{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,3,3]],"date-time":"2026-03-03T23:34:06Z","timestamp":1772580846429,"version":"3.50.1"},"reference-count":67,"publisher":"MDPI AG","issue":"6","license":[{"start":{"date-parts":[[2022,6,8]],"date-time":"2022-06-08T00:00:00Z","timestamp":1654646400000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"funder":[{"DOI":"10.13039\/501100002347","name":"German Federal Ministry of Education and Research","doi-asserted-by":"publisher","award":["01GY1713"],"award-info":[{"award-number":["01GY1713"]}],"id":[{"id":"10.13039\/501100002347","id-type":"DOI","asserted-by":"publisher"}]}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["Children"],"abstract":"<jats:p>Pediatric palliative care (PPC) patients with a severe neurologic impairment (SNI) suffer considerable morbidity and increased mortality from lower respiratory tract infections (LRTIs). The indication and choice of antibiotic therapy for bacterial LRTIs are often challenging given the lack of evidence-based treatment recommendations for this vulnerable patient population. We conducted an observational study before the SARS-CoV-2 pandemic in an eight-bed pediatric palliative care inpatient unit. During two years of surveillance, we diagnosed and treated 33 cases of a bacterial LRTI in patients with an SNI; 5 patients were hospitalized with an LRTI more than once. Two patients died from complications due to LRTIs during hospitalization. Three patients (15%) were colonized with multidrug-resistant organisms. An initial antibiotic treatment failed in one-third of the cases; a successful therapy of the LRTI was achieved with broad-spectrum and extended-spectrum penicillins (n = 13; in combination with \u03b2-lactamase inhibitors for n = 5 cases), cephalosporins (n = 13: n = 4 second-generation and n = 9 third-generation cephalosporins; in combination with other substances for n = 5 cases), ciprofloxacin (n = 3), and meropenem plus vancomycin (n = 2) or meropenem (n = 1). A respiratory specimen was obtained in 66.7% of cases with P. aeruginosa, E. coli, and K. pneumoniae accounting for the majority of the detected species. In most cases, there was no definite confirmation that the LRTI was caused by the species detected. The diagnostics and treatment of bacterial LRTIs in PPC patients with an SNI are challenging. The lack of controlled studies and the heterogeneity of this population often necessitate an individual approach. This lack of controlled studies may partly be compensated by a set of diagnostic and antibiotic stewardship criteria.<\/jats:p>","DOI":"10.3390\/children9060852","type":"journal-article","created":{"date-parts":[[2022,6,9]],"date-time":"2022-06-09T10:49:14Z","timestamp":1654771754000},"page":"852","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":7,"title":["Lower Respiratory Tract Infections in Pediatric Patients with Severe Neurological Impairments: Clinical Observations and Perspectives in a Palliative Care Unit"],"prefix":"10.3390","volume":"9","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-9618-5307","authenticated-orcid":false,"given":"Maximilian David","family":"Mauritz","sequence":"first","affiliation":[{"name":"Paediatric Palliative Care Centre, Children\u2019s and Adolescents\u2019 Hospital, Witten\/Herdecke University, 58448 Witten, Germany"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Carola","family":"Hasan","sequence":"additional","affiliation":[{"name":"Paediatric Palliative Care Centre, Children\u2019s and Adolescents\u2019 Hospital, Witten\/Herdecke University, 58448 Witten, Germany"},{"name":"Department of Children\u2019s