2020 pediatric hospital medicine advanced practice providers … · 2020. 11. 20. · 2020...

2020 Pediatric Hospital Medicine Advanced Practice Providers Virtual Conference

Presented in part by the AAP SOHM Subcommittee for Advanced Practice ProvidersChair: Leah Rawdon DNP, APRN, CPNPVice Chair: Rebecca Carlson MAN, APRN, CPNPVice Chair: Jodi Lohrey MSN, APRN, CFNP

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AgendaOctober 30th Central Standard Time

12:00 -12:10: Introductions, discuss goals and objectives for the day

12:10 -1:20: Pediatric Hospital Medicine Top 10: Review and Updates of the Most Frequently Encountered Diagnoses

1:20 -2:30: CBC with differential; interpretation leading to antibiotic therapy considerations.

2:30 -3:00: Ending remarks with an introduction from the Chair of the AAP Section on Hospital Medicine; H.Barrett Fromme, MD, MHPE. We will conclude with APP subcommittee updates.

Goals and Objectives for the Day:● The Conference provides an opportunity for APPs and other related providers to meet

specific learning needs while accommodating the ability to network with others in the field. ● Pediatric Hospital Medicine Top 10

○ Faculty will review current standards of care for the most common diagnoses in PHM, and highlight the most recent updates and changes to national guidelines.

○ They will also discuss recent research related to these diagnoses and changes that may be coming to practice

● CBC with differential and Culture Results○ Faculty will discuss interpretation leading to antibiotic therapy considerations and also review

components and interpretation through didactic education and case studies.○ They will also discuss abnormal results and considerations based on lab work; and also review

culture interpretation, identification of organism, and appropriate antibiotic choice based on lab findings and diagnosis

PEDIATRIC HOSPITAL MEDICINE TOP 10

Presented by: Rebecca Carlson, MAN, APRN, CPNP&

Abigail Burkett Vetter, MSN, APRN, CPNP-AC/PC

© 2020

We have no relevant financial relationships to disclose.

Disclosure

© 2020

• Review current standards of care for the most common diagnoses in Pediatric Hospital Medicine (PHM).

• Highlight recent updates and changes to national guidelines for the care of hospitalized children with these diagnoses.

• Examine current research and literature and identify changes that may be relevant to practice.

Learning Objectives

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• Reviewed AAP Guidelines and other organizational guidelines when appropriate.

• Consulted the Red Book and Cochrane Reviews when available.

• Reviewed articles from 2018-2020 from journals with the top 5 highest impact factors related to PHM

Our Process

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• Number of Advanced Practice Providers (APPs) are increasing.• 15.3 APPs/100 MDs in 2001• 28.2 APPs/100 MDs in 2016• 53.9 APPs/100 MDs in 2030

• Increasing number of hospital medicine services utilizing APPs

• APPs are filling a variety of rolls within PHM

State of APPs in PHM

33.3% in 2016 41.7% in 2018

Resident Team

Independent Rounding

Complex Care Team

Consult Service

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1 - Bronchiolitis

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• Viral lower respiratory tract infection• Inflammation, edema, necrosis of epithelial cells, increased mucous production• Most common reason for hospitalization

in children <12 months• Estimated $1.73 billion

per year in hospitalizations

Bronchiolitis Fun Facts

Virus Type

RSV Rhinovirus InfluenzaHMV Coronavirus Parainfluenza

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Bronchiolitis 2014 AAP Clinical GuidelinesDefinitely Maybe Definitely Not

Assess for risk factors 3% hypertonic saline Routine labs/radiographs

NG or IV fluids (if poor PO) Measure O2 sats Albuterol *

Racemic epinephrine

Systemic corticosteroids

Chest physiotherapy

Antibiotics *

BRONCHIOLITIS -NEVER HAVE I

EVER…• Given an albuterol neb• Performed bronchial drainage• Ordered steroids• Given hypertonic 3% saline

nebulizer

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3% Saline – Does it help?

Continuous vs. intermittent pulse oximetry and LOS: decrease LOS by 20 hours,

increased readmission from 3.3%-5%

HFNC on the floor?

Coronavirus & Bronchiolitis

Bronchiolitis: What’s New?

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2 -Croup

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Croup

• The most frequent cause of laryngotracheitis is parainfluenza• Standard treatment consists of:

– Decadron 0.6 mg/kg– Nebulized racemic epinephrine

• Cochrane Review 2018– Steroids improved symptoms at 2 hours and lasted at least 24 hours– Children given steroids less likely to have return visits compared to placebo

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Croup

https://www.childrensmn.org/ref erences/cds/croup-guideline-age-3-months-8-y ears.pdf

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Croup – How many racemic epinephrine nebs?

Disclaimer: This guideline is designed for general use with most patients; each clinician should use his or her own independent judgment to meet the needs of each individual patient. This guideline is not a substitute for professional medical advice, diagnosis or treatment.

https://w ww.childrensmn.org/references/cds/croup-guideline-age-3-months-8-years.pdf

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• Imaging/Labs/viral testing:– Drooling, tripod, trismus, limited neck ROM, lethargy or agitation

• Repeat Decadron dosing– Once? – Sure– More than once? – Hmmm…

Croup – When to do More

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Brief Resolved Unexplained Event

3 - BRUE

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Never Have I Ever…

• For a child admitted for BRUE• Skipped CPR training for parents • Done a swallow study• Assumed it was GERD• Prescribed GERD medication• Told a parent to chillax

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BRUE Guideline

• AAP 2016

• ALTE = BRUE

• Low risk infants

25

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2016 Low-risk BRUE Guidelines

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ALTE vs BRUEComparison of ALTE criteria to BRUE criteria

78 patients met ALTE criteria

Only 1 met BRUE criteria Most instances did not meet because event was not truly unexpected

Importance of thorough H&P

Use of BRUE criteria decrease admissions

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Higher-risk BRUE

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Post-BRUE

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4 – SSTISkin and Soft Tissue Infections

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IV antibiotic choice for infants

Combination = Staphylococcal coverage plus broad spectrum/neonatal sepsis abx to cover gram negative organisms

