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Abstract

  1. Top of page
  2. AbstractResumen: Manejo en el Servicio de Urgencias de la Neumonía Pediátrica en Estados Unidos Previamente a la Publicación de las Guías Clínicas Nacionales
  3. Methods
  4. Results
  5. Discussion
  6. Limitations
  7. Conclusions
  8. References

Background

Recent publication of national guidelines by the Pediatric Infectious Diseases Society (PIDS) and the Infectious Diseases Society of America (IDSA) provide recommendations around diagnostic testing and antibiotic treatment for children with community-acquired pneumonia (CAP). These guidelines emphasize limited use of chest radiograph (CXR) and complete blood count (CBC) and routinely performing viral testing and use of narrow-spectrum antibiotics.

Objectives

The objective was to estimate the rate of emergency department (ED) visits for pediatric CAP in the United States and to describe management of patients prior to publication of consensus national guidelines.

Methods

Data were obtained from the National Hospital Ambulatory Medical Care Survey (NHAMCS) for ED visits from 2001 through 2009 for children with CAP.

Results

During the study period there were an estimated 375,000 ED visits for CAP annually; 85% occurred within a general, rather than pediatric, ED. Overall, 20% of children with CAP were hospitalized. Among children discharged from EDs with CAP, CBC was performed during 30% of visits, CXR during 83%, and viral testing in only 13%. Twelve percent of children discharged from EDs with CAP had blood cultures obtained. No major differences were observed in the rates of laboratory testing or antibiotic administration between children treated in general versus pediatric EDs. During the study period, only 21% of children discharged from EDs with CAP received amoxicillin, the guideline-recommended antibiotic.

Conclusions

Most ED visits for CAP in the United States occur in general EDs. To encourage care that is consistent with national guidelines, efforts should be made to reduce the performance of certain diagnostic testing, such as CBC and CXR, among children discharged from EDs with CAP. Additionally, the use of narrow-spectrum antibiotics should be encouraged.

Resumen: Manejo en el Servicio de Urgencias de la Neumonía Pediátrica en Estados Unidos Previamente a la Publicación de las Guías Clínicas Nacionales

Introducción

La publicación reciente de las guías clínicas nacionales por la Pediatric Infectious Diseases Society y la Infectious Diseases Society of America proporciona recomendaciones sobre las pruebas diagnósticas y el tratamiento antibiótico para los niños con neumonía adquirida en la comunidad (NAC). Estas guías clínicas enfatizan el uso limitado de radiografía de tórax (RXT) y el hemograma, la realización de rutina del diagnóstico viral y el uso de antibióticos de amplio espectro.

Objetivos

El objetivo fue estimar el porcentaje de visitas al servicio de urgencias (SU) por NAC pediátrica en Estados Unidos y describir el manejo de los pacientes previamente a la publicación de las guías clínicas nacionales de consenso.

Metodología

Los datos se obtuvieron de la National Hospital Ambulatory Medical Care Survey (NHAMCS) para las visitas de niños con NAC al SU de 2001 hasta 2009.

Resultados

Durante el periodo del estudio hubo una estimación de 375.000 visitas al año al SU por NAC. De ellas, el 85% ocurrieron en un SU general en vez de pediátrico. Del total, el 20% de los niños con NAC fueron hospitalizados. De los niños dados de alta de un SU con NAC, se realizó un hemograma en el 30% de las visitas, una RXT en el 83% y un diagnóstico viral en sólo el 13%. Se obtuvo un hemocultivo en el 12% de los niños dados de alta de un SU con NAC. No se observaron grandes diferencias en los porcentajes de las pruebas de laboratorio o en la administración de antibiótico entre los niños tratados en un SU general frente al pediátrico. Durante el periodo del estudio, sólo el 21% de los niños dados de alta desde el SU con NAC recibieron amoxicilina, el antibiótico recomendado por las guías clínicas.

Conclusiones

La mayoría de las visitas al SU por NAC en Estados Unidos ocurren en SU generales. Con el fin de promocionar que la atención sea adecuada con las guías clínicas nacionales, se deberían realizar esfuerzos para reducir la realización de ciertas pruebas diagnósticas, como el hemograma y la RXT entre los niños dados de alta del SU con NAC. Además, el uso de antibióticos de amplio espectro debería ser promovido.

