Children with neurologic impairment (CNI) are hospitalized frequently for the treatment of pneumonia owing, in large part, to associated functional impairments in effective airway clearance.1 Although guidelines from the Pediatric Infectious Diseases Society and Infectious Diseases Society of America provide recommendations for the diagnosis and treatment of children hospitalized with community-acquired pneumonia (CAP),2 pneumonia in CNI was excluded largely owing to a paucity of clinical evidence to support best practices. This absence of formal recommendations has likely contributed to variation in the diagnosis, treatment, and outcomes of pneumonia in CNI.3,4 To address this gap, a group of experts from pediatric hospital medicine, pulmonology, and infectious diseases and complex care, as well as a parent of a child with CNI, recently convened to develop consensus-based recommendations (Stakeholders Evaluating Evidence to Address Respiratory Care for Hospitalized Children with Neurologic Impairment SEEARCH CNI).5 The result of this effort was 72 care recommendations addressing diagnostic testing, antimicrobial treatment, airway clearance, and discharge readiness criteria.In this issue of Hospital Pediatrics, Warniment and colleagues present a quality improvement (QI) initiative aimed at implementing recommendations made by the SEEARCH CNI team.6 A multidisciplinary group of health care professionals identified 15 of the 72 recommendations as acceptable and feasible for implementation and ultimately selected improving airway clearance strategies as both impactful to their patient population and having the greatest opportunity for improvement at their institution. A group of interprofessional stakeholders identified key drivers focused on knowledge of SEEARCH CNI recommendations, process standardization, effective communication among care team members, accurate medical history documentation, and buy-in from the multidisciplinary care team. Overall, the initiative improved the proportion of patients receiving recommendation-concordant airway clearance from 54% to 80% without significant changes in hospital lengths of stay or transfers to the intensive care unit. As with most QI initiatives, authors attributed their success to multiple factors highlighted in the article, including systematic use of provider education, standardized respiratory therapy consultation, changes to the electronic health record (EHR) order set, and the use of a clinical decision aid. These interventions present viable options for use at other sites caring for CNI, which would ultimately allow for greater concordance with the recommendations.Although not a primary focus, the QI initiative also assessed for concordance with SEEARCH CNI recommendations on antibiotic treatment, with specific recommendations pertaining to provider-perceived risk of aspiration and prior respiratory culture results on empirical antibiotic selection, route of administration, and total treatment duration. However, the institution’s baseline concordance of 96% with care recommendations left little room for meaningful improvement. This finding highlights the practicality of the antibiotic-related recommendations as achievable in clinical practice but also encourages reflection on future opportunities related to antibiotic stewardship. In other words, should concordance with these recommendations be the goal?Antibiotic stewardship in CNI is a complex principle that requires balancing the risk of non- and undertreatment (ie, inadequate coverage or duration) and the adverse effects associated with overtreatment (ie, adverse drug events, prolonged hospitalizations, health care costs, and development of multidrug-resistant organisms). This need is perhaps compounded in CNI, who experience more-frequent episodes of pneumonia compared with children without neurologic impairment, thereby theoretically increasing the cumulative risk of adverse effects with antibiotic overexposure. Indeed, in a cohort of children with tracheostomy, nearly 60% of whom had concomitant high-intensity neurologic impairment, patients received a median of nearly 4 courses of antibiotic treatment of respiratory tract infections per year, or nearly 34 days of antibiotic therapy, largely consisting of broad-spectrum antibiotics.7 The recommendations provided by the SEEARCH CNI team provide practical treatment recommendations but also highlight the growing need for additional research in this population to facilitate continued stewardship of antimicrobial therapy, particularly in the factors affecting clinicians’ decision to treat with antibiotics and the spectrum of treatment.Deciding to treat (or not to treat) suspected pneumonia in CNI is complicated by a lack of robust evidence for adjunctive diagnostic testing in guiding decision-making. Although frequently obtained in CNI, the utility of clinically available inflammatory marker testing (ie, white blood cell count, C-reactive protein, procalcitonin) remains largely unclear. In a multicenter study of freestanding children’s hospitals in the Pediatric Hospital Information System, more-frequent testing at the institutional level was not associated with meaningfully improved outcomes of pneumonia in CNI.8 More recently, in a prospective multicenter study of children with tracheostomy hospitalized with suspected bacterial