More likely to have fever and CSF testing LOS and cost 35-40% higher

Those receiving staphylococcal coverage alone

More likely infection

In infants <60 days of age utilization of combination therapy of IV antibiotics

Increased LOS Increased cost But not necessarily 30 day readmission

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Decolonization*• Those with MRSA colonization are at high risk for SSTI• Decolonization protocols are effective in eradicating colonization• But…

•Do not prevent recolonization or recurrence of MRSA infection

• High Risk for MRSA recurrence:• Personal or family hx of MRSA infection or abscess • Hispanic ethnicity• Fever on admission

• Decolonizing just MRSA pt not inferior to decolonizing every household member

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Tests aren’t needed

Yes No Maybe soHx and exam only for Dx

Blood cultures CBC, CRP, ESR

Use pathway

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Observations and 3-4 doses

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5 - Asthma

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AsthmaTranslating complex care guidelines into routine practice:• NHLBI Expert Panel Guidelines 2007• An International Consensus on Pediatric

Asthma 2012• British Thoracic Society/Scottish

Intercollegiate Guideline Network 2016• Global Strategy for Asthma Management and

Prevention 2017• The National Institute for Health and Care

Excellence asthma guideline consultation 2017• Global Initiative for Asthma (GINA) 2019

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Assessseverity using

a scoring tool

O2 if hypoxic

Give albuterol,

ipratropium & steroids

Consider magnesium,

or pulmonary

consult

Discharge on controller

when indicated

Asthma

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Vaccines: PPSV 23?Discharge criteria: Q4h?

Asthma

GINA 2019 Guidelines

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6 - Gastroenteritis

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Gastroenteritis - JAMA Clinical Guideline 2017Fluid Choice When to Test When to Treat Empirically Additional Therapies

ORS is preferred for mild-moderate dehydration

Fever or signs of sepsis <3 months with suspected bacterial infection

Consider antiemetics if patient >4

Consider NG for ORS Bloody or mucous stool Recent international traveler with fever

Consider probiotics

Isotonic IVF if severe dehydration, altered LOC, or ileus

Severe abdominal pain or tenderness

Ill appearing and suspected Shigella

Zinc

Human milk for infants *Recent travel, current outbreak, or immune compromise

*Avoid if Shiga toxin producing E. Coli

Return to age appropriate diet ASAP

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GastroenteritisProbiotics – Are they doing anything?• Multicenter, double blind, RCT with 886 participants

– 5 days of BID combination probiotic– No significant difference in development of moderate to severe diarrhea in 14 days

• Multicenter, double blind, RCT with 943 participants– 5 days of BID Lactobacillus rhamnosus– No significant difference in duration of diarrhea or vomiting, missed day care days, or rate of household transmission

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7 - Febrile Infant

43

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Clinical Pathways

• Implementation of a clinical pathway resulted in sustained reduction in invasive interventions for low-risk febrile infants without missed SBIs

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Febrile InfantFebrile infants without an identifiable source of fever Risk = 7%.

Distinct viral syndrome Low risk <1%

CRP and PCT Improve clinical decision-making

Among infants treated for UTI without CSF testing No cases of delayed meningitis

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Prediction Rule

Low Risk Prediction Rule

• Normal urinalysis• Absolute neutrophil count

≤4090/μL• Serum procalcitonin ≤1.71

ng/mL.• No meningitis was missed

Low Risk

• Normal urinalysis result• Absolute neutrophil count

<5185 cells per μL• A temperature <38.5°C • Fever by history only

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To LP or not to LP

Shared decision-

making with parents

Although ∼0.5% of all febrile infants have

bacterial meningitis, prevalence

among infants classified as low risk by these

algorithms may approach 0%

Poor outcomes• Hx of

prematurity

• Ill appearance

• Bacterial meningitis

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Dipstick UTILow sensitivity

Negative UA + Positive UCx = increased LOS• More likely to be contaminant• Does not follow current recommendations

Positive nitrite test independent risk factor for IBI

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8 - Urinary Tract

Infections

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UTI

Repeated infections can cause renal scarring

1Long term use of prophylactic abx may reduce symptomatic recurrence

2Long-term low-dose use of abx should be reserved for high risk •Young infants•Children with renal abnormalities

3

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Recurrent febrile UTI

Duration of fever prior to treatment

Presence/grade of VUR

Certain gene polymorphisms

• Procalcitonin• MMP-9• TIMP-1• Angiotensinogen• Endothelin – 1/Cr• IL-8• NGAL

Non-invasive biomarkers

Renal Scarring Risk Factors

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Narrow spectrum antibiotics are ok to use while waiting culture results

Typically resistant to 3rd gen cephalosporins

Risk factorsLower rates of

appropriate empiric antibiotic therapy

Higher rate of hospitalization

Higher rate of having undergone VCUG

Higher rate of recurrence in 30 days

Antibiotic Resistance

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Duration of IV Antibiotics

Young infants with bacteremic UTI who received ≤7 days of parenteral antibiotics

Did not have more frequent recurrent UTIs or hospital reutilization

Short-course parenteral therapy with early conversion to oral antibiotics

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Renal Bladder Ultrasound

After first febrile UTI in child 2- 24 mo• Not cost effective• Defer until after 2nd febrile UTI

Only 64% accurate

91pts would need to be screened to prevent 1 recurrent UTI

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Concurrent Infection with Positive Viral Illness

If low risk for UTI

Less than 1% chance of having UTI

UTI evaluation not required

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9 – Community Acquired

Pneumonia

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CXR and ABX in CAP

Good news

ABX are being prescribed appropriately, per guidelines

Bad News

More CXRs are obtained than

necessary

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CAP Diagnostics

• US saves time and money• Decreased ED LOS

Lung Ultrasound vs CXR

• Can differentiate between consolidation and atelectasis• Less accurate at lung abscesses d/t user experience

US

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Prediction of severityUse of biomarkers to predict CAP severity• WBC• ANC• CRP• Procalcitonin

Not generally useful

CRP and procalcitonin• Good at identifying

• Empyema requiring chest drainage• Sepsis requiring vasoactive infusions

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CAP and Bacteremia

• No routine blood cultures

Decreasing prevalence of bacteremia in children

• Complicated CAP: empyema, abscess, fistula, or metastatic complications• Requiring ICU care for shock and/or advanced respiratory support• Concern for pathogens other than penicillin sensitive S. pneumonia, immunocompromised, under-

immunized, inadequate response to empirical ampicillin

Get a blood culture from the following:

Procalcitonin elevated in those with bacteremia

Only 2.2% of BCx identify causative organism

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10

PALS IV Fluids

• 2018 AAP Guideline

–“Patients 28 days to 18 years of age requiring maintenance IVFs should receive isotonic solutions with appropriate KCl and dextrose because they significantly decrease the risk of developing hyponatremia.”