There is substantial variation in use of diagnostic testing and antibiotic selection for children with community-acquired pneumonia (CAP).[1-4] The Pediatric Infectious Diseases Society (PIDS) and the Infectious Diseases Society of America (IDSA) developed consensus guidelines in 2011 for the clinical management of pediatric CAP.[1] These guidelines have been endorsed by multiple national organizations, such as the American College of Emergency Physicians and the American Academy of Pediatrics. An important goal of these guidelines is to encourage appropriate diagnostic testing and reduce unnecessary use of broad-spectrum antibiotics for children with CAP.1

The 2011 PIDS/IDSA guidelines recommend against routinely performing laboratory and radiographic investigations for children with CAP in ambulatory care settings and to reserve most diagnostic testing for children with moderate or severe disease, including those children requiring hospitalization. Additionally, the guidelines recommend treatment with narrow-spectrum antibiotics, such as penicillin and aminopenicillins, for most fully immunized children with CAP.

Although studies have demonstrated differences in management for various conditions between children cared for within pediatric versus general emergency departments (EDs),[5-7] to the best of our knowledge, no studies have investigated differences in management for children with CAP. Large national databases, such as the National Hospital Ambulatory Medical Care Survey (NHAMCS), have been used to conduct epidemiologic studies of CAP[8] and as a tool to benchmark ED care.[9-11] Using this nationally representative database of ED visits, we sought to: 1) evaluate care patterns for children with CAP relative to nationally published guidelines and 2) compare testing and treatment patterns between pediatric and general EDs.

Methods

  1. Top of page
  2. AbstractResumen: Manejo en el Servicio de Urgencias de la Neumonía Pediátrica en Estados Unidos Previamente a la Publicación de las Guías Clínicas Nacionales
  3. Methods
  4. Results
  5. Discussion
  6. Limitations
  7. Conclusions
  8. References

Study Design

This was an analysis of data collected through the 2001 through 2009 NHAMCS. In accordance with the Common Rule (45 CFR 46.102(f)) and the policies of the Cincinnati Children's Hospital Medical Center Institutional Review Board, this research, using a deidentified, publically available data set, was not considered human subjects research.

Study Setting and Population

Annual data from the 2001 through 2009 NHAMCS were used to generate national estimates of ED visits for children with CAP. Patients aged 1 to 18 years with CAP were identified using a previously validated International Classification of Disease, Ninth Revision, Clinical Modification (ICD-9-CM) coding algorithm.[12, 13] Children were defined as having CAP if they had a primary ICD-9-CM diagnosis of pneumonia (480–483 and 485–486) or a primary diagnosis of a pneumonia-related symptom such as fever or cough (780.6, 786.0, 786.2–5, 786.7) and a secondary ICD-9-CM diagnosis of pneumonia, empyema (510), or pleurisy (511.0–1 and 511.9). Children less than 1 year of age were excluded because of their high rate of viral respiratory infections that are difficult to distinguish clinically from bacterial pneumonia. Patients with chronic or immunocompromising conditions (e.g., malignancies) were excluded from all analyses using previously defined ICD-9-CM codes.[12, 14] To ensure that antibiotics had been prescribed for pneumonia and not for other concurrent infections, patients with concurrent bacterial infections (e.g., meningitis, urinary tract infection) were excluded from analyses of antibiotic selection using previously defined ICD-9-CM codes.[12, 14]

Study Protocol

The NHAMCS is a four-stage probability sample of visits to noninstitutional general and short-stay hospitals in the United States, excluding federal, military, and Veterans Affairs hospitals. The NHAMCS is conducted annually by the Division of Health Care Statistics of the National Center for Health Statistics (NCHS), Centers for Disease Control and Prevention. The NCHS administers the NHAMCS after sampling geographic primary sampling units, hospitals within primary sampling units, EDs within hospitals, and patients within EDs. This multistage probability sampling procedure ensures that data collected in the NHAMCS are nationally representative. Hospital staff collect data during a randomly assigned 4-week data period for each of the sampled hospitals, during each year of the study period. Information collected in the survey pertains to procedures performed, medications prescribed, tests ordered, and diagnoses assigned. When the data collection forms are completed, they are sent to the NCHS where each visit is assigned up to three ICD-9-CM diagnosis codes.

