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A study of children hospitalized with community-acquired pneumonia (CAP) suggests that antibiotic decisions made in the emergency department (ED) have a significant impact on inpatient antibiotic use, researchers reported today in Pediatrics.

The study also found and that nearly a third of children without radiographic evidence of pneumonia received antibiotics, suggesting overuse is common.

In the prospective cohort study, which included children ages 3 months to 18 years who presented to the ED of a children's hospital with symptoms of a lower respiratory tract infection from July 2013 through December 2017, researchers estimated the risk factors associated with receipt of one or more doses of inpatient antibiotics and a full treatment course (5 or more days). Of the 1,142 children enrolled, 477 (median age, 2.8 years) met the criteria for inclusion; 51% had radiographic CAP or equivocal chest radiograph (CXR), and 49% had non-radiographic CAP.

Of the 477 children, 285 (60%) received at least one dose of antibiotics in the inpatient setting, and 254 (53%) received a full treatment course. Most patients (90%) who received antibiotics in the ED received inpatient antibiotics. In adjusted analyses, receipt of antibiotics in the ED (relative risk [RR], 4.33; 95% confidence interval [CI], 2.63 to 7.13), history of fever (RR, 1.66; 95% CI, 1.22 to 2.27), and use of supplemental oxygen (RR, 1.29; 95% CI, 1.11 to 1.50) were associated with an increased risk of inpatient antibiotic use, with similar findings for a full treatment course.

Children with radiographic CAP or equivocal CXRs had an increased risk of inpatient antibiotics compared with those with normal CXRs, but the increased risk was modest when antibiotics were given in the ED. Among the children with non-radiographic CAP, 29% received antibiotics, 21% received a full course, and ED antibiotics increased the risk of inpatient antibiotics.

The study authors say the frequent continuation of antibiotics in the inpatient setting may be explained by the concept of therapeutic momentum—the failure of clinicians to stop or reduce therapy that is not needed.

"Targeting therapeutic momentum and implementing other antibiotic stewardship strategies, focusing particularly on children with non-radiographic CAP, could help improve judicious antibiotic use," they wrote. Jul 1 Pediatrics abstract

A secondary analysis of data from a randomized clinical trial suggests that outpatient antibiotic management for select patients with acute appendicitis is safe, researchers reported today in JAMA Network Open.

The Comparison of Outcomes of Antibiotic Drugs and Appendectomy (CODA) trial, which involved 1,552 adults with image-confirmed appendicitis and was conducted from May 2016 through February 2020 at 25 US hospitals, found antibiotics to be non-inferior to appendectomy.

In this secondary analysis, researchers with the CODA Collaborative focused on the 776 patients in the trial who had been randomized to receive a 10-day course of antibiotics (intravenous followed by oral), nearly half of whom met stability criteria and were discharged from the ED within 24 hours with antibiotics. They compared outcomes among those who were discharged and those who received inpatient care.

Of the 776 patients included in the analysis, 335 were discharged within 24 hours, and 391 were discharged after 24 hours (inpatients). Over 7 days, severe adverse events (SAEs) occurred in 0.9 (95% CI, 0.2 to 2.6) per 100 outpatients, versus 1.3 (95% CI, 0.4 to 2.9) per 100 inpatients.

Appendectomies occurred in 9.9% (95% CI, 6.9% to 13.7%) of outpatients, versus 14.1% (95% CI, 10.8% to 18%) of inpatients (adjusted risk difference, –4.0 percentage points). Within 30 days, SAEs occurred in 1.8 (95% CI, 0.7 to 3.9) per 100 outpatients, versus 3.1 (95% CI, 1.6 to 5.4) per 100 inpatients, and appendectomies occurred in 12.6% (95% CI, 9.1% to 16.7%) of outpatients, versus 19% (95% CI, 15.1% to 23.4%) of inpatients.

Outpatients also missed fewer workdays (2.6 days; 95% CI, 2.3 to 2.9 days) than did inpatients (3.8 days; 95% CI, 3.4 to 4.3 days) and had similar frequency of return healthcare visits and high satisfaction and EuroQol 5-dimension (EQ-5D) scores.