BMV is reasonable compared with advanced airway during cardiac arrest in the out of hospital setting

ECPR for pediatric patients with cardiac diagnoses

Comatose after cardiac arrest

TTM 32oC –34oC or to use TTM 36oC to 37.5oC.

PALS IV Fluid Management

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Questions?

CONTACT INFORMATIONRebecca Carlson, MAN, APRN, CPNPChildren’s Minnesota [email protected]

Abigail Burkett Vetter, MSN, APRN, CPNP-AC/PCChildren’s MinnesotaNorth Dakota State [email protected]@ndsu.edu

mailto:[email protected]

mailto:[email protected]%E2%80%8B


© 2020

References1. Auerbach D.I., Staiger, D.O., & Buerhaus, P.I. (2018). Growing ranks of advanced practice clinicians - implications for the

physician workforce. The New England Journal of Medicine. 378, 2358-2360.2. State of hospital medicine report. (2018). Society of Hospital Medicine.

Bronchiolitis1. Ralston, S.L., Lieberthal, A.S., & Meissner, H. C. (2014). Clinical practice guideline: The diagnosis, management, and

prevention of bronchiolitis. Pediatrics, 134(5), e1474-e1502. Retrieved from https://pediatrics.aappublications.org/content/134/5/e1474

2. House, S. A., Gadomski, A. M., & Rawlston, S.L. (2020). Evaluating the placebo status of nebulized normal saline in patients with acute viral bronchiolitis. JAMA Pediatrics, 174(3), 250-259. doi:10.1001/jamapediatrics.2019.5195

3. Harrison, W., Angoulvant, F., House, S., Gajdos, V., & Ralston, S.L. (2018). Hypertonic saline in bronchiolitis and type I error: A trial sequential analysis. Pediatrics, 142(3):e20181144.

4. Mittal, S., et al. (2019). Successful use of quality improvement methodology to reduce inpatient length of stay in bronchiolitisthrough judicious use of intermittent pulse oximetry. Hospital Pediatrics, 9(2) 73-78.

5. Kalburgi, S., & Halley, T. (2020). High Flow Nasal Cannula Use Outside of the ICU Setting. Pediatrics,https://doi.org/10.1542/peds.2019-4083

6. Leyenaar, J.K., & Ralston, S.L. (2020). Widespread Adoption of Lo—Calue Therapy: The Case of Bronchiolitis and High Flow Nasal Cannula. Pediatrics. https://doi.org?10.1542/peds.2020-021188

7. Mansbach, J.M., et al. (2020). Severe Coronavirus Bronchiolitis in the Pre-COVID-19 Era. Pediatrics.https://doi.org/10.154/peds.2020-1267

https://pediatrics.aappublications.org/content/134/5/e1474

https://doi.org/10.1542/peds.2019-4083

https://doi.org/?10.1542/peds.2020-021188

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ReferencesCroup1. American Academy of Pediatrics. (2020). Parainfluenza Viral Infections. In The Red Book 31st Edition. American Academy of Pediatrics (593-595).

https://redbook.solutions.aap.org/chapter.aspx?sectionId=189640147&bookId=2205&resultClick=1

2. Colin, P.M., Cooper, M.N. (2019). Prednisolone versus dexamethasone for croup: A randomized controlled trial. Pediatrics, 144(3), 1-11.3. Gates, A., Johnson, D.W., Klassen, T.P. (2019). Glucocorticoids for croup in children. JAMA Pediatrics, 173(6), 595-596.4. Gates, A., Gates, M., & Vandermeer, B.. (2020). Glucocorticoids for croup in children. Cochrane Library. https://doi.org/10.1002/14651858.CD001955.pub4

5. Hester, G., Zenker, P., Chawla, S. (2019). Clinical guideline: Croup (age 3 months-8 years). https://www.childrensmn.org/references/cds/croup-guideline-age-3-months-8-years.pdf6. Hester, G., Barnes, T., O’Neill, J., Swanson, G., McGuinn, T., Nickel, A. (2019). Rate of airway intervention at a tertiary children’s hospital 2015-2016. The Journal Of Emergency Medicine, 57(3), 314-321.

7. Asmundsson, A.S., Arms, J., & Kaila, R. (2019). Hospital course of croup after emergency department management. Hospital Pediatrics, 9(5), 326-3328. Weatherly, J., Song, Y., Meister, K., and Berg, M. (2019). The runaway croup train: Off the pathway and into the woods. Hospital Pediatrics, 9(10), 820-823.

9. Tyler, A. et al. (2017). Variation in inpatient croup management and outcomes. Pediatrics, 139 (4), e20163582.

https://redbook.solutions.aap.org/chapter.aspx?sectionId=189640147&bookId=2205&resultClick=1

https://doi.org/10.1002/14651858.CD001955.pub4

https://www.childrensmn.org/references/cds/croup-guideline-age-3-months-8-years.pdf

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ReferencesBRUE:

1. Khan, A. et al. (2018). Caregivers’ perceptions and hospital experience after a brief resolved unexplained event: A qualitative study. Hospital Pediatrics, 9(7), 508-515. doi: https://doi.org/10.1542/hpeds.2018-0220

2. Ari, A. et al. (2019). Long-term follow-up of infants after a brief resolved unexplained event-related hospitalization. Pediatric Emergency Care, 35(11), 765 – 768.

