Systematic Review of Antimicrobial Lock Solutions for Prevention of Bacteremia in Pediatric Patients With Intestinal Failure

OBJECTIVES

The goal of this systematic review was to determine whether antimicrobial lock (AML) solutions prevent catheter-related bloodstream infections (CRBSI) in children with intestinal failure (IF).

METHODS

Electronic databases were searched: Ovid MEDLINE (1946-), Ovid Embase (1974-), Wiley Cochrane Library (inception-), and Web of Science Core Collection via Clarivate Analytics (1900-). Randomized and nonrandomized trials, case or cohort studies that studied any AML solution, and used comparator groups were included if they studied children with IF. A meta-analysis compared the rates of CRBSI with AML solutions versus controls, and a Boucher analysis was used to indirectly compare AML solutions.

RESULTS

Twenty-eight studies met eligibility criteria (1 open label and 27 observational studies). Quality was good (N = 13), fair (N = 9), and poor (N = 6). All but 4 studied ethanol and taurolidine. Of 15 ethanol studies, 11 reported a decrease and 3 reported a trend toward a decreased incidence of CRBSI compared to controls; 1 reported no difference. Of 9 taurolidine studies, 7 reported a decrease and 2 a trend toward decreased CRBSI rates. There was a decrease in CRBSI with ethanol versus control ( P = 0.008) and with taurolidine-citrate versus control ( P < 0.0005). Using Bucher indirect comparison of the pooled estimates from ethanol versus control to taurolidine versus control, the estimated difference was -0.99 (-4.125, 2.27; P = 0.55).

CONCLUSIONS

There were no randomized trials and over half of the 28 included studies were fair or poor quality. All but 1 reported at least a trend toward reduction in CRBSI. AML solutions appear to prevent CRBSI.

A150 MODERATE AGREEMENT IN ENDOSCOPIC DISEASE SCORING OF PEDIATRIC EOSINOPHILIC ESOPHAGITIS AMONG PEDIATRIC GASTROENTEROLOGISTS IN CANADA

Background

Endoscopy is an important tool in assessing the severity of gastrointestinal diseases including Eosinophilic Esophagitis (EoE). Agreement regarding endoscopy outcomes is important when using tools such as the Endoscopic Reference Score for EoE (EREFS).

Purpose

Our goal was to determine interrater and intrarater agreement of EREFS among Canadian pediatric gastroenterologists.

Method

Survey-based study of interrater and intrarater reliability amongst pediatric gastroenterologists with interest in pediatric EoE. Participants were sourced from the Canadian Pediatric EoE Network. Participants were asked how many years of training they’ve had with endoscopy for pediatric EoE and their comfort in disease scoring for pediatric EoE. Pediatric EoE cases were identified from the pediatric EoE registry at the Stollery Children’s Hospital with an endoscopic video associated with each case. Participants were asked to score each video using the EREFS questionnaire for the proximal, middle and distal segments of the esophagus. 15 endoscopic videos were evaluated, with 3 cases provided each week over a period of 5 weeks. Additional data included ratings of the video quality and endoscopy quality. Of 15 cases, 12 were unique cases, distributed evenly in severity between no active disease to severe disease. 3 cases were repeated to assess intrarater reliability. The maximum grade of the proximal, middle and distal segments of the esophagus for each component endoscopic finding (edema, rings, exudates, furrows, strictures) were used for reliability calculations. Fleiss Kappa was calculated for all EREFS items and for each component endoscopic finding. Cohen’s Kappa was calculated to assess intrarater reliability.

Result(s)

Fifteen participants were recruited for the study. The participants had a median of 12 years (IQR: 7, 19) of clinical experience in endoscopy for pediatric EoE. The majority of participants were “comfortable” (i.e., 4 on 5-point scale) with EREFS scoring for pediatric EoE. Fleiss Kappa for all EREFS items was 0.481. For each component endoscopic finding (edema, rings, exudates, furrows, strictures), Fleiss Kappa was 0.365, 0.293, 0.548, 0.263, 0.445 respectively. Cohen’s Kappa had a median of 0.620 (IQR: 0.593, 0.704). The majority of raters rated video quality and endoscopy quality as “good” (i.e., 4 on 5-point scale).

