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Importance: Although a viral etiology can be detected in most cases of pediatric pneumonia, antibiotic treatment is common. The effectiveness of antibiotics in the outpatient setting for children diagnosed with pneumonia is not known., Objective: To compare outcomes among children diagnosed with pneumonia who were and were not treated with oral antibiotics., Design, Setting, and Participants: This retrospective cohort study identified Medicaid-insured children and adolescents 17 years or younger diagnosed with pneumonia and discharged from ambulatory settings in a multistate claims database from January 1, 2017, to December 31, 2019. Propensity score matching was used to mitigate confounding. Data were analyzed from August 31, 2023, to August 16, 2024., Exposures: Antibiotic receipt, defined as an oral antibiotic dispensed from a pharmacy on the day of the index visit or on the subsequent day. Children who did not receive antibiotics included those who were not prescribed antibiotics and those who were prescribed antibiotics but did not fill the prescription., Main Outcomes and Measures: Treatment failure and severe outcomes within 2 to 14 days after the index visit. Treatment failure included hospitalization or ambulatory revisits for pneumonia, new antibiotic dispensation with a same-day ambulatory visit, or complicated pneumonia. Severe outcomes included hospitalization for pneumonia or complicated pneumonia., Results: Among the 103 854 children with pneumonia included in the analysis, the median age was 5 (IQR, 2-9) years, and 54 665 (52.6%) were male. Overall, 20 435 children (19.7%) did not receive an antibiotic within 1 day. The propensity score-matched analysis included 40 454 children (20 227 per group). Treatment failure occurred in 2167 children (10.7%) who did not receive antibiotics and 1766 (8.7%) who received antibiotics (risk difference, 1.98 [95% CI, 1.41-2.56] percentage points). Severe outcomes occurred in 234 of 20 435 children (1.1%) who did not receive antibiotics and in 133 of 83 419 (0.7%) who did (risk difference, 0.46 [95% CI, 0.28-0.64] percentage points)., Conclusions and Relevance: In this cohort study of children diagnosed with pneumonia in ambulatory settings, almost 20% did not receive antibiotics within a day of diagnosis. Although not receiving antibiotics was associated with a small increase in the risk of treatment failure, severe outcomes were uncommon regardless of whether antibiotics were received. These results suggest that some children diagnosed with pneumonia can likely be managed without antibiotics and highlight the need for prospective studies to identify these children.

Study Objective: The workload of clinical documentation contributes to health care costs and professional burnout. The advent of generative artificial intelligence language models presents a promising solution. The perspective of clinicians may contribute to effective and responsible implementation of such tools. This study sought to evaluate 3 uses for generative artificial intelligence for clinical documentation in pediatric emergency medicine, measuring time savings, effort reduction, and physician attitudes and identifying potential risks and barriers., Methods: This mixed-methods study was performed with 10 pediatric emergency medicine attending physicians from a single pediatric emergency department. Participants were asked to write a supervisory note for 4 clinical scenarios, with varying levels of complexity, twice without any assistance and twice with the assistance of ChatGPT Version 4.0. Participants evaluated 2 additional ChatGPT-generated clinical summaries: a structured handoff and a visit summary for a family written at an 8th grade reading level. Finally, a semistructured interview was performed to assess physicians' perspective on the use of ChatGPT in pediatric emergency medicine. Main outcomes and measures included between subjects' comparisons of the effort and time taken to complete the supervisory note with and without ChatGPT assistance. Effort was measured using a self-reported Likert scale of 0 to 10. Physicians' scoring of and attitude toward the ChatGPT-generated summaries were measured using a 0 to 10 Likert scale and open-ended questions. Summaries were scored for completeness, accuracy, efficiency, readability, and overall satisfaction. A thematic analysis was performed to analyze the content of the open-ended questions and to identify key themes., Results: ChatGPT yielded a 40% reduction in time and a 33% decrease in effort for supervisory notes in intricate cases, with no discernible effect on simpler notes. ChatGPT-generated summaries for structured handoffs and family letters were highly rated, ranging from 7.0 to 9.0 out of 10, and most participants favored their inclusion in clinical practice. However, there were several critical reservations, out of which a set of general recommendations for applying ChatGPT to clinical summaries was formulated., Conclusion: Pediatric emergency medicine attendings in our study perceived that ChatGPT can deliver high-quality summaries while saving time and effort in many scenarios, but not all., (Copyright © 2024 American College of Emergency Physicians. Published by Elsevier Inc. All rights reserved.)

Background: Emerging evidence suggests that initial oral and intravenous (IV) antibiotics have similar efficacy in pediatric community-acquired pneumonia (CAP), but further data are needed., Objective: We determined the association between hospital-level initial oral antibiotic rates and outcomes in pediatric CAP., Designs, Settings, and Participants: This retrospective cohort study included children hospitalized with CAP at 43 hospitals in the Pediatric Health Information System (2016-2022). Hospitals were grouped by whether initial antibiotics were given orally in a high, moderate, or low proportion of patients., Main Outcome and Measures: Regression models examined associations between high versus low oral-utilizing hospitals and length of stay (LOS, primary outcome), intensive care unit (ICU) transfers, escalated respiratory care, complicated CAP, cost, readmissions, and emergency department (ED) revisits., Results: Initial oral antibiotics were used in 16% (interquartile range: 10%-20%) of 30,207 encounters, ranging from 1% to 68% across hospitals. Comparing high versus low oral-utilizing hospitals (oral rate: 32% [27%-47%] and 10% [9%-11%], respectively), there were no differences in LOS, intensive care unit, complicated CAP, cost, or ED revisits. Escalated respiratory care occurred in 1.3% and 0.5% of high and low oral-utilizing hospitals, respectively (relative ratio [RR]: 2.96 [1.12, 7.81]), and readmissions occurred in 1.5% and 0.8% (RR: 1.68 [1.31, 2.17]). Initial oral antibiotics varied across hospitals without a difference in LOS. While high oral-utilizing hospitals had higher escalated respiratory care and readmission rates, these were rare, the clinical significance of these small differences is uncertain, and there were no differences in other clinically relevant outcomes. This suggests some children may benefit from initial IV antibiotics, but most would probably do well with oral antibiotics., (© 2024 Society of Hospital Medicine.)

