The epidemiology of cephalosporin allergy labels in pediatric primary care

Background

Recent studies have sought to understand the epidemiology and impact of beta-lactam allergy labels on children; however, most of these studies have focused on penicillin allergy labels. Fewer studies assess cephalosporin antibiotic allergy labels in children. The objective of this study was to determine the prevalence, factors associated with, and impact of cephalosporin allergy labels in children cared for in the primary care setting.

Methods

Cephalosporin allergy labels were reviewed among children in a dual center, retrospective, birth cohort who were born between 2010 and 2020 and followed in 90 pediatric primary care practices. Antibiotic prescriptions for acute otitis media were compared in children with and without cephalosporin allergies.

Results

334,465 children comprised the birth cohort and 2,877 (0.9%) were labeled as cephalosporin allergic during the study period at a median age of 1.6 years. Third-generation cephalosporins were the most common class of cephalosporin allergy (83.0%). Cephalosporin allergy labels were more common in children with penicillin allergy labels than those without (5.8% vs. 0.6%). Other factors associated with a cephalosporin allergy label included white race, private insurance, presence of a chronic condition, and increased health care utilization. Children with third-generation cephalosporin allergy labels received more amoxicillin/clavulanate (28.8% vs. 10.2%) and macrolides (10.4% vs. 1.9%) and less amoxicillin (55.8% vs. 70.9%) for treatment of acute otitis media than non-allergic peers p < 0.001.

Conclusions

One in 100 children is labeled as cephalosporin allergic, and these children receive different antibiotics for the treatment of acute otitis media compared to non-allergic peers.

Adjunctive Diagnostic Studies Completed Following Detection of Candidemia in Children: Secondary Analysis of Observed Practice From a Multicenter Cohort Study Conducted by the Pediatric Fungal Network

BACKGROUND

Adjunctive diagnostic studies (aDS) are recommended to identify occult dissemination in patients with candidemia. Patterns of evaluation with aDS across pediatric settings are unknown.

METHODS

Candidemia episodes were included in a secondary analysis of a multicenter comparative effectiveness study that prospectively enrolled participants age 120 days to 17 years with invasive candidiasis (predominantly candidemia) from 2014 to 2017. Ophthalmologic examination (OE), abdominal imaging (AbdImg), echocardiogram, neuroimaging, and lumbar puncture (LP) were performed per clinician discretion. Adjunctive diagnostic studies performance and positive results were determined per episode, within 30 days from candidemia onset. Associations of aDS performance with episode characteristics were evaluated via mixed-effects logistic regression.

RESULTS

In 662 pediatric candidemia episodes, 490 (74%) underwent AbdImg, 450 (68%) OE, 426 (64%) echocardiogram, 160 (24%) neuroimaging, and 76 (11%) LP; performance of each aDS per episode varied across sites up to 16-fold. Longer durations of candidemia were associated with undergoing OE, AbdImg, and echocardiogram. Immunocompromised status (58% of episodes) was associated with undergoing AbdImg (adjusted odds ratio [aOR] 2.38; 95% confidence intervals [95% CI] 1.51-3.74). Intensive care at candidemia onset (30% of episodes) was associated with undergoing echocardiogram (aOR 2.42; 95% CI 1.51-3.88). Among evaluated episodes, positive OE was reported in 15 (3%), AbdImg in 30 (6%), echocardiogram in 14 (3%), neuroimaging in 9 (6%), and LP in 3 (4%).

CONCLUSIONS

Our findings show heterogeneity in practice, with some clinicians performing aDS selectively, potentially influenced by clinical factors. The low frequency of positive results suggests that targeted application of aDS is warranted.

The Quality and Management of Penicillin Allergy Labels in Pediatric Primary Care

BACKGROUND AND OBJECTIVES

Penicillin allergy labels are the most common drug allergy label. The objective of this study was to describe the quality and management of penicillin allergy labels in the pediatric primary care setting.

METHODS

Retrospective chart review of 500 of 18 015 children with penicillin allergy labels born from January 1, 2010 to June 30, 2020 randomly selected from an outpatient birth cohort from Texas Children's Pediatrics and Children's Hospital of Philadelphia networks. Penicillin allergy risk classification ("not allergy," "low risk," "moderate or high risk," "severe risk," "unable to classify") was determined based on documentation within (1) the allergy tab and (2) electronic healthcare notes. Outcomes of allergy referrals and penicillin re-exposure were noted.

RESULTS

Half of penicillin allergy labels were "unable to classify" based on allergy tab documentation. Risk classification agreement between allergy tabs and healthcare notes was fair (Cohen's ĸ = 0.35 ± 0.02). Primary care physicians referred 84 of 500 (16.8%) children to an allergist, but only 54 (10.8%) were seen in allergy clinic. All children who were challenged (25 of 25) passed skin testing. Removal of allergy labels was uncommon (69 of 500, 13.8%) but occurred more often following allergy appointments (26 of 54, 48%) than not (43 of 446, 9.6%, P < .001). Children delabeled by primary care physicians were as likely to tolerate subsequent penicillin-class antibiotics as those delabeled by an allergist (94% vs 93%, P = .87).

