Medications and Adherence to Treatment Guidelines Among Children Hospitalized With Acute COVID-19

Abstract

Objectives: Coronavirus disease 2019 (COVID-19) treatment guidelines rapidly evolved during the pandemic. The December 2020 Infectious Diseases Society of America (IDSA) guideline, endorsed by the Pediatric Infectious Diseases Society, recommended steroids for critical disease, and suggested steroids and remdesivir for severe disease. We evaluated how medications for children hospitalized with COVID-19 changed after guideline publication.

Methods: We performed a multicenter, retrospective cohort study of children aged 30 days to <18 years hospitalized with acute COVID-19 at 42 tertiary care US children's hospitals April 2020 to December 2021. We compared medication use before and after the December 2020 IDSA guideline (pre- and postguideline) stratified by COVID-19 disease severity (mild-moderate, severe, critical) with interrupted time series.

Results: Among 18 364 patients who met selection criteria, 80.3% were discharged in the postguideline period. Remdesivir and steroid use increased postguideline relative to the preguideline period, although the trend slowed. Postguideline, among patients with severe disease, 75.4% received steroids and 55.2% remdesivir, and in those with critical disease, 82.4% received steroids and 41.4% remdesivir. Compared with preguideline, enoxaparin use increased overall but decreased among patients with critical disease. Postguideline, tocilizumab use increased and hydroxychloroquine, azithromycin, anakinra, and antibiotic use decreased. Antibiotic use remained high in severe (51.7%) and critical disease (81%).

Conclusions: Although utilization of COVID-19 medications changed after December 2020 IDSA guidelines, there was a decline in uptake and incomplete adherence for children with severe and critical disease. Efforts should enhance reliable delivery of guideline-directed therapies to children hospitalized with COVID-19 and assess their effectiveness.

Appendix Figure 1.

Hydroxychloroquine and Ivermectin Use Over Time in Children Hospitalized with COVID-19 Stratified by Disease Severity The dotted line represents the number of children hospitalized with mild-moderate COVID-19 disease; dashed line, children with severe (non-critical) disease; solid line, children with critical disease.

Figure 1.

Volume of Inpatient Discharges Over Time for Children Hospitalized with COVID-19 Stratified by Disease Severity The dotted line represents the number of children hospitalized with mild-moderate COVID-19 disease; dashed line, children with severe (non-critical) disease; solid line, children with critical disease.

Figure 2.

Trends in Medication Use Over Time for Children Hospitalized with COVID-19 Stratified by Disease Severity Vertical line indicates IDSA Guideline Version 3.5.1 online publication December 2, 2020. Solid orange line represents the trend of medication use pre-guideline; dashed orange line, the post-guideline trend; blue line, the projected trend post-guideline if no change occurred with guideline publication; p-value, the change in slope pre- to post-guideline.