“Diagnosing bacterial community-acquired pneumonia (CAP) among children who present with a lower respiratory tract infection (LRTI) is complicated, as there is no gold standard for how to define it,” Jillian Cotter, MD, MSCS, notes. “As a result, bacterial CAP is a diagnosis that is very susceptible to variability between providers and institutions, and we tend to overdiagnose it.”
Overdiagnosing bacterial CAP contributes to antibiotic overuse, which increases the risk for potential harms including side effects, adverse events such as anaphylaxis, and alterations to the gastrointestinal microbiome that have long-term implications—without benefit, Dr. Cotter continues. It also contributes to rising rates of antibiotic resistance, which is “a major public health threat.”
For a study published in the Journal of Hospital Medicine, Dr. Cotter and colleagues examined variations in the diagnosis and treatment of bacterial CAP in children hospitalized with LRTIs. The multicenter, cross-sectional study
included children with LRTIs admitted to 42 children’s hospitals between 2017 and 2019.
“After accounting for confounders, hospitals were categorized into high, moderate, and low CAP diagnosis groups,” Dr. Cotter explains. “We then looked at the association between high and low CAP diagnosis hospitals and outcomes.”
‘Lack of Meaningful Differences’ in Clinical Outcomes
Among 66,581 children hospitalized with LRTIs, most (67.3%) were aged less than 2, and 43.0% were White. “We reported substantial differences across hospitals in the proportion diagnosed with, and treated for, bacterial CAP (median, 27%; range, 12% to 42%),” Dr. Cotter notes. “This means that, at one hospital, a given patient with an LRTI is diagnosed with bacterial CAP only 12% of the time, but the chances of being diagnosed with—and treated with antibiotics for—bacterial CAP at another hospital is approximately four times higher.”
The researchers observed a “lack of meaningful differences” in clinical outcomes between hospitals with low versus high rates of bacterial CAP diagnoses. This indicates that “some institutions may overdiagnose and overtreat bacterial CAP,” Dr. Cotter says.
Furthermore, “a patient will not have improved outcomes at a hospital that diagnoses bacterial CAP
more frequently,” she continues. Compared with hospitals with low rates of CAP diagnoses, hospitals with high rates had greater rates of CAP-related revisits (0.6% vs 0.4%; P=0.04), chest radiographs (58% vs 46%; P=0.02), and blood tests (43% vs 26%; P=0.046). The researchers observed no significant differences in length of stay, all-cause revisits or readmissions, CAP-related readmissions, or costs (Table).
Improving Diagnosis & Treatment of Bacterial CAP
The variability from hospital to hospital indicates that provider-related and institutional factors are driving overdiagnosis and the related overuse of antibiotics, according to Dr. Cotter.
“At one hospital, a given patient may be diagnosed with a viral LRTI and receive no antibiotics, but at another hospital, a similar patient may be diagnosed with bacterial CAP and receive antibiotics,” she explains. “Our data suggest that these children will have similar outcomes, but the child who receives antibiotics is exposed to potential harms associated with antibiotic use.”
In addition, the results highlight opportunities for both diagnostic and antibiotic stewardship for this infection, Dr. Cotter notes. “Given increasing rates of antibiotic resistance, it is vital that we develop and institute evidenced-based
practices for the diagnosis and management of pediatric bacterial CAP.”
Future research should examine how clinicians at hospitals with high rates of bacterial CAP diagnoses evaluate, diagnose, and treat patients with LRTIs, as well as the differences between those settings and hospitals with low rates of such diagnoses, Dr. Cotter says.
“We need rigorous, large randomized controlled trials to identify children with bacterial CAP who need antibiotics and those with other LRTIs who do not,” she explains. “We also need a gold standard for defining bacterial pneumonia to improve both diagnostic and antibiotic stewardship.”
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