CONCLUSIONS

Penicillin allergy documentation within the allergy tab was uninformative, and children were infrequently referred to allergists. Future quality improvement studies should improve penicillin allergy documentation and expand access to allergy services.

Developing Consensus on Clinical Outcomes for Children with Mild Pneumonia: A Delphi Study

BACKGROUND

The absence of consensus for outcomes in pediatric antibiotic trials is a major barrier to research harmonization and clinical translation. We sought to develop expert consensus on study outcomes for clinical trials of children with mild community-acquired pneumonia (CAP).

METHODS

Applying the Delphi method, a multispecialty expert panel ranked the importance of various components of clinical response and treatment failure outcomes in children with mild CAP for use in research. During Round 1, panelists suggested additional outcomes in open-ended responses that were added to subsequent rounds of consensus building. For Rounds 2 and 3, panelists were provided their own prior responses and summary statistics for each item in the previous round. The consensus was defined by >70% agreement.

RESULTS

The expert panel determined that response to and failure of treatment should be addressed at a median of 3 days after initiation. Complete or substantial improvement in fever, work of breathing, dyspnea, tachypnea when afebrile, oral intake, and activity should be included as components of adequate clinical response outcomes. Clinical signs and symptoms including persistent or worsening fever, work of breathing, and reduced oral intake should be included in treatment failure outcomes. Interventions including receipt of parenteral fluids, supplemental oxygen, need for high-flow nasal cannula oxygen therapy, and change in prescription of antibiotics should also be considered in treatment failure outcomes.

CONCLUSIONS

Clinical response and treatment failure outcomes determined by the consensus of this multidisciplinary expert panel can be used for pediatric CAP studies to provide objective data translatable to clinical practice.

Impact of Penicillin Allergy Labels on Children Treated for Outpatient Respiratory Infections

BACKGROUND

Penicillin allergy is the most common antibiotic allergy, yet most children labeled as allergic tolerate penicillin. The impact of inaccurate penicillin allergy labels (PALs) on pediatric outpatients is unknown. The objective of this study was to compare outcomes between children with and without a PAL after treatment for outpatient respiratory tract infections (RTI).

METHODS

A retrospective, longitudinal birth cohort study was performed in children who received care in 90 pediatric primary care practices in Philadelphia and Houston metropolitan areas. Prescribing and clinical outcomes of children with a PAL at the time of an RTI were compared to non-allergic children, adjusting for potential confounders.

RESULTS

Antibiotics were prescribed for 663,473 non-recurrent RTIs among 200,977 children. Children with a PAL (5% of cohort) were more likely than non-allergic children to receive broad-spectrum antibiotics (adjusted relative risk (aRR) 3.24, 95% CI 3.22-3.26) and second-line antibiotics (aRR 4.87, 95% CI 4.83, 4.89). Compared to non-allergic children receiving first-line antibiotics, children with a PAL were more likely to return with adverse drug events (aRR 1.28, 95% CI 1.18-1.39). There was no difference in treatment failure between groups (aRR 0.95, 95% CI 0.90-1.00).

CONCLUSIONS

PALs lead to higher rates of broad-spectrum and second-line antibiotic prescribing in children treated for RTIs in primary care and contribute to unnecessary healthcare utilization through increased adverse events. Given the frequency of PALs, efforts to prevent inappropriate penicillin allergy labeling and promote de-labeling of existing inaccurate allergy labels may improve care of children treated for common bacterial infections.

Antibiotic Indications and Appropriateness in the Pediatric Intensive Care Unit: A 10-Center Point Prevalence Study

BACKGROUND

Antibiotics are prescribed to most pediatric intensive care unit (PICU) patients, but data describing indications and appropriateness of antibiotic orders in this population are lacking.

METHODS

We performed a multicenter point prevalence study that included children admitted to 10 geographically diverse PICUs over 4 study days in 2019. Antibiotic orders were reviewed for indication, and appropriateness was assessed using a standardized rubric.

RESULTS

Of 1462 patients admitted to participating PICUs, 843 (58%) had at least 1 antibiotic order. A total of 1277 antibiotic orders were reviewed. Common indications were empiric therapy for suspected bacterial infections without sepsis or septic shock (260 orders, 21%), nonoperative prophylaxis (164 orders, 13%), empiric therapy for sepsis or septic shock (155 orders, 12%), community-acquired pneumonia (CAP; 118 orders, 9%), and post-operative prophylaxis (94 orders, 8%). Appropriateness was assessed for 985 orders for which an evidence-based rubric for appropriateness could be created. Of these, 331 (34%) were classified as inappropriate. Indications with the most orders classified as inappropriate were empiric therapy for suspected bacterial infection without sepsis or septic shock (78 orders, 24%), sepsis or septic shock (55 orders, 17%), CAP (51 orders, 15%), ventilator-associated infections (47 orders, 14%), and post-operative prophylaxis (44 orders, 14%). The proportion of antibiotics classified as inappropriate varied across institutions (range, 19%-43%).

CONCLUSIONS

Most PICU patients receive antibiotics. Based on our study, we estimate that one-third of antibiotic orders are inappropriate. Improved antibiotic stewardship and research focused on strategies to optimize antibiotic use in critically ill children are needed.

