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Frost HM, Keith A, Fletcher DR, Sebastian T, Dominguez SR, Kurtz M, Parker SK, Wilson ML, Jenkins TC. Clinical Outcomes Associated with Amoxicillin Treatment for Acute Otitis Media in Children. J Pediatric Infect Dis Soc 2024; 13:203-210. [PMID: 38314853 DOI: 10.1093/jpids/piae010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2023] [Accepted: 02/04/2024] [Indexed: 02/07/2024]
Abstract
BACKGROUND Acute otitis media (AOM) is the most common reason children are prescribed antibiotics. Bacteria that produce beta-lactamase are an increasingly frequent cause of AOM and may be resistant to amoxicillin, the currently recommended treatment for AOM. We aimed to evaluate the clinical outcomes of children treated with amoxicillin for AOM and assessed whether outcomes vary by infecting pathogen or beta-lactamase production. METHODS 205 children 6-35 months old diagnosed with AOM and prescribed amoxicillin were included. Bacterial culture and qualitative multiplex real-time polymerase chain reaction were performed on nasopharyngeal swabs collected at enrollment. Parents completed surveys assessing symptoms, antibiotic adherence, and potential adverse events. The primary outcome was treatment failure with amoxicillin. Secondary outcomes included recurrence, symptom improvement, resolution, and adverse drug events (ADE). RESULTS 8 children (5.4%) experienced treatment failure and 14 (6.8%) had recurrence. By day 5, 152 (74.1%) children had symptom improvement and 97 (47.3%) had resolution. Parents reported ADE for 56 (27.3%) children. Among 149 children who did not take any amoxicillin before enrollment, 98 (65.8%) had one or more beta-lactamase-producing bacteria. Common bacterial otopathogens were Moraxella catarrhalis (79, 53.0%), Streptococcus pneumoniae (51, 34.2%), Haemophilus influenzae (30, 20.1%), and Staphylococcus aureus (21, 14.1%). Treatment failure did not differ between children that did (5, 5.1%) and did not (3, 5.9%) have beta-lactamase-producing otopathogens (p = .05). CONCLUSIONS Among children diagnosed with AOM treated with amoxicillin, treatment failure was uncommon and did not differ by pathogen or beta-lactamase production. These data support guidance recommending amoxicillin despite an increasing prevalence of beta-lactamase-producing bacteria.
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Affiliation(s)
- Holly M Frost
- Department of Pediatrics, Denver Health and Hospital Authority, Denver, CO, USA
- Center for Health Systems Research, Denver Health and Hospital Authority, Denver, CO, USA
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO, USA
| | - Amy Keith
- Center for Health Systems Research, Denver Health and Hospital Authority, Denver, CO, USA
| | | | - Thresia Sebastian
- Department of Pediatrics, Denver Health and Hospital Authority, Denver, CO, USA
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO, USA
- Department of Pediatrics, Alameda Health System, Oakland, CA, USA
| | - Samuel R Dominguez
- Department of Pediatric Infectious Diseases, University of Colorado School of Medicine, Aurora, CO, USA
- Department of Pediatric Infectious Diseases, Children's Hospital Colorado, Aurora, CO, USA
| | - Melanie Kurtz
- Center for Health Systems Research, Denver Health and Hospital Authority, Denver, CO, USA
| | - Sarah K Parker
- Department of Pediatric Infectious Diseases, University of Colorado School of Medicine, Aurora, CO, USA
- Department of Pediatric Infectious Diseases, Children's Hospital Colorado, Aurora, CO, USA
| | - Michael L Wilson
- Department of Pathology and Laboratory Services, Denver Health and Hospital Authority, Denver, CO, USA
- Department of Pathology, University of Colorado School of Medicine, Aurora, CO, USA
| | - Timothy C Jenkins
- Division of Infectious Diseases, Department of Medicine, Denver Health and Hospital Authority, Denver, CO, USA
- Division of Infectious Diseases, Department of Medicine, University of Colorado School of Medicine, Aurora, CO, USA
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Linz AM, Frost HM, Kitchner T, Anderson JL, Meece J. Clinical Presentation of Blastomycosis is Associated With Infecting Species, Not Host Genotype. Clin Med Res 2024; 22:6-12. [PMID: 38609141 DOI: 10.3121/cmr.2024.1880] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2023] [Revised: 01/15/2024] [Accepted: 01/19/2024] [Indexed: 04/14/2024]
Abstract
Objective: To determine if host genetics may be a risk factor for severe blastomycosis.Design: A cohort of patients who had contracted blastomycosis underwent targeted SNP (single nucleotide polymorphism) genotyping. The genetics of these patients were compared to a set of age and gender-matched controls and between patients with severe versus mild to moderate blastomycosis.Setting: The Marshfield Clinic Health System in central and northern WisconsinParticipants: Patients with a diagnosis of blastomycosis prior to 2017 were contacted for enrollment in this study. A phone hotline was also set up to allow interested participants from outside the Marshfield Clinic Health System to request enrollment.Methods: SNP frequency was assessed for significant differences between the patient cohort and controls and between patients with severe versus mild to moderate blastomycosis. We also tested the effect of Blastomyces species identified in clinical isolates on disease symptoms and severity.Results: No significant differences were found in SNP frequency between cases and controls or between those with severe or mild to moderate blastomycosis. We did detect significant differences in symptom frequency and disease severity by Blastomyces species.Conclusions: Our study did not identify any genetic risk factors for blastomycosis. Instead, the species of Blastomyces causing the infection had a significant effect on disease severity.
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Affiliation(s)
| | - Holly M Frost
- Department of Pediatrics, Denver Health and Hospital Authority, Denver, CO USA; Center for Health Services Research, Denver Health and Hospital Authority, Denver, CO USA; Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO USA; ORCID: 0000-0002-3016-3287
| | | | - Jennifer L Anderson
- Department of Pathology and Laboratory Medicine, University of Wisconsin-Madison, WI USA
| | - Jennifer Meece
- Marshfield Clinic Research Institute, Marshfield, WI USA
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Jenkins TC, Keith A, Stein AB, Hersh AL, Narayan R, Eggleston A, Rinehart DJ, Patel PK, Walter E, Hargraves IG, Frost HM. Interventions to de-implement unnecessary antibiotic prescribing for ear infections (DISAPEAR Trial): protocol for a cluster-randomized trial. BMC Infect Dis 2024; 24:126. [PMID: 38267837 PMCID: PMC10807124 DOI: 10.1186/s12879-023-08960-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2023] [Accepted: 12/28/2023] [Indexed: 01/26/2024] Open
Abstract
BACKGROUND Watchful waiting management for acute otitis media (AOM), where an antibiotic is used only if the child's symptoms worsen or do not improve over the subsequent 2-3 days, is an effective approach to reduce antibiotic exposure for children with AOM. However, studies to compare the effectiveness of interventions to promote watchful waiting are lacking. The objective of this study is to compare the effectiveness and implementation outcomes of two pragmatic, patient-centered interventions designed to facilitate use of watchful waiting in clinical practice. METHODS This will be a cluster-randomized trial utilizing a hybrid implementation-effectiveness design. Thirty-three primary care or urgent care clinics will be randomized to one of two interventions: a health systems-level intervention alone or a health systems-level intervention combined with use of a shared decision-making aid. The health systems-level intervention will include engagement of a clinician champion at each clinic, changes to electronic health record antibiotic orders to facilitate delayed antibiotic prescriptions as part of a watchful waiting strategy, quarterly feedback reports detailing clinicians' use of watchful waiting individually and compared with peers, and virtual learning sessions for clinicians. The hybrid intervention will include the health systems-level intervention plus a shared decision-making aid designed to inform decision-making between parents and clinicians with best available evidence. The primary outcomes will be whether an antibiotic was ultimately taken by the child and parent satisfaction with their child's care. We will explore the differences in implementation effectiveness by patient population served, clinic type, clinical setting, and organization. The fidelity, acceptability, and perceived appropriateness of the interventions among different clinician types, patient populations, and clinical settings will be compared. We will also conduct formative qualitative interviews and surveys with clinicians and administrators, focus groups and surveys of parents of patients with AOM, and engagement of two stakeholder advisory councils to further inform the interventions. DISCUSSION This study will compare the effectiveness of two pragmatic interventions to promote use of watchful waiting for children with AOM to reduce antibiotic exposure and increase parent satisfaction, thus informing national antibiotic stewardship policy development. CLINICAL TRIAL REGISTRATION NCT06034080.
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Affiliation(s)
- Timothy C Jenkins
- Division of Infectious Diseases, Department of Medicine, Denver Health and Hospital Authority, Denver, CO, USA
- Division of Infectious Diseases, Department of Medicine, University of Colorado School of Medicine, Aurora, CO, USA
| | - Amy Keith
- Center for Health Systems Research, Denver Health and Hospital Authority, 601 Broadway Ave, Denver, CO, USA.
| | - Amy B Stein
- Center for Health Systems Research, Denver Health and Hospital Authority, 601 Broadway Ave, Denver, CO, USA
| | - Adam L Hersh
- Division of Infectious Diseases, Department of Pediatrics, University of Utah, Salt Lake City, UT, USA
| | | | | | - Deborah J Rinehart
- Center for Health Systems Research, Denver Health and Hospital Authority, 601 Broadway Ave, Denver, CO, USA
- Division of General Internal Medicine, Department of Medicine, University of Colorado School of Medicine, Aurora, CO, USA
| | - Payal K Patel
- Division of Infectious Diseases and Clinical Epidemiology, Intermountain Health, Murray, UT, USA
| | | | - Ian G Hargraves
- Knowledge and Evaluation Research Unit, Mayo Clinic, Rochester, MN, USA
| | - Holly M Frost
- Center for Health Systems Research, Denver Health and Hospital Authority, 601 Broadway Ave, Denver, CO, USA.
- Department of Pediatrics, Denver Health and Hospital Authority, 601 Broadway Ave, Denver, CO, USA.
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO, USA.
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Simione M, Frost HM, Farrar-Muir H, Luo M, Granadeño J, Torres C, Boudreau AA, Moreland J, Wallace J, Young J, Orav J, Sease K, Hambidge SJ, Taveras EM. Evaluating the Implementation of the Connect for Health Pediatric Weight Management Program. JAMA Netw Open 2024; 7:e2352648. [PMID: 38270953 PMCID: PMC10811559 DOI: 10.1001/jamanetworkopen.2023.52648] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2023] [Accepted: 11/29/2023] [Indexed: 01/26/2024] Open
Abstract
Importance Adoption of primary care interventions to reduce childhood obesity is limited. Progress in reducing obesity prevalence and eliminating disparities can be achieved by implementing effective childhood obesity management interventions in primary care settings. Objective To examine the extent to which implementation strategies supported the uptake of research evidence and implementation of the Connect for Health pediatric weight management program. Design, Setting, and Participants This quality improvement study took place at 3 geographically and demographically diverse health care organizations with substantially high numbers of children living in low-income communities in Denver, Colorado; Boston, Massachusetts; and Greenville, South Carolina, from November 2019 to April 2022. Participants included pediatric primary care clinicians and staff and families with children aged 2 to 12 years with a body mass index (BMI) in the 85th percentile or higher. Exposures Pediatric weight management program with clinician-facing tools (ie, clinical decision support tools) and family-facing tools (ie, educational handouts, text messaging program, community resource guide) along with implementation strategies (ie, training and feedback, technical assistance, virtual learning community, aligning with hospital performance metrics) to support the uptake. Main Outcomes and Measures Primary outcomes were constructs from the Reach, Effectiveness, Adoption, Implementation, Maintenance (RE-AIM) Framework examined through parent, clinician, and leadership surveys and electronic health record data to understand the number of children screened and identified, use of the clinical decision support tools, program acceptability, fidelity to the intervention and implementation strategies, and program sustainability. Results The program screened and identified 18 333 children across 3 organizations (Denver Health, 8480 children [46.3%]; mean [SD] age, 7.97 [3.31] years; 3863 [45.5%] female; Massachusetts General Hospital (MGH), 6190 children [33.8%]; mean [SD] age, 7.49 [3.19] years; 2920 [47.2%] female; Prisma Health, 3663 children [20.0%]; mean [SD] age, 7.33 [3.15] years; 1692 [46.2%] female) as having an elevated BMI. The actionable flagging system was used for 8718 children (48%). The reach was equitable, with 7843 children (92.4%) from Denver Health, 4071 children (65.8%) from MGH, and 1720 children (47%) from Prisma Health being from racially and ethnically minoritized groups. The sites had high fidelity to the program and 6 implementation strategies, with 4 strategies (67%) used consistently at Denver Health, 6 (100%) at MGH, and 5 (83%) at Prisma Health. A high program acceptability was found across the 3 health care organizations; for example, the mean (SD) Acceptability of Intervention Measure score was 3.72 (0.84) at Denver Health, 3.82 (0.86) at MGH, and 4.28 (0.68) at Prisma Health. The implementation strategies were associated with 7091 (39%) uses of the clinical decision support tool. The mean (SD) program sustainability scores were 4.46 (1.61) at Denver Health, 5.63 (1.28) at MGH, and 5.54 (0.92) at Prisma Health. Conclusions and Relevance These findings suggest that by understanding what strategies enable the adoption of scalable and implementation-ready programs by other health care organizations, it is feasible to improve the screening, identification, and management of children with overweight or obesity and mitigate existing disparities.
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Affiliation(s)
- Meg Simione
- Department of Pediatrics, Mass General for Children, Boston, Massachusetts
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
| | - Holly M. Frost
- Center for Health Systems Research, Office of Research, Denver Health and Hospital Authority, Denver, Colorado
- Department of Pediatrics, Denver Health and Hospital Authority, Denver, Colorado
- Department of Pediatrics, University of Colorado School of Medicine, Aurora
| | - Haley Farrar-Muir
- Department of Pediatrics, Mass General for Children, Boston, Massachusetts
| | - Man Luo
- Department of Pediatrics, Mass General for Children, Boston, Massachusetts
| | - Jazmin Granadeño
- Department of Pediatrics, Mass General for Children, Boston, Massachusetts
| | - Carlos Torres
- Department of Pediatrics, Mass General for Children, Boston, Massachusetts
| | | | | | - Jessica Wallace
- Department of Pediatrics, Denver Health and Hospital Authority, Denver, Colorado
| | | | - John Orav
- Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Kerry Sease
- Prisma Health, Greenville, South Carolina
- Department of Pediatrics, University of South Carolina School of Medicine, Greenville
| | - Simon J. Hambidge
- Department of Pediatrics, University of Colorado School of Medicine, Aurora
- Ambulatory Care Services, Denver Health, Denver, Colorado
| | - Elsie M. Taveras
- Department of Pediatrics, Mass General for Children, Boston, Massachusetts
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
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O'Leary SC, Frost HM. Does HPV vaccination initiation at age 9, improve HPV initiation and vaccine series completion rates by age 13? Hum Vaccin Immunother 2023; 19:2180971. [PMID: 36892245 PMCID: PMC10026893 DOI: 10.1080/21645515.2023.2180971] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/10/2023] Open
Abstract
Vaccination for Human Papillomavirus (HPV) is important to reduce rates of cervical and oropharyngeal cancer. We aimed to evaluate if a program to initiate HPV vaccination at 9 years improved initiation and completion rates by 13 years of age. Data on empaneled patients aged 9-13 years from January 1, 2021 to August 30, 2022 were abstracted from the electronic health record. Primary outcome measures included HPV vaccination initiation and series completion by 13 years of age. The secondary outcome measure was missed opportunities for HPV vaccination. In total, 25,888 patients were included (12,433 pre-intervention, and 13,455 post-intervention). The percentage of patients aged 9-13 with an in-person visit who received at least 1 dose of HPV vaccine increased from 30% pre-intervention to 43% post-intervention. The percentage of patients who received 2 doses of vaccine increased from 19.3% pre-intervention to 42.7% post-intervention. For the overall population seen in-person, initiation of HPV vaccination by age 13 years increased from 42% to 54%. HPV completion increased as well (13% to 18%). HPV vaccination initiation at 9 years of age may be an acceptable and effective approach to improving vaccination rates.
