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Berkhout A, Cheng DR, McNab S, Lee LY, Daley AJ, Clifford V. Clinical and Health System Impact of Biofire Filmarray Meningitis/Encephalitis Routine Testing of CSF in a Pediatric Hospital: An Observational Study. Pediatr Infect Dis J 2023; 42:281-285. [PMID: 36728816 DOI: 10.1097/inf.0000000000003812] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND Rapid cartridge-based molecular test panels targeting multiple pathogens are increasingly available, improve pathogen detection and reduce turn-around-time but are more expensive than standard testing. Confirmation that these test panels contribute to improved patient or health service outcomes is required. METHODS In March 2021, our pediatric hospital laboratory implemented the BioFire Filmarray™ meningitis/encephalitis (M/E) panel as an additional routine test for all cerebrospinal fluid (CSF) samples collected from infants <90 days or from any patient in the emergency department. A retrospective chart review was done to ascertain changes in clinical outcomes, antimicrobial prescribing practices, and hospital length of stay, comparing two discrete 6-month periods: preimplementation (March-August 2019) and postimplementation (March-August 2021). RESULTS Both pre- and postimplementation groups were similar at baseline, except the preimplementation group had a higher proportion of infants with enterovirus and parechovirus meningitis. There was no significant difference between the groups in terms of median length of stay (2.94 vs 3.47 days, p = 0.41), duration of antibiotic treatment (2.0 vs 2.3 days, p = 0.25), need for central venous access (12.9% vs 17%, p = 0.38) or hospital-in-the-home admission (9.4% vs 9%, p = 0.92). A similar proportion of infants received aciclovir (33% vs 31%), however, a reduction in duration was observed (1.36 vs 0.90 days, p = 0.03) in the postimplementation period. CONCLUSIONS Introduction of the Biofire Filmarray™ M/E panel for routine testing of CSF samples reduced the duration of antiviral prescribing but had only a minor impact on antibiotic prescribing practices or health service outcomes in our pediatric hospital. The introduction of new laboratory testing needs to be supported by a comprehensive stewardship program to see optimal outcomes from new testing platforms.
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Affiliation(s)
- Angela Berkhout
- Laboratory Services, Royal Children's Hospital, Parkville, Victoria, Australia
- Murdoch Children's Research Institute, Parkville, Victoria, Australia
- General Medicine, Royal Children's Hospital, Parkville, Victoria, Australia
- The University of Queensland, Faculty of Medicine, Brisbane. Queensland, Australia
- Department of Paediatrics, University of Melbourne, Victoria, Australia
- Infection Management & Prevention Service, The Queensland Children's Hospital, Brisbane, Queensland, Australia
| | - Daryl R Cheng
- General Medicine, Royal Children's Hospital, Parkville, Victoria, Australia
- The University of Queensland, Faculty of Medicine, Brisbane. Queensland, Australia
- Department of Paediatrics, University of Melbourne, Victoria, Australia
| | - Sarah McNab
- General Medicine, Royal Children's Hospital, Parkville, Victoria, Australia
- The University of Queensland, Faculty of Medicine, Brisbane. Queensland, Australia
- Department of Paediatrics, University of Melbourne, Victoria, Australia
| | - Lai-Yang Lee
- Laboratory Services, Royal Children's Hospital, Parkville, Victoria, Australia
| | - Andrew J Daley
- Laboratory Services, Royal Children's Hospital, Parkville, Victoria, Australia
- General Medicine, Royal Children's Hospital, Parkville, Victoria, Australia
- The University of Queensland, Faculty of Medicine, Brisbane. Queensland, Australia
| | - Vanessa Clifford
- Laboratory Services, Royal Children's Hospital, Parkville, Victoria, Australia
- Murdoch Children's Research Institute, Parkville, Victoria, Australia
- General Medicine, Royal Children's Hospital, Parkville, Victoria, Australia
- The University of Queensland, Faculty of Medicine, Brisbane. Queensland, Australia
- Department of Paediatrics, University of Melbourne, Victoria, Australia
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Abstract
Neonatal herpes simplex virus infection (HSV) is rare in neonates, with an estimated global incidence of 10 per 100,000 live births. Neonatal HSV is challenging to diagnose due to often vague signs and symptoms. Untreated, the mortality of some HSV subtypes exceeds 80%. Overtesting and overtreatment can result in prolonged hospitalizations and expose neonates to medication toxicity. In contrast, prompt evaluation and use of empiric antiviral therapy before the results of definitive testing can improve outcomes for infants with HSV. A wide degree of practice variation exists with respect to testing and treatment for neonatal HSV, and more research is required to safely risk-stratify this population. This review presents the epidemiology, risk factors, presenting features, and emergency department management of neonatal HSV infection.