Antimicrobial Stewardship in the Pediatric Primary Care Setting

Antibiotics are the most commonly prescribed medications in the pediatric outpatient setting, yet 30% to 50% of these prescriptions are deemed to be unnecessary. Outpatient antimicrobial stewardship is the concerted effort to monitor and improve antibiotic use in the community setting. The best methods of conducting antimicrobial stewardship in the outpatient setting are currently unknown, and an individualized approach is likely needed. In this review, we discuss the importance of, resources for, and research supporting outpatient antimicrobial stewardship and review ways an individual pediatric provider can further steward efforts. [Pediatr Ann. 2022;51(5):e196-e201.].

Factors Associated With Penicillin Allergy Labels in Electronic Health Records of Children in 2 Large US Pediatric Primary Care Networks

Importance

Penicillin allergy labels influence clinical decision-making, yet most children who are labeled do not have type 1 hypersensitivity allergic reactions and instead have a history of predictable adverse reactions or unspecified illness symptoms while receiving penicillin for viral infections. Studies describing penicillin allergy labeling in the pediatric outpatient setting are lacking.

Objective

To describe the epidemiology and factors associated with penicillin allergy labels across 2 large US pediatric primary care networks.

Design, Setting, and Participants

This retrospective, longitudinal birth cohort study was conducted in 90 primary care pediatric practices serving a diverse population of children across Houston, Texas, Austin, Texas, Philadelphia, Pennsylvania, and parts of New Jersey. Participants were children born between January 2010 and June 2020 who had a health care visit in the first 14 days of life and at least 2 additional visits in the first year of life at one of 90 primary care pediatric practices. Censoring criteria were additionally applied to exclude data from children no longer seeking health care in the 90 clinics over time. Statistical analysis was performed from February to May 2021.

Exposures

Basic patient demographics, health care utilization, penicillin exposure, and primary clinic location.

Main Outcomes and Measures

Addition of penicillin allergy label in the electronic medical record.

Results

Among 334 465 children in the birth cohort, 164 173 (49.1%) were female; 72 831 (21.8%) were Hispanic, 59 598 (17.8%) were non-Hispanic Black, and 148 534 (44.4%) were non-Hispanic White; the median (IQR) age at censoring was 3.8 (1.7-6.6) years; 18 015 (5.4%) were labeled as penicillin allergic, but the prevalence of penicillin allergy labeling ranged from 0.9% to 10.2% across practices. Children were labeled at a median (IQR) age of 1.3 (0.9-2.3) years. Non-Hispanic White children were more likely to be labeled compared with non-Hispanic Black children after controlling for potential confounders (adjusted odds ratio, 1.7 [95% CI, 1.6-1.8]). There were 6797 allergic children (37.7%) labeled after receiving 1 penicillin prescription and 1423 (7.9%) labeled after receiving 0 penicillin prescriptions.

Conclusions and Relevance

In this cohort study of more than 330 000 children, penicillin allergy labeling was common and varied widely across practices. Children were labeled early in life, and almost half were labeled after receiving 1 or 0 penicillin prescriptions. These findings raise questions regarding the validity of penicillin allergy labels. Future work exploring the fidelity of and outcomes associated with penicillin allergy-labeling in children is warranted.

An evidence-based, risk-adapted algorithm for antifungal prophylaxis reduces risk for invasive mold infections in children with hematologic malignancies

BACKGROUND

Children with hematologic malignancies, especially those who receive intensive chemotherapy, are at high risk for invasive mold infections (IMI) that confer substantial mortality. Randomized controlled trials support the use of antifungal prophylaxis with antimold activity as an optimal strategy for risk reduction in this population, but studies outlining the practical application of evidence-based recommendations are lacking.

PROCEDURE

We conducted a 15-year, single-institution retrospective review in a diverse cohort of children with hematologic malignancies treated with chemotherapy to determine the incidence of proven or probable IMI diagnosed between 2006 and 2020. Multivariable logistic regression was used to identify host and disease factors associated with IMI risk. We then compared the incidence and type of IMI and related factors before and after 2016 implementation of an evidence-based, risk-adapted antifungal prophylaxis algorithm that broadened coverage to include molds in patients at highest risk for IMI.

RESULTS

We identified 61 cases of proven or probable IMI in 1456 patients diagnosed with hematologic malignancies during the study period (4.2%). Implementation of an antifungal prophylaxis algorithm reduced the IMI incidence in this population from 4.8% to 2.9%. Both Hispanic ethnicity and cancer diagnosis prior to 2016 were associated with risk for IMI.

CONCLUSION

An evidence-based, risk-adapted approach to antifungal prophylaxis for children with hematologic malignancies is an effective strategy to reduce incidence of IMI.

Risk factors for microbiologic failure in children with Enterobacter species bacteremia

Background

Enterobacter species are an important cause of healthcare-associated bloodstream infections (BSI) in children. Up to 19% of adult patients with Enterobacter BSI have recurrence of infection resistant to third-generation cephalosporins (3GCs) while on therapy with a 3GC. Data are lacking regarding the incidence of and risk factors for recurrence of infection in children with Enterobacter BSI.