Conclusion(s)

There is moderate interrater reliability in EREFS scoring for pediatric EoE. Interrater reliability was between fair to moderate for each component endoscopic finding. Intrarater reliability was good. This study shows there is room for improvement in disease scoring for pediatric EoE. This could be in the form of additional training, expert-defined conventions, or centralized reading which have reduced variability in endoscopic reporting for adult GI disease in past studies and could be used in a follow-up study to attempt to improve agreement. Additionally, incorporating EREFS into routine clinical practice may increase agreement amongst endoscopists.

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None

Disclosure of Interest

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A143 PEDIATRIC EOSINOPHILIC ESOPHAGITIS IN CANADA: A MULTI-CENTER COHORT WITH FOCUS ON THE STRICTURING PHENOTYPE

Background

Eosinophilic esophagitis (EoE) is a chronic eosinophil-predominant esophageal inflammatory condition, and is now recognized as one of the most common organic causes of dysphagia in pediatrics. While fibrostenotic esophageal strictures are a common complication of adult EoE, characterization of the stricturing phenotype in pediatric EoE remains at an early stage.

Purpose

Describe the Canadian pediatric EoE experience, with focus on the stricturing phenotype.

Method

New pediatric EoE diagnoses from 2015-2018 were retrospectively identified in Vancouver (BC), Northern Alberta (AB), Hamilton (ON) and Nova Scotia (NS). Incidence rates were calculated using 2016 Federal census data. Clinical, endoscopic and histologic data were gathered for each patient’s initial clinical encounter and for any esophagogastroduodenoscopies (EGD) until the end of the follow-up period (fall 2019).

Result(s)

332 new EoE cases were identified during the study period across all 4 sites. The incidence of EoE in patients less than 15 years old was 9.1 (AB), 6.5 (NS), 3.1 (BC) and 5.4 (combined) per 100,000 person-years. Incidence was not calculated for Hamilton due to risk of ascertainment bias given their catchment area overlaps with multiple other centers. Of identified cases, 40 (12.0%) had endoscopically-identified esophageal strictures at diagnosis or during the follow-up period, with a subset of 11 (3.3%) of these patients undergoing mechanical esophageal dilation. Another 11 (3.3%) patients had more subtle signs of esophageal narrowing (ex. mucosal rents), while the majority had no evidence of esophageal narrowing (281, 84.6%). The median age at diagnosis was higher in the cohort with strictures (12.4 years, IQR 8.9-14.1) than those without (10.3 years, IQR 6.1-13.6) but with wide IQR's. A similar trend was seen for the median duration of symptoms at diagnosis (1.5 years, IQR 0.5-3 versus 1.0 years, IQR 0.6-2.8). Patient reported food bolus impaction (OR 9.8, 95% CI 3.9-19.9) and dysphagia (OR 3.3, 95% CI 1.3-7.8) were associated with stricturing disease, with other symptoms less clearly linked. Trachealization was the endoscopic finding most closely associated with esophageal strictures (OR 5.7, 95% CI 2.8-11.5). Esophageal stricture(s) were noted on 72 EGDs, including 27 endoscopic esophageal dilations, but excluding 10 esophageal dilations by interventional radiology. Of the 65 EGDs done in follow-up of a known esophageal stricture (see Table), 4 of 31 had resolution of this finding post mechanical dilation, and 19 of 39 had resolution of the stricture after initiation of new medical or dietary treatments (without dilation).

Conclusion(s)

EoE is common in Canadian children, with esophageal strictures within a few years of diagnosis in 12% of cases. Interestingly, a large portion of strictures resolved without mechanical dilation, which seems to point away from fibrosis as the primary driver of esophageal strictures in this patient population.

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CAG, Other

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Women and Children's Health Research Institute

Disclosure of Interest

None Declared

Incidence of Pediatric Eosinophilic Esophagitis and Characterization of the Stricturing Phenotype in Alberta, Canada

Limited work has been done to characterize the stricturing pediatric eosinophilic esophagitis (EoE) phenotype. We aimed to determine, in pediatric EoE: the local incidence, the frequency of esophageal stricturing, and the safety of mechanical dilations.

Methods

We retrospectively identified all new cases of EoE at our center from 2015 to 2018 using esophageal biopsy reports, EoE clinic lists, and a local OR database of esophageal dilatations. Electronic medical records (EMRs) were reviewed to confirm EoE diagnosis. Clinical data were captured from the outpatient EMR and gastroscopy/pathology reports. Scope adverse event data were captured from multiple sources. The 2016 census data were used to calculate incidence rates.