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Keuning MW, van der Kuip M, van Hattem JM, Pajkrt D. Inconsistent Management of Neonatal Herpes Simplex Virus Infections. Hosp Pediatr 2019; 9:808-812. [PMID: 31570510 DOI: 10.1542/hpeds.2019-0001] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
OBJECTIVES The incidence of neonatal herpes simplex virus (nHSV) infections is monitored periodically in the Netherlands, yet management and outcome is unknown. Comprehensive national guidelines are lacking. We aim to describe management and outcome in the last decade to explore current diagnostic and therapeutic challenges. We aim to identify possible variability in management of patients with a suspected nHSV infection. METHODS We conducted a retrospective case series of management and outcome of nHSV infections at 2 tertiary care center locations in the Netherlands. RESULTS An nHSV infection was diagnosed in 1% (12 of 1348) of patients in whom polymerase chain reaction for HSV was performed. Of the patients with nHSV infection, 3 of 12 died, and 4 of 9 (44%) survivors suffered neurologic sequelae. Neurologic symptoms at presentation were seen in only 2 of 8 patients with nHSV encephalitis. A cerebral spinal fluid analysis was performed in 3 of 6 patients presenting with skin lesions. Only 3 of 6 patients with neurologic symptoms received suppressive therapy. nHSV infection was diagnosed in 8 of 189 (4%) patients who were empirically treated. CONCLUSIONS Management of nHSV infection, particularly when presented with skin lesions, is inconsistent. Many infants without a HSV infection are exposed to antiviral medication. There is substantial interhospital variation in diagnostic and therapeutic management of a suspected infection. Comprehensive guidelines need to be developed to standardize management of suspected nHSV infection.
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Affiliation(s)
- Maya W Keuning
- Department of Pediatric Hematology, Infectious Diseases, Immunology, and Rheumatology and
| | - Martijn van der Kuip
- Department of Pediatric Hematology, Infectious Diseases, Immunology, and Rheumatology and
| | - Jarne M van Hattem
- Medical Microbiology, Amsterdam University Medical Center,University of Amsterdam, Amsterdam, Netherlands
| | - Dasja Pajkrt
- Department of Pediatric Hematology, Infectious Diseases, Immunology, and Rheumatology and
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Brower LH, Wilson PM, Murtagh Kurowski E, Haslam D, Courter J, Goyal N, Durling M, Shah SS, Schondelmeyer A. Using Quality Improvement to Implement a Standardized Approach to Neonatal Herpes Simplex Virus. Pediatrics 2019; 144:peds.2018-0262. [PMID: 31345997 DOI: 10.1542/peds.2018-0262] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/23/2019] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVES Neonatal herpes simplex virus (HSV) infections are associated with high mortality and long-term morbidity. However, incidence is low and acyclovir, the treatment of choice, carries risk of toxicity. We aimed to increase the percentage of patients 0 to 60 days of age who are tested and treated for HSV in accordance with local guideline recommendations from 40% to 80%. METHODS This quality improvement project took place at 1 freestanding children's hospital. Multiple plan-do-study-act cycles were focused on interventions aimed at key drivers including provider buy-in, guideline availability, and accurate identification of high-risk patients. A run chart was used to track the effect of interventions on the percentage managed per guideline recommendations over time by using established rules for determining special cause. Pre- and postimplementation acyclovir use was compared by using a χ2 test. In HSV-positive cases, delayed acyclovir initiation, defined as >1 day from presentation, was tracked as a balancing measure. RESULTS The median percentage of patients managed according to guideline recommendations increased from 40% to 80% within 8 months. Acyclovir use decreased from 26% to 7.9% (P < .001) in non-high-risk patients but did not change significantly in high-risk patients (73%-83%; P = .15). There were no cases of delayed acyclovir initiation in HSV-positive cases. CONCLUSIONS Point-of-care availability of an evidence-based guideline and interventions targeted at provider engagement improved adherence to a new guideline for neonatal HSV management and decreased acyclovir use in non-high-risk infants. Further study is necessary to confirm the safety of these recommendations in other settings.