Background: It is unknown which factors are associated with chest radiograph (CXR) and antibiotic use for suspected community-acquired pneumonia (CAP) in children. We evaluated factors associated with CXR and antibiotic preferences among clinicians for children with suspected CAP using case scenarios generated through artificial intelligence (AI)., Methods: We performed a survey of general pediatric, pediatric emergency medicine, and emergency medicine attending physicians employed by a private physician contractor. Respondents were given 5 unique, AI-generated case scenarios. We used generalized estimating equations to identify factors associated with CXR and antibiotic use. We evaluated the cluster-weighted correlation between clinician suspicion and clinical prediction model risk estimates for CAP using 2 predictive models., Results: A total of 172 respondents provided responses to 839 scenarios. Factors associated with CXR acquisition (OR, [95% CI]) included presence of crackles (4.17 [2.19, 7.95]), prior pneumonia (2.38 [1.32, 4.20]), chest pain (1.90 [1.18, 3.05]) and fever (1.82 [1.32, 2.52]). The decision to use antibiotics before knowledge of CXR results included past hospitalization for pneumonia (4.24 [1.88, 9.57]), focal decreased breath sounds (3.86 [1.98, 7.52]), and crackles (3.45 [2.15, 5.53]). After revealing CXR results to clinicians, these results were the sole predictor associated with antibiotic decision-making. Suspicion for CAP correlated with one of 2 prediction models for CAP (Spearman's rho = 0.25). Factors associated with a greater suspicion of pneumonia included prior pneumonia, duration of illness, worsening course of illness, shortness of breath, vomiting, decreased oral intake or urinary output, respiratory distress, head nodding, focal decreased breath sounds, focal rhonchi, fever, and crackles, and lower pulse oximetry., Conclusions: Ordering preferences for CXRs demonstrated similarities and differences with evidence-based risk models for CAP. Clinicians relied heavily on CXR findings to guide antibiotic ordering. These findings can be used within decision support systems to promote evidence-based management practices for pediatric CAP., Competing Interests: Disclosure: The authors declare no conflict of interest., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Community-acquired pneumonia (CAP) is often considered for children presenting to the emergency department (ED) with respiratory symptoms. It is unclear how often children are diagnosed with CAP following an ED visit for respiratory illness. We performed a retrospective case-control study to evaluate 7-day CAP diagnosis among children 3 months to 18 years discharged from the ED with respiratory illness from 2011 to 2021 and who receive care at 4 hospital-affiliated primary care clinics. Logistic regression was performed to assess for predictors of 7-day CAP diagnosis. Seventy-four (0.7%, 95% confidence interval [CI] = 0.6%, 0.9%) of 10 329 children were diagnosed with CAP within 7 days, and fever at the index visit was associated with increased odds of diagnosis (odds ratio [OR] = 3.32, 95% CI = 1.75-6.28). Community-acquired pneumonia diagnosis after discharge from the ED with respiratory illness is rare, even among children who are febrile at time of initial evaluation., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Background: Incomplete uptake of guidelines can lead to nonstandardized care, increased expenditures, and adverse clinical outcomes. The objective of this study was to evaluate the impact of the 2011 Pediatric Infectious Diseases Society and Infectious Diseases Society of America (PIDS/IDSA) pediatric community-acquired pneumonia (CAP) guideline that emphasized aminopenicillin use and de-emphasized the use of chest radiographs (CXRs) in certain populations., Methods: This quasi-experimental study queried a national administrative database of children's hospitals to identify children aged 3 months-18 years with CAP who visited 1 of 28 participating hospitals from 2009 to 2021. PIDS/IDSA pediatric CAP guideline recommendations regarding antibiotic therapy, diagnostic testing, and imaging were evaluated. Segmented regression interrupted time series was used to measure guideline-concordant practices with interruptions for guideline publication and the Coronavirus Disease 2019 (COVID-19) pandemic., Results: Of 315 384 children with CAP, 71 804 (22.8%) were hospitalized. Among hospitalized children, there was a decrease in blood culture performance (0.5% per quarter) and increase in aminopenicillin prescribing (1.1% per quarter). Among children discharged from the emergency department (ED), there was an increase in aminopenicillin prescription (0.45% per quarter), whereas the rate of obtaining CXRs declined (0.12% per quarter). However, use of CXRs rebounded during the COVID-19 pandemic (increase of 1.56% per quarter). Hospital length of stay, ED revisit rates, and hospital readmission rates remained stable., Conclusions: Guideline publication was associated with an increase of aminopenicillin prescribing. However, rates of diagnostic testing did not materially change, suggesting the need to consider implementation strategies to meaningfully change clinical practice for children with CAP., Competing Interests: Potential conflicts of interest. L. A.'s institution receives funding from Pfizer Inc on her behalf for an unrelated study and also reports support from the National Institute of Allergy and Infectious Diseases, unrelated to this work (grant numbers K01AI125413 and R21AI154239). D. J. S. reports a grant or contract from the Agency for Healthcare Quality and Research, unrelated to this work (T32HS000063-28). J. C. reports grants or contracts unrelated to this work from Pfizer Inc. All other authors report no potential conflicts. All authors have submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Conflicts that the editors consider relevant to the content of the manuscript have been disclosed., (© The Author(s) 2023. Published by Oxford University Press on behalf of Infectious Diseases Society of America. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Background: Current guidelines and recent studies on pediatric pneumonia pertain to children older than 3 months of age. Little information exists regarding the diagnostic evaluation, management, and outcomes of infants less than 90 days with pneumonia., Methods: We compared infants <90 days of age diagnosed with pneumonia across 38 US children's hospitals from 2016 to 2021 to children 90 days to 5 years of age. We evaluated whether differences exist in patient characteristics, diagnostic testing, antibiotic treatment, and outcomes between young infants and older children. Additionally, we assessed seasonal variability and trends over time in pneumonia diagnoses by age group., Results: Among 109 796 children diagnosed with pneumonia, 3128 (2.8%) were <90 days of age. Compared with older children, infants <90 days had more laboratory testing performed (88.6% vs 48.8%, P < .001; median number of laboratory tests 4 [interquartile range: 2-5] vs 0 [interquartile range: 0-3] respectively), with wide variation in testing across hospitals. Chest radiograph utilization did not differ by age group. Infants <90 days were more likely to be hospitalized and require respiratory support than older children. Seasonal variation was observed for pneumonia encounters in both age groups., Conclusions: Infants <90 days with pneumonia were more likely to undergo laboratory testing, be hospitalized, and require respiratory support than children 90 days to 5 years of age. This may reflect inherent differences in the pathophysiology of pneumonia by age, the manner in which pneumonia is diagnosed, or possible overuse of testing in infants., (Copyright © 2023 by the American Academy of Pediatrics.)

Objective: Chest radiograph (CXR) is often performed for the evaluation of community-acquired pneumonia (CAP) in the ED setting. We sought to evaluate the association of undergoing CXR with 7-day hospitalization after emergency department (ED) discharge among patients with CAP., Methods: This was a retrospective cohort study including children 3 months to 17 years discharged from any ED within 8 states from 2014 to 2019. We evaluated the association of CXR performance with 7-day hospitalization at both the patient and ED levels using mixed-effects logistic regression models accounting for markers of illness severity. Secondary outcomes included 7-day ED revisits and 7-day hospitalization with severe CAP., Results: Among 206 694 children with CAP, rates of 7-day ED revisit, hospitalization, and severe CAP were 8.9%, 1.6%, and 0.4%, respectively. After adjusting for illness severity, CXR was associated with fewer 7-day hospitalizations (1.6% vs. 1.7%, adjusted odds ratio: [aOR] 0.82, 95% confidence interval [CI]: 0.73-0.92). CXR performance varied somewhat between EDs (median 91.5%, IQR: 85.3%-95.0%). EDs in the highest quartile had fewer 7-day hospitalizations (1.4% vs 1.9%, aOR: 0.78, 95% CI: 0.65-0.94), ED revisits (8.5% vs 9.4%, aOR: 0.88, 95% CI: 0.80-0.96) and hospitalizations for severe CAP (0.3% vs. 0.5%, aOR: 0.70, 95% CI: 0.51-0.97) as compared to EDs with the lowest quartile of CXR utilization., Conclusions: Among children discharged from the ED with CAP, performance of CXR was associated with a small but significant reduction in hospitalization within 7 days. CXR may be helpful in the prognostic evaluation of children with CAP discharged from the ED., (Copyright © 2023 by the American Academy of Pediatrics.)