Results

One hundred eighty-five new cases of EoE were diagnosed during the study period. For patients <15 years old living in Edmonton, the incidence over the 4 years was 11.1 cases per 100,000 person years. Eight of 185 (4%) patients had endoscopically confirmed esophageal strictures, 4 of which required mechanical dilation. Eleven of 185 (5.9%) patients had more subtle signs of esophageal narrowing, but no focal strictures. No perforations or episodes of significant bleeding were reported. Pain was reported after 15% of all scopes, including 50% of the 28 scopes with focal strictures. No unexpected admissions or emergency department visits occurred within 72 hours of a gastroscope with esophageal narrowing.

Conclusions

Edmonton zone has one of the highest incidences of pediatric EoE reported. In this cohort, 4% had focal esophageal strictures, and 6% had more subtle narrowing. Mechanical dilation of esophageal strictures was associated with no significant adverse events.

Canadian Nationwide Survey on Pediatric Malnutrition Management in Tertiary Hospitals

Background: Disease-associated malnutrition (DAM) is common in hospitalized children. This survey aimed to assess current in-hospital practices for clinical care of pediatric DAM in Canada. Methods: An electronic survey was sent to all 15 tertiary pediatric hospitals in Canada and addressed all pillars of malnutrition care: screening, assessment, treatment, monitoring and follow-up. Results: Responses of 120 health care professionals were used from all 15 hospitals; 57.5% were medical doctors (MDs), 26.7% registered dietitians (RDs) and 15.8% nurses (RNs). An overarching protocol for prevention, detection and intervention of pediatric malnutrition was present or “a work in progress”, according to 9.6% of respondents. Routine nutritional screening on admission was sometimes or always performed, according to 58.8%, although the modality differed among hospitals and profession. For children with poor nutritional status, lack of nutritional follow-up after discharge was reported by 48.5%. Conclusions: The presence of a standardized protocol for the clinical assessment and management of DAM is uncommon in pediatric tertiary care hospitals in Canada. Routine nutritional screening upon admission has not been widely adopted. Moreover, ongoing nutritional care of malnourished children after discharge seems cumbersome. These findings call for the adoption and implementation of a uniform clinical care pathway for malnutrition among pediatric hospitals.

A14 WIDE VARIATION IN CLINICAL MANAGEMENT OF PAEDIATRIC EOSINOPHILIC ESOPHAGITIS: A CANADIAN EXPERIENCE

Background

Eosinophilic esophagitis (EoE) is a chronic disorder treated by food elimination diet (FED), topical steroids and/or proton-pump inhibitors (PPI). Serial endoscopies and biopsies assess response to therapy. EoE management has evolved as guidelines are updated.

Aims

To identify practice variation among Canadian paediatric gastroenterologists (PG) who care for children with EoE.

Methods

An online survey using REDCap about decision-making in children with EoE was distributed to PG in Canada in November 2020.

Results

62 PG completed the survey (response rate 69%, 62/94). The majority work in academic centres (92%). 3 centers indicated an accrual of &gt;50 new patients per year; 9/16 centres have &gt;100 patients in follow-up. An EoE Clinic is present in 5 centres.

Diagnosis: Familiarity with the 2018 AGREE and 2020 AGA EoE guidelines was found to be 57% and 67% respectively. Criteria required to diagnose EoE according to current guidelines were correctly indicated by 42% of PG. (Figure 1).

Endoscopy: The majority of PG (95%) adhere to guidelines in terms of required number and location of biopsies for the initial diagnosis. Ideal timing of repeat endoscopy after change in therapy in patients who are not in histological remission was 8–12 weeks by 67% of PG, timing in stable patients on maintenance therapy varied (33% only if patient is symptomatic). 25% used the EREFS Score in reporting endoscopic findings.