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Affiliation(s)
- Laura H Brower
- Divisions of Hospital Medicine.,Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, Ohio
| | - Paria M Wilson
- Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, Ohio.,Pediatric Emergency Medicine.,Division of Pediatric Emergency Medicine, Children's Hospital of Pittsburgh, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania.,Department of Pediatrics, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Eileen Murtagh Kurowski
- Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, Ohio.,Pediatric Emergency Medicine.,James M. Anderson Center for Health Systems Excellence, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - David Haslam
- Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, Ohio.,Infectious Diseases, and
| | - Joshua Courter
- Pharmacy, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Neera Goyal
- Divisions of Hospital Medicine.,Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, Ohio.,Division of External Primary Care, Nemours/Alfred I duPont Hospital for Children, Wilmington, Delaware.,Department of Pediatrics, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania; and
| | | | - Samir S Shah
- Divisions of Hospital Medicine.,Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, Ohio.,James M. Anderson Center for Health Systems Excellence, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio.,Infectious Diseases, and
| | - Amanda Schondelmeyer
- Divisions of Hospital Medicine.,Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, Ohio.,James M. Anderson Center for Health Systems Excellence, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
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Cruz AT, Freedman SB, Kulik DM, Okada PJ, Fleming AH, Mistry RD, Thomson JE, Schnadower D, Arms JL, Mahajan P, Garro AC, Pruitt CM, Balamuth F, Uspal NG, Aronson PL, Lyons TW, Thompson AD, Curtis SJ, Ishimine PT, Schmidt SM, Bradin SA, Grether-Jones KL, Miller AS, Louie J, Shah SS, Nigrovic LE. Herpes Simplex Virus Infection in Infants Undergoing Meningitis Evaluation. Pediatrics 2018; 141:peds.2017-1688. [PMID: 29298827 PMCID: PMC5810597 DOI: 10.1542/peds.2017-1688] [Citation(s) in RCA: 42] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/14/2017] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Although neonatal herpes simplex virus (HSV) is a potentially devastating infection requiring prompt evaluation and treatment, large-scale assessments of the frequency in potentially infected infants have not been performed. METHODS We performed a retrospective cross-sectional study of infants ≤60 days old who had cerebrospinal fluid culture testing performed in 1 of 23 participating North American emergency departments. HSV infection was defined by a positive HSV polymerase chain reaction or viral culture. The primary outcome was the proportion of encounters in which HSV infection was identified. Secondary outcomes included frequency of central nervous system (CNS) and disseminated HSV, and HSV testing and treatment patterns. RESULTS Of 26 533 eligible encounters, 112 infants had HSV identified (0.42%, 95% confidence interval [CI]: 0.35%-0.51%). Of these, 90 (80.4%) occurred in weeks 1 to 4, 10 (8.9%) in weeks 5 to 6, and 12 (10.7%) in weeks 7 to 9. The median age of HSV-infected infants was 14 days (interquartile range: 9-24 days). HSV infection was more common in 0 to 28-day-old infants compared with 29- to 60-day-old infants (odds ratio 3.9; 95% CI: 2.4-6.2). Sixty-eight (0.26%, 95% CI: 0.21%-0.33%) had CNS or disseminated HSV. The proportion of infants tested for HSV (35%; range 14%-72%) and to whom acyclovir was administered (23%; range 4%-53%) varied widely across sites. CONCLUSIONS An HSV infection was uncommon in young infants evaluated for CNS infection, particularly in the second month of life. Evidence-based approaches to the evaluation for HSV in young infants are needed.
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Affiliation(s)
- Andrea T. Cruz
- Department of Pediatrics, Baylor College of Medicine, Houston, Texas
| | - Stephen B. Freedman
- Department of Pediatrics, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Dina M. Kulik
- Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada
| | - Pamela J. Okada
- Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Alesia H. Fleming
- Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia
| | - Rakesh D. Mistry
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, Colorado
| | - Joanna E. Thomson
- Department of Pediatrics, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
| | - David Schnadower
- Department of Pediatrics, Washington University School of Medicine in St Louis, St Louis, Missouri
| | - Joseph L. Arms
- Department of Pediatrics, Children’s Hospitals and Clinics of Minnesota, Minneapolis, Minnesota
| | - Prashant Mahajan
- Department of Pediatrics, Wayne State University School of Medicine, Detroit, Michigan
| | - Aris C. Garro
- Department of Emergency Medicine, Warren Alpert Medical School, Brown University, Providence, Rhode Island
| | - Christopher M. Pruitt
- Department of Pediatrics, School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - Fran Balamuth
- Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Neil G. Uspal
- Department of Pediatrics, University of Washington School of Medicine, Seattle, Washington
| | - Paul L. Aronson
- Departments of Pediatrics and Emergency Medicine, Yale School of Medicine, Yale University, New Haven, Connecticut
| | - Todd W. Lyons
- Division of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts
| | - Amy D. Thompson
- Departments of Pediatrics and Emergency Medicine, Alfred I. DuPont Hospital for Children, Wilmington, Delaware
| | - Sarah J. Curtis
- Department of Pediatrics, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Paul T. Ishimine