Methods

We conducted a retrospective case-control study of patients aged ≤21 years old admitted to Texas Children’s Hospital from January 2012 through December 2018 with Enterobacter BSI. The primary outcome was microbiologic failure from 72 hours to 30 days after the initial BSI (cases). The secondary outcome was isolation of a 3GC non-susceptible Enterobacter sp. from a patient with an initial 3GC-susceptible isolate.

Results

Twelve patients (6.7%) had microbiologic failure compared to 167 controls without microbiologic failure. Of the 138 patients (77.1%) with an Enterobacter sp. isolate that was initially susceptible to 3GCs, 3 (2.2%) developed a subsequent infection with a non-susceptible isolate. Predictors of microbiologic failure were having an alternative primary site of infection besides bacteremia without a focus or an urinary tract infection (OR, 9.64; 95% CI, 1.77–52.31; P < 0.01) and inadequate source control (OR, 22.16; 95% CI, 5.26–93.36; P < 0.001).

Conclusions

Source of infection and adequacy of source control are important considerations in preventing microbiologic failure. In-vitro susceptibilities can be used to select an antibiotic regimen for the treatment of Enterobacter BSI in children.

Comparative Effectiveness of Echinocandins vs Triazoles or Amphotericin B Formulations as Initial Directed Therapy for Invasive Candidiasis in Children and Adolescents

BACKGROUND

Invasive candidiasis is the most common invasive fungal disease in children and adolescents, but there are limited pediatric-specific antifungal effectiveness data. We compared the effectiveness of echinocandins to triazoles or amphotericin B formulations (triazole/amphotericin B) as initial directed therapy for invasive candidiasis.

METHODS

This multinational observational cohort study enrolled patients aged >120 days and <18 years with proven invasive candidiasis from January 1, 2014, to November 28, 2017, at 43 International Pediatric Fungal Network sites. Primary exposure was initial directed therapy administered at the time qualifying culture became positive for yeast. Exposure groups were categorized by receipt of an echinocandin vs receipt of triazole/amphotericin B. Primary outcome was global response at 14 days following invasive candidiasis onset, adjudicated by a centralized data review committee. Stratified Mantel-Haenszel analyses estimated risk difference between exposure groups.

RESULTS

Seven-hundred and fifty invasive candidiasis episodes were identified. After exclusions, 541 participants (235 in the echinocandin group and 306 in the triazole/amphotericin B group) remained. Crude failure rates at 14 days for echinocandin and triazole/amphotericin B groups were 9.8% (95% confidence intervals [CI]: 6.0% to 13.6%) and 13.1% (95% CI: 9.3% to 16.8%), respectively. The adjusted 14-day risk difference between echinocandin and triazole/amphotericin B groups was -7.1% points (95% CI: -13.1% to -2.4%), favoring echinocandins. The risk difference was -0.4% (95% CI: -7.5% to 6.7%) at 30 days.

CONCLUSIONS

In children with invasive candidiasis, initial directed therapy with an echinocandin was associated with reduced failure rate at 14 days but not 30 days. These results may support echinocandins as initial directed therapy for invasive candidiasis in children and adolescents.

CLINICAL TRIALS REGISTRATION

NCT01869829.

Impact of the final adjective in the Medical Student Performance Evaluation on determination of applicant desirability

BACKGROUND

The Medical Student Performance Evaluation (MSPE) is a primary source of information used by residency programs in their selection of trainees. The MSPE contains a narrative description of the applicant's performance during medical school. In 2002, the Association of American Medical Colleges' guideline for preparation of the MSPE recommended inclusion of a comparative summative assessment of the student's overall performance relative to his/her peers (final adjective).

OBJECTIVE

We hypothesize that the inclusion of a final adjective in the MSPE affects a reviewer's assessment of the applicant's desirability more than the narrative description of performance and designed a study to evaluate this hypothesis.

DESIGN

Fifty-six faculty members from the Departments of Pediatrics and Medicine with experience reviewing MSPEs as part of the intern selection process reviewed two pairs of mock MSPE letters. In each pair, the narrative in one letter was superior to that in the other. Two final adjectives describing relative class ranks were created. Each subject was first presented with a pair of letters with mismatched final adjective (study), i.e., the letter with the stronger narrative was presented with the weaker final adjective and vice versa. The subject was then presented with a second pair of letters without final adjectives (control). Subjects ranked the relative desirability of the two applicants in each pair.

RESULTS

The proportion of rankings congruent with the strength of the narratives under study and control conditions were compared. Subjects were significantly less likely to rank the applicants congruent with the strength of the narratives when the strength of the final adjectives conflicted with the strength of the narrative; 42.9% of study letters were ranked congruent with the narrative versus 82.1% of controls (p = 0.0001).

CONCLUSION

The MSPE final adjective had a greater impact than the narrative description of performance on the determination of applicant desirability.

ABBREVIATIONS

MSPE: Medical Student Performance Evaluation; AAMC: Association of American Medical Colleges; BCM: Baylor College of Medicine.

Dalbavancin Pharmacokinetics and Safety in Children 3 Months to 11 Years of Age

BACKGROUND

Dalbavancin is a novel lipoglycopeptide antibiotic that has potent in vitro activity against Gram-positive microorganisms.