Pain Therapy and Paediatric Palliative Care, Faculty of Health, School of Medicine, Witten\/Herdecke University, 58448 Witten, Germany"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Pia","family":"Schmidt","sequence":"additional","affiliation":[{"name":"Paediatric Palliative Care Centre, Children\u2019s and Adolescents\u2019 Hospital, Witten\/Herdecke University, 58448 Witten, Germany"},{"name":"Department of Children\u2019s Pain Therapy and Paediatric Palliative Care, Faculty of Health, School of Medicine, Witten\/Herdecke University, 58448 Witten, Germany"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-9558-3330","authenticated-orcid":false,"given":"Arne","family":"Simon","sequence":"additional","affiliation":[{"name":"Pediatric Oncology and Hematology, University Hospital Homburg Saar, 66421 Homburg, Germany"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Markus","family":"Knuf","sequence":"additional","affiliation":[{"name":"Department for Pediatric and Adolescent Medicine, Worms Clinic, 67550 Worms, Germany"},{"name":"Pediatric Infectious Diseases, University Medicine, 55131 Mainz, Germany"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-5875-3775","authenticated-orcid":false,"given":"Boris","family":"Zernikow","sequence":"additional","affiliation":[{"name":"Paediatric Palliative Care Centre, Children\u2019s and Adolescents\u2019 Hospital, Witten\/Herdecke University, 58448 Witten, Germany"},{"name":"Department of Children\u2019s Pain Therapy and Paediatric Palliative Care, Faculty of Health, School of Medicine, Witten\/Herdecke University, 58448 Witten, Germany"}],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"1968","published-online":{"date-parts":[[2022,6,8]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","first-page":"529","DOI":"10.1542\/peds.2010-0910","article-title":"Children with Medical Complexity: An Emerging Population for Clinical and Research Initiatives","volume":"127","author":"Cohen","year":"2011","journal-title":"Pediatrics"},{"key":"ref_2","doi-asserted-by":"crossref","first-page":"107","DOI":"10.1037\/fsh0000414","article-title":"Pediatric Palliative Care in the Medical Neighborhood for Children with Medical Complexity","volume":"37","author":"Yu","year":"2019","journal-title":"Fam. Syst. Health"},{"key":"ref_3","doi-asserted-by":"crossref","first-page":"662","DOI":"10.1016\/j.jpainsymman.2021.01.008","article-title":"Pediatric Palliative Care for Children with Severe Neurological Impairment and Their Families","volume":"62","author":"Bogetz","year":"2021","journal-title":"J. Pain Symptom Manag."},{"key":"ref_4","first-page":"302","article-title":"Inpatient Paediatric Palliative Care\u2014A Retrospective Study","volume":"17","author":"Garske","year":"2016","journal-title":"Z Palliativmed"},{"key":"ref_5","doi-asserted-by":"crossref","unstructured":"Hain, R., Devins, M., Hastings, R., and Noyes, J. (2013). Paediatric Palliative Care: Development and Pilot Study of a \u2018Directory\u2019 of Life-Limiting Conditions. BMC Palliat. Care, 12.","DOI":"10.1186\/1472-684X-12-43"},{"key":"ref_6","doi-asserted-by":"crossref","first-page":"1094","DOI":"10.1542\/peds.2010-3225","article-title":"Pediatric Palliative Care Patients: A Prospective Multicenter Cohort Study","volume":"127","author":"Feudtner","year":"2011","journal-title":"Pediatrics"},{"key":"ref_7","doi-asserted-by":"crossref","first-page":"1893","DOI":"10.1007\/s00431-019-03467-9","article-title":"Facing the Large Variety of Life-Limiting Conditions in Children","volume":"178","author":"Hoell","year":"2019","journal-title":"Eur. J. Pediatr."