Background: Limited data exist to inform antibiotic selection among people with cystic fibrosis (CF) with airway infection by multiple CF-related microorganisms. This study aimed to determine among children with CF co-infected with methicillin-resistant Staphylococcus aureus (MRSA) and Pseudomonas aeruginosa (Pa) if the addition of anti-MRSA antibiotics to antipseudomonal antibiotic treatment for pulmonary exacerbations (PEx) would be associated with improved clinical outcomes compared with antipseudomonal antibiotics alone., Methods: Retrospective cohort study using data from the CF Foundation Patient Registry-Pediatric Health Information System linked dataset. The odds of returning to baseline lung function and having a subsequent PEx requiring intravenous antibiotics were compared between PEx treated with anti-MRSA and antipseudomonal antibiotics and those treated with antipseudomonal antibiotics alone, adjusting for confounding by indication using inverse probability of treatment weighting., Results: 943 children with CF co-infected with MRSA and Pa contributed 2,989 PEx for analysis. Of these, 2,331 (78%) PEx were treated with both anti-MRSA and antipseudomonal antibiotics and 658 (22%) PEx were treated with antipseudomonal antibiotics alone. Compared with PEx treated with antipseudomonal antibiotics alone, the addition of anti-MRSA antibiotics to antipseudomonal antibiotic therapy was not associated with a higher odds of returning to ≥90% or ≥100% of baseline lung function or a lower odds of future PEx requiring intravenous antibiotics., Conclusions: Children with CF co-infected with MRSA and Pa may not benefit from the addition of anti-MRSA antibiotics for PEx treatment. Prospective studies evaluating optimal antibiotic selection strategies for PEx treatment are needed to optimize clinical outcomes following PEx treatment., Competing Interests: Declaration of Competing Interest Drs. Cogen and Ms. Faino received support from the Cystic Fibrosis Foundation (COGEN19A0) Dr. Gibson received support from the Cystic Fibrosis Foundation (GIBSON1R0) Drs. Hall, Ambroggio, Blaschke, Brogan, Cotter, Grijalva, Hersh, Lipsett, Shah, Shapiro, Neuman and Gerber have nothing to disclose at it relates to this manuscript., (Copyright © 2022 European Cystic Fibrosis Society. Published by Elsevier B.V. All rights reserved.)

Objectives: Procalcitonin (PCT) was approved by the Food and Drug Administration in 2016. We assessed changes in PCT utilization over time in emergency departments (EDs) at US Children's Hospitals and identified the most common conditions associated with PCT testing., Methods: We performed a cross-sectional study of children <18 years of age presenting to 1 of 33 EDs contributing data to the Pediatric Health Information System between 2016 and 2020. We examined trends in PCT utilization during an ED encounter between institutions and over the study period. Using All Patients Refined Diagnosis Related Groups, we identified the most common conditions for which PCT was obtained (overall, and relative to the performance of a complete blood count)., Results: The overall rate of PCT testing increased from 0.2% of all ED visits in 2016 to 1.8% in 2020. Across hospitals, the proportion of ED encounters with PCT obtained ranged from 0.0005% to 4.3% with marked variability in overall use. Among children who had PCT testing performed, the most common diagnoses were fever (10.7%), infections of the upper respiratory tract (9.2%), and pneumonia (5.9%). Relative to the performance of a complete blood count, rates of PCT testing were highest among children with sepsis (28.7%), fever (21.4%), pulmonary edema/respiratory failure (17.3%), and bronchiolitis/respiratory syncytial virus pneumonia (15.6%)., Conclusions: PCT utilization in the ED has increased over the past 5 years with variation between hospitals. PCT is most frequently obtained for children with respiratory infections and febrile illnesses., (Copyright © 2023 by the American Academy of Pediatrics.)

Background: Despite the increased availability of diagnostic tests for respiratory viruses, their clinical utility for children with community-acquired pneumonia (CAP) remains uncertain., Objective: To identify patterns of respiratory virus testing across children's hospitals prior to the COVID-19 pandemic and to determine whether hospital-level rates of viral testing were associated with clinical outcomes., Design, Setting, and Participants: Multicenter retrospective cohort study of children hospitalized for CAP at 19 children's hospitals in the United States from 2010-2019., Main Outcomes and Measures: Using a novel method to identify the performance of viral testing, we assessed time trends in the use of viral tests, both overall and stratified by testing method. Adjusted proportions of encounters with viral testing were compared across hospitals and were correlated with length of stay, antibiotic and oseltamivir use, and performance of ancillary laboratory testing., Results: There were 46,038 hospitalizations for non-severe CAP among children without complex chronic conditions. The proportion with viral testing increased from 38.8% to 44.2% during the study period (p < .001). Molecular testing increased (27.2% to 40.0%, p < .001) and antigen testing decreased (33.2% to 7.8%, p < .001). Hospital-specific adjusted proportions of testing ranged from 10.0% to 83.5% and were not associated with length of stay, antibiotic use, or antiviral use. Hospitals that performed more viral testing did not have lower rates of ancillary laboratory testing., Conclusions: Viral testing practices varied widely across children's hospitals and were not associated with clinically important process or outcome measures. Viral testing may not influence clinical management for many children hospitalized with CAP., (© 2022 Society of Hospital Medicine.)

