BackgroundBlood cultures are often recommended for the evaluation of community-acquired pneumonia (CAP). However, institutions vary in their use of blood cultures, and blood cultures have unclear utility in CAP management in hospitalized children.ObjectiveTo identify clinical factors associated with obtaining blood cultures in children hospitalized with CAP, and to estimate the association between blood culture obtainment and hospital length of stay (LOS).MethodsWe performed a multicenter retrospective cohort study of children admitted with a diagnosis of CAP to any of four pediatric hospitals in the United States from January 1, 2011-December 31, 2012. Demographics, medical history, diagnostic testing, and clinical outcomes were abstracted via manual chart review. Multivariable logistic regression evaluated patient and clinical factors for associations with obtaining blood cultures. Propensity score-matched Kaplan-Meier analysis compared patients with and without blood cultures for hospital LOS.ResultsSix hundred fourteen charts met inclusion criteria; 390 children had blood cultures obtained. Of children with blood cultures, six (1.5%) were positive for a pathogen and nine (2.3%) grew a contaminant. Factors associated with blood culture obtainment included presenting with symptoms of systemic inflammatory response syndrome (OR 1.78, 95% CI 1.10–2.89), receiving intravenous hydration (OR 3.94, 95% CI 3.22–4.83), receiving antibiotics before admission (OR 1.49, 95% CI 1.17–1.89), hospital admission from the ED (OR 1.65, 95% CI 1.05–2.60), and having health insurance (OR 0.42, 95% CI 0.30–0.60). In propensity score-matched analysis, patients with blood cultures had median 0.8 days longer LOS (2.0 vs 1.2 days, P < .0001) without increased odds of readmission (OR 0.94, 95% CI 0.45–1.97) or death (P = .25).ConclusionsObtaining blood cultures in children hospitalized with CAP rarely identifies a causative pathogen and is associated with increased LOS. Our results highlight the need to refine the role of obtaining blood cultures in children hospitalized with CAP.

Broad-spectrum antibiotic therapy for community-acquired pneumonia, especially third- and fourth-generation cephalosporins, often originates in the ED. When initiated in this setting, it is likely to be continued in the inpatient setting.

ILLUSTRATIVE CASE EIA is a recurring section of Hospital Pediatrics where expert pediatric hospitalists give their interpretation of the recent evidence in reference to common clinical questions encountered in their daily practice.Stevens-Johnson Syndrome, Mucositis, or Something Else?Stevens-Johnson syndrome (SJS) has been described in the literature as a combination of erythematous blistering skin lesions covering <10% of body surface area and ≥1 mucous membrane erosion.1 SJS is usually triggered by a medication or infection. Infectious causes are more common in children, most notably herpes simplex virus (HSV) and Mycoplasma pneumoniae. Mucous membrane erosions without signifi cant skin involvement have been classifi ed as "atypical SJS" and mucositis.2 Case: An 18-year-old high school senior presented to his physician with a 2-week history of sore throat and cough, 1-week history of fever, and 1-day history of swollen lips and mucosal ulcerations in his mouth accompanied by pain with swallowing. He was an otherwise healthy adolescent male, with the exception of a PICU admission for anaphylaxis without obvious trigger 8 years ago and attention-defi cit/hyperactivity disorder for which he is taking methylphenidate. The treating physician ordered a chest radiograph that demonstrated streaky infi ltrates in the right lower lobe and sent serology samples for Mycoplasma, immunoglobulin G (IgG) antibodies for HSV type 1 and 2, and HIV testing. The patient was started empirically on azithromycin and acyclovir, with lidocaine viscous for his mouth sores. The following day he developed conjunctival erythema, urethral ulceration, and continued to have poor oral intake; he was therefore admitted to the inpatient pediatric ward for intravenous hydration, pain control, and further observation. Question: Does this patient have SJS?Discussion: There is disagreement in the literature on the exact defi nition of SJS. As fi rst described by Stevens and Johnson in 1922, a patient must have a generalized skin eruption in conjunction with mucosal involvement to meet the defi nition.3 This patient never had a generalized skin eruption and therefore does not meet the classic criteria. He did, however, develop 1 targetoid lesion with a central blister on his glans penis, as well as meatal ulceration (Fig 1). In addition, the patient had bilateral nonexudative conjunctival erythema and oropharyngeal ulcerations seen externally on his lips (Fig 2).We characterized this illness as mucositis secondary to atypical pneumonia, not meeting the classic diagnosis of SJS due to lack of skin lesions. According to Schalock and Dinulos,4 patients with disease limited to the mucous membranes are not at risk for widespread skin involvement and often recover faster than children with skin involvement, making diagnosis important for prognosis. AUTHORS