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Affiliation(s)
- Sonja C O'Leary
- Department of General Pediatrics, Denver Health Medical Center, Denver, CO, USA
- Department of General Pediatrics, University of Colorado School of Medicine, Aurora, CO, USA
| | - Holly M Frost
- Department of General Pediatrics, Denver Health Medical Center, Denver, CO, USA
- Department of General Pediatrics, University of Colorado School of Medicine, Aurora, CO, USA
- Center for Health Systems Research, Denver Health, Denver, CO, USA
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Frost HM, Hersh AL, Hyun DY. Next Steps in Ambulatory Stewardship. Infect Dis Clin North Am 2023; 37:749-767. [PMID: 37640612 PMCID: PMC10592236 DOI: 10.1016/j.idc.2023.07.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/31/2023]
Abstract
Most antibiotics are prescribed in ambulatory setting and at least 30% to 50% of these prescriptions are unnecessary. The use of antibiotics when not needed promotes the development of antibiotic resistant organisms and harms patients by placing them at risk for adverse drug events and Clostridioides difficile infections. National guidelines recommend that health systems implement antibiotic stewardship programs in ambulatory settings. However, uptake of stewardship in ambulatory setting has remained low. This review discusses the current state of ambulatory stewardship in the United States, best practices for the successful implementation of effective ambulatory stewardship programs, and future directions to improve antibiotic use in ambulatory settings.
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Affiliation(s)
- Holly M Frost
- Center for Health Systems Research, Denver Health and Hospital Authority, Denver, CO, USA; Department of Pediatrics, Denver Health and Hospital Authority, Denver, CO, USA; Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO, USA.
| | - Adam L Hersh
- Division of Infectious Disease, Department of Pediatrics, 295 Chipeta Way, Salt Lake City, UT 8413, USA
| | - David Y Hyun
- Antimicrobial Resistance Project, The Pew Charitable Trusts, 901 East Street NW, Washington, DC 20004-2008, USA
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Keith A, Jenkins TC, O'Leary S, Stein AB, Katz SE, Newland J, Rinehart DJ, Gilbert A, Dodd S, Terrill CM, Frost HM. Reducing length of antibiotics for children with ear infections: protocol for a cluster-randomized trial in the USA. J Comp Eff Res 2023; 12:e230088. [PMID: 37855227 PMCID: PMC10690393 DOI: 10.57264/cer-2023-0088] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Accepted: 09/27/2023] [Indexed: 10/20/2023] Open
Abstract
Aim: Preventing unnecessarily long durations of antibiotic therapy is a key opportunity to reduce antibiotic overuse in children 2 years of age and older with acute otitis media (AOM). Pragmatic interventions to reduce durations of therapy that can be effectively scaled and sustained are urgently needed. This study aims to fill this gap by evaluating the effectiveness and implementation outcomes of two low-cost interventions of differing intensities to increase guideline-concordant antibiotic durations in children with AOM. Methods: The higher intensity intervention will consist of clinician education regarding guideline-recommended short durations of antibiotic therapy; electronic health record (EHR) prescription field changes to promote prescribing of recommended short durations; and individualized clinician audit and feedback on adherence to recommended short durations of therapy in comparison to peers, while the lower intensity intervention will consist only of clinician education and EHR changes. We will explore the differences in implementation effectiveness by patient population served, clinician type, clinical setting and organization as well as intervention type. The fidelity, feasibility, acceptability and perceived appropriateness of the interventions among different clinician types, patient populations, clinical settings and intervention type will be compared. We will also conduct formative qualitative interviews with clinicians and administrators and focus groups with parents of patients to further inform the interventions and study. The formative evaluation will take place over 1.5 years, the interventions will be implemented over 2 years and evaluation of the interventions will take place over 1.5 years. Discussion: The results of this study will provide a framework for other healthcare systems to address the widespread problem of excessive durations of therapy for AOM and inform national antibiotic stewardship policy development. Clinical Trial Registration: NCT05608993 (ClinicalTrials.gov).
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Affiliation(s)
- Amy Keith
- Center for Health Systems Research, Denver Health & Hospital Authority, Denver, CO 80201, USA
| | - Timothy C Jenkins
- Division of Infectious Diseases, Department of Medicine, Denver Health & Hospital Authority, Denver, CO 80204, USA
- Division of Infectious Diseases, Department of Medicine, University of Colorado School of Medicine, Aurora, CO 80045, USA
| | - Sonja O'Leary
- Department of General Pediatrics, Denver Health Medical Center, Denver, CO 80204, USA
- Department of General Pediatrics, University of Colorado School of Medicine, Aurora, CO 80045, USA
| | - Amy B Stein
- Center for Health Systems Research, Denver Health & Hospital Authority, Denver, CO 80201, USA
| | - Sophie E Katz
- Division of Infectious Diseases, Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN 37232, USA
| | - Jason Newland
- Division of Infectious Diseases, Department of Pediatrics, Washington University in St. Louis, St. Louis, MO 63110, USA
| | - Deborah J Rinehart
- Center for Health Systems Research, Denver Health & Hospital Authority, Denver, CO 80201, USA
- Division of General Internal Medicine, Department of Medicine, University of Colorado School of Medicine, Aurora, CO 80045,, USA
| | - Aiden Gilbert
- Center for Health Systems Research, Denver Health & Hospital Authority, Denver, CO 80201, USA
| | - Sherry Dodd
- Division of Infectious Diseases, Department of Pediatrics, Washington University in St. Louis, St. Louis, MO 63110, USA
| | - Cindy M Terrill
- Division of Infectious Diseases, Department of Pediatrics, Washington University in St. Louis, St. Louis, MO 63110, USA
| | - Holly M Frost
- Center for Health Systems Research, Denver Health & Hospital Authority, Denver, CO 80201, USA
- Department of General Pediatrics, Denver Health Medical Center, Denver, CO 80204, USA
- Department of General Pediatrics, University of Colorado School of Medicine, Aurora, CO 80045, USA
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Smith NR, Simione M, Farrar-Muir H, Granadeno J, Moreland JW, Wallace J, Frost HM, Young J, Craddock C, Sease K, Hambidge SJ, Taveras EM, Levy DE. Costs to Implement a Pediatric Weight Management Program Across 3 Distinct Contexts. Med Care 2023; 61:715-725. [PMID: 37943527 PMCID: PMC10478682 DOI: 10.1097/mlr.0000000000001891] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2023]
Abstract
BACKGROUND The Connect for Health program is an evidence-based program that aligns with national recommendations for pediatric weight management and includes clinical decision support, educational handouts, and community resources. As implementation costs are a major driver of program adoption and maintenance decisions, we assessed the costs to implement the Connect for Health program across 3 health systems that primarily serve low-income communities with a high prevalence of childhood obesity. METHODS We used time-driven activity-based costing methods. Each health system (site) developed a process map and a detailed report of all implementation actions taken, aligned with major implementation requirements (eg, electronic health record integration) or strategies (eg, providing clinician training). For each action, sites identified the personnel involved and estimated the time they spent, allowing us to estimate the total costs of implementation and breakdown costs by major implementation activities. RESULTS Process maps indicated that the program integrated easily into well-child visits. Overall implementation costs ranged from $77,103 (Prisma Health) to $84,954 (Denver Health) to $142,721 (Massachusetts General Hospital). Across implementation activities, setting up the technological aspects of the program was a major driver of costs. Other cost drivers included training, engaging stakeholders, and audit and feedback activities, though there was variability across systems based on organizational context and implementation choices. CONCLUSIONS Our work highlights the major cost drivers of implementing the Connect for Health program. Accounting for context-specific considerations when assessing the costs of implementation is crucial, especially to facilitate accurate projections of implementation costs in future settings.
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Affiliation(s)
- Natalie Riva Smith
- Department of Social and Behavioral Sciences, Harvard TH Chan School of Public Health
- Mongan Institute Health Policy Research Center, Massachusetts General Hospital
| | - Meg Simione
- Division of General Academic Pediatrics, Department of Pediatrics, Mass General for Children
- Department of Pediatrics, Harvard Medical School, Boston, MA
| | - Haley Farrar-Muir
- Division of General Academic Pediatrics, Department of Pediatrics, Mass General for Children
| | - Jazmin Granadeno
- Division of General Academic Pediatrics, Department of Pediatrics, Mass General for Children
| | | | | | - Holly M. Frost
- Department of Pediatrics, Denver Health
- Center for Health Systems Research, Denver Health, Denver
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO
| | | | - Cassie Craddock
- Department of Ambulatory Quality and Reliability, Prisma Health
| | - Kerry Sease
- Department of Pediatrics, University of South Carolina School of Medicine
- Prisma Health Children’s Hospital, Greenville, SC
| | - Simon J. Hambidge
- Ambulatory Care Services, Denver Health, Denver
- Harvard Medical School, Boston, MA
| | - Elsie M. Taveras
- Division of General Academic Pediatrics, Department of Pediatrics, Mass General for Children
- Department of Pediatrics, Harvard Medical School, Boston, MA
| | - Douglas E. Levy
- Mongan Institute Health Policy Research Center, Massachusetts General Hospital
- Harvard Medical School, Boston, MA
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Frost HM, Jenkins TC, Sebastian T, Parker SK, Keith A, Kurtz M, Fletcher DR, Wilson ML, Dominguez SR. Reliability of nasopharyngeal PCR for the detection of otopathogens in children with uncomplicated acute otitis media compared to culture. Diagn Microbiol Infect Dis 2023; 107:116040. [PMID: 37549633 PMCID: PMC10529968 DOI: 10.1016/j.diagmicrobio.2023.116040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2023] [Revised: 07/17/2023] [Accepted: 07/22/2023] [Indexed: 08/09/2023]
Abstract
Otopathogens in acute otitis media (AOM) have implications for care because the likelihood of resolution without antibiotics and optimal antibiotic agent varies by microorganism. We aimed to determine the sensitivity, specificity, positive predictive value, and negative predictive value of nasopharyngeal (NP) qualitative polymerase chain reaction (PCR) for common bacterial otopathogens in children with AOM compared to NP culture. NP flocked swabs collected from enrolled children aged 6 to 35 months with uncomplicated AOM in Denver, CO were tested by culture and multiplex PCR. The sensitivity and negative predictive value of PCR using culture as a reference were high (H. influenzae 93.3%, 98.0%; S. pneumoniae 94.2%, 95.1%; M. catarrhalis 92.3%, 86.4%); whereas the specificity and positive predictive value were lower and varied by organism (54.2%-84.1%, 55.1%-69.2%, respectively). PCR detected 1.5 times more organisms than culture. NP PCR has a high predictive value for excluding otopathogens compared to culture and warrants exploration as a diagnostic tool.
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Affiliation(s)
- Holly M Frost
- Department of Pediatrics, Denver Health and Hospital Authority, Denver, CO, USA; Center for Health Systems Research, Denver Health and Hospital Authority, Denver, CO, USA; Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO, USA.
| | - Timothy C Jenkins
- Division of Infectious Diseases, Department of Medicine, Denver Health and Hospital Authority, Denver, CO, USA; Division of Infectious Diseases, Department of Medicine, University of Colorado School of Medicine, Aurora, CO, USA
| | - Thresia Sebastian
- Department of Pediatrics, Denver Health and Hospital Authority, Denver, CO, USA; Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO, USA; Department of Pediatrics, Alameda Health System, Oakland, CA, USA
| | - Sarah K Parker
- Department of Pediatric Infectious Diseases, University of Colorado School of Medicine, Aurora, CO, USA; Department of Pediatric Infectious Diseases, Children's Hospital Colorado, Aurora, CO, USA
| | - Amy Keith
- Center for Health Systems Research, Denver Health and Hospital Authority, Denver, CO, USA
| | - Melanie Kurtz
- Center for Health Systems Research, Denver Health and Hospital Authority, Denver, CO, USA
| | | | - Michael L Wilson
- Department of Pathology and Laboratory Services, Denver Health and Hospital Authority, Denver, CO, USA; Department of Pathology, University of Colorado School of Medicine, Aurora, CO, USA
| | - Samuel R Dominguez
- Department of Pediatric Infectious Diseases, University of Colorado School of Medicine, Aurora, CO, USA; Department of Pediatric Infectious Diseases, Children's Hospital Colorado, Aurora, CO, USA
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Sebastian T, Durfee J, Wittmer N, Jack J, Keith A, Jenkins TC, Frost HM. Reducing Ophthalmic Antibiotic Use for Non-severe Conjunctivitis in Children. J Pediatric Infect Dis Soc 2023; 12:496-503. [PMID: 37696521 PMCID: PMC10533209 DOI: 10.1093/jpids/piad065] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Accepted: 09/06/2023] [Indexed: 09/13/2023]
Abstract
BACKGROUND Antibiotics are often overprescribed for pediatric conjunctivitis. We implemented a system-level quality improvement (QI) intervention to reduce unnecessary ophthalmic antibiotic use. METHODS The multi-faceted intervention in Denver, CO comprised a clinical care pathway, nurse protocol modifications, electronic health record (EHR) changes, parent education materials, and clinician education. We evaluated children aged 6 months-17 years with conjunctivitis seen between November 2018 and December 2022. A multi-interrupted time series model evaluated the effectiveness of the intervention over three time periods: Pre-COVID, Pre-Intervention (November 2018-February 2020), COVID, Pre-Intervention (March 2020-March 2021), and Post-Intervention (April 2021-December 2022). Fisher's exact tests compared treatment failure and healthcare utilization rates between time periods and among children receiving or not receiving ophthalmic antibiotics. RESULTS Among 6960 eligible encounters, ophthalmic antibiotic use was reduced by 18.8% (95% CI: 16.3, 21.3) from Pre-COVID, Pre-Intervention to Post-Intervention. During the Pre-Intervention period following the onset of COVID, a reduction of 16.1% (95% CI: 12.9, 19.3) was observed. Implementation of the intervention resulted in an additional 2.7% (95% CI: -0.4, 5.7) reduction in antibiotic prescribing, primarily in younger children (ages 6 months-5 years). The greatest reduction in prescribing occurred for nurse triage encounters with an 82.1% (95% CI: 76.8, 87.5) reduction in prescribing rates (92.6%-10.5%). Treatment failure occurred in 1301 (18.7%) children and was more common among children that received an ophthalmic antibiotic than those that did not (20.0 vs 17.9%; P = .03). CONCLUSION The QI intervention significantly reduced ophthalmic antibiotic prescribing for pediatric conjunctivitis without increasing treatment failure rates or health care utilization.
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Affiliation(s)
- Thresia Sebastian
- Department of Pediatrics, Denver Health and Hospital Authority, Denver, Colorado, USA
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, Colorado, USA
- Department of Pediatrics, Alameda Health System, Oakland, Calofornia, USA
| | - Josh Durfee
- Center for Health Systems Research, Denver Health and Hospital Authority, Denver, Colorado, USA
| | - Nancy Wittmer
- Center for Health Systems Research, Denver Health and Hospital Authority, Denver, Colorado, USA
| | - Jessica Jack
- Department of Pediatrics, Denver Health and Hospital Authority, Denver, Colorado, USA
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Amy Keith
- Center for Health Systems Research, Denver Health and Hospital Authority, Denver, Colorado, USA
| | - Timothy C Jenkins
- Division of Infectious Diseases and Department of Medicine, Denver Health and Hospital Authority, Denver, Colorado, USA
- Division of Infectious Diseases and Department of Medicine, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Holly M Frost
- Department of Pediatrics, Denver Health and Hospital Authority, Denver, Colorado, USA
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, Colorado, USA
- Center for Health Systems Research, Denver Health and Hospital Authority, Denver, Colorado, USA
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11
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El Feghaly RE, Nedved A, Katz SE, Frost HM. New insights into the treatment of acute otitis media. Expert Rev Anti Infect Ther 2023; 21:523-534. [PMID: 37097281 DOI: 10.1080/14787210.2023.2206565] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/26/2023]
Abstract
INTRODUCTION Acute otitis media (AOM) affects most (80%) children by 5 years of age and is the most common reason children are prescribed antibiotics. The epidemiology of AOM has changed considerably since the widespread use of pneumococcal conjugate vaccines, which has broad-reaching implications for management. AREAS COVERED In this narrative review we cover the epidemiology of AOM, best practices for diagnosis and management, new diagnostic technology, effective stewardship interventions, and future directions of the field. Literature review was performed using PubMed and ClinicalTrials.gov. EXPERT OPINION Inaccurate diagnoses, unnecessary antibiotic use, and increasing antimicrobial resistance remain major challenges in AOM management. Fortunately, effective tools and interventions to improve diagnostic accuracy, de-implement unnecessary antibiotic use, and individualize care are on the horizon. Successful scaling of these tools and interventions will be critical to improving overall care for children.