Background/objectives: Chest radiograph (CXR) is routinely performed among children with suspected pneumonia, though it is not clear how specific radiographic findings impact antibiotic treatment for pneumonia. We evaluated the impact of viral radiographic features on antibiotic treatment among children undergoing pneumonia evaluation in the emergency department (ED)., Methods: Children presenting to a pediatric ED who underwent a CXR for pneumonia evaluation were prospectively enrolled. Prior to CXR performance, physicians indicated their level of suspicion for pneumonia. The CXR report was reviewed to assess for the presence of viral features (peribronchial cuffing, perihilar markings, and interstitial infiltrate) as well as radiographic features suggestive of pneumonia (consolidation, infiltrate, and opacity). The relationship between viral radiographic features and antibiotic treatment was assessed based on the level of clinical suspicion for pneumonia prior to CXR., Results: Patients with normal CXRs (n = 400) and viral features alone (n = 370) were managed similarly, with 8.0% and 8.6% of patients receiving antibiotic treatment, respectively (P = .75). Compared with children with radiographic pneumonia (n = 174), patients with concurrent viral features and radiographic pneumonia (n = 177) were treated with antibiotics less frequently (86.2% vs 54.3%, P < .001). Among children with isolated viral features on CXR, antibiotic treatment rates were correlated with pre-CXR level of suspicion for pneumonia., Conclusions: Among children with suspected pneumonia, the presence of viral features alone on CXR is not associated with increased rates of antibiotic use. Among children with radiographic pneumonia, the addition of viral features on CXR is associated with lower rates of antibiotic use, as compared to children with radiographic pneumonia alone., (© The Author(s) 2022. Published by Oxford University Press on behalf of The Journal of the Pediatric Infectious Diseases Society. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Background and Objectives: Several studies have revealed the success of nonoperative management (NOM) of uncomplicated appendicitis in children. Large studies of current NOM utilization and its outcomes in children are lacking., Methods: We queried the Pediatric Health Information System database to identify children <19 years of age with a diagnosis code for appendicitis. We used linear trend analysis to assess the subsequent utilization and outcomes of NOM in children with nonperforated appendicitis over time. We calculated the proportion of children experiencing treatment failure, defined as either a subsequent appendectomy or hospitalization with a diagnosis code of perforated appendicitis., Results: We identified 117 705 children with appendicitis over the 9-year study period. Of the 73 544 children with nonperforated appendicitis, 10 394 (14.1%) underwent NOM. The odds of NOM significantly increased (odds ratio 1.10 per study quarter, 95% confidence interval [CI] 1.05-1.15). The 1-year and 5-year failure rates were 18.6% and 23.3%, respectively. Children who experienced failure of NOM had higher rates of perforation at the time of failure than did the general cohort at the time of initial presentation (45.7% vs 37.5%, P < .001). Patients undergoing NOM had higher rates of subsequent related emergency department visits (8.0% vs 5.1%, P < .001) and hospitalizations (4.2% vs 1.4%, P < .001) over a 12-month follow-up period., Conclusions: NOM of nonperforated appendicitis in children is increasing. Although the majority of children who undergo NOM remain recurrence-free years later, they carry a substantial risk of perforation at the time of recurrence and may experience a higher rate of postoperative complications than children undergoing an immediate appendectomy., (Copyright © 2022 by the American Academy of Pediatrics.)

Background: The diagnosis of pneumonia in children is challenging, given the wide overlap of many of the symptoms and physical examination findings with other common respiratory illnesses. We sought to derive and validate the novel Pneumonia Risk Score (PRS), a clinical tool utilizing signs and symptoms available to clinicians to determine a child's risk of radiographic pneumonia., Methods: We prospectively enrolled children 3 months to 18 years in whom a chest radiograph (CXR) was obtained in the emergency department to evaluate for pneumonia. Before CXR, we collected information regarding symptoms, physical examination findings, and the physician-estimated probability of radiographic pneumonia. Logistic regression was used to predict the presence of radiographic pneumonia, and the PRS was validated in a distinct cohort of children with suspected pneumonia., Results: Among 1181 children included in the study, 206 (17%) had radiographic pneumonia. The PRS included age in years, triage oxygen saturation, presence of fever, presence of rales, and presence of wheeze. The area under the curve (AUC) of the PRS was 0.71 (95% confidence interval [CI]: 0.68-0.75), while the AUC of clinician judgment was 0.61 (95% CI: 0.56-0.66) (P < 0.001). Among 2132 children included in the validation cohort, the PRS demonstrated an AUC of 0.69 (95% CI: 0.65-0.73)., Conclusions: In children with suspected pneumonia, the PRS is superior to clinician judgment in predicting the presence of radiographic pneumonia. Use of the PRS may help efforts to support the judicious use of antibiotics and chest radiography among children with suspected pneumonia., Competing Interests: This project was funded by the William F. Milton fund from Harvard University (awarded to Mark Neuman). The other authors have no conflicts of interest to disclose., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Objective: To compare the accuracy of computer versus physician predictions of hospitalization and to explore the potential synergies of hybrid physician-computer models., Materials and Methods: A single-center prospective observational study in a tertiary pediatric hospital in Boston, Massachusetts, United States. Nine emergency department (ED) attending physicians participated in the study. Physicians predicted the likelihood of admission for patients in the ED whose hospitalization disposition had not yet been decided. In parallel, a random-forest computer model was developed to predict hospitalizations from the ED, based on data available within the first hour of the ED encounter. The model was tested on the same cohort of patients evaluated by the participating physicians., Results: 198 pediatric patients were considered for inclusion. Six patients were excluded due to incomplete or erroneous physician forms. Of the 192 included patients, 54 (28%) were admitted and 138 (72%) were discharged. The positive predictive value for the prediction of admission was 66% for the clinicians, 73% for the computer model, and 86% for a hybrid model combining the two. To predict admission, physicians relied more heavily on the clinical appearance of the patient, while the computer model relied more heavily on technical data-driven features, such as the rate of prior admissions or distance traveled to hospital., Discussion: Computer-generated predictions of patient disposition were more accurate than clinician-generated predictions. A hybrid prediction model improved accuracy over both individual predictions, highlighting the complementary and synergistic effects of both approaches., Conclusion: The integration of computer and clinician predictions can yield improved predictive performance., (© The Author(s) 2021. Published by Oxford University Press on behalf of the American Medical Informatics Association. All rights reserved. For permissions, please email: journals.permissions@oup.com.)

Objective: To identify practice patterns in the duration of prescribed antibiotics for the treatment of ambulatory children with community-acquired pneumonia (CAP) and to compare the frequency of adverse clinical outcomes between children prescribed short-vs prolonged-duration antibiotics., Study Design: We performed a retrospective cohort study from 2010-2016 using the IBM Watson MarketScan Medicaid Database, a claims database of publicly insured patients from 11 states. We included children 1-18 years old with outpatient CAP who filled a prescription for oral antibiotics (n = 121 846 encounters). We used multivariable logistic regression to determine associations between the duration of prescribed antibiotics (5-9 days vs 10-14 days) and subsequent hospitalizations, new antibiotic prescriptions, and acute care visits. Outcomes were measured during the 14 days following the end of the dispensed antibiotic course., Results: The most commonly prescribed duration of antibiotics was 10 days (82.8% of prescriptions), and 10.5% of patients received short-duration therapy. During the follow-up period, 0.2% of patients were hospitalized, 6.2% filled a new antibiotic prescription, and 5.1% had an acute care visit. Compared with the prolonged-duration group, the aORs for hospitalization, new antibiotic prescriptions, and acute care visits in the short-duration group were 1.16 (95% CI 0.80-1.66), 0.93 (95% CI 0.85-1.01), and 1.06 (95% CI 0.98-1.15), respectively., Conclusions: Most children treated for CAP as outpatients are prescribed at least 10 days of antibiotic therapy. Among pediatric outpatients with CAP, no significant differences were found in rates of adverse clinical outcomes between patients prescribed short-vs prolonged-duration antibiotics., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Objectives: To describe testing and treatment practices for Mycoplasma pneumoniae ( Mp ) among children hospitalized with community-acquired pneumonia (CAP)., Methods: We conducted a retrospective cohort study using the Pediatric Health Information Systems database. We included children 3 months to 18 years old hospitalized with CAP between 2012 and 2018 and excluded children who were transferred from another hospital and those with complex chronic conditions. We examined the proportion of patients receiving Mp testing and macrolide therapy at the hospital level and trends in Mp testing and macrolide prescription over time. At the patient level, we examined differences in demographics, illness severity (eg, blood gas, chest tube placement), and outcomes (eg, ICU admission, length of stay, readmission) among patients with and without Mp testing., Results: Among 103 977 children hospitalized with CAP, 17.3% underwent Mp testing and 31.1% received macrolides. We found no correlation between Mp testing and macrolide treatment at the hospital level ( R 2 = 0.05; P = .11). Patients tested for Mp were more likely to have blood gas analysis (15.8% vs 12.8%; P < .1), chest tube placement (1.4% vs 0.8%; P < .1), and ICU admission (3.1% vs 1.4%; P < .1). Mp testing increased (from 15.8% to 18.6%; P < .001), and macrolide prescription decreased (from 40.9% to 20.6%; P < .001) between 2012 and 2018., Conclusions: Nearly one-third of hospitalized children with CAP received macrolide antibiotics, although macrolide prescription decreased over time. Clinicians were more likely to perform Mp testing in children with severe illness, and Mp testing and macrolide treatment were not correlated at the hospital level., Competing Interests: POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose., (Copyright © 2021 by the American Academy of Pediatrics.)

