139 - COVID-19 Medications and Adherence to Treatment Guidelines in Hospitalized Children

Poster Number: 139
Publication Number: 139.416

Julianne E. Burns, Stanford University School of Medicine, Redwood City, CA, United States; Cary Thurm, Children's Hospital Association, Lenexa, KS, United States; James W. Antoon, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, TN, United States; Carlos Grijalva, Vanderbilt University Medical Center, Nashville, TN, United States; Adam Hersh, University of Utah School of Medicine, Salt Lake City, UT, United States; Gabrielle Z. Hester, Children's Hospitals and Clinics of Minnesota, Duluth, MN, United States; Emilie Korn, Childrens Hospital of Philadelphia, Philadelphia, PA, United States; Mario A. Reyes, Florida International University Herbert Wertheim College of Medicine, Miami, FL, United States; Samir S. Shah, Journal of Hospital Medicine, Cincinnati, OH, United States; Balagangadhar R. Totapally, Nicklaus Children’s Hospital, Miami, FL, United States; Ronald J. Teufel, Medical University of South Carolina, Charleston, SC, United States

Background: COVID-19 guidelines for hospitalized children rapidly evolved during the pandemic. The December 2020 Infectious Diseases Society of America (IDSA) guideline consolidated key treatment recommendations and was endorsed by the Pediatric Infectious Disease Society. Steroids were recommended for critically ill children (mechanical ventilation, sepsis/multiorgan failure). Steroids and remdesivir were suggested for severe disease (SpO2 ≤ 94%). Hydroxychloroquine was not recommended, including in combination with azithromycin.

Objective: We evaluated how use of medications for children hospitalized with COVID-19 changed after publication of the December 2020 IDSA guidelines. We included trends in anticoagulation to prevent thrombotic complications and antibiotics for bacterial infections.

Design/Methods: We performed a multicenter retrospective cohort study of children ages 30 days to less than 18 years of age hospitalized with COVID-19 at 49 tertiary care U.S. children’s hospitals. We compared medication use in children hospitalized with COVID-19 before and after the December 2020 IDSA guideline (pre- and post-guideline). Comparisons were stratified by COVID-19 disease severity categories (mild-moderate, severe, and critical), and United States regions.

Results: Among 8,151 patients who met selection criteria, 59% (4807) were discharged from their index hospitalization in the post-guideline period (Table 1). While hydroxychloroquine abruptly decreased early in the pandemic, remdesivir and steroids gradually increased across the study period (Figure 1). An increase in remdesivir and steroids relative to the pre-guideline period was consistent across disease severity categories (Table 2). In the post-guideline period, among patients with severe disease, 65.7% received steroids and 40.9% remdesivir, and in those with critical disease, 81.5% received steroids and 27.2% remdesivir. Compared with the pre-guideline period, enoxaparin decreased in patients with critical disease. Antibiotics decreased across all disease severity categories, although remained high in patients with severe (54.2%) and critical disease (82.1%). Across all geographic regions, the use of remdesivir increased and antibiotics decreased. Steroid use increased in all regions except the West.Conclusion(s): Although utilization of COVID-19 therapies changed following the December 2020 IDSA guidelines, there was still incomplete adherence in the post-guideline period especially for children with severe and critical disease. Efforts should be aimed at enhancing reliable delivery of guideline-directed therapies to children hospitalized with COVID-19.
Table 1. Comparison of Demographics, COVID-19 Disease Severity, Medications, and Geographic Distribution across Pre/Post-Guideline Periods of COVID-19 Pandemic*Excluding azithromycin. Disease Severity Categories: Mild-moderate patients did not require the intensive care unit (ICU) or have ICD-10 codes consistent with respiratory failure. Severe non-critical patients included patients diagnosed with respiratory failure or in the ICU but without invasive mechanical ventilation, extracorporeal membrane oxygenation (ECMO), shock, sepsis, or death. Critical patients were in the ICU with invasive mechanical ventilation, ECMO, shock, sepsis, or death.
Figure 1. Medication Trends Stratified by COVID-19 Disease Severity