3. Duncan, D. R. et al. (2019). The impact of the american academy of pediatrics brief resolved unexplained event guidelines on gastrointestinal testing and prescribing practices. The Journal of Pediatrics, 211, 112-119.

4. Gerber, N. L., Fawcett, K.J., Weber, E. G., Patel, R., Glick, A. F.,Farkas, J. S., & Mojica, M. A. (2020) Brief resolved unexplained event. Pediatric Emergency Care. DOI:10.1097/PEC.0000000000002069

5.. Merritt, J. L. et al. (2019). A framework for evaluation of the higher-risk infant after a brief resolved unexplained event. Pediatrics, 144(2), e20184101. doi: https://doi.org/10.1542/peds.2018-4101

6.. Oglesbee, S. J. et al. (2020). Implementing lower‐risk brief resolved unexplained events guideline reduces admissions in a modeled population” Journal of Evaluation in Clinical Practice, 26, 343–356.

7. Sethi, A., Baxi, K., Cheng, D., Laffey,S., Hartman, N., & Heller, K. (2020). Impact of guidelines regarding brief unexplained events on care of patients in the emergency department. Pediatric Emergency Care, DOI: 10.1097/pec.0000000000002081

8. Soung, J., Ramgopal, S., & Pitetti, R. (2019). Patients with apparent life threatening events meeting criteria for brief resolved unexplained event. Pediatrics, 19(8), 963-968.

9. Tieder, J.S. et al. (2016). Clinical practice guideline: Brief resolved unexplained events (formerly apparent life-threatening events) and evaluation of lower-risk infants: Executive summary.” Pediatrics, 137(5), e20160591. doi: https://doi.org/10.1542/peds.2016-1488

https://doi.org/10.1542/hpeds.2018-0220


https://doi.org/10.1097/pec.0000000000002081


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ReferencesSSTI:1. Begem Lee, D. et al. (2020). Reducing unnecessary testing in uncomplicated skin and soft tissue infections: A quality improvement approach. Hospital Pediatrics, 10(2),129 – 137. doi: https://doi.org/10.1542/hpeds.2019-01792. Girdwood, S.T. et al. (2019). Improving the transition of intravenous to enteral antibiotics in pediatric patients with pneumonia or skin and soft tissue infections. Journal of Hospital Medicine, 15(1), 10-15. doi: 10.12788/jhm.32533. Hogan, P.G., Parrish, K.L., Mork, R.L., Boyle, M.G., Muenks, C.E., Thompson, R.M., Morelli,J.J., Sullivan,M.L., Hunstad, D.A., Bubeck Wardenburg, J., Rzhetsky, A., Gehlert, S.J., Burnham, C.D., & Fritz, S.A. HOME2 Study: Household Versus Personalized Decolonization in Households of Children With Methicillin-Resistant Staphylococcus aureus Skin and Soft Tissue Infection—A Randomized Clinical Trial, Clinical Infectious Diseases https://doi.org/10.1093/cid/ciaa7524. Markham, J. L. et al. (2019). Variation in antibiotic selection and clinical outcomes in infants <60 days hospitalized with skin and soft tissue infections. Hospital Pediatrics, 9(1), 30-38. doi: https://doi.org/10.1542/hpeds.2017-02375. Papastefan, S.T. et al. (2019). Impact of decolonization protocols and recurrence in pediatric MRSA skin and soft-tissue infections. Journal of Surgical Research, 242, 70-77. https://doi.org/10.1016/j.jss.2019.04.0406. Yusuf, S. et al. (2019). Managing skin and soft tissue infections in the emergency department observation unit. Pediatric Emergency Care, 35(3), 204-208. doi: 10.1097/PEC.0000000000000975


https://doi.org/10.1093/cid/ciaa752


https://doi.org/10.1016/j.jss.2019.04.040

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ReferencesAsthma1. Nkoy, F. L., Wilkins, V.L., & Fassl, B. A. (2019). Contextual factors influencing implementation of evidence-based care

for children hospitalized with asthma. Hospital Pediatrics, 9(12), 949-957.2. Tesse, R. et al. (2018). Treating pediatric asthma according to guidelines. Frontiers in Pediatrics, 6,

234. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6115494/3. Seattle Children’s. (2018) Asthma v7.0. https://www.seattlechildrens.org/pdf/asthma-pathway.pdf4. Connecticut Children’s Medical Center. (2019). Clinical pathway: Inpatient asthma.

https://www.connecticutchildrens.org/wp-content/uploads/2019/12/Asthma-Inpatient-Algorithm.pdf5. Kenyon, C. et al. (2018). Inpatient asthma pathway. Children’s Hospital of Philadelphia.https://www.chop.edu/clinical-

pathway/asthma-inpatient-care-clinical-pathway6. Lo, H.Y. (2018). Discharging asthma patients on 3-hour β-agonist treatments: A quality pmprovement Project. Hospital

Pediatrics, 8(12),733-739.7. Simmon, J.M., Biagini Myers, J.M., & Martin L.J. (2018). Ohio pediatric asthma repository: Opportunities to revise care

practices to decrease time to physiologic readiness for discharge. Hospital Pediatrics, 8(6), 305-313.8. Castro-Rodriguez, J.A., Abarca, K., Forno, E. (2020). Asthma and the risk of invasive pneumococcal disease.