- Department of Emergency Medicine, University of California San Diego School of Medicine, San Diego, California
| | - Suzanne M. Schmidt
- Department of Pediatrics, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Stuart A. Bradin
- Department of Pediatrics, University of Michigan Medical School, University of Michigan, Ann Arbor, Michigan
| | - Kendra L. Grether-Jones
- Department of Emergency Medicine, University of California Davis School of Medicine, Sacramento, California
| | - Aaron S. Miller
- Department of Pediatrics, Saint Louis University School of Medicine, St Louis, Missouri; and
| | - Jeffrey Louie
- Department of Pediatrics, University of Minnesota Masonic Children’s Hospital, Minneapolis, Minnesota
| | - Samir S. Shah
- Department of Pediatrics, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
| | - Lise E. Nigrovic
- Division of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts
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Abstract
BACKGROUND Tibial fractures are common in children less than 3 years old. The traditional management involves immobilization in an above knee cast for both confirmed (positive x-ray) and presumed (normal x-ray) toddler's fractures. This carries health care implications and causes unnecessary burden for patients and their families. There is a paucity of literature describing the ideal immobilization strategy for this injury. OBJECTIVES To determine: 1) the variation between Canadian emergency departments in management of toddler's fractures; 2) the variation in management between confirmed and presumed toddler's fractures; 3) the association between demographic variables and immobilization strategies. METHODS This was an email survey of all members of the Pediatric Emergency Research Canada network. The survey consisted of 2 clinical vignettes followed by multiple-choice questions. RESULTS Survey response rate was 73% (153/211). For confirmed toddler's fractures, 39% of physicians chose to immobilize with above knee circumferential cast, 27% with below knee circumferential cast and 20% with below knee splint. For presumed toddler's fractures, 44% of respondents chose to manage without casting, 22% with below knee splint and 14% with above knee circumferential cast. There was significant practice variation between Canadian pediatric emergency departments for both types of fractures and between the management of confirmed and presumed toddler's fractures. CONCLUSIONS Our study is the first to identify nationwide variation in the management of toddler's fractures. This variation highlights the need for future research to compare the different management strategies to determine families' preferences and functional outcomes in children with these injuries.
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Brower L, Schondelmeyer A, Wilson P, Shah SS. Testing and Empiric Treatment for Neonatal Herpes Simplex Virus: Challenges and Opportunities for Improving the Value of Care. Hosp Pediatr 2016; 6:108-11. [PMID: 26740558 DOI: 10.1542/hpeds.2015-0166] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Affiliation(s)
| | | | - Paria Wilson
- Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
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Burstein B, Dubrovsky AS, Greene AW, Quach C. National Survey on the Impact of Viral Testing for the ED and Inpatient Management of Febrile Young Infants. Hosp Pediatr 2016; 6:226-33. [PMID: 27005580 DOI: 10.1542/hpeds.2015-0195] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
OBJECTIVE Well-appearing febrile infants with viral illnesses cannot be distinguished from those with occult life-threatening infections. Infants with respiratory viruses are less likely to have serious bacterial infections; however, current risk-stratification criteria predate widespread viral testing and there are limited data to safely inform physician management with this now common diagnostic tool. This study sought to explore the possible impact of respiratory virus testing on clinical decision-making for the management of febrile young infants<6 weeks old. METHODS A scenario-based survey was sent to emergency department (ED) and inpatient physicians at all 16 Canadian tertiary pediatric centers. Participants were asked questions regarding management decisions with and without results of respiratory virus testing. RESULTS Response rate was 78% (n=330; 190 ED, 140 inpatient). Detection of a respiratory virus reduced admission rates among 3-week-old (83% vs 95%, P<.001) and 5-week-old infants (36% vs 52%, P<.001). Similarly, empirical antibiotic treatment was decreased by detection of a respiratory virus for 3-week-old (65% vs 92%, P<.001) and 5-week-old infants (25% vs 39%, P<.001). Management of 5-week-old infants differed between ED and inpatient physicians, both in the presence and absence of a respiratory virus. There was no consensus among inpatient physicians regarding admission duration for well infants with a detectable respiratory virus and otherwise negative workup. CONCLUSIONS Respiratory virus testing appears to influence clinical decision-making for febrile infants<6 weeks, reducing both rates of admission and antimicrobial treatment. Important work is needed to better understand how to safely incorporate viral testing for the management of this vulnerable patient population.
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Affiliation(s)
- Brett Burstein
- Division of Pediatric Emergency Medicine, Department of Pediatrics, and
| | | | | | - Caroline Quach
- Division of Infectious Diseases, Departments of Pediatrics and Medical Microbiology, The Montreal Children's Hospital of the McGill University Health Center, and Department of Epidemiology, Biostatistics, and Occupational Health, McGill University, Montreal, Quebec, Canada
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