In this multicenter study of 1783 children diagnosed with ovarian torsion from 2012 to 2017, 402 children (22.5%) underwent oophorectomy. The odds of oophorectomy were higher in children under 11 years of age, children with public insurance, and children with complex chronic conditions. Future efforts should target a preservation-first approach., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Background and Objectives: Children with deep neck infections (DNIs) are increasingly being managed nonsurgically with intravenous antibiotics. Our objective was to examine variation in the management of children with DNIs across US children's hospitals., Methods: We conducted a retrospective cohort study using the Pediatric Health Information System database. Children ≤12 years of age hospitalized for retropharyngeal or parapharyngeal abscesses from 2010 to 2018 were included. Hospital variation in management modality and imaging use was described. Temporal trends in management modality were assessed by using logistic regression. Medical management alone versus a combination of medical and surgical management was assessed, and the characteristics of children in these 2 groups were compared. The relationship between hospital rates of initial medical management and failed medical management was assessed by using linear regression., Results: Hospitals varied widely in their rates of surgical management from 17% to 70%. The overall rate of surgical management decreased from 42.0% to 33.5% over the study period. Children managed surgically had higher rates of ICU admission (11.5% vs 3.2%; P < .001) and higher hospital charges ($25 241 vs $15 088; P < .001) compared with those managed medically alone. Seventy-three percent of children underwent initial medical management, of whom 17.9% went on to undergo surgery. Hospitals with higher rates of initial medical management had lower rates of failed medical management (β = -.43)., Conclusions: Although rates of surgical management of pediatric DNI are decreasing over time, there remains considerable variation in management across US children's hospitals. Children managed surgically have higher rates of resource use and costs., Competing Interests: POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose., (Copyright © 2021 by the American Academy of Pediatrics.)

Objectives: To assess the characteristics of children hospitalized with complicated pneumonia at US children's hospitals and compare these characteristics with those of children hospitalized with community-acquired pneumonia (CAP)., Methods: We identified children hospitalized with complicated pneumonia (parapneumonic effusion, empyema, necrotizing pneumonia, or lung abscess) or CAP across 34 hospitals between 2011 and 2019. We evaluated differences in patient characteristics, antibiotic selection, and outcomes between children with complicated pneumonia and CAP. We, also, assessed seasonal variability in the frequency of these 2 conditions and evaluated the prevalence of complicated pneumonia over the 9-year study period., Results: Compared with children hospitalized with CAP ( n = 75 702), children hospitalized with complicated pneumonia ( n = 6402) were older (a median age of 6.1 vs 3.4 years; P < .001), with 59.4% and 35.2% of patients ≥5 years of age, respectively. Patients with complicated pneumonia had higher rates of antibiotic therapy targeted against methicillin-resistant Staphylococcus aureus (46.3% vs 12.2%; P < .001) and Pseudomonas (8.6% vs 6.7%; P < .001), whereas differences in rates of coverage against mycoplasma were not clinically significant. Children with complicated pneumonia had a longer median hospital length of stay and higher rates of ICU admissions, mechanical ventilation, 30-day readmissions, and costs. Seasonal variation existed in both complicated pneumonia and CAP, with 42.7% and 46.0% of hospitalizations occurring during influenza season. The proportion of pneumonia hospitalizations due to complicated pneumonia increased over the study period (odds ratio 1.04, 95% confidence interval: 1.02-1.06)., Conclusions: Complicated pneumonia more frequently occurs in older children and accounts for higher rates of resource use, compared to CAP., Competing Interests: POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose., (Copyright © 2021 by the American Academy of Pediatrics.)

Study Objective: We identify the incidence and predictors of missed fracture and characterize patterns of radiography performance in children with a diagnosis of radial head subluxation in the emergency department (ED) setting., Methods: We queried the Pediatric Health Information System database for visits by children younger than 10 years and with a diagnosis of radial head subluxation at 1 of 45 pediatric EDs from 2010 to 2018. The frequency of radiography use was assessed overall and between hospitals. Multivariable logistic regression was used to evaluate associations between patient-level characteristics and the outcome of missed fracture (return visit for upper extremity fracture within 7 days of the index visit)., Results: We identified 88,466 eligible visits; the median patient age was 2.1 years, 59% of visits were by female patients, and in visits in which laterality was noted, 60% of cases occurred in the left arm. Radiography was performed at 28.5% of visits; hospital rates of radiography performance ranged from 19.8% to 41.7%. Missed upper extremity fractures were observed in 247 cases (0.3% of the cohort). The odds of missed fracture were higher in children older than 6 years (adjusted odds ratio 2.32; 95% confidence interval 1.12 to 4.81), children who underwent radiography at the index visit (adjusted odds ratio 2.52; 95% confidence interval 1.84 to 3.43), and children receiving acetaminophen or ibuprofen (adjusted odds ratio 1.54; 95% confidence interval 1.15 to 2.06)., Conclusion: Radiographs were obtained for greater than one quarter of children presenting to a pediatric ED with radial head subluxation, with wide variation between hospitals. Missed fractures were rare. Future efforts should aim to reduce unnecessary radiography in this population., (Copyright © 2020 American College of Emergency Physicians. Published by Elsevier Inc. All rights reserved.)