Pediatrics, 145(1),1-11.9. Reddel, H., Boulet, L.P., & Levy, M. (2019). Asthma prevention and management for adults and children older

than five years. Global Initiative for Asthma. https://ginasthma.org/wp-content/uploads/2019/04/GINA-2019-main-Pocket-Guide-wms.pdf

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6115494/

https://www.seattlechildrens.org/pdf/asthma-pathway.pdf

https://www.connecticutchildrens.org/wp-content/uploads/2019/12/Asthma-Inpatient-Algorithm.pdf

https://www.chop.edu/clinical-pathway/asthma-inpatient-care-clinical-pathway

https://ginasthma.org/wp-content/uploads/2019/04/GINA-2019-main-Pocket-Guide-wms.pdf

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ReferencesGastroenteritis1. Parker, M. W., & Unaka, N. (2018). Diagnosis and management of infectious diarrhea. JAMA Pediatrics. 172(8), 775-776.2. Dhingra, U., et al. (2020). Lower Dose Zinc for Childhood Diarrhea – A Randomized, Multicenter Trial. New England Journal of

Medicine, 383(13), 1231-1241.3. Freedman, S.B., et al. (2018). Multicenter trial of a combination probiotic for children with gastroenteritis. New England Journal of

Medicine, 379(21), 2015-2026.4. Schnadower, D., Tarr, P.I., & Casper, T.C. (2018). Lactobacillus rhamnosus GG versus placebo for acute gastroenteritis in

children. New England Journal of Medicine, 379, 2002-2014.Febrile Infant1. Aronson, P. L., et al. (2019). Physicians’ and nurses’ perspectives on the decision to perform lumbar punctures on febrile infants ≤8 Weeks Old. Hospital Pediatrics, 9(6), 405-414. doi: https://doi.org/10.1542/hpeds.2019-00022. Aronson, P. L., et al. (2019). A prediction model to identify febrile infants ≤60 days at low risk of invasive bacterial infection for the Febrile Young Infant Research Collaborative, Pediatrics, (144)1, e20183604; doi: https://doi.org/10.1542/peds.2018-36043. Kasmire, K. E. et al. (2019). Reducing invasive care for low-risk febrile infants through implementation of a clinical pathway. Pediatrics, 134(3).4. Kupperman, N. et al., (2019). Prediction models for febrile infants: Time for a unified field theory. Pediatrics, 144(1), e20191375. doi: https://doi.org/10.1542/peds.2019-1375




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ReferencesFebrile Infant - Continued5. Kupperman, N. et al. (2019). A clinical prediction rule to identify febrile infants 60 days and younger at low risk for serious bacterial infections for the Febrile Infant Working Group of the Pediatric Emergency Care Applied Research Network (PECARN). Journal of the American Medical Association Pediatrics, 173(4), 342-351. doi:10.1001/jamapediatrics.2018.55016. Lendner, I. et al. (2019). Urine dipstick low sensitivity for UTI diagnosis in febrile infants. Infectious Diseases, 51(10), 764-771. doi: 10.1080/23744235.2019.16523397. Markham, J. L. et al. (2019). Variation in antibiotic selection and clinical outcomes in infants <60 days hospitalized with skin and soft tissue infections. Hospital Pediatrics, 9(1), 30-38. doi: https://doi.org/10.1542/hpeds.2017-02378. Pruitt, C. M. et al. (2019). Factors associated with adverse outcomes among febrile young infants with invasive bacterial infection on behalf of the Febrile Young Infant Research Collaborative. Journal of Pediatrics, 204, 177-82.9. Schroeder, A. R. et al. (2019). Negative urinalyses in febrile infants age 7 to 60 days treated for urinary tract infection. Journal of Hospital Medicine, 14(2),101-104.10. Stol, K. et al. (2019).Biomarkers for infection in children: Current clinical practice and future perspectives. The Pediatric Infectious Disease Journal, 38, (65), S7 – S13. doi: 10.1097/INF.000000000000231811. Velasco, R, et al on behalf of the Group of Study of Febrile Infant of the Spanish Pediatric Emergency Research Group. (2020). A positive nitrite test was an independent risk factor for invasive bacterial infections in infants under 90 days of age with fever without source. Acta Paediatr, 00, 1– 8. https://doi.org/10.1111/apa.1523012. Wang, M. E. et al. (2019). Testing for meningitis in febrile well-appearing young infants with a positive urinalysis.Pediatrics, 144(3), e20183979. doi: https://doi.org/10.1542/peds.2018-3979

https://doi.org/10.1080/23744235.2019.1652339


https://doi.org/10.1111/apa.15230


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ReferencesUTI

1. Desai, S. et al. (2019). Parenteral antibiotic therapy duration in young infants with bacteremic urinary tract infections on behalf of the Febrile Young Infant Research Collaborative, Pediatrics, 144(3), e20183844. doi: https://doi.org/10.1542/peds.2018-3844

2. Gaither, T. W. et al. (2020). Cost-effectiveness of screening ultrasound after a first, febrile urinary tract infection in children age 2-24 aonths, The Journal of Pediatrics, 216, 73-81.

3. Kang, K. T. et al. (2019). Third-generation cephalosporin-resistant urinary tract infections in children presenting to thepaediatric emergency department. Paediatrics & Child Health, 25(3), 166-172. https://doi.org/10.1093/pch/pxy175

4. Kosmeria, C. et al.(2019). An update on renal scarring after urinary tract infection in children: What are the risk factors?. Journal of Pediatric Urology, 15(6), 598-603.

5. Mattoo, T. K. & Asmar, B.I. (2020). Annotations on emerging concerns about antibiotic-resistant urinary tract infection. Pediatrics, 145(2), e20193512; DOI: https://doi.org/10.1542/peds.2019-3512

6. Schlechter Salinas, A. K. et al. (2019). Testing for urinary tract infection in the influenza/respiratory syncytial virus–positive febrile infant aged 2 to 12 months. Pediatric Emergency Care, 25(10), 666-670. doi: 10.1097/PEC.0000000000001073

7. Wang, M. E. et al. (2020). Clinical response to discordant therapy in third-generation cephalosporin-resistant UTIs. Pediatrics, 145(2), e20191608. doi: https://doi.org/10.1542/peds.2019-1608

8. Williams, G. & Craig, J.C. (2019). Long‐term antibiotics for preventing recurrent urinary tract infection in children. Cochrane Systematic Review – Intervention. https://doi.org/10.1002/14651858.CD001534.pub4


https://doi.org/10.1093/pch/pxy175



https://doi.org/10.1002/14651858.CD001534.pub4

© 2020

ReferencesCAP1. Bradley, J. S. et al. (2011). The management of community-acquired pneumonia in infants and children older than 3 months of age: Clinical practice guidelines by the Pediatric Infectious Diseases Society and the Infectious Diseases Society of America. Clinical Infectious Diseases: IDSA Guidelines, Oxford University Press on behalf of the Infectious Diseases Society of America. DOI: 10.1093/cid/cir531Emergency2. Fritz, C.Q. et al. (2019). Prevalence, Risk Factors, and Outcomes of Bacteremic Pneumonia in Children, Pediatrics, 144

