Emergency Department Management of Bronchiolitis in the United States

Gong, Constance; Byczkowski, Terri; McAneney, Constance; Goyal, Monika K.; Florin, Todd A.

doi:10.1097/pec.0000000000001145

Cited by 19 publications

(11 citation statements)

References 41 publications

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“…23 The factors that may have contributed to this wide range include 1 US study published before the US guidelines 32 and 2 studies from general EDs, where the rate of bronchiolitis interventions is higher. 16,22 Other publications represented collaborative efforts with focused resource-reducing interventions implemented by physicians trained in pediatric emergency medicine, which yielded low antibiotic use. 36 Our results reveal that the international rate of antibiotic administration is low and close to the published achievable benchmarks of care.…”

Section: Discussionmentioning

confidence: 99%

“…Furthermore, the use of these varies considerably among countries and institutions. [15][16][17][18] Infants with bronchiolitis are at low risk of serious bacterial infections, [19][20][21] and experts discourage routine laboratory testing and antibiotic use unless bacterial infections are suspected. 1,[6][7][8][9][10][11][12][13][14] Although the use of these interventions remains common, 22,23 our knowledge about their use has been derived primarily from studies of hospitalized patients.…”

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confidence: 99%

“…1,[6][7][8][9][10][11][12][13][14] Although the use of these interventions remains common, 22,23 our knowledge about their use has been derived primarily from studies of hospitalized patients. [24][25][26][27][28][29][30][31] Studies of ED patients are sparse, precede publication of recent bronchiolitis guidelines, 32,33 adopt single-center design, 34,35 are restricted geographically to a single region or country, 16,22,25,36 and most have not explored the association between intervention-and patient-level factors.…”

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confidence: 99%

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International Practice Patterns of Antibiotic Therapy and Laboratory Testing in Bronchiolitis

Zipursky¹,

Kuppermann

Finkelstein

et al. 2020

Pediatrics

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BACKGROUND AND OBJECTIVES: International patterns of antibiotic use and laboratory testing in bronchiolitis in emergency departments are unknown. Our objective is to evaluate variation in the use of antibiotics and nonindicated tests in infants with bronchiolitis in 38 emergency departments in Pediatric Emergency Research Networks in Canada, the United States, Australia and New Zealand, the United Kingdom and Ireland, and Spain and Portugal. We hypothesized there would be significant variation, adjusted for patient characteristics. METHODS:We analyzed a retrospective cohort study of previously healthy infants aged 2 to 12 months with bronchiolitis. Variables examined included network, poor feeding, dehydration, nasal flaring, chest retractions, apnea, saturation, respiratory rate, fever, and suspected bacterial infection. Outcomes included systemic antibiotic administration and urine, blood, or viral testing or chest radiography (CXR).RESULTS: In total, 180 of 2359 (7.6%) infants received antibiotics, ranging from 3.5% in the United Kingdom and Ireland to 11.1% in the United States. CXR (adjusted odds ratio [aOR] 2.3; 95% confidence interval 1.6-3.2), apnea (aOR 2.2; 1.1-3.5), and fever (aOR 2.4; 1.7-3.4) were associated with antibiotic use, which did not vary across networks (P = .15). In total, 768 of 2359 infants (32.6%) had $1 nonindicated test, ranging from 12.7% in the United Kingdom and Ireland to 50% in Spain and Portugal. Compared to the United Kingdom and Ireland, the aOR (confidence interval) results for testing were Canada 5.75 (2.24-14.76), United States 4.14 (1.70-10.10), Australia and New Zealand 2.25 (0.86-5.74), and Spain and Portugal 3.96 (0.96-16.36). Testing varied across networks (P , .0001) and was associated with suspected bacterial infections (aOR 2.12; 1.30-2.39) and most respiratory distress parameters. Viral testing (591 of 768 [77%]) and CXR (507 of 768 [66%]) were obtained most frequently.

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Section: Discussionmentioning

confidence: 99%

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confidence: 99%

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confidence: 99%

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International Practice Patterns of Antibiotic Therapy and Laboratory Testing in Bronchiolitis

Zipursky¹,

Kuppermann

Finkelstein

et al. 2020

Pediatrics

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“…Studies to assess clinical practices in emergency departments for the management of bronchiolitis revealed practices inconsistent with national guidelines. 14,[21][22][23] Similar to inpatient studies, local implementation of guidelines in an emergency department can be successful and reduce health costs. 14 Other challenges encountered in emergency departments are parental pressure and high patient volumes that lead to inappropriate antibiotic prescription.…”

Section: Discussionmentioning

confidence: 99%

Antibiotic Use for Inpatient Bronchiolitis: Did National Guidelines Impact Practice at a Pediatric Hospital?