Objectives: To describe antibiotic prescribing patterns in ambulatory children with community-acquired pneumonia and to assess the relationship between antibiotic selection and clinical outcomes., Study Design: This was a retrospective cohort study of ambulatory Medicaid-enrolled children 0-18 years of age diagnosed with community-acquired pneumonia from 2010 to 2016. The exposure was antibiotic class: narrow-spectrum (aminopenicillins), broad-spectrum (amoxicillin/clavulanate and cephalosporins), macrolide monotherapy, macrolides with narrow-spectrum antibiotics, or macrolides with broad-spectrum antibiotics. The associations between antibiotic selection and the outcomes of subsequent hospitalization and development of severe pneumonia (chest drainage procedure, intensive care admission, mechanical ventilation) were assessed, controlling for measures of illness severity., Results: Among 252 177 outpatient pneumonia visits, macrolide monotherapy was used in 43.2%, narrow-spectrum antibiotics in 26.1%, and broad-spectrum antibiotics in 24.7%. A total of 1488 children (0.59%) were subsequently hospitalized and 117 (0.05%) developed severe pneumonia. Compared with children receiving narrow-spectrum antibiotics, the odds of subsequent hospitalization were higher in children receiving broad-spectrum antibiotics (aOR, 1.34; 95% CI, 1.17-1.52) and lower in children receiving macrolide monotherapy (aOR, 0.64; 95% CI, 0.55-0.73) and macrolides with narrow-spectrum antibiotics (aOR, 0.62; 95% CI, 0.39-0.97). Children receiving macrolide monotherapy had lower odds of developing severe pneumonia than children receiving narrow-spectrum antibiotics (aOR, 0.56; 95% CI, 0.33-0.93). However, the absolute risk difference was <0.5% for all analyses., Conclusions: Macrolides are the most commonly prescribed antibiotic for ambulatory children with community-acquired pneumonia. Subsequent hospitalization and severe pneumonia are rare. Future efforts should focus on reducing broad-spectrum and macrolide antibiotic prescribing., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Background/objective: Traditional sources cite seasonal patterns for common infectious diseases, often based on microbiologic data, but little is known about cyclical trends in clinically diagnosed infectious conditions in the emergency department (ED). We leveraged the publicly available Nationwide Emergency Department Sample database to measure the seasonality of the most common pediatric infectious diseases diagnosed in US EDs., Methods: We searched the Nationwide Emergency Department Sample database to identify infectious diagnoses comprising at least 1% of all diagnosis codes ascribed to patients 21 years and younger in US EDs from 2009 to 2013. We used Fourier regression to examine seasonal trends in disease and calculated the peak-to-nadir ratio for each infectious condition., Results: Over 20% of pediatric visits during the study period were for infectious conditions. Upper respiratory infection, otitis media, gastroenteritis, urinary tract infection/pyelonephritis, cellulitis/abscess, and pneumonia showed a seasonal pattern that matched trends found in prior regional or microbiologic-based studies. The strongest seasonal trend as measured by goodness of model fit was found in pneumonia (peak-to-nadir incidence ratio of 2.7), followed by otitis media (2.0), cellulitis/abscess (2.0), gastroenteritis (1.6), upper respiratory infection (3.2), and urinary tract infection/pyelonephritis (1.4). Pharyngitis did not show a strong seasonal trend., Conclusions: Many of the most common pediatric infectious diseases diagnosed in US EDs exhibited seasonal patterns. Large administrative databases can be used to track seasonal disease patterns, with the advantage that they reflect clinician diagnosis beyond microbiologic confirmation. This methodology could aid in resource planning, infection control, and public health educational initiatives., Competing Interests: Disclosure: The authors declare no conflict of interest., (Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.)

Background and Objectives: National guidelines recommend against routine use of chest radiography (CXR) for community-acquired pneumonia (CAP) diagnosis in the pediatric emergency department (ED). Given that CXR is often used to exclude the diagnosis of CAP, a reduction in CXR use may result in overdiagnosis of CAP. We sought to evaluate trends in CXR use and assess the association between CXR performance and CAP diagnosis among children discharged from pediatric EDs., Methods: Children 3 months to 18 years of age discharged from 30 US EDs with (1) CAP or (2) fever or respiratory illness between 2008 and 2018 were included. Temporal trends in CXR use and rates of CAP diagnoses among patients with fever or respiratory illness were assessed. Correlation between hospital-level CXR use and CAP diagnosis rates were evaluated by using Spearman's correlation weighted by hospital volume., Results: CXR usage decreased from 86.6% to 80.4% ( P < .001) for patients with CAP and from 30.4% to 18.6% ( P < .001) for children with fever or respiratory illness over the 10-year study period. CAP diagnosis rates also declined from 7.8% to 5.9% ( P < .001). Hospital-level CXR use was correlated with pneumonia diagnosis rates (correlation coefficient 0.58; P < .001)., Conclusions: Over the past decade, there has been a decline in CXR use in the ED among children with pneumonia and respiratory illnesses, with a decrease in pneumonia diagnoses over the same time period. Future studies are needed to assess the role of CXR in the evaluation of children with possible pneumonia in the ED setting., Competing Interests: POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose., (Copyright © 2020 by the American Academy of Pediatrics.)

Background and Objectives: The yield of blood cultures in children hospitalized with community-acquired pneumonia (CAP) is low. Characteristics of children at increased risk of bacteremia remain largely unknown., Methods: We conducted a secondary analysis of a retrospective cohort study of children aged 3 months to 18 years hospitalized with CAP in 6 children's hospitals from 2007 to 2011. We excluded children with complex chronic conditions and children without blood cultures performed at admission. Clinical, laboratory, microbiologic, and radiologic data were assessed to identify predictors of bacteremia., Results: Among 7509 children hospitalized with CAP, 2568 (34.2%) had blood cultures performed on the first day of hospitalization. The median age was 3 years. Sixty-five children with blood cultures performed had bacteremia (2.5%), and 11 children (0.4%) had bacteremia with a penicillin-nonsusceptible pathogen. The prevalence of bacteremia was increased in children with a white blood cell count >20 × 10 3 cells per µL (5.4%; 95% confidence interval 3.5%-8.1%) and in children with definite radiographic pneumonia (3.3%; 95% confidence interval 2.4%-4.4%); however, the prevalence of penicillin-nonsusceptible bacteremia was below 1% even in the presence of individual predictors. Among children hospitalized outside of the ICU, the prevalence of contaminated blood cultures exceeded the prevalence of penicillin-nonsusceptible bacteremia., Conclusions: Although the prevalence of bacteremia is marginally higher among children with leukocytosis or radiographic pneumonia, the rates remain low, and penicillin-nonsusceptible bacteremia is rare even in the presence of these predictors. Blood cultures should not be obtained in children hospitalized with CAP in a non-ICU setting., Competing Interests: POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose., (Copyright © 2019 by the American Academy of Pediatrics.)

Conventional two-tiered testing (CTTT) for Lyme disease includes a first-tier enzyme immunoassay (EIA) followed by a supplemental immunoblot, and modified two-tiered testing (MTTT) relies on two different sequential EIAs without the inclusion of an immunoblot. MTTT has shown promising results as an alternative strategy for the diagnosis of Lyme disease in adults but has not yet been evaluated in children. We performed a cross-sectional study of children and adolescents ≤21 years of age undergoing clinical investigation for suspected Lyme disease. Serum specimens were analyzed with both a whole-cell sonicate (WCS) and a C6 EIA, with a supplemental immunoblot if either EIA was positive or equivocal. We compared CTTT (WCS EIA followed by supplemental immunoblot) to MTTT (WCS EIA followed by C6 EIA) using McNemar's test to evaluate for agreement beyond chance alone. We then used a kappa statistic to measure level of the agreement between testing strategies. We included 1,066 serum specimens, of which 156 (14.6%) had a positive CTTT and 165 (15.5%) had a positive MTTT. There were no significant differences between MTTT and CTTT ( P = 0.16). Although the overall agreement between MTTT and CTTT was high (kappa, 0.88; 95% confidence interval, 0.84 to 0.92), 33 children had discordant test results. In a cohort of children and adolescents undergoing investigation for suspected Lyme disease, CTTT and MTTT results agreed in most cases. Since immunoblots are time-consuming, laborious, and challenging to interpret, MTTT provides a promising alternate Lyme disease testing strategy for children., (Copyright © 2019 American Society for Microbiology.)