We obtained demographic information such as age, year of visit, sex, race/ethnicity, insurance type, and U.S. census region in which the ED is located. Mode of arrival and ED disposition (discharged versus hospitalized) were recorded. Hospitalized patients included those who were admitted to the hospital, intensive care unit, or observation unit and those children transferred to another institution, or dead on arrival. Rates of laboratory and radiographic testing were also obtained. From 2005 through 2009, chest radiograph (CXR) was not distinguished from other radiographs, and we assumed that in patients with pneumonia, all radiographs were CXRs. EDs were classified based on the proportion of patients younger than 18 years of age seen at that facility. EDs in which ≥75% of patients evaluated were younger than 18 years of age were considered to be pediatric rather than general EDs.[5] Antibiotics were classified into the following categories: penicillin (including aminopenicillins), cephalosporins, macrolides, and other (including quinolones, lincomycin derivatives, sulfonamides, carbapenems, aminoglycosides, and tetracyclines). Percentages reflect use of specific antibiotics as a proportion of all visits in which antibiotics were prescribed. Percentages sum to ≥100% because of coprescribing at certain visits.

Our analyses focus on the group of patients discharged from the ED for two reasons: 1) there are a paucity of data regarding the management of children discharged from the ED with CAP relative to hospitalized patients, and 2) small sample size limits our ability to compare diagnostic testing and treatment patterns by ED type for hospitalized patients.

Data Analysis

The NHAMCS enables the derivation of nationally representative estimates for patient visit rates and care occurring during those visits. This is achieved through an estimation process that accounts for the four-stage sampling procedure. The estimation incorporates three steps, including inflation based on the sampling probabilities, nonresponse adjustment, and population weighting ratio adjustment.[15] We derived population-based visit rates for CAP by using year-specific census estimates. All estimates were based on more than 30 unweighted observations, unless otherwise specified. Comparisons were not made if there were fewer than 30 observations in any given cell, due to the instability of the estimates.15

Stata version 11.2 (StataCorp, College Station, TX) was used for analyses. Chi-square tests were used to examine whether there were differences in the baseline characteristics of our study sample based on whether the patient had been seen in a pediatric or general ED. To determine whether specific antibiotic regimens or diagnostic tests were used more commonly in pediatric versus general EDs, we calculated the difference between the frequency of use in each setting and report 95% confidence intervals (CIs) for these differences. All p-values are two-tailed and statistical significance was defined by a p-value less than 0.05. We utilized the svy function of Stata to account for the complex survey design. After adjusting for the United States resident population,[16] a linear test for trend was used to assess time trends in the visit rate for CAP.

Results

  1. Top of page
  2. AbstractResumen: Manejo en el Servicio de Urgencias de la Neumonía Pediátrica en Estados Unidos Previamente a la Publicación de las Guías Clínicas Nacionales
  3. Methods
  4. Results
  5. Discussion
  6. Limitations
  7. Conclusions
  8. References

Over the study period, an estimated 375,000 CAP visits occurred annually in the United States, with 85% of patients evaluated in a general ED and 15% in a pediatric ED setting (Table 1). The national visit rate for CAP per 1000 population was 5.1 in all EDs, 4.3 in general EDs, and 0.8 in pediatric EDs. There was no time trend in the population-adjusted rate of visits in all EDs (p for trend = 0.53), general EDs (p for trend = 0.46), or pediatric EDs (p for trend = 0.99; Figure 1). Patients presenting to pediatric EDs versus general EDs did not differ with respect to age group, sex, race/ethnicity, or insurance type. Most visits occurred in the South U.S. Census region, although the geographic distribution of visits did not vary by ED type (general versus pediatric ED). Overall, 20% of children with CAP were hospitalized.

Table 1. Characteristics of Visits for Pneumonia in Children 1 to 18 Years Old, 2001 Through 2009 (N = 1,017)
CharacteristicWeighted Percentage of Visits in Which CAP Was Diagnosed
All EDsPediatric EDGeneral EDp-valuea
  1. a

    p value reflects the results from a chi-square test for a difference across ED settings (pediatric ED versus adult ED).

  2. b

    Data for mode of arrival were available for 2003 through 2009 only.

  3. c

    Includes patients admitted to the hospital, as well as those admitted to an observation unit.

  4. d

    Triage acuity was defined as the “immediacy with which the patient should be seen,” where 1 = immediate; 2 = 1 to 14 minutes; 3 = 15 to 60 minutes; 4 = >1 to 2 hours; 5 = >2 to 24 hours. Mean triage scores were calculated for 2004 through 2008 only, because other survey years did not include a definition of triage acuity that was consistent with the definition used from 2004 through 2008. A t-test was used to test for a difference between weighted means calculated for pediatric and general EDs.