METHODS

We performed a phase 1, open-label, multicenter study to investigate the pharmacokinetics (PK) and safety of a single dose of intravenous dalbavancin in hospitalized pediatric subjects 3 months to 11 years of age. We combined these data with previously collected adolescent PK data and performed a population PK analysis.

RESULTS

Model development was performed using 311 dalbavancin plasma concentrations from 43 subjects. The median age was 5.9 years (range: 0.3-16.9). A 3-compartment, linear PK model was developed. Based on simulations, the following age-dependent dosing regimen was found to achieve similar dalbavancin exposure to that in adults administered a 2-dose regimen: children 6 to <18 years of age, 12 mg/kg (1000 mg maximum) on day 1 and 6 mg/kg (500 mg maximum) on day 8 and children 3 months to <6 years of age, 15 mg/kg (1000 mg maximum) on day 1 and 7.5 mg/kg (500 mg maximum) on day 8. Similarly, the following age-dependent regimen was found to match adult exposure after a single-dose (1500 mg): 6 to <18 years of age, 18 mg/kg (1500 mg maximum) on day 1 and 3 months to <6 years of age, 22.5 mg/kg (1500 mg maximum) on day 1. Nineteen subjects experienced 36 treatment-emergent adverse events. Five of 36 adverse events were assessed as possibly or probably related to treatment.

CONCLUSIONS

Dalbavancin pediatric dosing that matched adult exposure was identified. Overall, dalbavancin was well tolerated in our study population.

Pediatric Neglected Tropical Diseases in a Major Metropolitan Children's Hospital in the United States, 2004-2013

We conducted a retrospective study of neglected tropical diseases (NTDs) diagnosed at Texas Children's Hospital between 2004 and 2013. Forty-three patients with an NTD were identified; 47% had never traveled outside of the United States. The results of this study highlight the importance of physician awareness of NTDs in children in the United States.

Failure to Validate a Multivariable Clinical Prediction Model to Identify Pediatric Intensive Care Unit Patients at High Risk for Candidemia

We attempted to validate a previously derived clinical prediction rule for candidemia in the pediatric intensive care unit. This multicenter case control study did not identify significant association of candidemia with most of the previously identified predictors. Additional study in larger cohorts with other predictor variables is needed.

Angiostrongylus cantonensis Infection: A Cause of Fever of Unknown Origin in Pediatric Patients

Fever of unknown origin (FUO) in children is frequently caused by infectious diseases. Angiostrongylus cantonensis, while a primary cause of eosinophilic meningitis, is rarely a cause of FUO. We present 2 pediatric cases of FUO caused by Angiostrongylus cantonensis acquired in Houston, Texas, outside its usual geographic distribution.

Solithromycin Pharmacokinetics in Plasma and Dried Blood Spots and Safety in Adolescents

We assessed the pharmacokinetics and safety of solithromycin, a fluoroketolide antibiotic, in a phase 1, open-label, multicenter study of 13 adolescents with suspected or confirmed bacterial infections. On days 3 to 5, the mean (standard deviation) maximum plasma concentration and area under the concentration versus time curve from 0 to 24 h were 0.74 μg/ml (0.61 μg/ml) and 9.28 μg · h/ml (6.30 μg · h/ml), respectively. The exposure and safety in this small cohort of adolescents were comparable to those for adults. (This study has been registered at ClinicalTrials.gov under registration no. NCT01966055.).

Application of Kern's Six-step approach to curriculum development by global health residents

BACKGROUND

Global health practitioners have a responsibility to deliver appropriate and effective health education to patients and families. We demonstrate how residents in a global health elective can utilize Kern's six-step approach to develop educational products for patients and their families.

METHODS

Residents completed a pre-curricular survey of knowledge, skills and attitudes regarding curriculum development. Kern's six-steps were introduced through a series of lectures; workshop exercises highlighted the application of each step: (i) Problem identification and general needs assessment, (ii) targeted needs assessment, (iii) goals and objectives, (iv) educational strategies, (v) implementation and (vi) evaluation and feedback. Residents used the six-steps to develop health education projects they subsequently implemented locally and abroad. Reflective exercises were conducted after utilization of each of the six steps. Residents also completed a post-curricular assessment of knowledge, skills and attitudes regarding curriculum development.

RESULTS

Mean scores on pre- and post-curricular self-assessment of knowledge were 18 and 26.5 (out of 28); skills 19.8 and 33.5 (out of 35); and attitudes 13.3 and 19.8 (out of 21), respectively. Reflective exercises highlighted resident sentiment that the six steps enabled them to be more thoughtful of the interventions they were undertaking in communities locally and abroad. They were impressed how the model allowed them to ensure their goals were aligned with those of patients and their families, fully engage their audience and effectively implement the curricula.

DISCUSSION

Kern's six-step approach to curriculum development is an effective method for global health residents to develop educational products for patients and families.

Candida speciation, antifungal treatment and adverse events in pediatric invasive candidiasis: results from 441 infections in a prospective, multi-national study

A multi-national prospective study of pediatric patients with invasive candidiasis between August 2007 and September 2012 was performed and included 441 infections. Variation in infecting Candida species and antifungals used was noted between US and non-US sites. Antifungal-associated adverse events were most common with polyene use.