},{"key":"ref_8","doi-asserted-by":"crossref","first-page":"81","DOI":"10.1016\/j.ejpn.2020.09.001","article-title":"Severe Neurological Impairment: A Delphi Consensus-Based Definition","volume":"29","author":"Allen","year":"2020","journal-title":"Eur. J. Paediatr. Neuro."},{"key":"ref_9","doi-asserted-by":"crossref","first-page":"188","DOI":"10.1016\/j.jpeds.2016.02.049","article-title":"Community-Acquired Pneumonia Hospitalization among Children with Neurologic Disorders","volume":"173","author":"Millman","year":"2016","journal-title":"J. Pediatr."},{"key":"ref_10","doi-asserted-by":"crossref","first-page":"e20190543","DOI":"10.1542\/peds.2019-0543","article-title":"Pneumonia Prevention Strategies for Children with Neurologic Impairment","volume":"144","author":"Lin","year":"2019","journal-title":"Pediatrics"},{"key":"ref_11","doi-asserted-by":"crossref","unstructured":"Armann, J., Doenhardt, M., Hufnagel, M., Diffloth, N., Reichert, F., Haas, W., Schilling, J., Haller, S., H\u00fcbner, J., and Simon, A. (2021). Risk Factors for Hospitalization, Disease Severity and Mortality in Children and Adolescents with COVID-19: Results from a Nationwide German Registry. medRxiv, Available online: https:\/\/www.medrxiv.org\/content\/10.1101\/2021.06.07.21258488v1.article-info.","DOI":"10.1101\/2021.06.07.21258488"},{"key":"ref_12","doi-asserted-by":"crossref","first-page":"297","DOI":"10.1097\/MOP.0000000000000495","article-title":"Influenza in Children","volume":"29","author":"Kondrich","year":"2017","journal-title":"Curr. Opin. Pediatr."},{"key":"ref_13","doi-asserted-by":"crossref","first-page":"155","DOI":"10.2174\/1874285801105010155","article-title":"Respiratory Syncytial Virus Infection in Children with Neuromuscular Impairment","volume":"5","author":"Simon","year":"2011","journal-title":"Open Microbiol. J."},{"key":"ref_14","doi-asserted-by":"crossref","first-page":"156","DOI":"10.1016\/j.jpeds.2016.07.024","article-title":"Diagnostic Testing and Hospital Outcomes of Children with Neurologic Impairment and Bacterial Pneumonia","volume":"178","author":"Thomson","year":"2016","journal-title":"J. Pediatr."},{"key":"ref_15","doi-asserted-by":"crossref","first-page":"203","DOI":"10.1097\/00008480-200006000-00004","article-title":"Current Concepts of Respiratory Complications of Neuromuscular Disease in Children","volume":"12","author":"Schramm","year":"2000","journal-title":"Curr. Opin. Pediatr."},{"key":"ref_16","doi-asserted-by":"crossref","first-page":"S222","DOI":"10.1097\/01.inf.0000144670.78558.c7","article-title":"Viral Respiratory Infections in Children with Technology Dependence and Neuromuscular Disorders","volume":"23","author":"Panitch","year":"2004","journal-title":"Pediatr. Infect. Dis. J."},{"key":"ref_17","doi-asserted-by":"crossref","first-page":"152","DOI":"10.1016\/j.prrv.2006.04.009","article-title":"Scoliosis and the Respiratory System","volume":"7","author":"Koumbourlis","year":"2006","journal-title":"Paediatr. Respir. Rev."},{"key":"ref_18","doi-asserted-by":"crossref","first-page":"646","DOI":"10.1111\/dmcn.14060","article-title":"Respiratory Morbidity in Children with Cerebral Palsy: An Overview","volume":"61","author":"Boel","year":"2019","journal-title":"Dev. Med. Child Neurol."},{"key":"ref_19","doi-asserted-by":"crossref","first-page":"216","DOI":"10.3928\/00904481-20100318-06","article-title":"Pulmonary Complications of Pediatric Neurological Diseases","volume":"39","author":"Healy","year":"2010","journal-title":"Pediatr. Ann."},{"key":"ref_20","doi-asserted-by":"crossref","first-page":"151","DOI":"10.1016\/j.jpeds.2015.09.064","article-title":"Factors Associated with Respiratory Illness in Children and Young Adults with Cerebral Palsy","volume":"168","author":"Blackmore","year":"2016","journal-title":"J. Pediatr."