Therapy: Improvement of symptoms was the highest ranked goal (64%), followed by remission of histologic findings (30%). A treatment algorithm was in place in 4 centers. The majority routinely assess adherence to therapy (73%) and consult a dietitian for FED (77%). Most (87%) do not consult an allergist for initial management. Preferred choices of 1st-line therapy varied among PG (Figure 2). When FED was selected, 32% of PG started with 1 food, 32% started with 2 foods, most frequently excluding dairy, followed by wheat. 14 (26%) start with ≥6 FED. Prescription of budesonide slurry was consistent among PG with doses of 1 and 2 mg/day in children &lt;10 and &gt;10 years, respectively.

Conclusions

The is the first Canadian study to assess the variation in management of children with EoE by PG. Overall, PG demonstrated good adherence to the guidelines in terms of initial diagnosis, but differences in maintenance therapy choice and timing of endoscopies. The results highlight a need for standardized management algorithms to deliver uniform care to this growing group. Grounding these guidelines in evidence will warrant a significant investment in further paediatric EoE research.

Funding Agencies

None

FODMAP intake in children with coeliac disease influences diet quality and health-related quality of life and has no impact on gastrointestinal symptoms

Children with coeliac disease (CD) following the gluten-free diet may experience ongoing gastrointestinal symptoms despite strict adherence. The study objective was to evaluate the association between foods high in fermentable oligo/di/monosaccharides, and polyols (FODMAP) and gastrointestinal symptoms, and the potential implications to diet quality and health-related quality of life in CD children. Dietary intake was studied in age-sex matched children 5-18 years (CD, n = 46; non-coeliac mild chronic gastrointestinal complaints [GIC], n = 46; healthy controls [HC], n = 46). CD children consumed fewer foods high in FODMAPs compared to GIC and HC (p < .0001). FODMAP intake was not related to gastrointestinal symptoms in CD children (p > 0.05) but was positively associated with child health-related quality of life (p < 0.05). FODMAP intake from fruits and vegetables was positively associated with diet adequacy and total diet quality in CD children (p < 0.05). FODMAP intake may influence diet quality and health-related quality of life but has no impact on gastrointestinal symptoms in CD children.

A196 INCIDENCE OF PEDIATRIC EOSINOPHILIC ESOPHAGITIS IN EDMONTON ZONE AND RISK OF STRICTURING AT DIAGNOSIS

Background

Eosinophilic esophagitis (EoE) is a common cause of esophageal dysfunction in children. A subset of children have a more severe phenotype of EoE, complicated by esophageal stricturing. Limited work has been done to characterize this phenotype.

Aims

To determine the incidence of EoE, and the frequency of esophageal stricturing in pediatric EoE.

Methods

We retrospectively identified all new cases of EoE at the Stollery Children’s Hospital from 2015–2018 using esophageal biopsy reports for the province of Alberta (CoPath database), EoE clinic lists and an OR database for esophageal dilatation at the Stollery. Electronic medical records (EMR) were reviewed to confirm EoE diagnosis. For each confirmed case, clinical data was captured from the outpatient EMR and gastroscopy/pathology reports. A review of peri-endoscopy OR/nursing charts was performed on a subset of patients (n=75) to capture scope adverse event. Statistics Canada 2016 census data was used to calculate incidence rates.

Results

185 new cases of EoE were diagnosed at our center during the study period (see table). For patients &lt; 15 years old living in Edmonton zone (n=73), the incidence over the 4 years was 11.1 cases per 100,000 person years {8.7 (0–4 year-old), 7.6 (5–9 year old), and 18.1 (10–14 year old)}. There was limited variation in incidence in the 4 years (9.1–12.1 per 100,000 person years). 8 of 185 (4%) patients had endoscopically confirmed esophageal strictures, 4 of which required mechanical dilation (mean 3.75 dilations per patient, range 1–6). 11/185 (5.9%) patients had more subtle signs of esophageal narrowing, but no strictures. No perforations or episodes of significant bleeding were reported in peri-endoscopy charts reviewed for 239 gastroscopes, including 16 dilations. Pain was reported after 15% of all scopes, including 50% of the 28 scopes with strictures and 63% of the 16 scopes involving dilations.

Conclusions

Edmonton zone has one of the highest incidences of EoE reported in children. In this cohort, 4% had esophageal stricture (half required dilatation) and 5.9% had more subtle narrowing. Patients with strictures were older, had more frequent food impaction and longer duration of symptoms (Table). This data will be included in an ongoing multicenter case-control study across Canada.