The correlation between the Food and Drug Administration-cleared C6 enzyme immunoassay (EIA) C6 index values and a diagnosis of Lyme disease has not been examined. We used pooled patient-level data from 5 studies of adults and children with Lyme disease and control subjects who were tested with the C6 EIA. We constructed a receiver operating characteristic curve using regression clustered by study and measured the area under the curve (AUC) to examine the accuracy of the C6 index values in differentiating between patients with noncutaneous Lyme disease and control subjects. In the 4821 included patients, the C6 index value had excellent ability to distinguish between patients with noncutaneous Lyme disease and control subjects [AUC 0.99; 95% confidence interval (CI) 0.99-1.00]. An index value cut point of ≥3.0 had a sensitivity of 90.9% (95% CI, 87.8-93.3) and specificity of 99.0% (95% CI, 98.6-99.2%) for Lyme disease., (Copyright © 2018 Elsevier Inc. All rights reserved.)

: media-1vid110.1542/5804413949001PEDS-VA&#95;2018-0236 Video Abstract BACKGROUND AND OBJECTIVES: The ability of the chest radiograph (CXR) to exclude the diagnosis of pneumonia in children is unclear. We sought to determine the negative predictive value of CXR in children with suspected pneumonia., Methods: Children 3 months to 18 years of age undergoing CXRs for suspected pneumonia in a tertiary-care pediatric emergency department (ED) were prospectively enrolled. Children currently receiving antibiotics and those with underlying chronic medical conditions were excluded. The primary outcome was defined as a physician-ascribed diagnosis of pneumonia independent of radiographic findings. CXR results were classified as positive, equivocal, or negative according to radiologist interpretation. Children with negative CXRs and without a clinical diagnosis of pneumonia were managed for 2 weeks after the ED visit. Children subsequently diagnosed with pneumonia during the follow-up period were considered to have had false-negative CXRs at the ED visit., Results: There were 683 children enrolled during the 2-year study period, with a median age of 3.1 years (interquartile range 1.4-5.9 years). There were 457 children (72.8%) with negative CXRs; 44 of these children (8.9%) were clinically diagnosed with pneumonia, and 42 (9.3%) were given antibiotics for other bacterial syndromes. Of the 411 children with negative CXRs who were managed without antibiotics, 5 were subsequently diagnosed with pneumonia within 2 weeks (negative predictive value of CXR 98.8%; 95% confidence interval 97.0%-99.6%)., Conclusions: A negative CXR excludes pneumonia in the majority of children. Children with negative CXRs and low clinical suspicion for pneumonia can be safely observed without antibiotic therapy., Competing Interests: POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose., (Copyright © 2018 by the American Academy of Pediatrics.)

To diagnose Lyme disease, a two-tier testing algorithm is used in which supplemental IgM and IgG immunoblots to detect antibody to Borrelia burgdorferi are reflexively performed if a first-tier assay, such as a whole-cell sonicate-based enzyme immunoassay (WCS EIA), is reactive. Recent data suggest that equal specificity is found by substituting the C6 peptide EIA for immunoblots. In this study using 3956 control sera, we demonstrated that although this two-tier testing algorithm does significantly improve diagnostic specificity compared with each of the EIAs individually, the WCS EIA and the C6 peptide EIA are not independent tests. Therefore, when the C6 peptide EIA is used as the second-tier test, it should be regarded as a supplemental rather than a confirmatory test., (Copyright © 2018. Published by Elsevier Inc.)

Objectives: To explore the variation in diagnostic testing and management for males diagnosed with three testicular conditions (testicular torsion, appendix testis torsion, epididymitis/orchitis) using a large pediatric health care database. Diagnostic testing is frequently used in evaluation of the acute scrotum; however, there is likely variability in the use of these tests in the emergency department setting., Methods: We conducted a cross-sectional study of males with the diagnoses of testicular torsion, appendix testis torsion, and epididymitis/orchitis. We identified emergency department patients in the Pediatric Health Information Systems (PHIS) database from 2010 to 2015 using diagnostic and procedure codes from the International Classification of Diseases Codes 9 and 10. Frequencies of diagnoses by demographic characteristics and of procedures and diagnostic testing (ultrasound, urinalysis, urine culture and sexually transmitted infection testing) by age group were calculated. We analyzed testing trends over time., Results: We identified 17,000 males with the diagnoses of testicular torsion (21.7%), appendix testis torsion (17.9%), and epididymitis/orchitis (60.3%) from 2010 to 2015. There was substantial variation among hospitals in all categories of testing for each of the diagnoses. Overall, ultrasound utilization ranged from 33.1-100% and urinalysis testing ranged from 17.0-84.9% for all conditions. Only urine culture testing decreased over time for all three diagnoses (40.6% in 2010 to 31.5 in 2015)., Conclusions: There was wide variation in the use of diagnostic testing across pediatric hospitals for males with common testicular conditions. Development of evaluation guidelines for the acute scrotum could decrease variation in testing., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Background and Objectives: National guidelines recommend blood cultures for children hospitalized with presumed bacterial community-acquired pneumonia (CAP) that is moderate or severe. We sought to determine the prevalence of bacteremia and characterize the microbiology and penicillin-susceptibility patterns of positive blood culture results among children hospitalized with CAP., Methods: We conducted a cross-sectional study of children hospitalized with CAP in 6 children's hospitals from 2007 to 2011. We included children 3 months to 18 years of age with discharge diagnosis codes for CAP using a previously validated algorithm. We excluded children with complex chronic conditions. We reviewed microbiologic data and classified positive blood culture detections as pathogens or contaminants. Antibiotic-susceptibility patterns were assessed for all pathogens., Results: A total of 7509 children hospitalized with CAP were included over the 5-year study period. Overall, 34% of the children hospitalized with CAP had a blood culture performed; 65 (2.5% of patients with blood cultures; 95% confidence interval [CI]: 2.0%-3.2%) grew a pathogen. Streptococcus pneumoniae accounted for 78% of all detected pathogens. Among detected pathogens, 50 (82%) were susceptible to penicillin. Eleven children demonstrated growth of an organism nonsusceptible to penicillin, representing 0.43% (95% CI: 0.23%-0.77%) of children with blood cultures obtained and 0.15% (95% CI: 0.08%-0.26%) of all children hospitalized with CAP., Conclusions: Among children without comorbidities hospitalized with CAP in a non-ICU setting, the rate of bacteremia was low, and isolated pathogens were usually susceptible to penicillin. Blood cultures may not be needed for most children hospitalized with CAP., Competing Interests: POTENTIAL CONFLICT OF INTEREST: Dr Blaschke collaborates with BioFire Diagnostics LLC on federally funded studies, has received research funding from BioFire Diagnostics for investigator-initiated research, has intellectual property licensed to BioFire Diagnostics, receives royalties through the University of Utah, and has acted as an advisor to BioFire Diagnostics and BioFire Defense LLC regarding risk assessment for US Food and Drug Administration–cleared products; and the other authors have indicated they have no potential conflicts of interest to disclose., (Copyright © 2017 by the American Academy of Pediatrics.)