},{"key":"ref_21","doi-asserted-by":"crossref","first-page":"625751","DOI":"10.3389\/fped.2021.625751","article-title":"All You Need Is Evidence: What We Know About Pneumonia in Children with Neuromuscular Diseases","volume":"9","author":"Cherchi","year":"2021","journal-title":"Front. Pediatr."},{"key":"ref_22","doi-asserted-by":"crossref","unstructured":"Souza, B.D., Richardson, S.E., Cohen, E., Mahant, S., Avitzur, Y., Carsley, S., and Rapoport, A. (2020). Gastric Flora in Gastrostomy Fed Children with Neurological Impairment on Antacid Medication. Children, 7.","DOI":"10.3390\/children7100154"},{"key":"ref_23","doi-asserted-by":"crossref","first-page":"75","DOI":"10.1136\/adc.88.1.75","article-title":"Respiratory Problems in Children with Neurological Impairment","volume":"88","author":"Seddon","year":"2003","journal-title":"Arch. Dis. Child"},{"key":"ref_24","doi-asserted-by":"crossref","first-page":"315","DOI":"10.1016\/j.jmii.2018.07.002","article-title":"Respiratory Tract Infections in Children with Tracheostomy","volume":"53","author":"Tan","year":"2020","journal-title":"J. Microbiol. Immunol. Infect."},{"key":"ref_25","doi-asserted-by":"crossref","unstructured":"Berry, J.G., Poduri, A., Bonkowsky, J.L., Zhou, J., Graham, D.A., Welch, C., Putney, H., and Srivastava, R. (2012). Trends in Resource Utilization by Children with Neurological Impairment in the United States Inpatient Health Care System: A Repeat Cross-Sectional Study. PLoS Med., 9.","DOI":"10.1371\/journal.pmed.1001158"},{"key":"ref_26","doi-asserted-by":"crossref","first-page":"767","DOI":"10.1111\/crj.12592","article-title":"Both Pharyngeal and Esophageal Phases of Swallowing Are Associated with Recurrent Pneumonia in Pediatric Patients","volume":"12","author":"Arslan","year":"2018","journal-title":"Clin Respir J"},{"key":"ref_27","doi-asserted-by":"crossref","first-page":"122","DOI":"10.1089\/jpm.2019.0654","article-title":"Multidrug-Resistant Organisms in Palliative Care: A Systematic Review","volume":"24","author":"Enninger","year":"2021","journal-title":"J Palliat Med"},{"key":"ref_28","doi-asserted-by":"crossref","first-page":"325","DOI":"10.1136\/adc.66.3.325","article-title":"Certified Cause of Death in Children and Young Adults with Cerebral Palsy","volume":"66","author":"Evans","year":"1991","journal-title":"Arch. Dis. Child"},{"key":"ref_29","doi-asserted-by":"crossref","first-page":"161","DOI":"10.1097\/00007611-199802000-00009","article-title":"Survival Rates Among Children with Severe Neurologic Disabilities","volume":"91","author":"Plioplys","year":"1998","journal-title":"South. Med. J."},{"key":"ref_30","doi-asserted-by":"crossref","first-page":"1626","DOI":"10.1002\/ppul.25306","article-title":"The Respiratory Problems of Patients with Cerebral Palsy Requiring Hospitalization: Reasons and Solutions","volume":"56","author":"Cinel","year":"2021","journal-title":"Pediatr. Pulm."},{"key":"ref_31","doi-asserted-by":"crossref","first-page":"E9","DOI":"10.1002\/ppul.23140","article-title":"Treating Dyspnea with Morphine Sulfate in Nonverbal Children with Neurological Impairment","volume":"50","author":"Hauer","year":"2015","journal-title":"Pediatr. Pulm."