Association of Guideline-Adherent Antibiotic Treatment With Readmission of Children With Sickle Cell Disease Hospitalized With Acute Chest Syndrome

Abstract

Importance: Acute chest syndrome (ACS) is a common, serious complication of sickle cell disease (SCD) and a leading cause of hospitalization and death in both children and adults with SCD. Little is known about the effectiveness of guideline-recommended antibiotic regimens for the care of children hospitalized with ACS.

Objectives: To use a large, national database to describe patterns of antibiotic use for children with SCD hospitalized for ACS and to determine whether receipt of guideline-adherent antibiotics was associated with lower readmission rates.

Design, setting, and participants: Retrospective cohort study including 14 480 hospitalizations in 7178 children (age 0-22 years) with a discharge diagnosis of SCD and either ACS or pneumonia. Information was obtained from 41 children's hospitals submitting data to the Pediatric Health Information System from January 1, 2010, to December 31, 2016.

Exposures: National Heart, Lung, and Blood Institute guideline-adherent (macrolide with parenteral cephalosporin) vs non-guideline-adherent antibiotic regimens.

Main outcomes and measures: Acute chest syndrome-related and all-cause 7- and 30-day readmissions.

Results: Of the 14 480 hospitalizations, 6562 (45.3%) were in girls; median (interquartile range) age was 9 (4-14) years. Guideline-adherent antibiotics were provided in 10 654 of 14 480 hospitalizations for ACS (73.6%). Hospitalizations were most likely to include guideline-adherent antibiotics for children aged 5 to 9 years (3230 of 4047 [79.8%]) and declined to the lowest level for children 19 to 22 years (697 of 1088 [64.1%]). Between-hospital variation in antibiotic regimens was wide, with use of guideline-adherent antibiotics ranging from 24% to 90%. Children treated with guideline-adherent antibiotics had lower 30-day ACS-related (odds ratio [OR], 0.71; 95% CI, 0.50-1.00) and all-cause (OR, 0.50; 95% CI, 0.39-0.64) readmission rates vs children who received other regimens (cephalosporin and macrolide vs neither drug class).

Conclusions and relevance: Current approaches to antibiotic treatment in children with ACS vary widely, but guideline-adherent therapy appears to result in fewer readmissions compared with non-guideline-adherent therapy. Efforts to increase the dissemination and implementation of SCD treatment guidelines are warranted as is comparative effectiveness research to strengthen the underlying evidence base.

Figure 1.. Variation in Antibiotic Treatment Across Hospitals for Children With Sickle Cell Disease Hospitalized With Acute Chest Syndrome (ACS)

Proportion of hospitalizations receiving a macrolide with cephalosporin (A), cephalosporin without macrolide (B), macrolide without cephalosporin (C), and neither drug class (D), by Pediatric Health Information System (PHIS) hospital, with PHIS hospitals ordered from lowest to highest ACS volume. Circles indicate proportion of discharges receiving the given antibiotic regimen, adjusted for patient-level factors; error bars indicate 95% CI.

Figure 2.. Association Between Hospital Acute Chest Syndrome (ACS) Volume and Antibiotic Use for Children With Sickle Cell Disease Hospitalized With ACS

Proportion of hospitalizations in which a given regimen was used, plotted against hospital total ACS volume for hospitalizations that administered macrolide with cephalosporin (A), cephalosporin without macrolide (B), macrolide without cephalosporin (C), and neither drug class (D).