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Affiliation(s)
- Rana E El Feghaly
- Department of Pediatrics, Children's Mercy Kansas City, Kansas City, MO, USA
- Department of Pediatrics, University of Missouri-Kansas City, Kansas City, MO, USA
| | - Amanda Nedved
- Department of Pediatrics, Children's Mercy Kansas City, Kansas City, MO, USA
- Department of Pediatrics, University of Missouri-Kansas City, Kansas City, MO, USA
| | - Sophie E Katz
- Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Holly M Frost
- Department of Pediatrics, Denver Health and Hospital Authority, Denver, CO, USA
- Center for Health Systems Research, Denver Health and Hospital Authority, Denver, CO, USA
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO, USA
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12
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Frost HM, Wittmer N, Keith A, Durfee MJ, Jenkins TC. Sustainability of Interventions to Increase Guideline-Concordant Durations of Antibiotic Therapy for Children with Acute Otitis Media. J Pediatr 2023; 253:292-296.e2. [PMID: 36088995 PMCID: PMC10231306 DOI: 10.1016/j.jpeds.2022.09.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2022] [Revised: 07/29/2022] [Accepted: 09/06/2022] [Indexed: 01/04/2023]
Abstract
Two low-cost pragmatic interventions (change in the options in the electronic health record; change in the electronic health record plus education plus feedback comparing prescribing with peers) to improve prescribing of guideline-concordant short antibiotic durations for children 2 years and older with uncomplicated acute otitis media were highly effective and results were sustained 18 months after discontinuation of the active components of the interventions.
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Affiliation(s)
- Holly M Frost
- Department of Pediatrics, Denver Health and Hospital Authority, Denver, CO; Center for Health Systems Research, Denver Health and Hospital Authority, Denver, CO; Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO.
| | - Nancy Wittmer
- Center for Health Systems Research, Denver Health and Hospital Authority, Denver, CO
| | - Amy Keith
- Center for Health Systems Research, Denver Health and Hospital Authority, Denver, CO
| | - Michael J Durfee
- Center for Health Systems Research, Denver Health and Hospital Authority, Denver, CO
| | - Timothy C Jenkins
- Department of Medicine Division of Infectious Diseases, Denver Health and Hospital Authority, Denver, CO; Department of Medicine Division of Infectious Diseases, University of Colorado School of Medicine, Aurora, CO
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13
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McGrath LJ, Frost HM, Newland JG, O’Neil CA, Sahrmann JM, Ma Y, Butler AM. Utilization of nonguideline concordant antibiotic treatment following acute otitis media in children in the United States. Pharmacoepidemiol Drug Saf 2023; 32:256-265. [PMID: 36269007 PMCID: PMC9877117 DOI: 10.1002/pds.5554] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2022] [Revised: 10/10/2022] [Accepted: 10/14/2022] [Indexed: 01/28/2023]
Abstract
PURPOSE Acute otitis media (AOM) is a common indication for antibiotics in children. We sought to characterize the frequency of nonguideline concordant antibiotic therapy for AOM in the United States, by agent and duration. METHODS Using national administrative claims data (2016-2019), we identified children aged 6 months to 17 years with an oral antibiotic dispensed within 3 days of a new diagnosis of suppurative AOM. Use of nonguideline concordant agents and durations, defined based on national treatment guidelines, were summarized by age, race, rurality, region, and insurance type. Subsequent oral antibiotic dispensing within the year after AOM diagnosis was also evaluated. We created sunburst diagrams to visualize longitudinal patterns of within-person antibiotic utilization for AOM, by agent and duration. RESULTS We identified 789 424 eligible commercially-insured and 502 239 medicaid-insured children. Among commercially insured children, 35% received nonguideline concordant agents for AOM, including cefdinir (16%), amoxicillin-clavulanate (12%), and azithromycin (7%). Fewer children age <2 years received a nonguideline concordant initial agent (27%) compared to age ≥6 years (41%). More children age <2 years received three or more antibiotics over the following year (34% vs. 3% for children age ≥6 years). The most common treatment duration was 10 days for all ages; treatment duration for the initial antibiotic was nonguideline concordant for 95% and 89% of children age 2-5 years and ≥6 years, respectively. Patterns were similar for medicaid-insured children. CONCLUSIONS Nonguideline concordant antibiotic use is common when treating AOM in children, including use of broad-spectrum agents and longer-than-recommended antibiotic durations.
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Affiliation(s)
| | - Holly M. Frost
- Department of Pediatrics, Denver Health Medical Center, Denver, Colorado
- Office of Research, Denver Health Medical Center, Denver, Colorado
- Department of Pediatrics, School of Medicine, University of Colorado, Aurora, Colorado
| | - Jason G. Newland
- Department of Pediatrics, School of Medicine, Washington University, St. Louis, MO, USA
| | - Caroline A. O’Neil
- Department of Medicine, School of Medicine, Washington University, St. Louis, MO, USA
| | - John M. Sahrmann
- Department of Medicine, School of Medicine, Washington University, St. Louis, MO, USA
| | - Yinjiao Ma
- Department of Medicine, School of Medicine, Washington University, St. Louis, MO, USA
| | - Anne M. Butler
- Department of Medicine, School of Medicine, Washington University, St. Louis, MO, USA
- Department of Surgery, School of Medicine, Washington University, St. Louis, MO, USA
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14
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Frost HM, Geno Rasmussen C, Shorrosh H, Pyle L, Bautista K, Frohnert BI, Stahl M, Simmons K, Steck AK, Jia X, Yu L, Rewers M. Prevalence of SARS-CoV-2 Antibodies Among Healthy Children From Colorado From 2020 to 2021: A Brief Report. J Prim Care Community Health 2023; 14:21501319231189147. [PMID: 37501515 PMCID: PMC10375226 DOI: 10.1177/21501319231189147] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Revised: 06/26/2023] [Accepted: 07/04/2023] [Indexed: 07/29/2023] Open
Abstract
There are few estimates of the seroprevalence of SARS-CoV-2 antibodies among children in the United States. We measured vaccine and infection induced seroprevalence among nearly 5000 healthy 1 to 17-year-old children in Colorado from 2020 to 2021. By December 2021, 89% of older children, ages 12 to 18, had antibodies detected. The increase was largely driven from vaccination rather than infection.
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Affiliation(s)
- Holly M. Frost
- Denver Health and Hospital Authority, Denver, CO, USA
- University of Colorado, Aurora, CO, USA
| | | | | | | | | | | | | | | | | | | | - Liping Yu
- University of Colorado, Aurora, CO, USA
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15
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Frost HM, Wilson ML, Roosevelt GE. Improving Management of Suspected Chlamydia and Gonorrhea in Adolescents with a Rapid Diagnostic Test. Pediatr Qual Saf 2023; 8:e634. [PMID: 36798111 PMCID: PMC9925102 DOI: 10.1097/pq9.0000000000000634] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2022] [Accepted: 01/14/2023] [Indexed: 02/16/2023] Open
Abstract
We aimed to determined the impact of an intervention using rapid chlamydia (CT)/gonorrhea (GC) testing on reducing unnecessary antibiotic use, undertreatment of CT and/or GC, and length of stay (LOS) in an urban safety-net pediatric emergency department. Methods Before 2020, we tested for CT/GC using a batched nucleic acid amplification test, with results available the following day. Starting in January 2020, we implemented rapid nucleic acid amplification test. Our primary outcome variables were undertreatment and overtreatment. We defined undertreatment as GC and/or CT-positive patients who did not receive appropriate treatment. We defined overtreatment as GC or CT-negative patients who received antibiotics. The balancing measure was the LOS. Results There were 758 patients evaluated in the preimplementation period (2019), 612 in the implementation period (2020), and 626 in the postimplementation period (2021). Postimplementation, overtreatment decreased from 18.4% to 8.1%. Undertreatment did not differ by period but was less common among those tested with rapid versus standard testing (12.7% versus 9.9%, P = 0.05). Median LOS increased from 166 minutes (preimplementation) to 187 minutes (implementation) and 202 minutes (postimplementation; P < 0.001). Conclusions Rapid CT/GC testing reduced unnecessary antibiotic use but increased LOS due to patients waiting for the test results before being discharged. Given the rapid increases in CT/GC rates and antimicrobial resistance, health systems should consider implementing rapid testing to appropriately direct antimicrobials to patients most likely to benefit.
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Affiliation(s)
- Holly M. Frost
- From the Department of Pediatrics, Denver Health and Hospital Authority, Denver, Colo
- Center for Health Systems Research, Denver Health and Hospital Authority, Denver, Colo
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, Colo
| | - Michael L. Wilson
- Department of Pathology, Denver Health and Hospital Authority, Denver, Colo
- Department of Pathology, University of Colorado School of Medicine, Aurora, Colo
| | - Genie E. Roosevelt
- Department of Emergency Medicine, Denver Health and Hospital Authority, Denver, Colo
- Department of Emergency Medicine, University of Colorado School of Medicine, Aurora, Colo
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16
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Rinehart DJ, Frost HM, Thomas-Gale T, Depue C, Shlay JC. Progress in the Use of Text-Messaging to Support Adolescent Sexual and Reproductive Health. Acad Pediatr 2022:S1876-2859(22)00628-3. [PMID: 36572099 DOI: 10.1016/j.acap.2022.12.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2022] [Revised: 11/29/2022] [Accepted: 12/06/2022] [Indexed: 12/24/2022]
Affiliation(s)
- Deborah J Rinehart
- Center for Health Systems Research, Office of Research, Denver Health and Hospital Authority (DJ Rinehart and HM Frost), Denver, Colo; Division of General Internal Medicine, School of Medicine, University of Colorado Anschutz Medical Campus (DJ Rinehart), Aurora, Colo.
| | - Holly M Frost
- Center for Health Systems Research, Office of Research, Denver Health and Hospital Authority (DJ Rinehart and HM Frost), Denver, Colo; Department of Pediatrics, Denver Health and Hospital Authority (HM Frost), Denver, Colo; Department of Pediatrics, University of Colorado School of Medicine (HM Frost), Aurora, Colo
| | - Tara Thomas-Gale
- Ambulatory Care Services, Denver Health and Hospital Authority (T Thomas-Gale and C Depue), Denver, Colo
| | - Cori Depue
- Ambulatory Care Services, Denver Health and Hospital Authority (T Thomas-Gale and C Depue), Denver, Colo
| | - Judith C Shlay
- Public Health Institute at Denver Health (JC Shlay), Denver, Colo; Department of Family Medicine, School of Medicine, University of Colorado Anschutz Medical Campus (JC Shlay), Aurora, Colo
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17
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Sebastian T, Toseef M, Kurtz M, Frost HM. 187. Nasopharyngeal Testing to Individualize Management of Acute Otitis Media. Open Forum Infect Dis 2022. [PMCID: PMC9751960 DOI: 10.1093/ofid/ofac492.265] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Background There are > 10 million antibiotics prescribed yearly for acute otitis media (AOM). The associated organism can influence the likelihood of antibiotic benefit and optimal treatment. A rapid diagnostic test (RDT) for AOM could prevent unnecessary antibiotic use, while assuring those likely to benefit from antibiotics receive the appropriate agent. Nasopharyngeal (NP) polymerase chain reaction can effectively exclude the presence of organisms in middle ear fluid and may be useful to individualize care. Objective: To explore the potential cost-effectiveness and reduction in antibiotics with NP RDTs to direct AOM management. Methods We developed two algorithms for AOM management based on NP bacterial otopathogens (Figure1). The algorithms provide recommendations on prescribing strategy (immediate, delayed, or observation) and antimicrobial agent. We utilized a tiering system based on expected pathogen-associated severity and resistance. The primary outcome was the incremental cost-effectiveness ratio (ICER) expressed as cost per quality adjusted life day gained (QALD). We used a decision-analytic model to evaluate the cost-effectiveness of the RDT algorithms compared to usual care from a societal perspective over a 30-day time horizon. Secondary outcomes included the (1) cost at which a RDT would be cost-effective and (2) potential reduction in annual antibiotics used. Flow diagram
Flow diagram for management of AOM including RDT-DP and RDT-OBS algorithms ![]() Results An RDT algorithm that used immediate, delayed prescribing, and observation based on pathogen (RDT-DP) had an ICER of $1336.15/QALD compared with usual care and strongly dominated the RDT that used only immediate prescribing and observation (RDT-OBS). At an RDT cost of $278.56, the ICER for RDT-DP exceeded the willingness to pay threshold ($274 per QALD gained); however, if the cost of the RDT was < $212.10, the ICER was below the threshold. Both algorithms reduced annual antibiotic use, including broad-spectrum use, compared to usual care (RDT-DP 4.7 million (56% reduction), RDT-OBS 5.4 million (49% reduction), usual care 10.5 million). Conclusion The use of a NP RDT for AOM is likely to be cost-effective and substantially reduce unnecessary antibiotic use. These iterative algorithms could be modified to guide AOM management as scientific knowledge evolves. Disclosures All Authors: No reported disclosures.
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Affiliation(s)
| | | | - Melanie Kurtz
- Denver Health and Hospital Authority, Denver, Colorado
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18
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Frost HM, Sebastian T, Jenkins TC, Keith A, Kurtz M, Meece JK, Dominguez SR, Savor-Price C. 1318. Etiology of Infectious Conjunctivitis in Children: A Multi-Center Case-Controlled Study. Open Forum Infect Dis 2022. [DOI: 10.1093/ofid/ofac492.1148] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Abstract
Background
Acute infectious conjunctivitis (AIC) is a common pediatric infection affecting one in eight children annually. The etiology of AIC is poorly understood but important to inform treatment and return to school recommendations. Additionally, the association of bacteria isolated from the conjunctiva with the development of clinical AIC is not well defined. We aimed to determine the bacterial and viral causes of AIC in children.
Methods
Patients age 6 months-18 years with AIC at Denver Health (Denver, CO) and Marshfield Clinic (Marshfield, WI) from 2019-2021 were included. Age-matched healthy and upper respiratory infection (URI) controls without conjunctivitis were enrolled within 30 days of each case. Patients had a conjunctival flocked swab (Eswab®, Copan Diagnostics) obtained. Nucleic acids were extracted using the NucliSENS® easyMAG® system (Quidel, San Diego, CA) per manufacturer’s instructions. Multiplex RT-PCR for S.pneumoniae, H.influenzae, M.catarrhalis, S.aureus , and 11 respiratory viruses were completed using Lyra® (Quidel, San Diego, CA) and AnDiaTec® assay kits (Quidel Germany GmbH, Kornwestheim, Germany, Table). Nucleic acid amplification and detection was completed on the Applied Biosystems® (ABI) 7500 Fast Dx Real-Time PCR Instrument. Odds ratios were computed for each organism.
Results
A total of 78 cases and 71 controls (33 healthy, 38 URI) were included (Table). Bacteria were detected in 59 (75.6%) cases and 36 (50.7%) of controls (OR 14.3; 4.7,33.7). Respiratory viruses were infrequently detected (cases 2, 2.6%; controls 6, 8.5%), including in the pre-pandemic period. Of bacteria detected in cases, H.influenzae was the most common (56.4%) and had the highest association with conjunctivitis (OR 11.8; 4.8, 29.1) followed by M.catarrhalis (35.9% cases, OR 2.5; 1.2, 5.3). S.pneumoniae was detected more often in controls than cases (33.8% v 26.9%).
Conclusion
H.influenzae is likely the most important pathogen associated with AIC in children. Though data have suggested marginal benefit of antibiotic treat for conjunctivitis overall, studies specifically looking at benefit by organism would advance the field. A rapid diagnostic test for H.influenzae and possibly M.catarrhalis could help direct antibiotic treatment to children most likely to benefit.