},{"key":"ref_32","first-page":"284","article-title":"Home Oxygen Therapy in Children with Chronic Respiratory Failure","volume":"126","author":"Bertrand","year":"1998","journal-title":"Rev. M\u00e9dica De Chile"},{"key":"ref_33","doi-asserted-by":"crossref","first-page":"e20160682","DOI":"10.1542\/peds.2016-0682","article-title":"Trends in Health Care Spending for Children in Medicaid with High Resource Use","volume":"138","author":"Agrawal","year":"2016","journal-title":"Pediatrics"},{"key":"ref_34","doi-asserted-by":"crossref","first-page":"1119","DOI":"10.1136\/archdischild-2017-314346","article-title":"Predicting Respiratory Hospital Admissions in Young People with Cerebral Palsy","volume":"103","author":"Blackmore","year":"2018","journal-title":"Arch. Dis. Child"},{"key":"ref_35","doi-asserted-by":"crossref","first-page":"621","DOI":"10.1111\/jpc.13163","article-title":"Medical Service Use in Children with Cerebral Palsy: The Role of Child and Family Characteristics","volume":"52","author":"Meehan","year":"2016","journal-title":"J. Paediatr. Child Health"},{"key":"ref_36","doi-asserted-by":"crossref","first-page":"72","DOI":"10.1542\/hpeds.2017-0106","article-title":"Length of Stay and Hospital Revisit After Bacterial Tracheostomy\u2013Associated Respiratory Tract Infection Hospitalizations","volume":"8","author":"Russell","year":"2018","journal-title":"Hosp. Pediatr."},{"key":"ref_37","first-page":"515","article-title":"Guidelines for the Management of Community Acquired Pneumonia in Children and Adolescents (Pediatric Community Acquired Pneumonia, PCAP)","volume":"74","author":"Rose","year":"2020","journal-title":"Pneumologie"},{"key":"ref_38","doi-asserted-by":"crossref","first-page":"e25","DOI":"10.1093\/cid\/cir531","article-title":"The Management of Community-Acquired Pneumonia in Infants and Children Older Than 3 Months of Age: Clinical Practice Guidelines by the Pediatric Infectious Diseases Society and the Infectious Diseases Society of America","volume":"53","author":"Bradley","year":"2011","journal-title":"Clin. Infect. Dis."},{"key":"ref_39","doi-asserted-by":"crossref","first-page":"214","DOI":"10.1111\/j.1469-8749.1997.tb07414.x","article-title":"Development and Reliability of a System to Classify Gross Motor Function in Children with Cerebral Palsy","volume":"39","author":"Palisano","year":"1997","journal-title":"Dev. Med. Child Neurol."},{"key":"ref_40","doi-asserted-by":"crossref","unstructured":"Schmidt, P., Hasan, C., Mauritz, M.D., Simon, A., Stening, K., Hartenstein-Pinter, A., Zernikow, B., and Wager, J. (2022). Multidrug-resistant Organisms in Paediatric Palliative Care Patients\u2014Prevalence, Risk Factors and the Impact of a Liberal Hygiene Concept. J. Paediatr. Child Health, Epub ahead of print.","DOI":"10.1111\/jpc.15980"},{"key":"ref_41","doi-asserted-by":"crossref","first-page":"67","DOI":"10.2165\/00151829-200403020-00001","article-title":"Guidelines for Community-Acquired Pneumonia\u2014Are They Reflected in Practice?","volume":"3","author":"Flanders","year":"2004","journal-title":"Treat. Respir. Med."},{"key":"ref_42","doi-asserted-by":"crossref","first-page":"164","DOI":"10.1016\/j.copsyc.2021.09.007","article-title":"Prosociality in the Social Dilemma of Antibiotic Prescribing","volume":"44","author":"Krockow","year":"2021","journal-title":"Curr. Opin. Psychol."},{"key":"ref_43","doi-asserted-by":"crossref","first-page":"1354","DOI":"10.1007\/s00247-019-04470-w","article-title":"Evaluation of Implanted Venous Port-a-Caths in Children with Medical Complexity and Neurologic Impairment","volume":"49","author":"Pezeshkpour","year":"2019","journal-title":"Pediatr. Radiol."},{"key":"ref_44","doi-asserted-by":"crossref","unstructured":"Rojas-Reyes, M., and Rugeles, C.G. (2006). Oral Antibiotics versus Parenteral Antibiotics for Severe Pneumonia in Children. Cochrane Database Syst. Rev., CD004979.","DOI":"10.1002\/14651858.CD004979.pub2"},{"key":"ref_45","doi-asserted-by":"crossref","first-page":"1132","DOI":"10.1089\/mdr.2019.0065","article-title":"Effective Oral Combination Treatment for Extended-Spectrum Beta-Lactamase-Producing Escherichia Coli","volume":"25","author":"Albalawi","year":"2019","journal-title":"Microb. Drug Resist."