(1) e20183090; DOI: https://doi.org/10.1542/peds.2018-30903. Florin, T.A. et al (2020). Biomarkers and Disease Severity in Children With Community-Acquired Pneumonia,

Pediatrics,145(6). DOI: 10.1542/peds.2019-37284. Harel‐Sterling, M., Diallo, M., Santhirakumaran, S., Maxim, T., & Tessaro, M. (2018). Emergency Department Resource Use in Pediatric Pneumonia: Point‐of‐ Care Lung Ultrasonography versus Chest Radiography, Journal of Ultrasound Medicine, 38(2). https://doi.org/10.1002/jum.147034. Johnson, D. P. et al. (2020). Things We Do For No Reason: Routine Blood Culture Acquisition for Children Hospitalized

with Community-Acquired Pneumonia. Journal of Hospital Medicine, 15(2), 107-110.4. McLaren, et al. (2019). Guideline Adherence in Diagnostic Testing and Treatment of Community-Acquired Pneumonia in Children. Pediatric Emergency Care. doi: 10.1097/pec.00000000000017457. Yan, C. (2019). Lung ultrasound vs. chest X-ray in children with suspected pneumonia confirmed by chest computed tomography: A retrospective cohort study. Experimental and Therapeutic Medicine, 19(2). https://doi.org/10.3892/etm.2019.8333


https://doi.org/10.1002/jum.14703

https://doi.org/10.3892/etm.2019.8333

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PALS1. Duff, J.P. et al. (2019). American Heart Association Focused Update on Pediatric Advanced Life

Support. Circulation, 140, e904–e914. doi: 10.1161/CIR.0000000000000731IV Fluid Management1. Feld, L. G., et al. (2018). Clinical practice guideline: Maintenance intravenous fluids in children.

Pediatrics, 142(6), e20183083. doi: 10.1542/peds.2018-3083.

References

www.akronchildrens.org/giving

Interpretation of CBC with differential and Culture Results leading to antibiotic therapy considerations


Presented By:

Elizabeth Byler MSN, APRN, CPNP

Jackie Pressman MSN, APRN, CPNP

Leah Rawdon DNP, APRN, CPNP


Disclosures

No conflicts of interest noted for this presentation


Objectives:

• Review components and interpretation through didactic education and case studies.

• Discuss abnormal results and considerations based on lab work.

• Review culture interpretation, identification of organism and appropriate antibiotic choice based on lab findings and diagnosis.


Breaking Down a CBC


Why is a CBC so Important?


CBC Includes:

• Red Blood Cells (RBC)

• White Blood Cells (WBC)

• Platelets


RBC• Components:

– HGB (Hemoglobin)

– HCT (Hematocrit)

– MCV (Mean Cell Volume)

(Doig & Zhang, 2017)


RBC Cont. • MCH (Mean Cell Hemoglobin)

• MCHC (Mean Cell Hemoglobin Concentration)

• RDW (Red Cell Distribution Width)



RBC Terminology and Interpretation

• Hemoglobin Low: Anemia

• If total RBCs are High: Polycythemia



WBC Components

•Basophils •Eosinophils •Monocyte •Neutrophils

• Bands• Segs

•Lymphocyte(Calihan, 2021)


WBC Terminology and Interpretation

• Low: Leukopenia:– Causes: Viral suppression,

Medications, or Cancer (Doig & Thompson, 2017)

(Calihan, 2021)


WBC Terminology and Interpretation Cont.

• High: Leukocytosis:– Causes:

1.Infection 2.Cancer 3.Steroids4.Stress/Post-op

(Doig & Thompson, 2017) (Celkan, 2020)


WBC Terminology and Interpretation Cont.

• Increase: neutrophilia, lymphocytosis, monocytosis, eosinophilia, basophilia

• Decrease: neutropenia and lymphopenia. Monocytopenia, eosinopenia, and basopenia are not typically noted since the lower limits of the normal reference intervals are so low

(Doig & Thompson, 2017) (Celkan, 2020)


Left Shift

(Honda et al, Thompson, 2016)


Left Shift Cont.

(Honda et al, Thompson, 2016)


Platelet Terminology and Interpretation

• Low: Thrombocytopenia – Causes: Bone marrow issues, Drug induced,

chemo, viral suppression, TTP, HUS, Cancer • High: Thrombocytosis (concerns for increased

risk for clotting) – Causes: Leukemia, inflammatory disease, acute

blood loss, IBD, Kawasaki, RA, Bacterial Disease

(Celkan, 2020), (Calihan, 2021)


Mean Platelet Volume

• MPV– Low: Average size of platelets are small. Can

indicate there is a condition affecting the production of platelets from bone marrow.

– High: High number of larger platelets. Younger ones. Can be due to bone marrow producing and releasing platelets rapidly.

(Calihan, 2021)


Pancytopenia

• All Three Cell Lines are low

• General originates from the bone marrow.

(Celkan, 2020)


IDENTIFYING THE BUG! BACTERIAL INFECTIONS


When treating bacterial infections:

● Choose the antibiotic with the narrowest spectrum that covers the pathogen

● Collect cultures prior to starting antibiotics ● If immunocompromised or critically ill, treat

broad for 1-3 days until pathogen is identified

● Always reassess your antibiotic choice and narrow when possible!