Disclosures
Samuel R. Dominguez, MD PhD, Biofire DIagnostics: Advisor/Consultant|Biofire DIagnostics: Grant/Research Support|DiaSorin Molecular: Advisor/Consultant|Karius: Advisor/Consultant|Pfizer: Grant/Research Support.
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Affiliation(s)
- Holly M Frost
- Denver Health and Hospital Authority , Denver, Colorado
| | | | | | - Amy Keith
- Denver Health and Hospital Authority , Denver, Colorado
| | - Melanie Kurtz
- Denver Health and Hospital Authority , Denver, Colorado
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19
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Frost HM, Wilson ML, Roosevelt GD. 194. Rapid diagnostic testing to improve management of suspected chlamydia and gonorrhea in adolescents in a Pediatric Emergency Department. Open Forum Infect Dis 2022. [PMCID: PMC9751754 DOI: 10.1093/ofid/ofac492.272] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Background Standard turnaround times for Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (GC) testing result in unnecessary antibiotic use for patients without infection and undertreatment of patients with infection(s). We aimed to determine the impact of rapid CT/GC testing on reducing unnecessary antibiotic use, undertreatment of CT and/or GC, and length of stay in an urban safety-net pediatric emergency department (PED). Methods Before 2020, testing for CT/GC was performed using a batched nucleic acid amplification test (NAAT; Hologic Aptima Combo2) with results available the following day. Starting January 2020, the GeneXpert rapid NAAT (Cepheid Xpert CT/NG) with turnaround time between 90-120 minutes was available. Our primary outcome variables were under- and over-treatment. Undertreatment was defined as GC and/or CT positive patients who did not receive appropriate antibiotic treatment in the PED. Overtreatment was defined as GC or CT negative patients who received antibiotic treatment in the PED. Under- and over-treatment percentages were plotted on Statistical Process Control p charts. The balancing measure was length of stay (LOS). Results There were 739 patients evaluated in the baseline period (2019), 631 in the intervention period (2020) and 626 in the post-intervention period (2021). There were no differences in gender, race, ethnicity, and insurance across the 3 time periods. After introduction of the GeneXpert, over-treatment decreased from 18.4% to 8.1% (Figure). Under-treatment did not differ. Median turnaround for the GeneXpert was 119 minutes. Median LOS in minutes increased from 165 minutes (baseline) to 182 minutes (intervention) and 202 minutes (post-intervention; p< .001). Percentage of patients over-treated for chlamydia and gonorrhea.
![]() Conclusion Rapid CT/GC testing substantially reduced unnecessary antibiotic use but increased LOS. Given the rapid increases in CT/GC rates and antimicrobial resistance health systems should consider implementation of rapid testing to appropriately direct antimicrobials to patients most likely to benefit. A more rapid test would likely increase appropriate antibiotic use and limit impact on LOS. Disclosures All Authors: No reported disclosures.
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Affiliation(s)
- Holly M Frost
- Denver Health and Hospital Authority, Denver, Colorado
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20
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Frost HM, Bizune D, Gerber JS, Hersh AL, Hicks LA, Tsay SV. Amoxicillin Versus Other Antibiotic Agents for the Treatment of Acute Otitis Media in Children. J Pediatr 2022; 251:98-104.e5. [PMID: 35944719 PMCID: PMC10122571 DOI: 10.1016/j.jpeds.2022.07.053] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Revised: 06/17/2022] [Accepted: 07/22/2022] [Indexed: 01/04/2023]
Abstract
OBJECTIVES The objective of the study was to compare the antibiotic treatment failure and recurrence rates between antibiotic agents (amoxicillin, amoxicillin-clavulanate, cefdinir, and azithromycin) for children with uncomplicated acute otitis media (AOM). STUDY DESIGN We completed a retrospective cohort study of children 6 months-12 years of age with uncomplicated AOM identified in a nationwide claims database. The primary exposure was the antibiotic agent, and the primary outcomes were treatment failure and recurrence. Logistic regression was used to estimate ORs, and analyses were stratified by primary exposure, patient age, and antibiotic duration. RESULTS Among the 1 051 007 children included in the analysis, 56.6% were prescribed amoxicillin, 13.5% were prescribed amoxicillin-clavulanate, 20.6% were prescribed cefdinir, and 9.3% were prescribed azithromycin. Most prescriptions (93%) were for 10 days, and 98% were filled within 1 day of the medical encounter. Treatment failure and recurrence occurred in 2.2% (95% CI: 2.1, 2.2) and 3.3% (3.2, 3.3) of children, respectively. Combined failure and recurrence rates were low for all agents including amoxicillin (1.7%; 1.7, 1.8), amoxicillin-clavulanate (11.3%; 11.1, 11.5), cefdinir (10.0%; 9.8, 10.1), and azithromycin (9.8%; 9.6, 10.0). CONCLUSIONS Despite microbiologic changes in AOM etiology, treatment failure and recurrence were uncommon for all antibiotic agents and were lower for amoxicillin than for other agents. These findings support the continued use of amoxicillin as a first-line agent for AOM when antibiotics are prescribed.
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Affiliation(s)
- Holly M Frost
- Department of Pediatrics, Denver Health and Hospital Authority, Denver, CO; Center for Health Systems Research, Denver Health and Hospital Authority, Denver, CO; Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO.
| | - Destani Bizune
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, GA
| | - Jeffrey S Gerber
- Division of Infectious Diseases, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Adam L Hersh
- Division of Pediatric Infectious Diseases, University of Utah, Salt Lake City, UT
| | - Lauri A Hicks
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, GA
| | - Sharon V Tsay
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, GA
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21
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Tomcho MM, Lou Y, O’Leary SC, Rinehart DJ, Thomas-Gale T, Penny L, Frost HM. Closing the Equity Gap: An Intervention to Improve Chlamydia and Gonorrhea Testing for Adolescents and Young Adults in Primary Care. J Prim Care Community Health 2022; 13:21501319221131382. [PMID: 36300428 PMCID: PMC9619876 DOI: 10.1177/21501319221131382] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND Chlamydia trachomatis and Neisseria gonorrhea are the most reported sexually transmitted infections in the United States. Testing rates remain suboptimal and may be subject to implicit bias. We evaluated the effectiveness of an opt-out chlamydia and gonorrhea testing program for adolescents and young adults in improving testing rates and promoting equity. METHODS An opt-out testing program that standardized testing to once annually for 14 to 24-year-old patients was implemented across 28 federally qualified health centers spanning 4 specialties. A quasi-experimental design using interrupted time series analyses evaluated testing and infection rates between baseline, intervention, and pandemic-associated test shortage periods. Reduction in testing inequities based on sex, race, ethnicity, insurance, and language preference were also examined. RESULTS A total of 57 452 encounters during the baseline, 17 320 during the intervention, and 26 993 during the test supply shortage periods were included. Testing increased from 66.8% to 81.0% (14.2% absolute increase) between baseline and intervention periods. Pediatric clinics demonstrated the largest improvement compared to other settings (absolute increase 30.9%). We found significant reductions in testing inequities for language preference (P < .001), and un-insured and public insured individuals (P < .001). More cases of chlamydia and gonorrhea were detected in the intervention period (chlamydia-29.7; gonorrhea-7.4 per 1000 patients) than in the baseline period (chlamydia-20.7; gonorrhea-4.4 per 1000 patients; P < .001). CONCLUSIONS An opt-out approach increased testing, reduced inequities between some groups and detected more infections than a risk-based approach. Opt-out testing should be considered as an approach to increase detection of chlamydia and gonorrhea and promote equity.
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Affiliation(s)
- Margaret M. Tomcho
- Denver Health and Hospital Authority,
Denver, CO, USA,University of Colorado School of
Medicine, Aurora, CO, USA
| | - Yingbo Lou
- Denver Health and Hospital Authority,
Denver, CO, USA
| | - Sonja C. O’Leary
- Denver Health and Hospital Authority,
Denver, CO, USA,University of Colorado School of
Medicine, Aurora, CO, USA
| | - Deborah J. Rinehart
- Denver Health and Hospital Authority,
Denver, CO, USA,University of Colorado School of
Medicine, Aurora, CO, USA
| | | | - Lara Penny
- Denver Health and Hospital Authority,
Denver, CO, USA,University of Colorado School of
Medicine, Aurora, CO, USA
| | - Holly M. Frost
- Denver Health and Hospital Authority,
Denver, CO, USA,University of Colorado School of
Medicine, Aurora, CO, USA,Holly M. Frost, Department of General
Pediatrics, Denver Health and Hospital Authority, 601 Broadway Ave, Denver, CO
80004, USA.
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22
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Frost HM, Hersh AL. More Recent Literature Does Not Support Premise or Conclusions-Reply. JAMA Pediatr 2022; 176:827-828. [PMID: 35696153 DOI: 10.1001/jamapediatrics.2022.1763] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Holly M Frost
- Department of Pediatrics, Denver Health and Hospital Authority, Denver, Colorado
| | - Adam L Hersh
- Department of Pediatrics, Division of Pediatric Infectious Diseases, The University of Utah, Salt Lake City
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23
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Sebastian T, Frost HM. A qualitative evaluation of pediatric conjunctivitis medical decision making and opportunities to improve care. J AAPOS 2022; 26:113.e1-113.e6. [PMID: 35421542 PMCID: PMC10119943 DOI: 10.1016/j.jaapos.2021.12.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2021] [Revised: 12/01/2021] [Accepted: 12/08/2021] [Indexed: 11/15/2022]
Abstract
BACKGROUND Acute infectious conjunctivitis is a common childhood illness, and the role of antibiotic treatment remains unclear. The purpose of this study was to describe the decision-making process providers use when managing infectious conjunctivitis, to identify factors that reduce unnecessary antibiotic prescribing, and to evaluate how the COVID-19 pandemic influenced prescribing behavior. METHODS We conducted semi-structured interviews with 20 providers caring for children in primary care, urgent cares, and emergency departments in Denver, Colorado. Interviews were evaluated for major themes using deductive and inductive content analysis methods. RESULTS Significant drivers for deciding to treat infectious conjunctivitis with antibiotics included patient's clinical presentation, family expectations, antibiotic stewardship concerns, etiological diagnostic uncertainty, and school/daycare policies. High variability existed in approaches used to distinguish viral from bacterial conjunctivitis. No providers were aware of pediatric treatment guidelines or standardized recommendations for return to school or daycare. Providers reported higher antibiotic prescribing during the COVID-19 pandemic. Factors identified that could reduce unnecessary antibiotic prescribing included family education, a reliable diagnostic test to decrease diagnostic uncertainty, pediatric clinical guidelines, and standardizing exclusion policies for school/daycare. CONCLUSIONS Management of pediatric infectious conjunctivitis is inconsistent. Creation of guidelines for the evaluation and management of infectious conjunctivitis in children could help reduce unnecessary prescribing and the burden for families and the health care system. In addition, updated guidelines for school/daycare exclusion may be important to establish streamlined and evidence-based exclusion practices.
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Affiliation(s)
- Thresia Sebastian
- Department of Pediatrics, Denver Health and Hospital Authority, Denver, Colorado; Department of Pediatrics, University of Colorado School of Medicine, Aurora, Colorado.
| | - Holly M Frost
- Department of Pediatrics, Denver Health and Hospital Authority, Denver, Colorado; Department of Pediatrics, University of Colorado School of Medicine, Aurora, Colorado; Office of Research, Denver Health and Hospital Authority, Denver, Colorado
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24
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McWhirter L, Lou Y, Reingold S, Warsh S, Thomas-Gale T, Haynes C, Rinehart D, Wendel KA, Frost HM. Rates of Appropriate Treatment and Follow-Up Testing After a Gonorrhea and/or Chlamydia Infection in an Urban Network of Federally Qualified Health Center Systems. Sex Transm Dis 2022; 49:319-324. [PMID: 35001017 PMCID: PMC9018487 DOI: 10.1097/olq.0000000000001600] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Reinfection and partner transmission are common with Neisseria gonorrhoeae (GC) and Chlamydia trachomatis (CT). We assessed treatment and follow-up laboratory testing for GC and CT and evaluated associations with patient- and system-level factors. METHODS The analysis included positive GC and/or CT nucleic acid amplification test results from patients aged 14 to 24 years at a federally qualified health center system site in Denver, CO, from January 2018 to December 2019. Outcomes assessed include treatment within 14 days, HIV/syphilis testing within 6 months, and repeat GC and CT testing within 2 to 6 months. Bivariate and multivariable regression modeling assessed associated factors. RESULTS Among 27,168 GC/CT nucleic acid amplification tests performed, 1.8% (484) were positive for GC and 7.8% (2125) were positive for CT. Within the assessed time frames, 87% (2275) of patients were treated, 54.1% (1411) had HIV testing, 50.1% (1306) had syphilis testing, and 39.9% (1040) had GC and CT retesting. Older patients were more likely to receive treatment (adjusted odds ratio 1.13; 95% confidence interval, 1.00-1.27; P = 0.05) than younger patients, whereas males were less likely to receive GC and CT retesting (adjusted odds ratio, 0.19; 95% confidence interval, 0.11-0.33; P < 0.001) than females. Patients treated on the day of testing were less likely to receive follow-up laboratory tests than those treated 2 to 14 days after. CONCLUSIONS Although most patients received antibiotic treatment, only about half received HIV/syphilis testing and less than half received GC and CT retesting. It is critical to find innovative strategies to improve treatment and follow-up management of these infections to decrease complications, reduce transmission, and combat the rising rates of sexually transmitted infections.
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Affiliation(s)
| | - Yingbo Lou
- Denver Health Medical Center, Community Health Services, Denver, CO
| | - Sarah Reingold
- University of Colorado School of Medicine, Department of Internal Medicine-Pediatrics, Aurora, CO
| | - Sarah Warsh
- Denver Health Medical Center, Community Health Services, Denver, CO
| | - Tara Thomas-Gale
- Denver Health Medical Center, Community Health Services, Denver, CO
| | - Christine Haynes
- Denver Health Medical Center, Department of Internal Medicine, Denver, CO
- University of Colorado School of Medicine, Department of Medicine, Division of General Internal Medicine, Aurora, CO
| | | | - Karen A. Wendel
- Denver Health Medical Center, Department of Internal Medicine, Division of Infectious Diseases, Denver, CO
- University of Colorado School of Medicine, Department of Internal Medicine, Division of Infectious Diseases, Aurora, CO
| | - Holly M Frost
- Denver Health Medical Center, Office of Research, Denver, CO
- Denver Health Medical Center, Department of Pediatrics, Denver, CO
- University of Colorado School of Medicine, Department of Pediatrics, Aurora, CO
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25
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Affiliation(s)
- Holly M Frost
- Department of Pediatrics, Denver Health and Hospital Authority, Denver, Colorado.,Department of Pediatrics, University of Colorado School of Medicine, Aurora
| | - Adam L Hersh
- Division of Pediatric Infectious Diseases, Department of Pediatrics, University of Utah, Salt Lake City
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26
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Frost HM, Sebastian T, Keith A, Kurtz M, Dominguez SR, Parker SK, Jenkins TC. COVID-19 and Acute Otitis Media in Children: A Case Series. J Prim Care Community Health 2022; 13:21501319221082351. [PMID: 35289210 PMCID: PMC8928385 DOI: 10.1177/21501319221082351] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Background: The association of SARS-CoV-2 with acute otitis media (AOM) in children is poorly understood. Methods: Cases were identified as a subpopulation within the NO TEARS prospective AOM study in Denver, CO from March to December 2020. Children enrolled were 6 to 35 months of age with uncomplicated AOM; those with AOM and SARS-CoV-2 were included. Data was obtained from electronic medical records and research case report forms. Results: A total of 108 patients enrolled in the NO TEARS study from May 2019 through December 2020 (all subsequently tested for SARS CoV-2). During the COVID-19 pandemic study period (March-December 2020), 16 patients enrolled, and 7 (43.6%) were identified with AOM/COVID-19 co-infection. Fever was present in 3 of 7 children (29%). Four children (57%) attended daycare. Only 2 children (29%) had SARS CoV-2 testing as part of their clinical workup. Mean AOM-SOS© scores were similar among SARS CoV-2 positive and negative patients with no statistical significance with two-sided t-tests: 13.6 (±4.5) versus 14.2 (±4.9) at enrollment, 1.4 (±1.8) versus 4.2 (±4.9) on Day 5, and 0.6 (±0.9) versus 2.5 (±6.1) on Day 14. Among the 7 cases, no child had an AOM treatment failure or recurrence within 3 to 14 or 15 to 30 days respectively. Of the 6 patients with completed bacterial and viral testing, a bacterial pathogen was identified in all 6, and a viral pathogen in 3 (50%). Conclusions: COVID-19 and AOM can co-exist. Providers should maintain a high index of suspicion for COVID-19 even in patients with clinical AOM and should not use a diagnosis of AOM to exclude COVID-19.