Lopez¹,

Aslanova

Bridger

et al. 2020

Hospital Pediatrics

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BACKGROUND AND OBJECTIVES: Bronchiolitis is a common lower respiratory tract infection that affects infants and young children. Because of variability in physician practice, inpatient management varies among pediatricians. In 2014, the Canadian Pediatric Society published national guidelines aimed at standardizing the inpatient management of this illness, which included recommending against the need for antibiotics for most patients. The study objective was to evaluate antibiotic prescription and supportive investigations for inpatient management of bronchiolitis before and after the publication of national guidelines. METHODS: This study was a single-center retrospective chart review of inpatients with bronchiolitis. We included healthy children 1 to 24 months of age who were admitted from November 2011 to October 2016. Those admitted before December 2014 were analyzed in the preguidelines cohort; the remaining, in the postguidelines cohort. The main outcome was antibiotic prescription. The secondary outcome was the frequency of chest radiographs, nasopharyngeal swabs, and blood cultures. RESULTS: A total of 131 patients were included in the first cohort; 71, in the second cohort. The rates of antibiotic initiation were almost equal in both cohorts (∼44%; P 5 .98). More antibiotics were discontinued during hospitalization in the second cohort compared with the first cohort (10% vs 20%; P 5 .001). Significantly fewer patients were discharged with antibiotics in the second cohort (31% vs 16%; P 5 .02). CONCLUSIONS: Our study revealed a reduction in antibiotic use after the release of national guidelines, illustrating that antibiotic prescribing practices can change. However, there is still a pressing need for local initiatives to continue to reduce the unnecessary use of antibiotics within the pediatric setting.

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“…No drug therapy has proven effective for this disease; bronchiolitis practice guidelines advocate for the use of supportive measures only, and discourage routine use of pharmacotherapy and investigations [ 1 , 3 – 10 ]. Nonetheless, the use of unnecessary interventions in bronchiolitis is common globally [ 11 – 13 ].…”

Section: Introductionmentioning

confidence: 99%

Healthcare cost attributable to bronchiolitis: A population-based cohort study

Sander

Finkelstein

et al. 2021

PLoS ONE

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Objective To determine 1-year attributable healthcare costs of bronchiolitis. Methods Using a population-based matched cohort and incidence-based cost analysis approach, we identified infants <12 months old diagnosed in an emergency department (ED) or hospitalized with bronchiolitis between April 1, 2003 and March 31, 2014. We propensity-score matched infants with and without bronchiolitis on sex, age, income quintile, rurality, co-morbidities, gestational weeks, small-for-gestational-age status and pre-index healthcare cost deciles. We calculated mean attributable 1-year costs using a generalized estimating equation model and stratified costs by age, sex, income quintile, rurality, co-morbidities and prematurity. Results We identified 58,375 infants with bronchiolitis (mean age 154±95 days, 61.3% males, 4.2% with comorbidities). Total 1-year mean bronchiolitis-attributable costs were $4,313 per patient (95%CI: $4,148–4,477), with $2,847 (95%CI: $2,712–2,982) spent on hospitalizations, $610 (95%CI: $594–627) on physician services, $562 (95%CI: $556–567)] on ED visits, $259 (95%CI: $222–297) on other healthcare costs and $35 ($27–42) on drugs. Attributable bronchiolitis costs were $2,765 (95%CI: $2735–2,794) vs $111 (95%CI: $102–121) in the initial 10 days post index date, $4,695 (95%CI: $4,589–4,800) vs $910 (95%CI: $847–973) in the initial 180 days and $1,158 (95%CI: $1,104–1213) vs $639 (95%CI: $599–679) during days 181–360. Mean 1-year bronchiolitis costs were higher in infants <3 months old [$5,536 (95%CI: $5,216–5,856)], those with co-morbidities [$17,530 (95%CI: $14,683–20,377)] and with low birthweight [$5,509 (95%CI: $4,927–6,091)]. Conclusions Compared to no bronchiolitis, bronchiolitis incurs five-time and two-time higher healthcare costs within the initial and subsequent six-months, respectively. Most expenses occur in the initial 10 days and relate to hospitalization.

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Emergency Department Management of Bronchiolitis in the United States

Cited by 19 publications

References 41 publications

International Practice Patterns of Antibiotic Therapy and Laboratory Testing in Bronchiolitis

International Practice Patterns of Antibiotic Therapy and Laboratory Testing in Bronchiolitis

Antibiotic Use for Inpatient Bronchiolitis: Did National Guidelines Impact Practice at a Pediatric Hospital?

Healthcare cost attributable to bronchiolitis: A population-based cohort study

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