(Schleiss, 2016)


Bacterial Vs. Viral Infection Hints

• “Left shift” on CBC (high band neutrophils- immature cells)

• High inflammatory markers: CRP, ESR, Procalcitonin

• PCR-based diagnostic panels • Fever height

(Schleiss, 2016)


Bacteria Shorthand● Streptococcus pneumoniae- “pneumococcus”● Haemophilus influenza- “H. Flu”● MSSA- methicillin-sensitive staph aureus● MRSA- methicillin-resistant staph aureus● VRE- vancomycin-resistant enterococcus

(Gilbert, 2018)


Interpreting Culture Results

• Gram stain: positive versus negative• Preliminary or presumptive bacteria

identification• Sterile versus nonsterile culture sites• What cultures DON’T tell you:

– Presence of infection vs colonization vs contamination


Interpreting Culture Sensitivities


Gram Staining 4 categories:1. Gram + cocci

-Clusters: staphylococcus-Chains: enterococcus or streptococcus

2. Gram + rods (very uncommon!): -Clostridium

3. Gram – rods: -E. Coli, Klebsiella, Enterobacter,

pseudomonas4. Gram - cocci:

-Neisseria, Moraxella(Burnham & Storch, 2016)


Some bacteria do not fall into a category, because of variable shape: coccobacilli

○ Gram + coccobacilli: listeria○ Gram - coccobacilli: H. Flu,

Bordetella, legionella

(Burnham & Storch, 2016)

www.akronchildrens.org/giving(Giuliano et al., 2019)


Bacteria Classification

Classified by:● Bacteria Morphology: cocci, rod/bacilli,

coccobacilli● Gram Stain: positive, negative, or variable● Antibiotic Resistance: MSSA vs. MRSA● Oxygen Requirement: Aerobic or Anaerobic

(Strong, 2013) (Upinder, 2018)


Hints from Preliminary Report● Gram + Cocci in clusters: Staphylococcus● Gram + Cocci in pairs and chains:

Streptococcus or Enterococcus● Gram + diplococci: Streptococcus

pneumoniae● Gram - coccobacilli: H. flu● Gram - rods, lactose fermenting: E. coli,

Klebsiella, Enterobacter

(Burnham & Storch, 2016)


Sites of Infection by Bacteria Type ● Gram + cocci

○ Skin, soft tissue, heart, lung, bone, joint, hardware, central lines

● Gram - rods○ Lung (CAP, HAP, VAP), abdominal organs, GU

system● Anaerobes

○ Lung abscess, oral cavity, abdominal organs● Atypicals

○ Lung (CAP)

(Burnham & Storch, 2016) (Strong, 2013)


Lungs:CAP >1 month: S. pneumo, H. flu, Mycoplasma, ChlamydiaAspiration PNA/Lung abscess: Anaerobes, Klebsiella, S. aureus, Streptococci

Musculoskeletal:Osteo: S. aureus, Group A StrepSeptic Arthritis: S. aureus, Streptococci, N. Gonorrhea

Skin:Cellulitis: Staph Aureus, GABHS

GU:UTI/Pyelonephritis: E. coli, Proteus, Klebsiella, enterococcus, EnterobacterGenital: N. gonorrhea, Chlamydia, Enteric GNR

GI:Bacterial Gastro: E. coli, Shigella, Salmonella, CampylobacterColitis: C. difficile

ENT:Otitis media- S. pneumo, H. flu, MoraxellaSinusitis- S. pneumo, H. flu, Moraxella

Meningitis: <1 month- Group B Strep, Listeria, GNR>1 month- Strep. Pneumonia, N. Meningitidis, HIB

(Schleiss, 2013)


Antibiotic Therapy Considerations


Beta-Lactams

○ Penicillin○ Cephalosporins (5 generations) ○ Carbapenems

(Calihan, 2021)


Penicillins

● Examples: Penicillin, Ampicillin, Amoxicillin

)

Gram + Gram -Strep, Staph, listeria E.coli, H. Influenzae,

Neisseria

(Calihan, 2021)


Penicillins

Can be combined with Beta-Lactamase Inhibitor to give broader spectrum of coverage against beta-lactamase producing organisms

○ Amoxicillin/Clavulanate (Augmentin) ○ Ampicillin/Sulbactam (Unasyn)○ Piperacillin/Tazobactam (Zosyn)

(Calihan, 2021)


Penicillin Resistance

• S. Pneumoniae have intermediate to high resistance to penicillin antibiotics.

• High Dose (80-90 mg/kg/day) amoxicillin helps overcome this resistance

(Calihan, 2021)


Cephalosporins

● 5 generations. Treats a wide range of infections.

● Gram-negative coverage improves with each generation.

● Does not cover LAME (Listeria, Atypicals, MRSA and Enterococci)

(Calihan, 2021)


First Generation

• Examples: (Cefazolin,Cephalexin)

Gram + Gram –Most Streptococci and staphylococci

proteus mirabilisE coliKlebsiella

(Calihan, 2021)


Second Generation

• Example: Cefuroxime

Gram + Gram -

Same as 1st Generation Same as 1st generation plusH. influenza, Enterobacter aerogenes, Neisseria species, and Serratia marcescens

(Calihan, 2021)


Third Generation

• Example: Ceftriaxone, Cefotaxime

Gram + Gram -S. Pnumoniae (majority) S. pyogenes, Viridansstreptococcus

E.coli, H. Influenzae, Klebsiella, M. catarrhalis, Proteus, Neisseria

(Calihan, 2021)


Fourth Generation

• Example: Cefepime

Gram + Gram -Same as third generation plus MSSA

Same as third generation plus Pseudomonas aeruginosa.

(Calihan, 2021)


Fifth Generation

• Example: Ceftaroline

Gram + Gram -Same as third generation plus MRSA

Enteric gm negative rods

(Calihan, 2021)


Carbapenem

• Example: Meropenem, Imipenem

Gram + Gram -MSSA, S pneumonia, S. pyogens, S. agalactiae, Enterococcus

Pseudomonas, Acinetobacter, Serratia, Klebsiella, E. coli

(Calihan, 2021)


Vancomycin

Gm + Gm-Streptococci, staphylococciEnterococci

(Calihan, 2021)


Macrolides

● Example: Erythromycin, Azithromycin

AtypicalsMycoplasma, Chlamydia, H. Flu,

and Legionella

(Calihan, 2021)


Anaerobic Coverage

● Example: Clindamycin

Gm + Gm -Staphylococcus aureusStreptococcus pneumoniaStaphylococcus eidermis

(Calihan, 2021)


Anaerobic Coverage

● Example: Metronidazole

Gm + Gm -Clostridium Bacterioides

FusobacteriumH Pylori

(Calihan, 2021)


Case

K.D is a 2 year old with no significant past medical history brought to the ED for fever and poor po intake.