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Affiliation(s)
- Holly M Frost
- Denver Health and Hospital Authority, Denver, CO, USA.,University of Colorado School of Medicine, Aurora, CO, USA
| | - Thresia Sebastian
- Denver Health and Hospital Authority, Denver, CO, USA.,University of Colorado School of Medicine, Aurora, CO, USA
| | - Amy Keith
- Denver Health and Hospital Authority, Denver, CO, USA
| | - Melanie Kurtz
- Denver Health and Hospital Authority, Denver, CO, USA
| | - Samuel R Dominguez
- University of Colorado School of Medicine, Aurora, CO, USA.,Children's Hospital Colorado, Aurora, CO, USA
| | - Sarah K Parker
- University of Colorado School of Medicine, Aurora, CO, USA.,Children's Hospital Colorado, Aurora, CO, USA
| | - Timothy C Jenkins
- Denver Health and Hospital Authority, Denver, CO, USA.,University of Colorado School of Medicine, Aurora, CO, USA
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27
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Frost HM, Lou Y, Keith A, Byars A, Jenkins TC. Increasing Guideline-Concordant Durations of Antibiotic Therapy for Acute Otitis Media. J Pediatr 2022; 240:221-227.e9. [PMID: 34274307 PMCID: PMC8792957 DOI: 10.1016/j.jpeds.2021.07.016] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2021] [Revised: 06/17/2021] [Accepted: 07/12/2021] [Indexed: 01/03/2023]
Abstract
OBJECTIVE To compare the effectiveness of 2 interventions in improving prescribing of guideline-concordant durations of therapy for acute otitis media (AOM). STUDY DESIGN This was a quasi-experimental mixed methods analysis that compared a bundled quality improvement intervention consisting of individualized audit and feedback, education, and electronic health record (EHR) changes to an EHR-only intervention. The bundle was implemented in 3 pediatric clinics from January to August 2020 and an EHR-only intervention was implemented in 6 family medicine clinics. The primary outcome measure was prescription of an institutional guideline-concordant 5-day duration of therapy for children ≥2 years of age with uncomplicated AOM. Propensity score matching and differences-in-differences analysis weighted with inverse probability of treatment were completed. Implementation outcomes were assessed using the Reach, Effectiveness, Adoption, Implementation, Maintenance Framework. Balance measures included treatment failure and recurrence. RESULTS In total, 1017 encounters for AOM were included from February 2019 to August 2020. Guideline-concordant prescribing increased from 14.4% to 63.8% (difference = 49.4%) in clinics that received the EHR-only intervention and from 10.6% to 85.2% (difference = 74.6%) in clinics that received the bundled intervention. In the adjusted analysis, the bundled intervention improved guideline-concordant durations by an additional 26.4% (P < .01) compared with the EHR-only intervention. Providers identified EHR-prescription field changes as the most helpful components. There were no differences in treatment failure or recurrence rates between baseline and either intervention. CONCLUSIONS Both interventions resulted in improved prescribing of guideline-concordant durations of antibiotics. The bundled intervention improved prescribing more than an EHR-only intervention and was acceptable to providers.
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Affiliation(s)
- Holly M Frost
- Department of Pediatrics, Denver Health, Denver, CO; Center for Health Systems Research, Office of Research, Denver Health, Denver, CO; Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO.
| | - Yingbo Lou
- Department of Ambulatory Care Services, Denver Health, Denver, CO
| | - Amy Keith
- Center for Health Systems Research, Office of Research, Denver Health, Denver, CO
| | - Andrew Byars
- Department of Surgery, Denver Health, Denver, CO
| | - Timothy C Jenkins
- Department of Medicine, Division of Infectious Diseases, Denver Health, Denver, CO,Department of Medicine, Division of Infectious Diseases, University of Colorado School of Medicine, Aurora, CO
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28
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Frost HM, Sebastian T, Keith A, Kurtz M, Dominguez SR, Dominguez SR, Parker S, Jenkins TC. 347. SARS-CoV-2 and Acute Otitis Media in Children: A Case Series. Open Forum Infect Dis 2021. [PMCID: PMC8644041 DOI: 10.1093/ofid/ofab466.548] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Background Reports in adults with COVID-19 and acute otitis media (AOM) show that severe symptoms and hearing loss may be more common than with the clinical presentation of typical AOM. However, the association of SARS-CoV-2 with AOM in children is poorly understood. Methods Cases were identified as a subpopulation enrolled in the NOTEARS prospective AOM study in Denver, CO from March-December 2020. Children enrolled were 6-35 months of age with uncomplicated AOM and prescribed amoxicillin. Children diagnosed with AOM and SARS-CoV-2, detected by polymerase chain reaction assay, were included in the case series. Data was obtained from electronic medical records and research case report forms. Patients completed surveys at enrollment and 5, 14 and 30 days after enrollment that included the Acute Otitis Media Severity of Symptoms (AOM-SOS©) scale. All patients had nasopharyngeal otopathogen testing completed. Results A total of 108 patients had been enrolled through December 2020 (all of whom were subsequently tested for SARS CoV-2). During the study period for this case series, 16 patients were enrolled, and 7 (43.6%) were identified with AOM/SARS-CoV-2 co-infection. Among these 7 patients, fever was present in 3 children (29%). Four children (57%) attended daycare. Only 2 children (29%) had testing for SARS CoV-2 as part of their clinical workup. Mean AOM-SOS© scores were similar among the SARS CoV-2 positive and negative patients with no statistical significance noted with two-sided t-tests: 13.6 (± 4.5) vs 14.2 (± 4.9) at enrollment, 1.4 (± 1.8) vs 4.2 (±4.9) on Day 5, and 0.6 (± 0.9) vs. 2.5 (±6.1) on Day 14 (Table 1). Among the 7 patients, no child had an AOM treatment failure or recurrence. Of the 6 patients in whom bacterial and viral testing have been completed, a bacterial otopathogen was identified in 6 (100%), and a viral pathogen in 3 (50%) children (Table 2). Table 1. Clinical features of children with concurrent SARS-CoV-2 and AOM ![]()
Table 2. Laboratory findings of children with concurrent SARS-CoV-2 and AOM. ![]()
Conclusion SARS-CoV-2 can occur in children with AOM. It is important that providers maintain a high index of suspicion for COVID-19 even in patients with clinical evidence of AOM, particularly to ensure families are appropriately advised on isolation and quarantine requirements. AOM with SARS-CoV-2 does not appear to be more severe than AOM without SARS-CoV-2. Disclosures Samuel R. Dominguez, MD, PhD, BioFire Diagnostics (Consultant, Research Grant or Support)DiaSorin Molecular (Consultant)Pfizer (Grant/Research Support) Samuel R. Dominguez, MD, PhD, BioFire (Individual(s) Involved: Self): Consultant, Research Grant or Support; DiaSorin Molecular (Individual(s) Involved: Self): Consultant; Pfizer (Individual(s) Involved: Self): Grant/Research Support
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Affiliation(s)
- Holly M Frost
- Denver Health and Hospital Authority, University of Colorado School of Medicine, Denver, Colorado
| | | | - Amy Keith
- Denver Health and Hospital Authority, Denver, Colorado
| | - Melanie Kurtz
- Denver Health and Hospital Authority, Denver, Colorado
| | | | | | | | - Timothy C Jenkins
- Denver Health Medical Center, University of Colorado School of Medicine, Denver, Colorado
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29
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Frost HM, Sebastian T, Keith A, Kurtz M, Bress A, Egan R, Dominguez SR, Dominguez SR, Parker S, Jenkins TC. 113. Reliability of Nasopharyngeal PCR for the Detection of Otopathogens in Children with Uncomplicated Acute Otitis Media. Open Forum Infect Dis 2021. [PMCID: PMC8644707 DOI: 10.1093/ofid/ofab466.113] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Background
Among children with acute otitis media (AOM) S.pneumoniae, H.influenzae, and M.catarrhalis are the predominant bacterial otopathogens. There is a high correlation between nasopharyngeal (NP) and middle ear fluid (MEF) organisms during AOM. Thus, NP samples could serve as a surrogate for detection of otopathogens and are more easily collected in a typical practice environment than MEF. Though culture is considered the gold standard for detection, it is time-consuming, which can limit its diagnostic utility to guide clinical care. We aimed to determine the sensitivity, specificity, positive (PPV) and negative predictive value (NPV) for NP qualitative PCR for bacterial otopathogens compared to NP culture.
Methods
Patients age 6-35 months with uncomplicated AOM who were prospectively enrolled in an AOM study in Denver, CO from Jan 2019-Dec 2020 were included. All patients had an NP flocked swab (Eswab®, Copan Diagnostics) at enrollment. Otopathogen culture was completed using standard techniques. Nucleic acids were extracted using the NucliSENS® easyMAG® system (Quidel, San Diego, CA) per manufacturer’s instructions. Multiplex RT-PCR for S.pneumoniae, H.influenzae, and M.catarrhalis was completed using Lyra® (Quidel, San Diego, CA) and AnDiaTec® assay kits (Quidel Germany GmbH, Kornwestheim, Germany). Nucleic acid amplification and detection was completed on the Applied Biosystems® (ABI) 7500 Fast Dx Real-Time PCR Instrument.
Results
Of the 80 children included, 18 (22.5%) had no organism detected on culture, 31 (38.8%) had one and 31 (38.8%) had multiple organisms detected. The most commonly identified organisms on culture were M.catarrhalis (42, 52.5%), followed by S.pneumoniae (30, 37.5%), and H.influenzae (17, 21.3%). Of H.influenzae isolates 8 (47.1%) produced beta-lactamase. The sensitivity of PCR was high ( >94%) for all organisms whereas the specificity was lower (50.0-77.8%) and varied by organism (Table). NPV were high ( >96%) for all otopathogens, whereas, PPV ranged from 53.3 to 68.9%. PCR detected 1.6 times more organisms than culture (149 vs. 96).
Sensitivity, specificity, positive and negative predictive value of PCR compared to culture for otopathogens.
Conclusion
NP PCR has a high predictive value for excluding otopathogens and warrants further exploration as a diagnostic tool to evaluate for otopathogens in children.
Disclosures
Andreas Bress, PhD, Quidel Laboratories- Germany (Employee) Richard Egan, PhD, Quidel Laboratories (Employee) Samuel R. Dominguez, MD, PhD, BioFire Diagnostics (Consultant, Research Grant or Support)DiaSorin Molecular (Consultant)Pfizer (Grant/Research Support) Samuel R. Dominguez, MD, PhD, BioFire (Individual(s) Involved: Self): Consultant, Research Grant or Support; DiaSorin Molecular (Individual(s) Involved: Self): Consultant; Pfizer (Individual(s) Involved: Self): Grant/Research Support
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Affiliation(s)
- Holly M Frost
- Denver Health and Hospital Authority, University of Colorado School of Medicine, Denver, Colorado
| | | | - Amy Keith
- Denver Health and Hospital Authority, Denver, Colorado
| | - Melanie Kurtz
- Denver Health and Hospital Authority, Denver, Colorado
| | - Andreas Bress
- Quidel Laboratories, Kornwestheim, Baden-Wurttemberg, Germany
| | - Richard Egan
- Quidel Laboratories, Kornwestheim, Baden-Wurttemberg, Germany
| | | | | | | | - Timothy C Jenkins
- Denver Health Medical Center, University of Colorado School of Medicine, Denver, Colorado
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30
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Frost HM, Sebastian T, Durfee J, Jenkins TC. Ophthalmic antibiotic use for acute infectious conjunctivitis in children. J AAPOS 2021; 25:350.e1-350.e7. [PMID: 34737083 PMCID: PMC9109048 DOI: 10.1016/j.jaapos.2021.06.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Revised: 06/08/2021] [Accepted: 06/13/2021] [Indexed: 10/19/2022]
Abstract
BACKGROUND Infectious conjunctivitis is among the most common pediatric infections worldwide; antibiotics are often not indicated. We aimed to determine factors associated with ophthalmic antibiotic prescribing and changes in prescribing prior to and during the COVID-19 pandemic at a single center. METHODS Encounters for children with infectious conjunctivitis from 2017 to 2020 at Denver Health and Hospital Authority clinics were analyzed retrospectively. Factors associated with prescribing were evaluated using multivariable logistic regression modeling. Encounter numbers and prescribing patterns for telephone versus in-person visits before and during the pandemic were compared and stratified. RESULTS Of 5,283 patients encounters for conjunctivitis, 3,841 (72.7%) resulted in an ophthalmic antibiotic prescription. Concurrent diagnosis with acute otitis media (adjusted odds ratio [aOR] 0.20 (95% CI, 0.16-0.25) and later study year (2018-aOR = 0.76 [95% CI, 0.65-0.89]; 2019- aOR = 0.57 [95% CI, 0.48-0.67]) were associated with reduced odds of prescribing. Compared with those evaluated in pediatric clinics, patients evaluated in family medicine (aOR = 0.69 [95% CI, 0.58-0.83]) or optometry/ophthalmology clinics (aOR = 0.06 [95% CI, 0.02-0.14]) were less likely to have antibiotics prescribed, whereas, patients evaluated via telephone had a 5.43 (95% CI, 3.97-7.42) greater odds of being prescribed ophthalmic antibiotics. Antibiotic prescribing increased from 67.8% prior to the COVID-19 pandemic to 81.9% during the pandemic (P < 0.0001). CONCLUSIONS Discordant with national guideline recommendations, ophthalmic antibiotic use for conjunctivitis was high. Telephone visits were associated with higher rates of prescribing. Rates of prescribing increased significantly during the COVID-19 pandemic.
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Affiliation(s)
- Holly M Frost
- Department of Pediatrics, Denver Health and Hospital Authority, Denver, Colorado; University of Colorado School of Medicine, Aurora, Colorado; Office of Research, Denver Health and Hospital Authority, Denver, Colorado.
| | - Thresia Sebastian
- Department of Pediatrics, Denver Health and Hospital Authority, Denver, Colorado; University of Colorado School of Medicine, Aurora, Colorado
| | - Josh Durfee
- Office of Research, Denver Health and Hospital Authority, Denver, Colorado
| | - Timothy C Jenkins
- University of Colorado School of Medicine, Aurora, Colorado; Division of Infectious Diseases and Department of Medicine, Denver Health and Hospital Authority, Denver, Colorado
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31
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Tomcho MM, Lou Y, O'Leary SC, Rinehart DJ, Thomas-Gale T, Douglas CM, Wu FJ, Penny L, Federico SG, Frost HM. An Intervention to Improve Chlamydia and Gonorrhea Testing Among Adolescents in Primary Care. Pediatrics 2021; 148:e2020027508. [PMID: 34675130 PMCID: PMC8972200 DOI: 10.1542/peds.2020-027508] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/29/2021] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Rates of chlamydia and gonorrhea among adolescents continue to rise. We aimed to evaluate if a universal testing program for chlamydia and gonorrhea improved testing rates in an urban general pediatric clinic and an urban family medicine clinic within a system of federally qualified health care centers and evaluated the feasibility, cost, and logistic challenges of expanding implementation across 28 primary care clinics within a federally qualified health care centers system. METHODS A universal testing quality improvement program for male and female patient 14 to 18 years old was implemented in a general pediatrics and family medicine clinic in Denver, Colorado. The intervention was evaluated by using a controlled pre-post quasi-experimental design. The difference in testing rates due to the intervention was assessed by using a difference-in-differences regression model weighted with the inverse probability of treatment. RESULTS In total, 15 541 pediatric encounters and 5420 family medicine encounters were included in the analyses. In pediatrics, the unadjusted testing rates increased from 32.0% to 66.7% in the intervention group and from 20.9% to 28.9% in the comparison group. For family medicine, the rates increased from 38.5% to 49.9% in the intervention group and decreased from 26.3% to 24.8% in the comparison group. The intervention resulted in an adjusted increase in screening rates of 25.2% (P < .01) in pediatrics and 11.8% (P < .01) in family medicine. The intervention was well received and cost neutral to the clinic. CONCLUSIONS Universal testing for chlamydia and gonorrhea in primary care pediatrics and family medicine is a feasible approach to improving testing rates .
