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Association of empiric antibiotic selection and clinical outcomes in hospitalised children with severe orbital infections: a retrospective cohort study
  1. Carsten Krueger1,
  2. Emily Lan-Vy Nguyen2,
  3. Sanjay Mahant2,3,4,5,
  4. Cornelia M Borkhoff2,3,4,5,
  5. Jessica Cichon4,
  6. Olivier Drouin6,7,8,
  7. Catherine Pound9,10,
  8. Julie Quet9,10,
  9. Gita Wahi11,
  10. Ann Bayliss12,
  11. Gemma Vomiero1,
  12. Jessica Foulds13,14,
  13. Ronik Kanani15,
  14. Mahmoud Sakran16,
  15. Anupam Sehgal17,
  16. Eleanor Pullenayegum4,18,
  17. Elysa Widjaja2,
  18. Arun Reginald2,19,
  19. Nikolaus Wolter2,20,
  20. Patricia Parkin2,3,4,5,
  21. Peter J Gill2,3,4,5
  22. on behalf of Periorbital and Orbital Cellulitis (POC) Multicenter Study Group and the Canadian Paediatric Inpatient Research Network (PIRN)
    1. 1Alberta Children's Hospital, Calgary, Alberta, Canada
    2. 2The Hospital for Sick Children, Toronto, Ontario, Canada
    3. 3Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada
    4. 4Child Health Evaluative Sciences, SickKids Research Institute, Toronto, Ontario, Canada
    5. 5Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
    6. 6Division of General Pediatrics, CHU Sainte-Justine, Montreal, Quebec, Canada
    7. 7Department of Social and Preventive Medicine, School of Public Health, Université de Montréal, Montreal, Quebec, Canada
    8. 8Division of General Pediatrics, Department of Pediatrics, CHU Sainte-Justine, Montreal, Quebec, Canada
    9. 9Department of Pediatrics, University of Ottawa, Ottawa, Ontario, Canada
    10. 10Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada
    11. 11Department of Pediatrics, McMaster University Faculty of Health Sciences, Hamilton, Ontario, Canada
    12. 12Department of Pediatrics, Trillium Health Partners, Mississauga, Ontario, Canada
    13. 13Stollery Children's Hospital, Edmonton, Alberta, Canada
    14. 14Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
    15. 15North York General Hospital, Toronto, Ontario, Canada
    16. 16Lakeridge Health, Oshawa, Ontario, Canada
    17. 17Kingston Health Sciences Centre, Kingston, Ontario, Canada
    18. 18Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
    19. 19Department of Ophthalmology and Visual Sciences, University of Toronto, Toronto, Ontario, Canada
    20. 20Department of Otolaryngology - Head & Neck Surgery, University of Toronto, Toronto, Ontario, Canada
    1. Correspondence to Dr Peter J Gill, Department of Pediatrics, University of Toronto, Toronto, Canada; peter.gill{at}sickkids.ca

    Abstract

    Objective To determine the association of initial empiric antibiotic regimens with clinical outcomes in hospitalised children with severe orbital infections.

    Design Multi-centre observational cohort study using data from 2009 to 2018 clinical records.

    Setting Canadian children’s hospitals (7) and community hospitals (3).

    Patients Children between 2 months and 18 years hospitalised for >24 hours with severe orbital infections.

    Interventions Empiric intravenous antibiotic regimen in the first 24 hours of hospitalisation.

    Main outcome measures Length of hospital stay and surgical intervention using multivariable median regression and multivariate logistic regression, with adjustment for covariates.

    Results Of 1421 patients, 60.0% were male and the median age was 5.5 years (IQR 2.4–9.9). Median length of stay was 86.4 hours (IQR 56.9–137.5) and 180 (12.7%) received surgical intervention. Patients receiving broad-spectrum empiric antibiotics had an increased median length of stay, ranging from an additional 13.8 hours (third generation cephalosporin and anaerobic coverage) to 19.5 hours (third generation cephalosporin, staphylococcal and anaerobic coverage). No antibiotic regimen was associated with a change in the odds of surgical intervention. These findings remained unchanged in sensitivity analyses restricted to more severely ill patients. There was a twofold increase in the percentage of patients receiving the broadest empiric antibiotic regimens containing both staphylococcal and anaerobic coverage from 17.8% in 2009 to 40.3% in 2018.

    Conclusions Empiric use of broad-spectrum antibiotics with staphylococci and anaerobic coverage was associated with longer length of stay and similar rates of surgery in children with orbital infections. There is an urgent need for comparative effectiveness studies of various antibiotic regimes.

    • Infectious Disease Medicine
    • Paediatrics
    • Child Health
    • Ophthalmology

    Data availability statement

    All data relevant to the study are included in the article or uploaded as supplementary information. Not applicable.

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    Data availability statement

    All data relevant to the study are included in the article or uploaded as supplementary information. Not applicable.

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    Footnotes

    • CK and EL-VN are joint first authors.

    • X @peterjgill

    • Collaborators The Periorbital and Orbital Cellulitis (POC) Multicenter Study Group include: Semipe Oni, Rashid Anwar, Dana Arafeh, Carol Chan, Nurshad Begum (Hospital for Sick Children, Toronto, Ontario, Canada); Hossam Louriachi, Camille Bédard-Gauthier (CHU Sainte-Justine, Montreal, Quebec, Canada); Yipeng Ge, Nardin Kirolos (Children’s Hospital of Eastern Ontario (CHEO), Ottawa, Ontario, Canada); Ashaka Patel (McMaster University, McMaster Children’s Hospital, Hamilton, Ontario, Canada); Hardika Jasani, Emily Kornelsen, Yasmeen Razvi (Joanna Matthews Trillium Health Partners, Mississauga, Ontario, Canada); Ashton Chugh, Olivia Genereux, Jovey Sharma, Jessica Cooper, Natalie Czuczman, Rouzbeh Ghadiry-Tavi (Alberta Children’s Hospital, Calgary, Alberta, Canada); Sandra Gouda (Stollery Children’s Hospital, Edmonton, Alberta, Canada); Susan Akbaroghli (North York General Hospital, Toronto, Ontario, Canada); Morgyn McKerlie (Kingston Health Sciences Centre, Kingston, Ontario, Canada); Jack Warren, Natascha Kozlowski (Lakeridge Health, Oshawa, Ontario).

    • Contributors PJG, PP and SM participated in conceptualisation and study design, interpretation of results, drafting of initial manuscript and critical review and manuscript revision. CK, EL-VN, JC and CMB participated in study design, data analysis, interpretation of results and critical review and manuscript revision. OD, CP, JQ, GW, AB, GV, RK, MS, AS, EP, EW, AR and NW. NW designed the data collection instruments, collected data and reviewed and revised the manuscript. All authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work. PJG is guarantor.

    • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors. The Pediatric Outcomes Research Team (PORT) is supported by a grant from the Hospital for Sick Children Foundation.

    • Competing interests PJG has received grants from the Canadian Institutes of Health Research (CIHR), the PSI Foundation and The Hospital for Sick Children. He has received non-financial support from the EBMLive Steering Committee (expenses reimbursed to attend conferences) and the CIHR Institute of Human Development, Child and Youth Health (as a member of the institute advisory board, expenses reimbursed to attend meetings), is a member of the CMAJ Open and BMJ Evidence-Based Medicine Editorial Board. OD was supported by a Chercheur Boursier Clinicien Award, from the Fonds de recherche du Québec – Santé. PP has received grants from the Hospital for Sick Children Foundation and CIHR. The other authors have no conflicts of interest to disclose.

    • Provenance and peer review Not commissioned; externally peer reviewed.

    • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.