respiratory tract infections (including pneumonia) and a high prevalence of neuromuscular disease, neither the receipt of inflammatory marker testing nor individual levels were associated with the receipt of treatment.9 Thus, although the negative predictive value of normal inflammatory markers may be helpful for CAP in previously healthy children, evidence to guide appropriate antibiotic use in CNI remains limited.10,11Similarly, the utility of a positive bacterial culture from a respiratory source (such as sputum or tracheal aspirate in children with an artificial airway) also remains uncertain for several reasons. First, respiratory cultures may not be attainable from all CNI, and reserving cultures just to those with a tracheostomy or who are acutely endotracheally intubated pose several diagnostic challenges largely pertaining to a contemporary understanding that the airway is not sterile and instead hosts a diverse microbiome.12 Second, certain bacteria that are frequently isolated in respiratory cultures, such as Pseudomonas aeruginosa, may be chronically present in the airway and not reflect acute infection by a pathogen that necessitates treatment.13 Despite this mounting evidence, positive respiratory cultures continue to be a significant factor in driving the decision to administer antibiotics for pneumonia.9,14,15 For this reason, the SEEARCH CNI team and others such as the Testing STewardship for Antibiotic Reduction (BrightT STAR) collaborative recommend caution with routinely obtaining respiratory cultures among those with artificial airways.5,16Finally, the pathobiology of concomitant viral infections in pneumonia in CNI and subsequent impact on clinical outcomes remain largely unknown. Although certain positive respiratory pathogen testing, such as influenza, may result in reduced unnecessary antibiotic exposure in CAP,17 the impact may not translate to all viruses.18 It remains unknown whether antibiotic treatment can be avoided altogether in patients with a detected respiratory virus. Although evidence specific to pneumonia in CNI is sparse, early findings of cohorts inclusive of CNI suggest variable associations between positive respiratory virus testing and clinician treatment of pneumonia with antibiotics.9,19 Nonetheless, studies aimed at determining which CNI with positive viral testing can safely avoid antibiotic treatment are critical for reducing antibiotic overuse.The recommendations by SEEARCH CNI on the spectrum of therapy are grounded in key stewardship principles and centered on treating the most-common causes of bacterial pneumonia while addressing unique situations commonly facing CNI (ie, aspiration risk, tracheostomy). In the current article, authors focused on recommendations pertaining to risk of aspiration and presence of a tracheostomy. Although existing evidence has identified associations between empirical anaerobic coverage among those with aspiration pneumonia, the determination of which patients are at risk is problematic because of a lack of a widely acceptable definition or helpful diagnostic testing in identifying aspiration pneumonia. Challenged with this dilemma, members of the QI initiative relied on review of the EHR for mention of risk of aspiration pneumonia. Although the investigators achieved success with being concordant with care recommendations, it is still highly probable that unnecessarily broad spectra of antimicrobials were provided in at least some patients. As highlighted in the SEEARCH CNI recommendations, in the absence of a widely acceptable definition or helpful diagnostic testing, clinicians are to rely on their own risk assessment for aspiration in CNI, which presumably (and understandably) could result in overestimation of risk and exposure of CNI to unnecessarily broad spectra of antibiotics despite being recommendation-concordant. Similarly, there is a lack of robust evidence to unequivocally support choosing empirical antibiotic regimens based on prior respiratory culture results (ie, antipseudomonal antibiotic prescribed for history of P. aeruginosa).Warniment and colleagues showcased the feasibility of improving the standardization of care for CNI hospitalized with pneumonia using pragmatic, generalizable strategies that incorporate care recommendations from the SEEARCH CNI team.6 Several key opportunities for future investigation remain to advance the care for pneumonia in CNI, including understanding the utility of clinically available and novel biomarkers in the diagnosis and prognosis of pneumonia and the utility of respiratory cultures and viral testing in guiding empirical antibiotic treatment decisions. Additionally, as promising evidence mounts to support shorter courses of antibiotics in outpatient treatment of CAP,20 there remains a similar need for research to determine which populations of CNI with pneumonia may similarly be candidates for shorter courses of therapy. Finally, although recommendations to increase airway clearance during acute illness are intuitive and were without negative effects in this QI initiative, investment into understanding how to personalize regimens on an individual level to minimize the duration of hospitalization, potentially reduce the number of antibiotic treatment days, and prevent infection recurrence is essential.
Pluguez et al. (Tue,) studied this question.