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Affiliation(s)
| | - Yingbo Lou
- Ambulatory Care Services, Denver Health Medical Center, Denver, Colorado
| | - Sonja C O'Leary
- Departments of General Pediatrics
- Departments of General Pediatrics
| | | | - Tara Thomas-Gale
- Ambulatory Care Services, Denver Health Medical Center, Denver, Colorado
| | - Claudia M Douglas
- Departments of General Pediatrics
- Departments of General Pediatrics
- Internal Medicine
| | - Florence J Wu
- Departments of General Pediatrics
- Departments of General Pediatrics
| | - Lara Penny
- Family Medicine
- Family Medicine, School of Medicine, University of Colorado, Aurora, Colorado
| | | | - Holly M Frost
- Departments of General Pediatrics
- Center for Health Systems Research, Denver, Colorado
- Departments of General Pediatrics
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Frost HM, Monti JD, Andersen LM, Norlin C, Bizune DJ, Fleming-Dutra KE, Czaja CA. Improving Delayed Antibiotic Prescribing for Acute Otitis Media. Pediatrics 2021; 147:e2020026062. [PMID: 33980695 PMCID: PMC8168601 DOI: 10.1542/peds.2020-026062] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/28/2020] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVES Acute otitis media (AOM) is the most-common indication for antibiotics in children. Delayed antibiotic prescribing for AOM can significantly reduce unnecessary antibiotic use and is recommended by the American Academy of Pediatrics for select children. We sought to improve delayed prescribing for AOM across 8 outpatient pediatric practices in Colorado. METHODS Through a collaborative initiative with American Academy of Pediatrics and the Centers for Disease Control and Prevention, we implemented an economical 6-month antimicrobial stewardship intervention that included education, audit and feedback, online resources, and content expertise. Practices used The Model for Improvement and plan-do-study-act cycles to improve delayed antibiotic prescribing. Generalized estimating equations were used to generate relative risk ratios (RRRs) for outcomes at the intervention end and 3- and 6-months postintervention. Practice surveys were evaluated. RESULTS In total, 69 clinicians at 8 practice sites implemented 27 plan-do-study-act cycles. Practices varied by size (range: 6-37 providers), payer type, and geographic setting. The rate of delayed antibiotic prescribing increased from 2% at baseline to 21% at intervention end (RRR: 8.96; 95% confidence interval [CI]: 4.68-17.17). Five practices submitted postintervention data. The rate of delayed prescribing at 3 months and 6 months postintervention remained significantly higher than baseline (3 months postintervention, RRR: 8.46; 95% CI: 4.18-17.11; 6 months postintervention, RRR: 6.69; 95% CI: 3.53-12.65) and did not differ from intervention end (3 months postintervention, RRR: 1.12; 95% CI: 0.62-2.05; 6-months postintervention, RRR: 0.89; 95% CI: 0.53-1.49). CONCLUSIONS Baseline rate of delayed prescribing was low. A low-cost intervention resulted in a significant and sustained increase in delayed antibiotic prescribing across a diversity of settings.
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Affiliation(s)
- Holly M Frost
- Department of Pediatrics, Denver Health Medical Center, Denver, Colorado;
- Office of Research, Denver Health Medical Center, Denver, Colorado
- Department of Pediatrics, School of Medicine, University of Colorado, Aurora, Colorado
| | | | | | - Chuck Norlin
- Department of Pediatrics, University of Utah, Salt Lake City, Utah
| | - Destani J Bizune
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia; and
| | - Katherine E Fleming-Dutra
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia; and
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Douglas CM, O’ Leary SC, Tomcho MM, Wu FJ, Penny L, Federico SG, Wilson ML, Rinehart DJ, Frost HM. Gonorrhea and Chlamydia Rates Among 12- to 24-Year-Old Patients in an Urban Health System. Sex Transm Dis 2021; 48:161-166. [PMID: 33003186 PMCID: PMC7867586 DOI: 10.1097/olq.0000000000001302] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (GC) infection rates continue to rise. Screening guidelines have largely focused on sexually active female individuals and men who have sex with men populations. Health care system testing and infection rates, particularly among heterosexual male individuals, are poorly understood. Our aim was to evaluate CT and GC testing and prevalence among 12- to 24-year-old patients in an urban federally qualified health center system. METHODS This retrospective study analyzed electronic health record data from 2017 to 2019 in a large system of federally qualified health centers in Denver, CO. Abstracted data included demographics, sexual activity, sexual orientation, and laboratory results. χ2 Tests were used to evaluate differences between groups. RESULTS Of the 44,021 patients included, 37.6% were tested, 15.0% were positive for CT, and 3.4% were positive for GC. Heterosexual male patients had a testing rate of 22.8% and positivity rates of CT and GC at 13.1% and 3.0%, respectively. Among tested patients documented as not sexually active, 7.5% were positive for CT. Multiple or reinfections were detected in 29% of patients. CONCLUSIONS This study shows low testing rates and high rates of CT and GC infections among all patients, including heterosexual male patients and those documented as not sexually active. Improved screening of these populations in the primary care setting may be key to combating the sexually transmitted disease epidemic.
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Affiliation(s)
- Claudia M. Douglas
- Department of General Pediatrics, Denver Health Medical Center, Denver, CO
- Department of General Pediatrics, University of Colorado School of Medicine, Aurora, CO
- Department of Internal Medicine, University of Colorado School of Medicine, Aurora, CO
| | - Sonja C. O’ Leary
- Department of General Pediatrics, Denver Health Medical Center, Denver, CO
- Department of General Pediatrics, University of Colorado School of Medicine, Aurora, CO
| | - Margaret M. Tomcho
- Department of General Pediatrics, Denver Health Medical Center, Denver, CO
- Department of General Pediatrics, University of Colorado School of Medicine, Aurora, CO
| | - Florence J. Wu
- Department of General Pediatrics, Denver Health Medical Center, Denver, CO
- Department of General Pediatrics, University of Colorado School of Medicine, Aurora, CO
| | - Lara Penny
- Department of Family Medicine, Denver Health Medical Center, Denver, CO
- Department of Family Medicine, University of Colorado School of Medicine, Aurora, CO
| | - Steven G. Federico
- Department of General Pediatrics, Denver Health Medical Center, Denver, CO
- Department of General Pediatrics, University of Colorado School of Medicine, Aurora, CO
| | - Michael L. Wilson
- Department of Pathology and Laboratory Services, Denver Health Medical Center, Denver, CO
- Department of Pathology, University of Colorado School of Medicine, Aurora, CO
| | - Deborah J. Rinehart
- Department of Internal Medicine, University of Colorado School of Medicine, Aurora, CO
- Center for Health Systems Research, Denver Health, Denver, CO
| | - Holly M. Frost
- Department of General Pediatrics, Denver Health Medical Center, Denver, CO
- Department of General Pediatrics, University of Colorado School of Medicine, Aurora, CO
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Frost HM, Knepper BC, Shihadeh KC, Jenkins TC. A Novel Approach to Evaluate Antibiotic Utilization Across the Spectrum of Inpatient and Ambulatory Care and Implications for Prioritization of Antibiotic Stewardship Efforts. Clin Infect Dis 2021; 70:1675-1682. [PMID: 31162539 DOI: 10.1093/cid/ciz466] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2019] [Accepted: 06/03/2019] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Antibiotic overuse remains a significant problem. The objective of this study was to develop a methodology to evaluate antibiotic use across inpatient and ambulatory care sites in an integrated healthcare system to prioritize antibiotic stewardship efforts. METHODS We conducted an epidemiologic study of antibiotic use across an integrated healthcare system on 12 randomly selected days from 2017 to 2018. For inpatients and perioperative patients, administrations of antibiotics were recorded, whereas prescriptions were recorded for outpatients. RESULTS On the study days, 10.9% (95% confidence interval [CI], 10.6%-11.3%) of patients received antibiotics. Of all antibiotics, 54.1% were from ambulatory care (95% CI, 52.6%-55.7%), 38.0% were from the hospital (95% CI, 36.6%-39.5%), and 7.8% (95% CI, 7.1%-8.7%) were perioperative. The emergency department/urgent care centers, adult outpatient clinics, and adult non-critical care inpatient wards accounted for 26.4% (95% CI, 25.0%-27.7%), 23.8% (95% CI, 22.6%-25.2%), and 23.9% (95% CI, 22.7%-25.3%) of antibiotic use, respectively. Only 9.2% (95% CI, 8.3%-10.1%) of all antibiotics were administered in critical care units. Antibiotics with a broad spectrum of gram-negative activity accounted for 30.4% (95% CI, 29.0%-31.9%) of antibiotics. Infections of the respiratory tract were the leading indication for antibiotics. CONCLUSIONS In an integrated healthcare system, more than half of antibiotic use occurred in the emergency department/urgent care centers and outpatient clinics. Antibiotics with a broad spectrum of gram-negative activity accounted for a large portion of antibiotic use. Analysis of antibiotic utilization across the spectrum of inpatient and ambulatory care is useful to prioritize antibiotic stewardship efforts.
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Affiliation(s)
- Holly M Frost
- Department of Pediatrics, Denver Health Medical Center.,University of Colorado School of Medicine
| | - Bryan C Knepper
- Department of Patient Safety and Quality, Denver Health Medical Center, Colorado
| | | | - Timothy C Jenkins
- University of Colorado School of Medicine.,Division of Infectious Diseases and Department of Medicine, Denver Health Medical Center, Colorado
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Frost HM, Dominguez S, Parker S, Byars A, Michelson S, Keith A, Jenkins TC. 1342. Clinical failure rates of amoxicillin for the treatment of acute otitis media in young children. Open Forum Infect Dis 2020. [PMCID: PMC7777226 DOI: 10.1093/ofid/ofaa439.1524] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Background
Acute otitis media(AOM) is the most common indication for antibiotics in children. The primary pathogens that cause AOM have changed since the introduction of the pneumococcal conjugate vaccine(PCV). The clinical failure rate of amoxicillin for treatment of AOM post-PCV is unknown.We aimed to determine the clinical failure rate of amoxicillin for the treatment of uncomplicated AOM in children.
Organisms identified on culture and amoxicillin treatment failure from nasopharyngeal specimens of children age 6-35 months with uncomplicated acute otitis media at Denver Health, Denver, CO from April 2019-March 2020.
Methods
Children age 6-35 months seen at Denver Health, Denver, CO with uncomplicated AOM and prescribed amoxicillin were prospectively enrolled. An interim analysis of patients enrolled from April 2019-March 2020 was completed. Patients completed surveys that included the AOM-SOS©(UPMC, Pittsburgh, PA) at enrollment, days 5, 14, and 30 and had chart abstraction completed. Treatment failure was defined as: (1) requiring a new antibiotic within 14 days; (2) AOM-SOS© score on day 5 or 14 not improved by a relative reduction of ≥ 55% from baseline. Recurrence was defined as requiring a new antibiotic within 15-30 days. Nasopharyngeal swabs were obtained and bacterial culture was completed.
Results
In total,110 patients were enrolled. Rates of treatment failure defined by AOM-SOS© were 28.4%(37; 95%CI:25.5-33.6%) at 5 days and 15.5%(27; 95%CI:17.5-24.5%) at 14 days. However, only 4.5%(5; 95%CI:2.0-4.5%) required a new antibiotic. Recurrence occurred in 5.5% (6, 95%CI:2.5-5.5%) of patients. Of patients who had not received antibiotics before enrollment(82), culture yielded no organism in 17.0%, one organism in 42.7%, and multiple organisms in 40.0% (Table). M.catarrhalis was the most frequently identified organism (53.7% of children). Of H.influenzae isolates 52.9% (9/17) produced beta-lactamase, resulting in no treatment failures or recurrences requiring a new antibiotic. Failure rates were similar between organisms.
Conclusion
Despite the change in otopathogen prevalence post-PCV, preliminary data suggest that while early subjective treatment failure was common, the 14 day treatment failure and 30 day recurrence rates was low when measured by need for a new antibiotic. Failure was low even among patients with organisms that would not be expected to be treated successfully with amoxicillin, such as those with beta-lactamase producing H.influenzae and M.catarrhalis.
Disclosures
Samuel Dominguez, MD, PhD, BioFire (Consultant, Research Grant or Support)
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Affiliation(s)
- Holly M Frost
- Denver Health and Hospital Authority, University of Colorado School of Medicine, Denver, CO
| | - Samuel Dominguez
- University of Colorado, School of Medicine, San Francisco, California
| | | | - Andrew Byars
- Denver Health and Hospital Authority, Denver, Colorado
| | | | - Amy Keith
- Denver Health and Hospital Authority, Denver, Colorado
| | - Timothy C Jenkins
- Denver Health Medical Center, University of Colorado School of Medicine, Denver, Colorado
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Anderson JL, Frost HM, Meece JK. Spontaneous resolution of blastomycosis symptoms caused by B. dermatitidis. Med Mycol Case Rep 2020; 30:43-45. [PMID: 33150126 PMCID: PMC7599114 DOI: 10.1016/j.mmcr.2020.10.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2020] [Revised: 10/19/2020] [Accepted: 10/20/2020] [Indexed: 11/20/2022] Open
Abstract
Given the propensity of blastomycosis to disseminate or reoccur and the inability to predict which infections will experience severe manifestations, nearly all cases of blastomycosis are treated. Although, spontaneous resolution of symptoms is referred to generally in the literature, to our knowledge an individual case of this has not been previously reported. We report the spontaneous resolution of blastomycosis symptoms in a 40 year-old Caucasian male.
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Affiliation(s)
- Jennifer L. Anderson
- Integrated Research and Development aLaboratory, Marshfield Clinic Research Institute, Marshfield Clinic Health System, Marshfield, WI, 54449, USA
- Corresponding author.
| | - Holly M. Frost
- Denver Health and Hospital Authority, Department of Pediatrics, Denver, CO, 80204, USA
- Denver Health and Hospital Authority, Office of Research, Denver, CO, 80204, USA
- University of Colorado School of Medicine, Department of Pediatrics, Aurora, CO, 80045, USA
| | - Jennifer K. Meece
- Integrated Research and Development aLaboratory, Marshfield Clinic Research Institute, Marshfield Clinic Health System, Marshfield, WI, 54449, USA
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Koester TM, Timothy P, Meece JK, Osborn RA, Frost HM. Suspected Neuro-invasive Powassan Virus Infection in a Pediatric Patient. Clin Med Res 2020; 18:95-98. [PMID: 32060042 PMCID: PMC7428206 DOI: 10.3121/cmr.2020.1512] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2019] [Revised: 10/13/2019] [Accepted: 01/02/2020] [Indexed: 11/18/2022]
Abstract
Powassan virus lineage II (POWV), also known as deer tick virus, is an emerging tick-borne pathogen transmitted by Ixodes scapularis, the natural vector for the organisms that causes Lyme disease, babesiosis, and anaplasmosis. POWV is the only tick-borne flavivirus in North America known to cause disease in humans. We present a suspected pediatric case of POWV infection in northern Wisconsin.