Per mother, patient developed a fever 4 days prior to admission. 2 days prior to admission, she was noted to have decreased PO intake and decreased wet diapers. On day of admission, she started vomiting and was unable to hold fluids down. Mother then brought to the ED for further evaluation.


In the ED, K.D was febrile to 39.5 C, tachycardic to 170 bpm, stable room air, no respiratory symptoms, minimal interest in PO, 2 wet diapers in last 12 hours.

Lab work obtained: CBC, BMP, CRP and UA with Culture.


• Urine Culture Pending • UA:


You are the hospital medicine provider seeing the patient on arrival to the floor.

What antibiotic do you start?


Lungs:CAP >1 month: S. pneumo, H. flu, Mycoplasma, ChlamydiaAspiration PNA/Lung abscess: Anaerobes, Klebsiella, S. aureus, Streptococci

Musculoskeletal:Osteo: S. aureus, Group A StrepSeptic Arthritis: S. aureus, Streptococci, N. Gonorrhea

Skin:Cellulitis: Staph Aureus, GABHS

GU:UTI/Pyelonephritis: E. coli, Proteus, Klebsiella, enterococcus, EnterobacterGenital: N. gonorrhea, Chlamydia, Enteric GNR

GI:Bacterial Gastro: E. coli, Shigella, Salmonella, CampylobacterColitis: C. difficile

ENT:Otitis media- S. pneumo, H. flu, MoraxellaSinusitis- S. pneumo, H. flu, Moraxella

Meningitis: <1 month- Group B Strep, Listeria, GNR>1 month- Strep. Pneumonia, N. Meningitidis, HIB

(Schleiss, 2013)


Third Generation

• Example: Ceftriaxone, Cefotaxime

Gram + Gram -S. Pnumoniae (majority) S. pyogenes, Viridansstreptococcus

E.coli, H. Influenzae, Klebsiella, M. catarrhalis, Proteus, Neisseria

(Calihan, 2021)


In the next 24 hours, gram stain results: gram negative rod and patient’s fever

curve improving. What to do with current antibiotic

therapy?


24 hours later, Urine culture results: >100,000 CFU E. Coli. Sensitive to all

cephalosporins, resistant to ampicillin and Bactrim.

Which antibiotic do you narrow coverage to?


References

Calihan, J. (2021). Hematology. In K. Kleinman, L. McDaniel & M. Molloy, The Harriet Lane Handbook (22nd ed., pp. 328-367). Philadelphia: Elsevier.

Calihan, J. (2021). Hematology. In K. Klembczyk, & S. McAleese, The Harriet Lane Handbook (22nd ed., pp. 408-446). Philadelphia: Elsevier.

Celkan TT. What does a hemogram say to us? Turk Pediatri Ars. 2020 Jun 19;55(2):103-116.

Doig, K., & Thompson, L. (2017). A Methodical Approach to Interpreting the White Blood Cell Parameters of the Complete Blood Count. American Society For Clinical Laboratory Science, 30 (3), 186-193.

Doig, K., & Zhang, B. (2017). A Methodical Approach to Interpreting the Red Blood Cell Parameters of the Complete Blood Count. American Society For Clinical Laboratory Science, 30(3), 173-185.


Freeman, J., Roberts, S. (2020). Approach to gram stain and culture results in the microbiology laboratory. In: UpToDate. (Accessed on October

01, 2020). Gilbert, D. (2018). Sanford guide to antimicrobial therapy. New York: McGraw

Hill. Honda, T., Uehara, T., Matsumoto, G., Arai, S., & Sugano, M., (2016).

neutrophil left shift and white blood cell count as markers of bacterial infection. Clinica Chimica Acta. 46-53.

Schleiss, M. (2016). Principles of antibacterial therapy. In R. M. Kliegman (Ed.), Nelson textbook of pediatrics 20th edition (1298-1315). Philadelphia, PA: Elsevier.

Strong, E. [Strong Medicine]. (2013, January 5). Eric Strong of Stanford Antibiotic Lecture Series [Video file]. Retrieved from https://www.youtube.com/watch?v=OOGGM6mxjY0

H. Barrett Fromme, MD, MHPE, FAAP , is a Professor of Pediatrics and a pediatric hospitalist at the University of Chicago, Pritzker School of Medicine, where she is the Associate Dean for Faculty Development in Medical Education and Section Chief of Pediatric Hospital Medicine. She is also well known to us as the Chair of theAAP Section on Hospital Medicine.

AAP SOHM Subcommittee for Advanced Practice Providers

ChairLeah Rawdon DNP, APRN, [email protected]

Vice ChairRebecca Carlson MAN, APRN, [email protected]

Vice ChairJodi Lohrey MSN, APRN, [email protected]




AAP SOHM Subcommittee for APPs

The goals of this subcommittee are:

● ·To be a resource for hospitalist APPs● ·To help advance the scope of practice for hospitalist APPs● ·Act as a resource for hospitals looking to add APPs to their hospitalist

services● ·Contribute to research in pediatric hospital medicine● ·Offer mentorship opportunities for new APP hospitalists or new APP

hospitalist programs● ·Utilize the subcommittees’ listserv to provide a structured environment for

communication in sharing best practices

AAP SOHM Subcommittee for APPs Activities:

● Quarterly Microsoft Teams calls● Participate in listserv discussions● Promote educational discussions

○ Twitter account @appjournalclub● Promote research in PHM and the role of APPs● Be on the lookout for a survey specific to APPs coming out in early November

○ Sent out through both listservs● Hopeful for pre -conference at PHM 2021

How you can join:

Go to https://shop.aap.org/aap -membership/ and choose Nurse Practitioner/PA membership

Questions contact: [email protected]

https://shop.aap.org/aap-membership/

Obtaining continuing education creditClaim Credit:

1. Log on to http://transcript.aap.org with your AAP Username and Password

a. Note: If you are already logged into PediaLink (www.pedialink.org) , click on the Continuing Education tab then the CME Transcript button to access the transcript site and continue to step 2.

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