Antimicrobial stewardship in pediatrics: how every pediatrician can be a steward

Antimicrobial stewardship (AS) programs are effective in improving clinical outcomes associated with antimicrobial therapies while improving patient safety by reducing adverse events and development of bacterial resistance. Understanding the basic principles of AS is essential to the successful development and implementation of AS strategies. Identifying and developing strategies to address barriers and challenges to AS can facilitate the establishment of financial, administrative, and organizational support, and agreement and participation by individual prescribers. Review of published outcomes of AS demonstrates the effectiveness in reducing unnecessary antimicrobial use and adverse events such as Clostridium difficile infections. We also illustrate the need for further research and expansion of AS activities to office-based practices and communities by using novel and innovative AS strategies and by influencing regional and national policies.

Ustilago as a Cause of Fungal Peritonitis: Case Report and Review of the Literature

Fungal peritonitis is an uncommon complication of ambulatory peritoneal dialysis in children and often necessitates catheter removal, prolonged hospitalization and conversion to hemodialysis. The majority of these infections are due to Candida albicans and related species. We present an uncommon case of peritonitis due to the unusual plant pathogen Ustilago.

Value placed on formal training in education by pediatric department chairs and residency program directors

BACKGROUND

While much is known about how educational leaders at the medical school level (eg, deans) view the importance of formal training in education for medical school teachers, little is known about how leaders at the clinical level (eg, department chairs) view such training. We sought to determine how pediatric department chairs and residency program directors view the value of formal training in education, such as that at a Master of Education (MEd) level, and to estimate the number of clinical pediatric faculty with or pursuing such training.

METHODS

A survey designed to assess the value placed on formal training in education and to estimate the number of clinical faculty with or pursuing such training was mailed to pediatric department chair persons and residency program directors at all 131 allopathic medical schools in the United States and Puerto Rico.

RESULTS

Eighty department chairs (61%) responded, and most indicated that when hiring new faculty, they view an applicant with an MEd as having an advantage. Both chairs and residency directors considered an MEd to be advantageous for a residency director by a ranking of 4.5 and 4.2, respectively, on a scale of 1 to 5 (P  =  .008). Of the 80 chairs who responded, 58.8% of respondents reported one or more faculty in their department had or was pursuing an MEd. Of the 72 responding residency directors (55%), 11 respondents (15.3%) indicated that they had an MEd.

CONCLUSION

More than half the medical school pediatric chairs responding to the survey had one or more clinical faculty with or pursuing an MEd in their departments. Survey results indicated that such training is valued by both department chairs and residency directors. Given the time and expense involved in obtaining an MEd, awareness of these data 5 be helpful to those considering pursuing, offering, or requiring such training.

Once-daily gentamicin dosing in pediatric patients without cystic fibrosis

STUDY OBJECTIVE

To estimate an appropriate once-daily gentamicin dose and dosing interval for non-critical care pediatric patients older than 3 months of age without cystic fibrosis.

DESIGN

Pharmacokinetic analysis of data from a retrospective medical record review.

SETTING

Large academic children's hospital.

PATIENTS

One hundred fourteen non-critical care pediatric patients older than 3 months of age without cystic fibrosis who received multiple-daily dosing regimens of gentamicin between September 2007 and April 2008.

MEASUREMENTS AND MAIN RESULTS

Patient-specific pharmacokinetic parameters were calculated using drug concentrations obtained at steady state. Once-daily doses were extrapolated for each patient to achieve goal peak and trough concentrations. Using the average of these doses and the patient-specific pharmacokinetic parameters, theoretical once-daily peak and trough concentrations were calculated for each patient. Patient characteristics were analyzed to determine differences between patients who did and those who did not achieve adequate peak concentrations. Mean +/- SD pharmacokinetic parameters were as follows: elimination rate constant 0.32 +/- 0.06 hour(-1), half-life 2.28 +/- 0.54 hours, and volume of distribution 0.24 +/- 0.08 L/kg. The only patient demographic characteristic found to have a significant effect on the extrapolated peak concentration was age. The following age-specific once-daily doses were calculated: 3 months to less than 2 years, 9.5 mg/kg; 2 years to less than 8 years, 8.5 mg/kg; and 8-18 years, 7 mg/kg.

CONCLUSION

Age was the primary factor in determining the once-daily dose of gentamicin in our pediatric population. Further prospective research is necessary to determine the safety and efficacy of these age-based, once-daily doses for gentamicin.

Prevalence of respiratory syncytial virus (RSV) risk factors and cost implications of immunoprophylaxis to infants 32 to 35 weeks gestation for health plans in the United States

BACKGROUND

During the period of this study, the American Academy of Pediatrics (AAP) 2006 guidelines recommended respiratory syncytial virus (RSV) prophylaxis for infants 32 to 35 weeks gestation age (wGA) with two or more of five risk factors (RFs). New recommendations have recently been published in 2009. The cost implications of expanding this list of RFs to include other evidence-based RFs like passive smoke exposure (PSE), crowded living conditions (CLCs), and young chronological age (YCA) are unclear.