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Affiliation(s)
- Trever M Koester
- Department of Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - Priyanka Timothy
- Department of Internal Medicine and Pediatrics, Marshfield Clinic Health System, Marshfield, Wisconsin, USA
| | - Jennifer K Meece
- Integrated Research and Development Laboratory, Marshfield Clinic Research Institute, Marshfield, Wisconsin, USA
| | - Rebecca A Osborn
- Wisconsin Department of Health Services, Madison, Wisconsin, USA
| | - Holly M Frost
- Department of Pediatrics, Denver Health and Hospital Authority, Denver, Colorado, USA
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, Colorado, USA
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Simione M, Frost HM, Cournoyer R, Mini FN, Cassidy J, Craddock C, Moreland J, Wallace J, Metlay J, Kistin CJ, Sease K, Hambidge SJ, Taveras EM. Engaging stakeholders in the adaptation of the Connect for Health pediatric weight management program for national implementation. Implement Sci Commun 2020; 1:55. [PMID: 32885211 PMCID: PMC7427919 DOI: 10.1186/s43058-020-00047-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2020] [Accepted: 06/05/2020] [Indexed: 01/01/2023] Open
Abstract
Background Connect for Health is an evidence-based weight management program with clinical- and family-facing components for delivery in pediatric primary care for families of children ages 2 to 12 years. We used the Consolidated Framework for Implementation Research (CFIR) to guide formative work prior to national implementation. The purpose of this study was to describe the process and results of stakeholder engagement and program adaptation. Methods We used mixed qualitative and quantitative methods to iteratively adapt and optimize the program by assessing needs and perspectives of clinicians and parents, as well as contextual barriers, facilitators, and organizational readiness for the uptake of the proposed program tools and implementation strategies. We conducted interviews with primary care clinicians from four health care organizations in Boston, MA; Denver, CO; and Greenville, SC, and used principles of immersion-crystallization for qualitative analyses. We also conducted surveys of parents of children with a body mass index ≥ 85th percentile. Results We reached thematic saturation after 52 clinician interviews. Emergent themes representing the CFIR domains of intervention characteristics, outer and inner setting, and process included (1) importance of evidence-based clinical decision support tools that integrate into the workflow and do not extend visit time, (2) developing resources that respond to family’s needs, (3) using multimodal delivery options for family resources, (4) addressing childhood obesity while balancing competing demands, (5) emphasizing patient care rather than documentation and establishing sustainability plans, and (6) offering multiple training methods that incorporate performance feedback. Of the parents surveyed (n = 400), approximately 50% were Spanish-speaking and over 75% reported an annual income < $50,000. Parents affirmed the importance of addressing weight management during well-child visits, being provided with referrals and resources, and offering multiple methods for resource delivery. Decisions about program modifications were made at the program and healthcare-system level and based on stakeholder engagement findings. Modifications included cultural, geographic, and target audience adaptations, as well as varied resource delivery options. Conclusions To ensure the fit between the Connect for Health program and national implementation settings, adaptations were systematically made through engagement of clinician and parent stakeholders to support adoption, sustainability, and health outcomes. Trial registration NCT04042493
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Affiliation(s)
- Meg Simione
- Division of General Academic Pediatrics, MassGeneral Hospital for Children, 125 Nashua Street, Suite 860, Boston, MA 02114 USA.,Department of Pediatrics, Harvard Medical School, Boston, MA USA
| | - Holly M Frost
- Denver Health, Denver, CO USA.,Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO USA
| | - Rachel Cournoyer
- Division of General Academic Pediatrics, MassGeneral Hospital for Children, 125 Nashua Street, Suite 860, Boston, MA 02114 USA
| | - Fernanda Neri Mini
- Division of General Academic Pediatrics, MassGeneral Hospital for Children, 125 Nashua Street, Suite 860, Boston, MA 02114 USA
| | | | | | | | | | - Joshua Metlay
- Division of General Internal Medicine, Massachusetts General Hospital, Boston, MA USA
| | - Caroline J Kistin
- Department of Pediatrics, Boston Medical Center, Boston, MA USA.,Boston University School of Medicine, Boston, MA USA
| | - Kerry Sease
- Prisma Health, Greenville, SC USA.,Department of Pediatrics, University of South Carolina School of Medicine, Greenville, SC USA
| | - Simon J Hambidge
- Denver Health, Denver, CO USA.,Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO USA
| | - Elsie M Taveras
- Division of General Academic Pediatrics, MassGeneral Hospital for Children, 125 Nashua Street, Suite 860, Boston, MA 02114 USA.,Department of Pediatrics, Harvard Medical School, Boston, MA USA.,Department of Nutrition, Harvard T.H. Chan School of Public Health, Boston, MA USA
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Douglas CM, O’ Leary SC, Tomcho MM, Wu FJ, Federico SJ, Frost HM. 418. Testing and Positivity Rates for Gonorrhea and Chlamydia in a Large Federally Qualified Health Center System. Open Forum Infect Dis 2019. [PMCID: PMC6809633 DOI: 10.1093/ofid/ofz360.491] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
Background Gonorrhea (GC) and Chlamydia (CT) are the most reported sexually transmitted infections in the United States. Little is known about testing and positivity rates for GC/CT in clinical practice, particularly for male patients. In this study, we analyzed rates of GC/CT testing and positivity among 11–24 years old patients presenting to a system of federally qualified health centers (FQHC). Methods This retrospective data review was conducted at Denver Health (DH) in Denver, CO. Data were abstracted for 11–24 years old who were seen at least once at a DH FQHC in 2018. Abstracted data included patient age, gender, clinic location, and testing for GC/CT. The percentage of patients tested ≥1 time within the preceding year and the percentage of tested patients that were positive for GC and/or CT ≥1 time were calculated along with Wald 95% confidence intervals. Results In total, 34,416 unique patients were included. GC/CT testing was completed for 7.3% (95% CI: 6.8%, 7.6%) of 11–15 years old, 30.6% (95% CI: 29.5%, 31.6%) of 16–18 years old, and 45.6% (95% CI: 44.8%, 46.4%) of 19–24 years old. Rates of testing varied by gender and age and were lowest among males and younger patients (Figure 1). Of patients tested, 11.4% (95% CI: 10.7%, 12.1%) of females and 9.1% (95% CI: 7.8%, 10.4%) of males were positive for CT and 1.7% (95% CI: 1.4%, 2.0%) of females and 2.3% (95% CI: 1.6%, 2.9%) of males were positive for GC (Figure 2). Though less likely to be tested than older patients, females 11–15 years old had the highest rates of GC (2.1%; 95% CI: 1.2%, 3.0%) and the second highest rate of CT (13.5%; 95% CI: 11.3%, 15.6%) among females tested. Conclusion Despite efforts to improve GC/CT screening, less than 50% of 11–24 years old patients were tested within the prior year. Rates of GC/CT were higher than previously reported, particularly for females less than 16 years old. Male patients were less likely to be tested; however, the males who were tested had higher GC positivity rates and only slightly lower rates of CT than females who were tested. Future studies evaluating the effectiveness of interventions to reduce GC/CT among 11–24 years old are critically needed. ![]()
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Disclosures All authors: No reported disclosures.
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Affiliation(s)
- Claudia M Douglas
- Denver Health and Hospital Authority, University of Colorado School of Medicine, Denver, Colorado
| | - Sonja C O’ Leary
- Denver Health and Hospital Authority, University of Colorado School of Medicine, Denver, Colorado
| | - Margaret M Tomcho
- Denver Health and Hospital Authority, University of Colorado School of Medicine, Denver, Colorado
| | - Florence J Wu
- Denver Health and Hospital Authority, University of Colorado School of Medicine, Denver, Colorado
| | - Steven J Federico
- Denver Health and Hospital Authority, University of Colorado School of Medicine, Denver, Colorado
| | - Holly M Frost
- Denver Health and Hospital Authority, University of Colorado School of Medicine, Denver, Colorado
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Anderson JL, Frost HM, King JP, Meece JK. 259. Racial Differences in Clinical Phenotype and Hospitalization of Blastomycosis Patients. Open Forum Infect Dis 2019. [PMCID: PMC6810469 DOI: 10.1093/ofid/ofz360.334] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Background Dimorphic fungal infections, such as blastomycosis, cause significant morbidity and mortality. Most studies describing blastomycosis have focused on non-Hispanic Caucasians and our understanding of the clinical presentation and outcomes for patients of other race/ethnicities is limited. We evaluated whether clinical presentation and disease severity varied across racial/ethnic groups. Methods Blastomycosis patients were identified from Marshfield Clinic Health System and patient data were abstracted from electronic medical records. Blastomyces genotyping was performed for cases with available isolates. Univariate analyses using χ 2 tests and multivariate logistic regression modeling were used to determine the association of race/ethnicity with clinical presentation. Significance was defined as P ≤ 0.05. Results In total 477 patients were included.Age differences were observed across race/ethnicity categories (P < 0.0001). Non-Hispanic, Caucasians were oldest (47 years, SD 20) and Asians were the youngest (30 years, SD 18). Underlying medical conditions were more common in non-Hispanic Caucasians (55%) and African Americans (AA) (52%) than Hispanic Caucasians (27%) and Asians (29%, P = 0.0002). Risk for hospitalization was highest for Hispanic Caucasian (aOR 2.9, 95% CI 1.2–1.7), American Indian Alaskan Native (AIAN) (aOR = 2.4; 95% CI 1.0–5.5), and Asian (aOR = 1.9; 95% CI 1.0–3.6) patients when compared with non-Hispanic Caucasian patients. Ninety percent of B. dermatitidis infections occurred in non-Hispanic Caucasians whereas blastomycosis in Hispanic Caucasian, AIAN, and Asian patients was frequently caused by B. gilchristii (P < 0.0001). Conclusion Hispanic Caucasian, AIAN, and Asian blastomycosis patients were younger and healthier, but more frequently hospitalized. Patients in these racial/ethnic groups may need more aggressive treatment and closer therapeutic monitoring. Underlying host factors along with organism virulence likely play a role in these differences. Disclosures All authors: No reported disclosures.
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Affiliation(s)
| | - Holly M Frost
- Denver Health and Hospital Authority, University of Colorado School of Medicine, Denver, Colorado
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Frost HM, Knepper BC, Shihadeh KC, Jenkins TC. 1007. A novel approach to evaluate antibiotic utilization across the spectrum of inpatient and ambulatory care and implications for prioritization of antibiotic stewardship efforts. Open Forum Infect Dis 2019. [PMCID: PMC6810947 DOI: 10.1093/ofid/ofz360.871] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Background Antibiotic overuse remains a significant problem in inpatient and outpatient settings. The objective of this study was to develop a methodology to evaluate antibiotic use across inpatient and ambulatory care sites in an integrated healthcare system in order to prioritize antibiotic stewardship efforts. Methods We conducted an epidemiologic study of antibiotic use across an integrated healthcare system on 12 randomly-selected days between October 1, 2017 and September 30, 2018. Inpatients and perioperative patients were recorded as having received an antibiotic if they were administered ≥1 dose of a systemic antibacterial agent. Outpatients were recorded as having received an antibiotic if they were prescribed ≥1 systemic antibacterial agent. Results On the study days, 10.9% (95% CI 10.6–11.3%) of patients received an antibiotic. Of all antibiotics administered or prescribed, 54.1% were from ambulatory care (95% CI 52.6–55.7%), 38.0% were from the hospital, (95% CI 36.6–39.5%), and 7.8% (95% CI 7.1–7.8%) were perioperative. The emergency department/urgent care centers, adult outpatient clinics, and adult noncritical care inpatient wards accounted for 26.4% (95% CI: 25.0–27.7%), 23.8% (95% CI: 22.6–25.2), and 23.9% (95% CI 22.7–25.3) of antibiotic use, respectively. Only 9.2% (95% CI: 8.3–10.1%) of all antibiotics were administered in critical care units. Antibiotics with a broad spectrum of Gram-negative activity accounted for 30.4% (95% CI: 29.0–31.9%) of all antibiotics prescribed. Infections of the respiratory tract were the leading indication for antibiotic use. Conclusion In an integrated healthcare system, nearly three-quarters of antibiotic use occurred in the emergency department/urgent care centers, adult outpatient clinics, and adult noncritical care inpatient wards. Antibiotics with a broad spectrum of Gram-negative activity accounted for a large portion of antibiotic use. Analysis of antibiotic utilization across the spectrum of inpatient and ambulatory care is useful to prioritize antibiotic stewardship efforts. Disclosures All authors: No reported disclosures.
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Affiliation(s)
- Holly M Frost
- Denver Health and Hospital Authority, University of Colorado School of Medicine, Denver, Colorado
| | | | | | - Timothy C Jenkins
- Denver Health Medical Center, University of Colorado School of Medicine, Denver, Colorado
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Anderson JL, Frost HM, King JP, Meece JK. Racial Differences in Clinical Phenotype and Hospitalization of Blastomycosis Patients. Open Forum Infect Dis 2019; 6:ofz438. [PMID: 31696142 PMCID: PMC6824527 DOI: 10.1093/ofid/ofz438] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2019] [Accepted: 10/01/2019] [Indexed: 01/09/2023] Open
Abstract
Background Dimorphic fungal infections, such as blastomycosis, cause significant morbidity and mortality. Historically, blastomycosis studies have focused on non-Hispanic whites, which limits our understanding of the clinical presentation and outcomes for patients of other races and ethnicities. We evaluated whether clinical presentation and disease severity varied across racial and ethnic groups. Methods Blastomycosis patients were identified from Marshfield Clinic Health System and data were abstracted from electronic medical records. Blastomyces genotyping was performed for cases with available isolates. Bivariate analyses (χ 2 tests/analysis of variance) assessed associations of race and/or ethnicity, Blastomyces spp, and hospitalization status with demographics and clinical presentation. Multivariable logistic regression was used to evaluate the association of race and/or ethnicity and hospitalization. Results In total, 477 patients were included. Age differences were observed across race and ethnicity categories (P < .0001). Non-Hispanic whites were oldest (median, 48 years; interquartile range [IQR], 31–62) and Asians were youngest (26 years; IQR, 19–41). Non-Hispanic whites (55%) and African Americans (52%) had underlying medical conditions more frequently than Hispanic whites (27%) and Asians (29%). Odds of hospitalization were 2 to 3 times higher for Hispanic whites (adjusted odds ratio [aOR], 2.9; 95% confidence interval [CI], 1.2–1.7), American Indian or Alaska Native (AIAN) (aOR, 2.4; 95% CI, 1.0–5.5), and Asian (aOR, 1.9; 95% CI, 1.0–3.6) patients compared with non-Hispanic white patients. Ninety percent of Blastomyces dermatitidis infections occurred in non-Hispanic whites, whereas blastomycosis in Hispanic whites, AIAN, and Asian patients was frequently caused by Blastomyces gilchristii (P < .0001). Conclusions Hispanic whites, AIAN, and Asian blastomycosis patients were younger and healthier but more frequently hospitalized. Patients in these racial and ethnic groups may need more aggressive treatment and closer therapeutic monitoring.
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Affiliation(s)
- Jennifer L Anderson
- Integrated Research and Development Laboratory, Marshfield Clinic Research Institute, Marshfield Clinic Health System, Marshfield, Wisconsin
| | - Holly M Frost
- Department of Pediatrics, Denver Health Medical Center, University of Colorado School of Medicine, Denver, Colorado
| | - Jennifer P King
- Center for Clinical Epidemiology and Population Health, Marshfield Clinic Research Institute, Marshfield Clinic Health System, Marshfield, Wisconsin
| | - Jennifer K Meece
- Integrated Research and Development Laboratory, Marshfield Clinic Research Institute, Marshfield Clinic Health System, Marshfield, Wisconsin
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Abstract
OBJECTIVE To evaluate the epidemiology, clinical features, and antibiotic prescribing patterns for nongroup A streptococci (NGAS) in children. STUDY DESIGN Throat cultures obtained for pharyngitis were assessed at a large community-based health system over 10 years. Epidemiologic and clinical features of children with NGAS were compared with children with group A Streptococcus (GAS) and negative cultures. Antibiotic prescribing patterns were evaluated. RESULTS A total of 224 328 rapid streptococcal antigen tests and 116 578 throat cultures were performed. Clinical analysis was completed for 602 GAS-positive patients, 535 NGAS-positive patients, and 480 patients with negative cultures. Incidence of NGAS did not vary annually or by season but increased with age from 2% at ≤5 years to 7% at 18 years of age. Patients with NGAS were more likely than those with negative cultures to have tonsillar exudate (20.3% vs 13.1%, P = .003) and enlarged tonsils (28.6% vs 19.3%, P < .001). Modified Centor scores did not differ between groups (score ≥2, P = 1.0; score ≥3, P = .50). Patients with GAS were more likely than those with NGAS to have fever (32.6% vs 24.5%, P = .003), palatal petechiae (14.0% vs 3.1%, P < .001), and modified Centor score ≥2 (47.8% vs 27.1%; P < .001). Of patients with NGAS, 65% were prescribed antibiotics. CONCLUSIONS NGAS likely exist in both carriage and infectious states and incidence increases with age. Infections associated with NGAS are milder than with GAS, and complications are rare. Laboratory reporting of NGAS results in high antibiotic use, despite current recommendations against treatment.
