CPG, antibiotic spectrum may be safely narrowed in pediatric CAP.

Citation: Newman RE, Hedican EB, Herigon JC, Williams DD, Williams AR, Newland JG. Impact of a guideline on management of children hospitalized with community-acquired pneumonia. Pediatrics. 2012;129(3):e597-604.

Reviewed by Pediatric Editor Mark Shen, MD, FHM, medical director of hospital medicine at Dell Children’s Medical Center, Austin, Texas.

Clinical question: What is the impact of a clinical practice guideline for hospitalized children with community-acquired pneumonia (CAP) on antibiotic selection?

Background: CAP is one of the most common reasons for hospitalizations in children. Broad-spectrum antibiotics frequently are prescribed for presumed bacterial pneumonia in children. Recent guidelines for CAP in children have emphasized that ampicillin is an appropriate empiric inpatient treatment option.

Study design: Retrospective review.

Setting: Tertiary referral children’s hospital.

Synopsis: Patients older than two months old with acute, uncomplicated CAP and without significant secondary illness were identified in the 12-month periods preceding and following the implementation of a clinical practice guideline (CPG) that recommended empiric treatment with ampicillin upon admission, and amoxicillin upon discharge.

A total of 1,033 patients were identified, 530 pre-CPG and 503 post-CPG, and the groups were similar. After the CPG, there was a significant increase in empiric ampicillin use (13% to 63%) and concomitant decrease in ceftriaxone use (72% to 21%). Rates of outpatient narrow-spectrum antibiotic prescribing increased as well, and the rate of treatment failure was similar between the groups.

Complex regression analysis was used to analyze the impact of a concomitant antibiotic stewardship program (ASP), implemented three months prior to the initiation of the CPG and demonstrating a separate and additive effect of both initiatives. Thus, changes in antibiotic prescribing were multifactorial over this time period.

The outcomes remain impressive in the context of two increasingly popular QI efforts—CPGs and ASPs. This study represents a meaningful contribution toward demonstration of outcomes-based quality improvement (QI).

Bottom line: In the context of a CPG, antibiotic spectrum may be safely narrowed in pediatric CAP.

Citation: Newman RE, Hedican EB, Herigon JC, Williams DD, Williams AR, Newland JG. Impact of a guideline on management of children hospitalized with community-acquired pneumonia. Pediatrics. 2012;129(3):e597-604.

Reviewed by Pediatric Editor Mark Shen, MD, FHM, medical director of hospital medicine at Dell Children’s Medical Center, Austin, Texas.