Prevalence of Bacteremia in Pediatric Patients With CAP
Prevalence of Bacteremia in Pediatric Patients With CAP
Background: National guidelines recommend obtaining blood cultures in children hospitalized with moderate or severe community-acquired pneumonia (CAP). The objectives of this study were to determine the prevalence of bacteremia in children, identify factors associated with bacteremia and quantify the influence of positive blood cultures on clinical management in children hospitalized with CAP.
Methods: This multicenter retrospective study included children from 60 days to 18 years of age requiring hospitalization for CAP. Categories analyzed were bacteremia, culture negative and no culture.
Results: Blood cultures were performed in 369 (56%) of 658 children with CAP. The prevalence of bacteremia was 7% (4.7–10.1%) in patients with a blood culture obtained. Bacteremia occurred in 21% of patients with a pleural drainage procedure and 75% of patients with distant site of infection (eg, osteomyelitis). Patients with bacteremia had longer duration of fever before admission and higher C-reactive protein values compared with those with negative or no blood culture. However, differences in white blood cell count and erythrocyte sedimentation rate between those with bacteremia and those without were not significant. Contamination rates were low and similar across institutions, ranging from 1% to 3.8% (P = 0.63). Blood culture–directed changes in antibiotic management occurred in 33% of patients with a contaminated culture and 65% of bacteremic patients. Antibiotic therapy was narrowed in 26% of bacteremic patients at hospital discharge.
Conclusion: The prevalence of bacteremia was higher than previously reported in children hospitalized with CAP and consistent across children's hospitals. Positive blood cultures should prompt change to narrow-spectrum antibiotic therapy
Blood cultures are often performed in the diagnostic evaluation of children hospitalized with community-acquired pneumonia (CAP). Recent clinical practice guidelines for the management of pediatric CAP recommend that blood cultures be performed routinely in children requiring hospitalization for moderate or severe CAP, but the quality of evidence supporting this recommendation is low.
Guidelines for adult patients also recommend obtaining a blood culture in patients hospitalized with CAP, and this recommendation has been cited as a quality indicator by The Joint Commission and the Centers for Medicare and Medicaid Services. Sandora et al reviewed the blood culture recommendations for adults and applied this recommendation in a hospitalized pediatric population with CAP, revealing a bacteremia rate of 1.4% and bringing into question the utility of obtaining a blood culture on a routine basis in this patient group. Most other studies have also reported a low prevalence of bacteremia among children hospitalized with uncomplicated CAP, with rates ranging from 1.1% to 2.7%.However, a single-center study of children in Utah documented a substantially higher prevalence of bacteremia (11.4%) in children with uncomplicated CAP.
The prevalence of bacteremia is higher in children with pneumonia complicated by effusion or empyema, ranging from 13% to 26%, and obtaining a blood culture in this setting has been shown to confirm a pathogen in 7–21% of patients with negative pleural fluid cultures. However, some of these data are in the prepneumococcal conjugate vaccine period and all were obtained from single-center studies. A multicentered study conducted in Italy revealed a pathogen by blood culture alone for 2 patients (4.3%), raising the possibility that blood culture may not provide added clinical data over molecular testing (eg, polymerase chain reaction for Streptococcus pneumoniae and Staphylococcus aureus) performed on blood and pleural fluid. Although children with complicated pneumonia have a higher rate of bacteremia, only 1 study to date has determined the impact of positive results on patient management.
The objectives of this study were to (1) determine the prevalence of documented bacteremia in children hospitalized with CAP across 4 children's hospitals, (2) determine differences in clinical characteristics and outcomes of patients with documented bacteremia compared with those without and (3) quantify the influence of positive and contaminated blood cultures on antibiotic management.
Abstract and Introduction
Abstract
Background: National guidelines recommend obtaining blood cultures in children hospitalized with moderate or severe community-acquired pneumonia (CAP). The objectives of this study were to determine the prevalence of bacteremia in children, identify factors associated with bacteremia and quantify the influence of positive blood cultures on clinical management in children hospitalized with CAP.
Methods: This multicenter retrospective study included children from 60 days to 18 years of age requiring hospitalization for CAP. Categories analyzed were bacteremia, culture negative and no culture.
Results: Blood cultures were performed in 369 (56%) of 658 children with CAP. The prevalence of bacteremia was 7% (4.7–10.1%) in patients with a blood culture obtained. Bacteremia occurred in 21% of patients with a pleural drainage procedure and 75% of patients with distant site of infection (eg, osteomyelitis). Patients with bacteremia had longer duration of fever before admission and higher C-reactive protein values compared with those with negative or no blood culture. However, differences in white blood cell count and erythrocyte sedimentation rate between those with bacteremia and those without were not significant. Contamination rates were low and similar across institutions, ranging from 1% to 3.8% (P = 0.63). Blood culture–directed changes in antibiotic management occurred in 33% of patients with a contaminated culture and 65% of bacteremic patients. Antibiotic therapy was narrowed in 26% of bacteremic patients at hospital discharge.
Conclusion: The prevalence of bacteremia was higher than previously reported in children hospitalized with CAP and consistent across children's hospitals. Positive blood cultures should prompt change to narrow-spectrum antibiotic therapy
Blood cultures are often performed in the diagnostic evaluation of children hospitalized with community-acquired pneumonia (CAP). Recent clinical practice guidelines for the management of pediatric CAP recommend that blood cultures be performed routinely in children requiring hospitalization for moderate or severe CAP, but the quality of evidence supporting this recommendation is low.
Introduction
Guidelines for adult patients also recommend obtaining a blood culture in patients hospitalized with CAP, and this recommendation has been cited as a quality indicator by The Joint Commission and the Centers for Medicare and Medicaid Services. Sandora et al reviewed the blood culture recommendations for adults and applied this recommendation in a hospitalized pediatric population with CAP, revealing a bacteremia rate of 1.4% and bringing into question the utility of obtaining a blood culture on a routine basis in this patient group. Most other studies have also reported a low prevalence of bacteremia among children hospitalized with uncomplicated CAP, with rates ranging from 1.1% to 2.7%.However, a single-center study of children in Utah documented a substantially higher prevalence of bacteremia (11.4%) in children with uncomplicated CAP.
The prevalence of bacteremia is higher in children with pneumonia complicated by effusion or empyema, ranging from 13% to 26%, and obtaining a blood culture in this setting has been shown to confirm a pathogen in 7–21% of patients with negative pleural fluid cultures. However, some of these data are in the prepneumococcal conjugate vaccine period and all were obtained from single-center studies. A multicentered study conducted in Italy revealed a pathogen by blood culture alone for 2 patients (4.3%), raising the possibility that blood culture may not provide added clinical data over molecular testing (eg, polymerase chain reaction for Streptococcus pneumoniae and Staphylococcus aureus) performed on blood and pleural fluid. Although children with complicated pneumonia have a higher rate of bacteremia, only 1 study to date has determined the impact of positive results on patient management.
The objectives of this study were to (1) determine the prevalence of documented bacteremia in children hospitalized with CAP across 4 children's hospitals, (2) determine differences in clinical characteristics and outcomes of patients with documented bacteremia compared with those without and (3) quantify the influence of positive and contaminated blood cultures on antibiotic management.