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Affiliation(s)
- Holly M Frost
- Department of Pediatrics, University of Colorado, Aurora, CO; Department of Pediatrics, Denver Health and Hospital Authority, Denver, CO; Marshfield Clinic Research Institute, Marshfield, WI.
| | - Thomas R Fritsche
- Marshfield Clinic Research Institute, Marshfield, WI; Department of Pathology, Marshfield Clinic Health System, Marshfield, WI
| | - Matthew C Hall
- Department of Medicine, Division of Infectious Diseases, Marshfield Clinic Health System, Marshfield, WI
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Frost HM, McLean HQ, Chow BDW. Variability in Antibiotic Prescribing for Upper Respiratory Illnesses by Provider Specialty. J Pediatr 2018; 203:76-85.e8. [PMID: 30195553 DOI: 10.1016/j.jpeds.2018.07.044] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2018] [Revised: 06/11/2018] [Accepted: 07/11/2018] [Indexed: 12/24/2022]
Abstract
OBJECTIVE To evaluate variation in antibiotic prescribing between pediatric and nonpediatric providers for common upper respiratory illnesses. STUDY DESIGN Patient encounters for children aged <18 years from a regional health care system were identified. Electronic medical records from 2011 to 2016 were extracted for diagnoses of upper respiratory infection, pharyngitis, acute otitis media, and sinusitis. Encounters with competing medical diagnoses, recent hospitalization, and antibiotic prescriptions within 30 days were excluded. Adherence to antibiotic guidelines was assessed by provider training (pediatric, nonpediatric physicians, and advance practice providers). Additional factors assessed were calendar year, and patient's age, sex, insurance status, and number of sick visits in the prior year. RESULTS Across 6 years, 141 361 visits were examined: 43 914 for upper respiratory infection, 43 701 for pharyngitis, 43 925 for acute otitis media, and 9821 for sinusitis. Pediatricians were more likely than Advanced practice providers (APP) and nonpediatric providers to have guideline-concordant prescribing for pharyngitis (pediatricians, 66.7% [95% CI, 54.5-77.0]; nonpediatricians, 49.1% [95% CI, 36.3-62.0], APPs, 52.2% [95% CI, 39.4-64.7]; P < .0001) and sinusitis (pediatricians, 70.8% [95% CI, 53.8-83.4], nonpediatricians, 63.3% [95% CI, 46.8-77.2], APPs, 62.1% [95% CI, 45.1-76.5]; P = .48) and to withhold antibiotics for upper respiratory infection than APPs and nonpediatric providers (pediatricians, 86.6% [95% CI, 81.2-90.6], nonpediatricians, 80.8% [95% CI, 73.0-86.8], APPs, 76.8% [95% CI, 68.4-83.5]; P < .0001). Pediatricians were less likely to prescribe antibiotics for pharyngitis without a positive test for group A Streptococcus than APPs and nonpediatric providers (pediatricians, 15.1% [95% CI, 10.4-21.6], nonpediatricians, 29.4% [95% CI, 20.8-39.6], APPs, 27.2% [95% CI, 19.3-36.9]; P < .0001). First-line antibiotic prescribing for acute otitis media did not differ between provider specialties. A trend toward more guideline-concordant prescribing was seen for pharyngitis and sinusitis over the study period. CONCLUSIONS Pediatricians were more likely to adhere to guidelines for management of pediatric acute respiratory infections. Pediatric antibiotic stewardship efforts should also target nonpediatricians.
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Affiliation(s)
- Holly M Frost
- University of Colorado, Department of Pediatrics, Aurora, CO; Denver Health and Hospital Authority, Department of Pediatrics, Denver, CO; Marshfield Clinic Research Institute, Marshfield, WI.
| | | | - Brian D W Chow
- Tufts Medical Center, Division of Geographic Medicine and Infectious Diseases, Boston, MA; Tufts University School of Medicine, Boston, MA
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Koester TM, Meece JK, Fritsche TR, Frost HM. Infectious Mononucleosis and Lyme Disease as Confounding Diagnoses: A Report of 2 Cases. Clin Med Res 2018; 16:66-68. [PMID: 30166498 PMCID: PMC6306145 DOI: 10.3121/cmr.2018.1419] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2018] [Revised: 06/28/2018] [Accepted: 07/17/2018] [Indexed: 11/18/2022]
Abstract
Lyme disease and infectious mononucleosis are common illnesses that share similar clinical presentations. Significant cross-reactivity is known to occur between Lyme and EBV serologic assays complicating the diagnosis. To date, no prior cases of concurrent acute Lyme and EBV infections have been reported. We describe the clinical presentation of two children with confirmed early Lyme disease and features suggestive of infectious mononucleosis, including one case of probable Lyme and EBV co-infection.
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Affiliation(s)
- Trever M Koester
- University of Wisconsin-Stout, Menomonie, WI, USA
- Integrated Research and Development Laboratory, Marshfield Clinic Research Institute, Marshfield, WI, USA
| | - Jennifer K Meece
- Integrated Research and Development Laboratory, Marshfield Clinic Research Institute, Marshfield, WI, USA
| | - Thomas R Fritsche
- Division of Laboratory Medicine, Marshfield Clinic Health System, Marshfield, WI, USA
- Department of Microbiology, University of Wisconsin-La Crosse, La Crosse, WI, USA
| | - Holly M Frost
- Integrated Research and Development Laboratory, Marshfield Clinic Research Institute, Marshfield, WI, USA
- Department of Pediatrics, Denver Health Medical Center, Denver, CO, USA
- Department of Pediatrics, University of Colorado School of Medicine, Denver, CO, USA
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Frost HM, McLean H, Chow B. 2568. Variability in Pediatric Antibiotic Prescribing for Upper Respiratory Illnesses by Provider Specialty. Open Forum Infect Dis 2018. [PMCID: PMC6252461 DOI: 10.1093/ofid/ofy209.176] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Background Antibiotic prescribing varies among providers, contributing to antibiotic resistance and adverse drug reactions. Objective. To evaluate variation in antibiotic prescribing between pediatric and nonpediatric providers for common upper respiratory illnesses. Methods Patient encounters for children aged <18 years from a regional healthcare system were identified. Electronic medical records from 2011 to 2016 were extracted for diagnoses of upper respiratory infection (URI), pharyngitis, acute otitis media (AOM), and sinusitis. Encounters with competing medical diagnoses, recent hospitalization, and antibiotic prescriptions within 30 days were excluded. Adherence to antibiotic guidelines was assessed by provider training (pediatric, nonpediatric physicians, and advance practice providers [APP]). Additional factors assessed included clinic or urgent care setting, calendar year, and patient’s age, gender, insurance status, and number of sick visits in the prior year. Results Across 6 years, 141,361 visits were examined: 43,914 for URI, 43,701 for pharyngitis, 43,925 for AOM, and 9,821 for sinusitis. Pediatricians were more likely than APPs and nonpediatric providers to have guideline-concordant prescribing for pharyngitis (pediatricians 66.7 (54.5, 77.0)%, nonpediatricians 49.1 (36.3, 62.0)%, APPs 52.2(39.4, 64.7)%, P < 0.0001) and sinusitis (pediatricians 70.8(53.8, 83.4)%, nonpediatricians 63.3(46.8, 77.2)%, APPs 62.1(45.1, 76.5)%, P = 0.48) and to withhold antibiotics for URI than APPs and nonpediatric providers (pediatricians 86.6(81.2, 90.6)%, nonpediatricians 80.8(73.0, 86.8)%, APPs 76.8(68.4, 83.5)%, P < 0.0001). Pediatricians were less likely to prescribe antibiotics for pharyngitis without a positive Group A Streptococcus test than APPs and nonpediatric providers (pediatricians 15.1(10.4, 21.6)%, nonpediatricians 29.4(20.8, 39.6)%, APPs 27.2(19.3, 36.9)%, P < 0.0001). First-line antibiotic prescribing for pharyngitis and AOM did not differ between provider specialties. A trend toward more guideline-concordant prescribing was seen for pharyngitis and sinusitis over the study period. Conclusion Pediatricians were more likely to adhere to guidelines for pediatric acute respiratory infections. Pediatric antibiotic stewardship efforts should also target non-pediatricians. Disclosures All authors: No reported disclosures.
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Affiliation(s)
- Holly M Frost
- Marshfield Clinic Research Institue, Marshfield, Wisconsin, Pediatrics, University of Colorado, Aurora, Colorado, Pediatrics, Denver Health and Hospital Authority, Denver, Colorado
| | - Huong McLean
- Marshfield Clinic Research Institute, Marshfield, Wisconsin
| | - Brian Chow
- Tufts Medical Center and Tufts School of Medicine, Boston, Massachusetts
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Frost HM, Fritsche T, Hall MC. 1454. Β-Hemolytic Non-Group A Streptococcus Pharyngitis in Children. Open Forum Infect Dis 2018. [PMCID: PMC6252611 DOI: 10.1093/ofid/ofy210.1285] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Background Non-Group A Streptococci (NGAS) are common isolates from patients with pharyngitis. Few studies have assessed the epidemiology and clinical features of these infections in children. Methods The epidemiology, clinical features, and antibiotic prescribing patterns for NGAS among children with throat cultures obtained for pharyngitis were assessed at a large community-based health system over 10 years. Children with NGAS were compared with children with Group A Streptococcus (GAS) and negative cultures using uni- and multi-variate analysis. Antibiotic prescribing patterns were evaluated. Results A total of 224,328 rapid Streptococcus tests and 116, 578 throat cultures were performed. Clinical analysis was completed for 602 GAS patients, 535 NGAS patients, and 480 patients with negative cultures. Incidence of NGAS did not vary annually or by season, but increased with age from 2% at ≤ 5 years to 7% at 18 years. Patients with NGAS were more likely than those with negative cultures to have exudates (20.3% vs. 13.1%, P = 0.003) and enlarged tonsils (28.6% vs. 19.3%, P < 0.001). Modified Centor scores did not differ between groups (score>2, P = 1.0; score>3, P = 0.50). Patients with GAS were more likely than those with NGAS to have fever (32.6% vs. 24.5%, P = 0.003), petechiae (14.0% vs. 3.1%, P < 0.001) and modified Centor score >2 (47.8% vs. 27.1%; P < 0.001). Of patients with NGAS 65% were prescribed antibiotics. Conclusion NGAS likely exists in both a carriage and infectious state and the incidence increases with age. When NGAS causes infection the infection is milder than GAS and complications are rare. Laboratory reporting of NGAS results in high antibiotic use, despite current recommendations against treatment. Disclosures All authors: No reported disclosures.
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Affiliation(s)
- Holly M Frost
- Pediatrics, Denver Health and Hospital Authority, Denver, Colorado
- Pediatrics, University of Colorado, Aurora, Colorado
- Marshfield Clinic Research Institue, Marshfield, Wisconsin
| | - Thomas Fritsche
- Pediatrics, Denver Health and Hospital Authority, Denver, Colorado
- Pediatrics, University of Colorado, Aurora, Colorado
- Marshfield Clinic Research Institue, Marshfield, Wisconsin
| | - Matthew C Hall
- JMI Laboratories, North Liberty, Iowa
- Marshfield Clinic, Marshfield, Wisconsin
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Schotthoefer AM, Hall MC, Vittala S, Bajwa R, Frost HM. Clinical Presentation and Outcomes of Children With Human Granulocytic Anaplasmosis. J Pediatric Infect Dis Soc 2018; 7:e9-e15. [PMID: 28520981 DOI: 10.1093/jpids/pix029] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2017] [Accepted: 04/07/2017] [Indexed: 11/13/2022]
Abstract
BACKGROUND Adults with the tick-borne disease human granulocytic anaplasmosis (HGA) have a spectrum of acute febrile illnesses that, if untreated, might be severe. Clinical presentation and outcomes of children with HGA have been poorly described. METHODS A retrospective analysis was conducted to determine the frequency, presentation, and outcomes of pediatric patients with HGA between 1994 and 2015 in a region of Wisconsin in which HGA is highly endemic. Patients with related International Classification of Diseases Ninth and Tenth Revision (ICD-9 and ICD-10, respectively) codes or positive HGA laboratory test results were evaluated and classified as having had confirmed, probable, or suspected HGA on the basis of the Centers for Disease Control and Prevention (CDC) case definition. The Fisher's exact and Wilcoxon rank-sum tests were used in statistical comparisons. RESULTS Of 187 children identified with possible HGA, 17 (9%) had confirmed, 75 (40%) had probable, and 91 (49%) had suspected infections. The number of cases rose sharply in 2010 and has remained between 16 and 36 cases per year since that time. A minority of children with confirmed or probable infections had elevated liver transaminase levels (33%), leukopenia (24%), thrombocytopenia (17%), or anemia (8%); 6 (7%) of these children required hospitalization. Children with evidence of concurrent HGA and Lyme disease (27% of confirmed or probable cases) had a higher risk of hospitalization (odds ratio, 6.55 [95% confidence interval, 1.11-38.78]). None of these children had life-threatening disease or died. CONCLUSIONS Evidence suggests that the frequency of HGA in children is increasing. Although most children had mild disease, doxycycline remains the treatment of choice, because outcome data for children without treatment remains limited.
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Affiliation(s)
| | | | - Satya Vittala
- Marshfield Clinic, Marshfield, Wisconsin.,Banner Health, Phoenix, Arizona
| | - Raza Bajwa
- Marshfield Clinic, Marshfield, Wisconsin
| | - Holly M Frost
- Marshfield Clinic Research Institute.,Marshfield Clinic, Marshfield, Wisconsin
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Frost HM, Schotthoefer AM, Thomm AM, Dupuis AP, Kehl SC, Kramer LD, Fritsche TR, Harrington YA, Knox KK. Serologic Evidence of Powassan Virus Infection in Patients with Suspected Lyme Disease 1. Emerg Infect Dis 2018; 23:1384-1388. [PMID: 28726610 PMCID: PMC5547799 DOI: 10.3201/eid2308.161971] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Powassan virus (POWV) lineage II is an emerging tickborne flavivirus with an unknown seroprevalence in humans. In a Lyme disease–endemic area, we examined the seroreactivity to POWV in 2 patient cohorts and described the clinical features of the POWV-seroreactive patients. POWV disease might be less neuroinvasive than previously thought.
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Mareedu N, Schotthoefer AM, Tompkins J, Hall MC, Fritsche TR, Frost HM. Risk Factors for Severe Infection, Hospitalization, and Prolonged Antimicrobial Therapy in Patients with Babesiosis. Am J Trop Med Hyg 2017; 97:1218-1225. [PMID: 28722598 DOI: 10.4269/ajtmh.17-0146] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
Babesiosis is an emerging tick-borne disease transmitted by the hard tick Ixodes scapularis, which also transmits Lyme disease. Better gradation of prognostic indicators are needed to determine which patients may develop serious complications requiring hospitalization, and to provide early guidance on appropriate therapy. In this study, we evaluated 128 patients with smear or real time polymerase chain reaction-confirmed Babesia microti infections over a period of 16 years. Patients with asplenia or immunocompromising conditions were more likely to have severe infection (P < 0.01), require hospitalization (P < 0.01), or receive prolonged courses of antimicrobials (P < 0.01). Nausea or vomiting (P < 0.01) and diarrhea (P < 0.01) along with hyperbilirubinemia (P < 0.01) were predictive of severe infection, hospitalization, and prolonged antimicrobial therapy. Patients with concurrent Lyme disease were less likely to require hospitalization and had similar severity of disease and length of antibiotic treatment compared with those without Lyme disease.
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Affiliation(s)
| | | | | | | | - Thomas R Fritsche
- University of Wisconsin, La Crosse, Wisconsin.,Marshfield Clinic Health System, Marshfield, Wisconsin
| | - Holly M Frost
- Marshfield Clinic Health System, Minocqua, Wisconsin.,Marshfield Clinic Research Institute, Marshfield, Wisconsin
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