Objective: To compare the complexity and severity of presentation of children in general vs pediatric emergency departments (EDs)., Study Design: We performed a cross-sectional study of pediatric ED visits using the National Emergency Department Sample from 2008 to 2012. We classified EDs as "pediatric" if >75% of patients were <18 years old; all other EDs were classified as "general." The presence of an International Classification of Diseases, Ninth Revision code for a complex chronic condition was used as an indicator of patient complexity. Patient severity was evaluated with the severity classification system. In addition, rates of critical procedures and hospitalization were assessed., Results: We identified 9.6 million encounters to pediatric EDs and 169 million to general EDs. Younger children account for a greater proportion of visits at pediatric EDs than general EDs; children <1 year of age account for 18% of visits to a pediatric ED compared with 9% of visits to a general ED (P < .01). Encounters at pediatric EDs had greater complexity (5% vs 2%; P < .01). Although severity classification system scores did not significantly differ by ED type, pediatric EDs had greater rates of hospitalization (10% vs 4%)., Conclusions: Pediatric EDs provided care to a greater proportion of medically complex children than general EDs and had greater rates of hospitalization. This information may inform educational efforts in residency or postgraduate training to ensure high-quality care for children with complex health care needs., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Background and Objectives: Nonoperative management (NOM) of uncomplicated pediatric appendicitis has promise but remains poorly studied. NOM may lead to an increase in resource utilization. Our objective was to investigate the trends in NOM for uncomplicated appendicitis and study the relevant clinical outcomes including subsequent appendectomy, complications, and resource utilization., Methods: Retrospective analysis of administrative data from 45 US pediatric hospitals. Patients <19 years of age presenting to the emergency department (ED) with appendicitis between 2010 and 2016 were studied. NOM was defined by an ED visit for uncomplicated appendicitis treated with antibiotics and the absence of appendectomy at the index encounter. The main outcomes included trends in NOM among children with uncomplicated appendicitis and frequency of subsequent diagnostic imaging, ED visits, hospitalizations, and appendectomy during 12-month follow-up., Results: 99 001 children with appendicitis were identified, with a median age of 10.9 years. Sixty-six percent were diagnosed with nonperforated appendicitis, of which 4190 (6%) were managed nonoperatively. An increasing number of nonoperative cases were observed over 6 years (absolute difference, +20.4%). During the 12-month follow-up period, NOM patients were more likely to have the following: advanced imaging (+8.9% [95% confidence interval (CI) 7.6% to 10.3%]), ED visits (+11.2% [95% CI 9.3% to 13.2%]), and hospitalizations (+43.7% [95% CI 41.7% to 45.8%]). Among patients managed nonoperatively, 46% had a subsequent appendectomy., Conclusions: A significant increase in NOM of nonperforated appendicitis was observed over 6 years. Patients with NOM had more subsequent ED visits and hospitalizations compared with those managed operatively at the index visit. A substantial proportion of patients initially managed nonoperatively eventually had an appendectomy., Competing Interests: POTENTIAL CONFLICT OF INTEREST: Dr Bachur holds a patent for biomarkers of appendicitis (US 8535891 B2) and has had research support from Astute Medical, Inc (San Diego, CA); and Drs Lipsett and Monuteaux have indicated they have no potential conflicts of interest to disclose., (Copyright © 2017 by the American Academy of Pediatrics.)

Concerns about radiation exposure have led to a decrease in the use of computed tomography in suspected appendicitis, with increased reliance on ultrasound. Children with suspected appendicitis should be risk stratified using a combination of clinical signs and symptoms, white blood cell count, and ultrasound in order to guide further evaluation and management. Magnetic resonance imaging is a promising imaging modality but remains costly. Ongoing research is evaluating the role of nonoperative management in children with confirmed appendicitis.

Background: The commercially-available C6 Lyme enzyme immunoassay (EIA) has been approved to replace the standard whole-cell sonicate EIA as a first-tier test for the diagnosis of Lyme disease and has been suggested as a stand-alone diagnostic. However, the C6 EIA has not been extensively studied in pediatric patients undergoing evaluation for Lyme disease., Methods: We collected discarded serum samples from children and adolescents (aged ≤21 years) undergoing conventional 2-tiered testing for Lyme disease at a single hospital-based clinical laboratory located in an area endemic for Lyme disease. We performed a C6 EIA on all collected specimens, followed by a supplemental immunoblot if the C6 EIA result was positive but the whole-cell sonicate EIA result was negative. We defined a case of Lyme disease as either a clinician-diagnosed erythema migrans lesion or a positive standard 2-tiered serologic result in a patient with symptoms compatible with Lyme disease. We then compared the performance of the C6 EIA alone and as a first-tier test followed by immunoblot, with that of standard 2-tiered serology for the diagnosis of Lyme disease., Results: Of the 944 specimens collected, 114 (12%) were from patients with Lyme disease. The C6 EIA alone had sensitivity similar to that of standard 2-tiered testing (79.8% vs 81.6% for standard 2-tiered testing; P = .71) with slightly lower specificity (94.2% vs 98.8% 2; P < .002). Addition of a supplemental immunoblot improved the specificity of the C6 EIA to 98.6%., Conclusions: For children and adolescents undergoing evaluation for Lyme disease, the C6 EIA could guide initial clinical decision making, although a supplemental immunoblot should still be performed., (© The Author 2016. Published by Oxford University Press for the Infectious Diseases Society of America. All rights reserved. For permissions, e-mail journals.permissions@oup.com.)

In our cross-sectional sample of 7289 serologic tests for Lyme disease, we identified 167 instances of a positive IgM immunoblot but a negative IgG immunoblot test result. Considering that only 71% (95% CI 64%-78%) of patients had Lyme disease, a positive IgM immunoblot alone should be interpreted with caution to avoid over-diagnosis of Lyme disease., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Purpose of Review: We review the current evidence concerning the diagnosis of Lyme disease in children for application in the acute care setting., Recent Findings: Recent studies suggest that Lyme disease incidence is substantially higher than previously described. Although efforts are ongoing to identify alternative testing strategies, two-tiered serologic testing remains the diagnostic standard in children with compatible clinical syndromes. Published clinical prediction rules can assist clinicians caring for children with potential Lyme disease., Summary: Two-tiered serologic testing remains the mainstay of the diagnosis of Lyme disease. To minimize the risk of a false positive test, serologic testing should be limited to those children with symptoms compatible with Lyme disease with potential exposure to ticks from endemic regions.

By using a Lyme enzyme-linked immunosorbent assay (ELISA), we demonstrated that high ELISA index values are strongly predictive of Lyme disease. In children with clinical presentations consistent with Lyme disease, ELISA index values ≥3.0 had a positive predictive value of 99.4% (95% confidence interval: 98.1-99.8%) for Lyme disease, making a supplemental Western immunoblot potentially unnecessary.