Funding Agencies

CAGWomen and Children’s Health Research Institute (Univ. Alberta)

Clostridium ventriculi Infection in a Child with Phenylketonuria

Disabled individuals may be at risk for common and rare infections. We report on a 13-year-old female who had a diagnosis of phenylketonuria (PKU). The child received a percutaneous endoscopic gastrostomy (PEG) feeding tube at five years of age for the supplementation of her specialized formula. After eight years, she no longer required the gastrostomy tube for formula supplementation, and she presented for the closure of the gastrocutaneous fistula tract. The histological examination revealed acute and chronic inflammation and colonization by gram-positive bacteria with a characteristic tetrad packet arrangement known as Clostridium ventriculi (formerly Sarcina ventriculi). A review of the literature evidenced the rarity of this infection in children. This patient is the 11^th case of such infection in literature, and the first patient affected with PKU. Physically and mentally disabled children are particularly vulnerable to infection because of their different feeding abilities, toilet needs, and sanitary arrangements.

Screening for Pediatric Malnutrition at Hospital Admission: Which Screening Tool Is Best?

Background

Identifying children at malnutrition risk on admission to hospital is considered best practice; however, nutrition screening in pediatric populations is not common. The aim of this study was to determine which screening tool is able to identify children with malnutrition on admission to hospital.

Methods

A nurse administered 2 pediatric nutrition screening tools, Screening Tool for Risk on Nutritional Status and Growth (STRONGkids) and Pediatric Nutrition Screening Tool (PNST) to patients admitted to medicine and surgery units (n = 165). The Subjective Global Nutritional Assessment (SGNA) was then completed by a dietitian, blinded to the results of the screens. Sensitivity, specificity, and κ were calculated for both screening tools against the SGNA. A receiver operating characteristic (ROC) curve assessed alternate cutoffs for each tool. Length of hospital stay (LOS) was used to assess prospective validity.

Results

Using the recommended cutoffs, the sensitivity of STRONGkids was 89%, specificity 35%, and κ 0.483. The sensitivity of PNST was 58%, specificity 88%, and κ 0.601. Using adjusted cutoffs, PNST's sensitivity improved to 87%, specificity 71%, and κ 0.681, and STRONGkids specificity improved to 61%, sensitivity 80%, and κ 0.5. Children identified at nutrition risk had significantly longer LOS (P < 0.05).

Conclusion

This study showed neither tool was appropriate for clinical use based on published cutoffs. By adjusting the cutoffs using ROC curve analysis, both tools improved overall agreement with the SGNA without significantly impacting the prospective validity. PNST with adjusted cutoffs is the most appropriate for clinical use in this population.

A multicentre assessment of prostate MRI quality and compliance with UK and international standards

AIM

To assess prostate magnetic resonance imaging (MRI) image quality and compliance with technical standards between centres in the South West region of the UK.

MATERIALS AND METHODS

Fifteen imaging sites in the region submitted seven consecutive anonymised MRI studies. These were assessed by two experienced radiologists in consensus. Overall, subjective image quality for T2-weighted imaging (T2W), diffusion weighted imaging (DWI), and dynamic contrast enhancement (DCE) was scored on a five-point Likert scale. Five additional quality parameters were also assessed visually, including image noise, motion, artefact, and distortion. The degree of compliance by each site with 21 published technical standards was also assessed.

RESULTS

Ninety-four MRI examinations were reviewed from across all sites (mean 6.3 scans per site, range 5-7). Mean compliance with technical standards was 63% (range 38-86%). Forty-seven percent of sites did not perform DCE. One site used a 3 T scanner. The percentage of patients with overall quality scores of ≥3 (diagnostically acceptable) were 68% for T2W, 81% for DWI, and 60% for both T2W and DWI. Ninety-three percent of the 45 patients who underwent DCE had diagnostically acceptable studies. By scanner age, the percentage of patients with diagnostically acceptable T2W scores was 53% for scanners ≥7 years and 80% when <7 years (p=0.006). Comparing individual sites, the mean overall quality scores were 2.9 (range 2.2-4.2) for T2W, 3.2 (1.8-4.7) for DWI, and 3.4 (2.5-4.7) for DCE.

CONCLUSION

There is wide variation in compliance with recognised technical standards and image quality across sites. If MRI is to replace biopsy in selected low-risk patients, improvements in image quality may be required.