METHODS

We estimated the prevalence of RSV RFs in a US sample of infants 32 to 35 wGA referred for prophylaxis from nine specialty pharmacy providers during the 2007-2008 season. We estimated the percent eligible for RSV prophylaxis under various potential RF coverage policies. Using a budget impact model, we calculated the per-member-per-month (PMPM) cost for each policy in 2007 USD for a hypothetical one million member plan.

RESULTS

Infants 32 to 35 wGA represented 0.08% of the plan. Approximately 20.2% of these infants met at least two or more of five AAP RFs. Expanding this list to include one additional RF of PSE, CLC, or YCA increased the percent of infants potentially prophylaxed to 29.9%, 23.9%, and 47%, respectively. Adding all three RFs to the list (two or more of eight) increased the percent of infants potentially prophylaxed to 55.6%, and increased payer costs by 9 cents PMPM.

CONCLUSION

Expanding the AAP RF criteria to include PSE, CLC, and YCA would identify more 32 to 35 wGA infants at high risk for severe RSV disease at an acceptable budget impact.

What is a clinical pearl and what is its role in medical education?

BACKGROUND

Despite the advent of evidence-based medicine, clinical pearls, verbal and published, remain a popular and important part of medical education.

AIMS

The purpose of this study was to establish a definition of a clinical pearl and to determine criteria for an educationally sound clinical pearl.

METHODS

The authors searched the Medline database for material dealing with clinical pearls, examined and discussed the information found, and formulated a consensus opinion regarding the definition and criteria.

RESULTS

Clinical pearls are best defined as small bits of free standing, clinically relevant information based on experience or observation. They are part of the vast domain of experience-based medicine, and can be helpful in dealing with clinical problems for which controlled data do not exist.

CONCLUSIONS

While there are no universally accepted criteria for preparing or evaluating a clinical pearl, we propose some rational guidelines for both.

Group B Streptococcal Colonization and Serotype-Specific Immunity in Healthy Elderly Persons

BACKGROUND

The burden from group B streptococcal (GBS) disease in elderly persons (age, >or=65 years) has increased. Rates of colonization and prevalence of antibodies against capsular polysaccharides (CPS) that might confer protection against invasive GBS disease in such persons are not defined.

METHODS

A cross-sectional survey was conducted in an outpatient setting in Houston. GBS colonization rates in this convenience sample were assessed by self-obtained vaginal and rectal specimens (for women) and rectal and urine specimens (for men). The CPS type distribution among GBS isolates was determined, and CPS-specific antibodies against GBS types Ia, Ib, II, III, and V were quantified by enzyme-linked immunosorbent assays.

RESULTS

The GBS colonization rate among 254 healthy elderly participants (mean age, 73 years) was 21.7%. CPS types Ia (22.8%), III (12.3%), and V (47.3%) predominated, and 12.3% of colonizing isolates were nontypeable. Random selection of 1 member of 33 participating married couples did not alter the overall colonization rate (21.7%) or GBS serotype distribution. The geometric mean concentrations of CPS-specific IgG in serum specimens were low and were significantly lower for GBS type V, compared with other serotypes (P<.001).

CONCLUSIONS

Adults >or=65 years of age are colonized with GBS at a rate similar to that of younger persons, but older adults are significantly more likely to carry type V, the leading cause of invasive disease in elderly persons, and to lack type V CPS-specific serum IgG. The CPS of type V GBS should be included in candidate GBS vaccines so that adults >or=65 years of age theoretically could be protected against invasive disease.

Emergence of new strains of methicillin-resistant Staphylococcus aureus in a neonatal intensive care unit

BACKGROUND

Genetically distinct strains of methicillin-resistant Staphylococcus aureus (MRSA) of community rather than hospital origin have emerged in many areas of the United States. We determined if MRSA strains causing bacteremia in infants treated from birth in a neonatal intensive care unit (NICU) demonstrated the genetic traits of community-associated MRSA.

METHODS

A retrospective cohort study was conducted among NICU infants with bacteremia due to MRSA during 2003 in a large tertiary care center NICU in Houston. MRSA isolates were characterized by antimicrobial susceptibility testing and staphylococcal cassette chromosome mec (SCCmec) typing by polymerase chain reaction. All MRSA cases were reviewed for clinical severity of infection and outcome.

RESULTS

During 2003, a total of 8 (47%) of 17 infants with bacteremia due to S. aureus had MRSA infection. Isolates from 6 (75%) of these 8 infants carried the SCCmec genes (class B mec and ccr2) that are characteristic of community MRSA; 4 isolates were type IVa. All 6 isolates were resistant to beta-lactam antibiotics and erythromycin; 1 was also resistant to clindamycin. One isolate was nontypeable, and another carried the SCCmec type II gene (typical of hospital-associated strains) and was susceptible only to vancomycin. Seven (88%) of 8 infants presented in septic shock. Despite initial treatment with vancomycin, 3 (38%) died, and 3 survivors had complications requiring prolonged antimicrobial therapy; these 6 infants had MRSA isolates with genetic characteristics of isolates of community origin.

CONCLUSIONS

Community-associated MRSA strains have emerged as a significant cause of sepsis in neonates hospitalized in NICU since birth and have caused disseminated infection with substantial morbidity and mortality.