  5. CAP = community-acquired pneumonia; SCHIP = State Children's Health Insurance Program.

ED type
 Pediatric15N/AN/A 
 General85N/AN/A
Age (years)0.82
 1–4616062 
 5–10222522
 11–18161616
Sex0.19
 Female465345 
 Male544755
Race/ethnicity0.14
 White, non-Hispanic483750 
 Black, non-Hispanic242923
 Hispanic243223
 Other434
Insurance status0.15
 Private395037 
 Public (Medicaid/Medicare/SCHIP)504251
 Self-Pay/other11812
U.S. census region0.19
 Northeast17919 
 Midwest233521
 South404638
 West201022
Mode of arrivalb0.50
 Ambulance575 
 Other959395
Disposition0.11
 Not admitted808879 
 Admittedc201221
 Mean (±SE) triage acuityd3.14 (±0.07)3.12 (±0.17)3.21 (±0.08)0.62
image

Figure 1. Mean annual visit rates for pneumonia by setting, 2001 through 2009. Error bars represent 95% CI.

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The rates of obtaining diagnostic testing for children discharged from EDs with CAP are shown in Table 2. Complete blood counts (CBCs) were obtained in 30% of children, with no difference observed based upon ED type. A blood culture was obtained in 12% of patients, and influenza testing was performed in 13% of patients discharged from an ED during influenza season (October–April during 2001 to 2008 and all months—spanning both seasonal and pandemic H1N1 influenza seasons—in 2009). Due to small sample size, we are unable to evaluate the associations between obtaining a blood culture and influenza testing and ED type, as blood culture was only listed on the NHAMCS survey for certain years of the study period, and the rate of influenza testing was low. Eighty-three percent of children diagnosed with pneumonia in the ED setting had CXRs performed, with no difference observed based upon ED type.

Table 2. Diagnostic Testing Performed Among Discharged Patients, Stratified by ED Setting
Diagnostic TestWeighted Percentage of Patients With CAP Who Received Testing (95% CI)
All EDsPediatric EDGeneral EDDifference
  1. a

    Data for blood culture were not available in 2005–2006.

  2. b

    From 2005 through 2009, CXR was not distinguished from other radiograph. We assumed that in patients with pneumonia, the radiograph obtained was a CXR.

  3. CBC = complete blood count; CXR = chest radiograph; NC = not calculable—estimates based on fewer than 30 observations are not reliable.

CBC30 (26 to 35)26 (14 to 43)31 (26 to 36)–5 (–21 to 10)
Blood culturea12 (8 to 16)15 (5 to 37)11 (8 to 15)NC
Influenza testing13 (8 to 21)23 (7 to 55)11 (7 to 18)NC
CXRb83 (78 to 86)70 (53 to 83)85 (81 to 88)–15 (–31 to 1)

Overall, 84% of children discharged from EDs with diagnosis of CAP were prescribed antimicrobials, with no difference observed based on ED type or age group (Table 3). Macrolides, either alone or in combination, were the most frequently prescribed antibiotic class, followed by cephalosporins and penicillins. No differences in prescribing patterns were observed based on ED type. Twenty-seven percent of discharged children cared for in pediatric EDs were prescribed amoxicillin, compared with 20% of children cared for in general EDs.

Table 3. Antibiotic Administration for Discharged Patients, Stratified by ED Setting
Patient Population/Antibiotic Weighted Percentage of Visits in Which Antibiotics Were Prescribed
All EDsPediatric EDGeneral EDDifference
  1. Values are reported as % (95% CI).

  2. a

    Percentages reflect use of specific antibiotics as a proportion of all visits in which antibiotics were prescribed. Percentages sum to >100% because of coprescribing at certain visits.

  3. NC = not calculable—estimates based on fewer than 30 observations are not reliable.

Frequency of antibiotic prescribinga84 (80 to 87)84 (70 to 92)84 (79 to 87)0 (–11 to 12)
Antibiotic selection (all ages)
 Penicillins21 (17 to 25)27 (16 to 40)19 (16 to 23)7 (–5 to 20)
 Cephalosporins36 (31 to 43)35 (22 to 51)37 (31 to 42)–1 (–17 to 15)
 Macrolides48 (42 to 53)36 (19 to 57)50 (45 to 55)–14 (–34 to 7)
 Single agent38 (33 to 43)32 (18 to 50)39 (35 to 45)–8 (–25 to 10)
 Combination therapy9 (6 to 13)4 (2 to 11)10 (7 to 15)NC
 Other antibiotics11 (8 to 14)9 (4 to 19)11 (8 to 14)NC

Overall, 85% of children 1 to 4 years of age discharged from an ED with CAP received an antibiotic, compared to 81% of children 5 to 18 years of age (Table 4). No differences were observed in the rates of prescribing of specific antibiotic classes between pediatric and general EDs. Cephalosporins were the most common antibiotic class administered or prescribed to children 1 to 4 years of age, and macrolides were the most common antibiotic class among older children discharged from the ED.