},{"key":"ref_46","doi-asserted-by":"crossref","first-page":"e20162706","DOI":"10.1542\/peds.2016-2706","article-title":"The Use of Systemic and Topical Fluoroquinolones","volume":"138","author":"Jackson","year":"2016","journal-title":"Pediatrics"},{"key":"ref_47","doi-asserted-by":"crossref","first-page":"874","DOI":"10.1136\/adc.2010.208843","article-title":"Ciprofloxacin Safety in Paediatrics: A Systematic Review","volume":"96","author":"Adefurin","year":"2011","journal-title":"Arch. Dis. Child"},{"key":"ref_48","doi-asserted-by":"crossref","unstructured":"Yu, P.-H., Hu, C.-F., Liu, J.-W., Chung, C.-H., Chen, Y.-C., Sun, C.-A., and Chien, W.-C. (2020). The Incidence of Collagen-Associated Adverse Events in Pediatric Population with the Use of Fluoroquinolones: A Nationwide Cohort Study in Taiwan. BMC Pediatr., 20.","DOI":"10.1186\/s12887-020-1962-0"},{"key":"ref_49","doi-asserted-by":"crossref","first-page":"341","DOI":"10.1016\/j.ijantimicag.2015.01.004","article-title":"Appropriate Use of Fluoroquinolones in Children","volume":"45","author":"Principi","year":"2015","journal-title":"Int. J. Antimicrob. Agents"},{"key":"ref_50","doi-asserted-by":"crossref","first-page":"1107","DOI":"10.1017\/ice.2019.215","article-title":"Prior Antibiotic Use and Acquisition of Multidrug-Resistant Organisms in Hospitalized Children: A Systematic Review","volume":"40","author":"Murray","year":"2019","journal-title":"Infect. Control Hosp. Epidemiol."},{"key":"ref_51","doi-asserted-by":"crossref","first-page":"j2739","DOI":"10.1136\/bmj.j2739","article-title":"Advances in the Diagnosis of Pneumonia in Children","volume":"358","author":"Zar","year":"2017","journal-title":"BMJ"},{"key":"ref_52","doi-asserted-by":"crossref","first-page":"348","DOI":"10.1016\/j.ijid.2022.01.026","article-title":"Induced Sputum as an Adequate Clinical Specimen for the Etiological Diagnosis of Community-Acquired Pneumonia (CAP) in Children and Adolescents","volume":"116","author":"Rueda","year":"2022","journal-title":"Int. J. Infect. Dis."},{"key":"ref_53","doi-asserted-by":"crossref","first-page":"135","DOI":"10.1097\/MOP.0000000000000713","article-title":"Advances in Pediatric Antimicrobial Agents Development","volume":"31","author":"Wood","year":"2019","journal-title":"Curr. Opin. Pediatr."},{"key":"ref_54","doi-asserted-by":"crossref","first-page":"141","DOI":"10.1016\/j.pcl.2021.09.003","article-title":"Multidrug-Resistant Infections in the Developing World","volume":"69","author":"Singh","year":"2022","journal-title":"Pediatric Clin. N. Am."},{"key":"ref_55","doi-asserted-by":"crossref","first-page":"56","DOI":"10.1093\/jpids\/piz085","article-title":"Treatment of Carbapenem-Resistant Enterobacteriaceae Infections in Children","volume":"9","author":"Chiotos","year":"2019","journal-title":"J. Pediatr. Infect. Dis. Soc."},{"key":"ref_56","doi-asserted-by":"crossref","first-page":"141","DOI":"10.1080\/08964289.2017.1288607","article-title":"Behavioral Interventions to Reduce Infections in Pediatric Long-Term Care Facilities: The Keep It Clean for Kids Trial","volume":"44","author":"Larson","year":"2017","journal-title":"Behav. Med."},{"key":"ref_57","doi-asserted-by":"crossref","first-page":"872","DOI":"10.1001\/jamapediatrics.2017.1482","article-title":"Incidence, Risks, and Types of Infections in Pediatric Long-Term Care Facilities","volume":"171","author":"Saiman","year":"2017","journal-title":"JAMA Pediatr."