Features of invasive staphylococcal disease in neonates

OBJECTIVE

Most clinical descriptions of invasive staphylococcal disease (ISD) in neonates date from before the mid-1980s, when neonatal viability and intensive care differed substantially from current standards. We aimed to describe the contemporary incidence, clinical features, and outcome of infants with ISD in a neonatal intensive care unit.

METHODS

A retrospective cohort study was conducted of infants who had ISD and were in the neonatal intensive care unit of the Woman's Hospital of Texas, Houston, from January 2000 to June 2002. Confirmed ISD was defined as clinical sepsis and Staphylococcus aureus (SA) isolated from > or =1 blood culture (BC) or a sterile body site excluding urine or coagulase-negative staphylococci (CoNS) isolated from > or =2 BC or from 1 BC and a sterile body site. Probable ISD was defined as CoNS isolated from 1 BC or a sterile body site for which clinical and laboratory data review by 3 infectious disease specialists indicated that antimicrobial treatment was appropriate. Confirmed and combined confirmed plus probable cases were analyzed.

RESULTS

A total of 149 episodes (83 confirmed [39 SA, 44 CoNS], 66 probable) in 137 infants (mean gestational age [GA]: 27.6 weeks [22.4-36.4]; mean birth weight: 981 g [350-2995]) were reviewed. Four (3%) infants had early-onset infection (2 SA, 2 CoNS). Median age at infection onset was similar (17 days SA; 18 days CoNS). Intravascular catheters (IVC) were in situ in a minority of infants with ISD episodes (38% SA, 43% CoNS). CoNS more than SA infections were associated with very low birth weight (<1500 g), lower GA, a history of more IVCs and concurrent total parenteral nutrition, but IVC and parenteral nutrition days were similar. By multivariate analysis correcting for birth weight and complications of prematurity, hypoxia at the time of sepsis evaluation was significantly associated with CoNS and hypotension with SA infections; other clinical features were similar. Methicillin-resistant SA caused 8% of SA infections. Among bacteremic infants, SA more frequently than CoNS involved > or =2 sites. Overall, SA had more focal complications (primarily bone and joint) than CoNS, resulting in a 2- to 3-fold higher SA-associated morbidity rate. Mortality directly attributable to either organism was similar (5% SA; 5% confirmed, 3% confirmed/probable CoNS).

CONCLUSION

CoNS ISD occurred in smaller, more premature infants than SA and was IVC associated in a minority of cases. Hypoxia and hypotension were the only presenting features that differentiated CoNS and SA. SA-associated morbidity was substantial, but SA infection carried no greater risk of death (5%) than CoNS.

Use of Type V Group B Streptococcal Conjugate Vaccine in Adults 65–85 Years Old

One-third of the cases of invasive group B streptococcal (GBS) disease now occur in adults >or=65 years old. Serotype V is most frequent among these invasive isolates. The safety and immunogenicity of type V GBS capsular polysaccharide (CPS)-tetanus toxoid (V-TT) conjugate vaccine (CV) were assessed in 32 healthy adults 65-85 years old who were randomized to receive a single intramuscular dose of V-TT CV (n=22) or licensed tetanus-diphtheria toxoid vaccine (Td) (n=10; double-masked design). V-TT CV elicited significant increases in type V CPS-specific immunoglobulin (Ig) G, IgM, and IgA serum concentrations 4, 8, 26, and 52 weeks after immunization. V-TT-induced type V CPS-specific antibodies promoted the opsonophagocytic killing of type V GBS in vitro. Both vaccines elicited similar concentrations of TT-specific IgG in 4-week postimmunization serum samples. These results suggest the potential for prevention of invasive type V GBS infections in healthy elderly adults through immunization.

Hemophagocytic syndrome after Kawasaki disease

Hemophagocytic syndrome (HPS) is a rare and life-threatening disease in which a generalized histiocytic proliferation results in hemophagocytosis and up-regulation of inflammatory cytokines. This syndrome has been associated with infections, malignancy, drugs and immunologic triggers such as Kawasaki disease (KD). We describe the clinical and laboratory features of two children with HPS after KD and review the three previously reported pediatric cases of recrudescence of HD leading to HPS.

Hemophagocytic syndrome in children: an important diagnostic consideration in fever of unknown origin

To study the evolution of hemophagocytic syndrome (HPS) in children, we performed a retrospective review of 19 patients (median age, 17.4 months) in whom an infectious diseases consultation was requested at Texas Children's Hospital during the period of September 1991 through September 2001. Clinical findings consistent with HPS most frequently presented during days 6-14 of illness, concomitant with laboratory abnormalities. Fever was present for a median of 19 days before the diagnosis of HPS. Elevated serum lactate dehydrogenase and ferritin levels were noted in all patients. An infectious agent was identified in 42% of patients; 16% were found to have immunologic or vasculitic disease. HPS is a rare but often fatal disease that can initially present as fever of unknown origin with varying clinical findings, and it can be recognized by physicians who are familiar with the evolution of HPS. It is likely that many of these cases remain undiagnosed because of the HPS's rapidly fatal course.