Table 4. Antibiotic Prescribing for Discharged Patients, Stratified by Age
VariableWeighted Percentage of Visits in Which Antibiotics Were Prescribeda
1 to 4 Years5 to 18 Years
  1. a

    No differences observed in the rates of prescribing specific antibiotics between pediatric and general EDs.

  2. b

    Percentages reflect use of specific antibiotics as a proportion of all visits in which antibiotics were prescribed. Percentages sum to >100% because of coprescribing at certain visits.

Frequency of antibiotic prescribing8581
Antibiotic selectionb
 Penicillins2711
 Cephalosporins4327
 Macrolides3764
 Single agent2953
 Combination therapy811
 Other antibiotics1012

Discussion

  1. Top of page
  2. AbstractResumen: Manejo en el Servicio de Urgencias de la Neumonía Pediátrica en Estados Unidos Previamente a la Publicación de las Guías Clínicas Nacionales
  3. Methods
  4. Results
  5. Discussion
  6. Limitations
  7. Conclusions
  8. References

This study provides national estimates of pediatric visits to EDs for CAP and analyses of diagnostic testing rates and antibiotic prescribing patterns prior to publication of consensus guidelines in 2011. We observed that 85% of CAP visits in the United States occur in general EDs, rather than pediatric ED settings, and that the rate of CAP ED visits has been stable, despite widespread pneumococcal immunization in children during this time period. We also observed that relative to recommendations from national guidelines, a large proportion of children discharged from EDs with CAP undergo CBC and CXR, and a small proportion of children are prescribed a narrow-spectrum antibiotic.

Recently published guidelines from the PIDS and IDSA in 2011 provide evidence-supported recommendations for diagnostic testing and treatment of children with CAP.[1] The guidelines address the management of CAP in both the inpatient and the outpatient settings, including children cared for in the ED setting, and include a systematic weighting of the quality of evidence supporting each recommendation, as well as the strength of the recommendation provided.

The consensus guidelines recommend that a blood culture should not be routinely performed in non–toxic-appearing, fully immunized children, but to reserve this testing for children who fail to improve on antibiotics.1 We observed that 12% of children discharged from EDs had this testing performed, which likely reflects a baseline level of care that is consistent with the national guidelines. Despite the recommendation not to routinely perform a CBC in outpatient settings unless there are signs of respiratory distress or severe disease, we observed that this test was performed in 30% of children discharged from EDs with CAP. Last, PIDS/IDSA guidelines recommend performing viral testing, as this may reduce unnecessary ancillary diagnostic studies and antibiotic use and may promote appropriate use of antiviral agents for influenza. Although the evidence supporting the recommendation is categorized as “strong,” and supported by high quality evidence, only 13% of patients discharged from EDs with CAP during influenza season had influenza testing performed.

Over 80% of children discharged from EDs with CAP had CXRs performed. This rate is quite high, considering the consensus guideline provides a “strong recommendation” that routine CXRs are not necessary for the confirmation of suspected CAP in patients well enough to be treated in the outpatient setting.1 The guidelines reserve the use of CXR for patients with hypoxemia or significant respiratory distress or those who have failed antibiotic therapy. The high rate of CXR use for children with pneumonia is consistent with findings from a previous national study of U.S. children's hospitals, although there was considerable variability in the rate of CXR use among institutions included in the study.[3] The reliance on CXR in the ED may reflect the challenges in establishing the diagnosis based on clinical and historical findings alone.[17, 18] The risk of radiation,[19] variability in interpretation of CXRs among radiologists for the diagnosis of pneumonia,[20] and inability to distinguish a viral from bacterial process based on CXR findings[21, 22] are factors that support the consensus guideline to avoid the use of CXR for outpatients with pneumonia. Additionally, other studies have found that CXR findings rarely change clinical management of children with pneumonia.[23, 24]

