Management and Outcomes of Salmonella Gastroenteritis in the Era of Rapid Molecular Testing.

BACKGROUND AND OBJECTIVES: Molecular diagnostics provide a rapid and sensitive diagnosis of gastroenteritis compared with a stool culture. In this study, we seek to describe the changes in medical management and outcomes of children with Salmonella gastroenteritis as our hospital system adopted molecular diagnostics. METHODS: This study is a retrospective chart review of children <18 years of age diagnosed with nontyphoidal Salmonella gastroenteritis between 2008 and 2018 at a large pediatric health care system in the southeastern United States. Those with immunocompromising conditions and hemoglobinopathies were excluded. Patients diagnosed via molecular testing were compared with those diagnosed solely by stool culture for aspects of management including admission rates, blood culture obtainment, and antibiotic administration. RESULTS: Of 965 eligible patients with Salmonella gastroenteritis, 264 (27%) had a stool molecular test and 701 (73%) only had a stool culture performed. Groups were similar in age and presentation. Those diagnosed by molecular methods had higher hospitalization rates (69% vs 50%, P <.001), more blood cultures obtained (54% vs 44%, P <.01), and received more antibiotics (49% vs 34%, P <.001) despite statistically similar rates of bacteremia (11% vs 19%, P = .05). CONCLUSIONS: The rapid diagnosis of Salmonella gastroenteritis by molecular methods was associated with increased hospital admission rates, blood culture obtainment, and antibiotic use. This suggests possible overmedicalization of uncomplicated Salmonella gastroenteritis, and clinicians should remain cognizant of the possibility of providing low-value care for uncomplicated disease.

Intravenous Antibiotic Duration for Nontyphoidal Salmonella Bacteremia in Children.

BACKGROUND AND OBJECTIVE: The optimal duration of intravenous (IV) antibiotic therapy for children with nontyphoidal Salmonella bacteremia (NTSB) is unknown. The objective of the authors of this study is to evaluate differences in outcomes among children with NTSB who received a short (≤3 days; short-duration group [SDG]) versus long (>3 days; long-duration group [LDG]) course of IV antibiotics. METHODS: This is a retrospective study of children 3 months to 18 years old with NTSB admitted to a tertiary pediatric health care system in the southeastern United States between 2008 and 2018. RESULTS: Among 57 patients with NTSB without focal infection, 24 (42%) were in the SDG and received IV antibiotics for a median of 3.0 days and 33 (58%) were in the LDG and received IV antibiotics for a median of 5.0 days. Demographic and clinical characteristics were similar between the SDG and LDG. The median total duration of antibiotics was 11.5 days in the SDG and 13.0 in the LDG (P = .068). The median length of stay was 3.0 days in the SDG and 4.0 in the LDG (P ≤ .001). Two children in the SDG (8%) and 1 child in the LDG (3%) returned to the emergency department for care unrelated to the duration of their IV antibiotic therapy (P = .567). None of the children were readmitted for sequelae related to salmonellosis. CONCLUSIONS: The duration of IV antibiotics varied for NTSB, but the outcomes were excellent regardless of the initial IV antibiotic duration. Earlier transitions to oral antibiotics can be considered for NTSB.

Quality Initiative to Reduce High-Flow Nasal Cannula Duration and Length of Stay in Bronchiolitis.

OBJECTIVES: High-flow nasal cannula (HFNC) use in bronchiolitis may prolong length of stay (LOS) if weaned more slowly than medically indicated. We aimed to reduce HFNC length of treatment (LOT) and inpatient LOS by 12 hours in 0- to 18-month-old patients with bronchiolitis on the pediatric hospital medicine service. METHODS: After identifying key drivers of slow weaning, we recruited a multidisciplinary "Wean Team" to provide education and influence provider weaning practices. We then implemented a respiratory therapist-driven weaning protocol with supportive sociotechnical interventions (huddles, standardized orders, simplification of protocol) to reduce LOT and LOS and promote sustainability. RESULTS: In total, 283 patients were included: 105 during the baseline period and 178 during the intervention period. LOT and LOS control charts revealed special cause variation at the start of the intervention period; mean LOT decreased from 48.2 to 31.2 hours and mean LOS decreased from 84.3 to 60.9 hours. LOT and LOS were less variable in the intervention period compared with the baseline period. There was no increase in PICU transfers or 72-hour return or readmission rates. CONCLUSIONS: We reduced HFNC LOT by 17 hours and LOS by 23 hours for patients with bronchiolitis via multidisciplinary collaboration, education, and a respiratory therapist-driven weaning protocol with supportive interventions. Future steps will focus on more judicious application of HFNC in bronchiolitis.