"It appears that most patients who choose antibiotics can avoid hospitalization without incurring increased risk of serious complications or appendectomy," the study authors wrote. "Outpatient management should be included in shared decision-making discussions of patient preferences for outcomes associated with nonoperative and operative care." Jul 1 JAMA Netw Open study

The Centers for Disease Control and Prevention (CDC) yesterday announced a Listeria outbreak that has so far sickened 23 people, 1 fatally, from 10 states, but so far, no common food source has been identified.

Of the 22 people with available information, 20 had lived in or traveled to Florida within a month of getting sick. Of the sick people, 22 were hospitalized. Five were pregnant women, and one experienced fetal loss. The patient who died was from Illinois.

Twelve of the patients are from Florida. Patient ages range from 1 to 92, and 52% are male.

Illness onsets range from Jan 24, 2021, through Jun 12, 2022. Whole genome sequencing of the Listeria monocytogenes from patients shows a close genetic match, suggesting the patients were sickened by the same food. So far, interviews with sick patients has not turned up a suspected source.

The CDC said the true number of illnesses is probably larger, given the time it takes to link illnesses to outbreaks. Jun 30 CDC outbreak announcement

A new study in Clinical Infectious Diseases shows that 22.4% of US university athletes fully vaccinated against COVID-19 later tested positive for the virus, which the authors say underscores the need for maintaining infection-control precautions.

The study, led by the Centers for Disease Control and Prevention (CDC) COVID-19 Response Team, analyzed data from 21 National Collegiate Athletic Association (NCAA) universities in 15 states on 1,378 male and female student athletes who tested positive for the virus from January to November 2021, before the emergence of the Omicron variant.

Fully vaccinated athletes had received either two doses of the Pfizer/BioNTech or Moderna COVID-19 vaccines or one dose of the Johnson & Johnson (J&J) vaccine at least 2 weeks before infection.

Of the 1,378 infected athletes, 77.6% were unvaccinated, and 22.4% were fully vaccinated. Fewer fully vaccinated Black athletes were infected than their White counterparts (40 [14.7%] vs 168 [23.9%]), although the authors said that the difference may have been driven by study sample limitations. There was no significant difference between the sexes.

The most infections among fully vaccinated athletes occurred in August 2021 (29.7%) and September 2021 (30.3%), when the school year began and the highly transmissible Delta variant was dominant. The proportion of infections after full vaccination differed significantly by vaccine type, at 90 (45%) among J&J recipients, compared with 178 (31.2%) with Pfizer, and 40 (23.8%) with Moderna.

Eleven (0.8%) of all athletes (vaccinated or unvaccinated) were reinfected with COVID-19. Average time from infection to reinfection was about 6.5 months. Three reinfected athletes were unvaccinated, and one was partially vaccinated. Seven participants were infected twice before full vaccination, and none had two or more infections after completing the vaccine regimen.

"The level of infections experienced among student athletes after full vaccination indicates the need for maintaining precautions to prevent infection, particularly when community transmission rates increase," the researchers wrote. "Further study of COVID-19 vaccination, infection, and reinfection among the well-resourced and diverse population of student athletes might contribute further understanding of factors that play a role in health equity among young adults." Jun 30 Clin Infect Dis study

Three countries reported more polio cases this week, including Pakistan with another wild poliovirus type 1 (WPV1) case, and Niger and Nigeria with more circulating vaccine-derived poliovirus type 2 (cVDPV2) cases.

Pakistan's case is part of an ongoing rise, all in Khyber Pakhtunkhwa province in the northwest near the border with Afghanistan. The new illness lifts Pakistan's total to 11 this year. Earlier this week, gunmen on motorcycles attacked a polio vaccination team in the affected area, killing a health worker and two policemen.

In Africa, Niger reported two more cVDPV2 cases, both from Tillaberi, putting its total for the year at four. Also, Nigeria reported one more case, which involves a patient from Zamfara, lifting its 2022 total to 27. Jun 30 GPEI update Jun 28 Al Jazeera story

In other developments, the World Health Organization’s (WHO) polio emergency committee recently met to review the latest developments, and agreed that the situation still warrants a public health emergency of international concern (PHEIC). It raised concerns about the continued threat of international spread, pointing to the importation of the virus into Malawi and Mozambique. The group also cited Pakistan's rise in WPV1 cases, Afghanistan's unpredictable situation, and multiple vaccine gaps. The groups meets every 3 months, or more often as needed. Its latest meeting marked the 32nd for polio. Jun 24 WHO statement

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