The 2011 consensus guidelines recommend that antimicrobial therapy is not routinely required for preschool-aged children with CAP because viral pathogens are responsible for the great majority of clinical disease.[1] We observed that 85% of children 1 to 4 years of age who were discharged from an ED were prescribed antimicrobial agents, a rate that was similar to that of older children in our study. The guidelines also recommend the use of a narrow-spectrum antibiotic, such as amoxicillin, as first-line therapy for previously healthy, immunized infants and preschool children with mild–moderate CAP, because Streptococcus pneumoniae is the most common bacterial cause.[1, 12] Although penicillin and aminopenicillins such as amoxicillin were used more often in younger children than older children, they were prescribed to only 27% of children in this age group. Broad-spectrum antibiotics, including cephalosporins, were predominantly used among children 1 to 4 years of age who were discharged from EDs with CAP. Two recent studies found that the use of a clinical practice guideline supported by an antibiotic stewardship program increased the use of narrow spectrum antibiotics, without an increase in adverse outcomes or treatment failures.[25, 26]

The 2011 consensus guidelines also strongly recommend the consideration of atypical bacterial pathogens (e.g., Mycoplasma pneumoniae) in management decisions.[1] The guidelines further recommend that macrolide antibiotics should be prescribed for preschool-aged children and adolescents evaluated in an outpatient setting with findings compatible with CAP caused by atypical pathogens.1 Although we are unable to determine whether atypical pneumonia was considered by clinicians, macrolide antibiotics such as azithromycin were used either alone or in combination in 37% of children 1 to 4 years of age and in 64% of older children. Although once-a-day dosing makes the use of azithromycin in children attractive for the treatment of pneumonia, the use of macrolides as a single agent is not recommended due to the escalating rate of resistance of S. pneumoniae to macrolide antibiotics.[27, 28]

Limitations

  1. Top of page
  2. AbstractResumen: Manejo en el Servicio de Urgencias de la Neumonía Pediátrica en Estados Unidos Previamente a la Publicación de las Guías Clínicas Nacionales
  3. Methods
  4. Results
  5. Discussion
  6. Limitations
  7. Conclusions
  8. References

The NHAMCS data only contain information about interventions that occurred in the ED. As a result, medical care that may have occurred before the ED visit, or after disposition for hospitalized patients, most likely will not be recorded (e.g., antibiotic use before ED visit). Although our characterization of pediatric versus general ED has been previously described,[7, 29, 30] we may be falsely characterizing a hospital as a general ED based upon proportion of children presenting to that ED even though they have services and physicians similar to a dedicated pediatric ED. Also, our study was limited to children in whom pneumonia was diagnosed and not the population of children at risk of pneumonia, such as children with cough or fever. Additionally, aside from hospitalization status, we did not account for illness severity and could not account for immunization status and comorbidities, which may influence decisions around disposition, diagnostic testing, and antibiotic administration. Also, we are unable to conduct a comparison between pediatric and general ED care for certain aspects of care due to sample size limitations. Last, a limitation of the retrospective study design is that data may be missed due to relying on documentation in, and retrieval from, medical records. Nevertheless, this combined database provides important information on outcomes that are known to be collected with accuracy (e.g., medication treatment and ED disposition).[31, 32]

Conclusions

  1. Top of page
  2. AbstractResumen: Manejo en el Servicio de Urgencias de la Neumonía Pediátrica en Estados Unidos Previamente a la Publicación de las Guías Clínicas Nacionales
  3. Methods
  4. Results
  5. Discussion
  6. Limitations
  7. Conclusions
  8. References

The publication of consensus guidelines in 2011 may help to reduce variation in diagnostic testing and treatment patterns for children with community-acquired pneumonia and reduce morbidity and mortality associated with this disease. Our study provides the national rates of community-acquired pneumonia visits in children, as well as the rates of diagnostic testing and antibiotic prescribing for children with community-acquired pneumonia prior to the publication of pediatric community-acquired pneumonia guidelines. Recent patterns of testing and antibiotic selection in EDs underscore the need for targeted initiatives to bring the management of community-acquired pneumonia into alignment with Pediatric Infectious Diseases Society/Infectious Diseases Society of America guidelines.

References

  1. Top of page
  2. AbstractResumen: Manejo en el Servicio de Urgencias de la Neumonía Pediátrica en Estados Unidos Previamente a la Publicación de las Guías Clínicas Nacionales
  3. Methods
  4. Results
  5. Discussion
  6. Limitations
  7. Conclusions
  8. References