OBJECTIVES: Procalcitonin (PCT) is a relatively novel biomarker that may be superior to C-reactive protein (CRP) in identifying bacterial infection. PCT use in pediatric hospitals is relatively unknown. We aimed to evaluate PCT and CRP use, describe PCT testing variability across children’s hospitals, and compare temporal rates of PCT and CRP testing for patients admitted with pneumonia, sepsis, or fever in young infants. METHODS: In this multicenter cohort study, we identified children ≤18 years old hospitalized from 2014–2018 with pneumonia, sepsis, or fever in infants <2 months by using the Pediatric Health Information System. To determine use, we evaluated the proportion of encounters with PCT or CRP testing from 2017-2018. We generated heat maps to describe PCT use across hospitals. We also compared PCT and CRP rates over time from 2014 to 2018. RESULTS: From 2017–2018, PCT testing occurred in 3988 of 34c231 (12%) hospitalizations. Febrile infants had the highest PCT testing proportion (18%), followed by sepsis (15%) and pneumonia (9%). There was across-hospital variability in PCT testing, particularly for febrile infants. Over time, the odds of PCT testing increased at a significantly greater rate than that of CRP. CONCLUSIONS: Despite limited guideline recommendations for PCT testing during the study period, PCT use increased over time with across-hospital variability. For pneumonia and sepsis, given the importance of high-value care, we need to understand the impact of PCT on patient outcomes. With recent guidelines recommending PCT in the evaluation of febrile infants, we identified baseline testing behaviors for future studies on guideline impact.
OBJECTIVES: There are no data to inform the ideal length of in-hospital observation after symptom improvement or to inform the ideal dexamethasone dose in critically ill children with croup. We describe a cohort of critically ill children with croup who rebound (have return of symptom(s) after meeting hospital discharge criteria) and examine the association between the cumulative dexamethasone dose before PICU discharge and both the odds and timing of rebound. METHODS: In this single-center retrospective cohort study of subjects 6 months to 13 years of age admitted to the PICU with a primary diagnosis of croup, we employed multivariable logistic regression to evaluate the association between cumulative pre-PICU discharge dexamethasone dose and rebound. In the model, we controlled for subject age and sex, insurance, season, and history of prematurity, croup, or intubation. Kaplan-Meier curves were used to compare time to rebound between subjects receiving ≤2 standard (0.6 mg/kg) doses and those receiving >2 standard doses of dexamethasone before PICU discharge. RESULTS: Data were analyzed over 69 months (January 2011–October 2016), and 275 unique subjects met inclusion criteria. The median cumulative dose of dexamethasone in the hospital was 1.57 mg/kg (interquartile range 0.98–2.63). Thirty-seven percent (n = 102) of subjects developed rebound croup symptoms after meeting hospital discharge criteria. The median time to rebound was 13.1 hours (interquartile range 6.1–23.7). There was no association between cumulative pre-PICU discharge dexamethasone dose and the odds (odds ratio = 1.00; 95% confidence interval 0.83–1.19; P = .96) or timing of rebound. CONCLUSIONS: A clinically significant number of critically ill patients with croup rebounded. Total pre-PICU discharge dexamethasone dose did not predict either the odds or timing of rebound.
OBJECTIVES: Evidence supports using dexamethasone for mild-to-moderate asthma exacerbations in the emergency department, but the effectiveness of dexamethasone versus prednisone for asthmatic patients who are hospitalized is unclear. Our aim was to compare outcomes for inpatients before and after our emergency department’s adoption of dexamethasone for the treatment of acute asthma exacerbations. METHODS: In this single-center retrospective cohort study, we employed interrupted time series analyses to control for secular trends while evaluating our outcomes of length of stay, total inflation-adjusted hospital charges, and ICU transfer rates for patients admitted with asthma. RESULTS: Data were analyzed over 36 months (January 2014–April 2017) and included 1015 subjects (606 in the preprotocol change [pre-PC] group and 409 in the postprotocol change [post-PC] group). In the pre-PC group, prednisone only was used in 96% of subjects. In the post-PC group, prednisone only was used in 7% of subjects, dexamethasone in 65% of subjects, and a combination of the 2 steroids in 28% of subjects. Controlling for other variables in the interrupted time series model, we found no significant immediate differences between the pre-PC and post-PC periods for the outcomes of length of stay (P = .68), total charges (P = .66), and ICU transfers (P = .98). The rate of ICU transfers was stable pre-PC and increased by 10% (95% confidence interval: 2%–19%) per month (odds ratio = 1.10; 95% confidence interval: 1.02–1.19; P = .02) in the post-PC period. CONCLUSIONS: After dexamethasone replaced prednisone as the most commonly prescribed steroid type for inpatients with asthma at our institution, we found no immediate changes in outcomes for asthmatic patients who were hospitalized but an upward trend in ICU transfers.