},{"key":"ref_58","doi-asserted-by":"crossref","first-page":"859","DOI":"10.1017\/ice.2016.73","article-title":"Impact of Infection Prevention and Control Initiatives on Acute Respiratory Infections in a Pediatric Long-Term Care Facility","volume":"37","author":"Murray","year":"2016","journal-title":"Infect. Control Hosp. Epidemiol."},{"key":"ref_59","doi-asserted-by":"crossref","first-page":"468","DOI":"10.1016\/j.ajic.2017.09.031","article-title":"Antimicrobial Stewardship in Pediatric Post-Acute Care Facilities","volume":"46","author":"Johnson","year":"2018","journal-title":"Am. J. Infect. Control"},{"key":"ref_60","doi-asserted-by":"crossref","first-page":"581","DOI":"10.1007\/s15010-018-1137-1","article-title":"Antibiotic Stewardship and Horizontal Infection Control Are More Effective than Screening, Isolation and Eradication","volume":"46","author":"Lemmen","year":"2018","journal-title":"Infection"},{"key":"ref_61","doi-asserted-by":"crossref","first-page":"357","DOI":"10.1016\/S0194-5998(98)70078-6","article-title":"Sinusitis in Neurologically Impaired Children","volume":"119","author":"Brook","year":"1998","journal-title":"Otolaryngol.\u2014Head Neck Surg."},{"key":"ref_62","doi-asserted-by":"crossref","first-page":"723","DOI":"10.1016\/j.cmi.2021.10.019","article-title":"A Host Signature Based on TRAIL, IP-10, and CRP for Reducing Antibiotic Overuse in Children by Differentiating Bacterial from Viral Infections: A Prospective, Multicentre Cohort Study","volume":"28","author":"Papan","year":"2021","journal-title":"Clin. Microbiol. Infect."},{"key":"ref_63","doi-asserted-by":"crossref","first-page":"e20180236","DOI":"10.1542\/peds.2018-0236","article-title":"Negative Chest Radiography and Risk of Pneumonia","volume":"142","author":"Lipsett","year":"2018","journal-title":"Pediatrics"},{"key":"ref_64","first-page":"CD011530","article-title":"Antibiotics for Preventing Lower Respiratory Tract Infections in High-risk Children Aged 12 Years and Under","volume":"9","author":"Onakpoya","year":"2015","journal-title":"Cochrane Database Syst. Rev."},{"key":"ref_65","doi-asserted-by":"crossref","first-page":"885","DOI":"10.1016\/j.cden.2015.06.007","article-title":"Does Treatment of Periodontal Disease Influence Systemic Disease?","volume":"59","author":"Borgnakke","year":"2015","journal-title":"Dent. Clin. N. Am."},{"key":"ref_66","first-page":"CD012628","article-title":"Oral Hygiene Interventions for People with Intellectual Disabilities","volume":"5","author":"Waldron","year":"2019","journal-title":"Cochrane Database Syst. Rev."},{"key":"ref_67","doi-asserted-by":"crossref","first-page":"7","DOI":"10.1370\/afm.2340","article-title":"Impact of Repeated Influenza Immunization on Respiratory Illness in Children with Preexisting Medical Conditions","volume":"17","author":"Venekamp","year":"2019","journal-title":"Ann. Fam. Med."}],"container-title":["Children"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/2227-9067\/9\/6\/852\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,10,10]],"date-time":"2025-10-10T23:26:01Z","timestamp":1760138761000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/2227-9067\/9\/6\/852"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2022,6,8]]},"references-count":67,"journal-issue":{"issue":"6","published-online":{"date-parts":[[2022,6]]}},"alternative-id":["children9060852"],"URL":"https:\/\/doi.org\/10.3390\/children9060852","relation":{},"ISSN":["2227-9067"],"issn-type":[{"value":"2227-9067","type":"electronic"}],"subject":[],"published":{"date-parts":[[2022,6,8]]}}}