Pediatric Tuberculosis Infection Care Facilitators and Barriers: A Qualitative Study

BACKGROUND

A total of 700 000 US children and adolescents are estimated to have latent tuberculosis (TB) infection. Identifying facilitators and barriers to engaging in TB infection care is critical to preventing pediatric TB disease. We explored families' and clinicians' perspectives on pediatric TB infection diagnosis and care.

METHODS

We conducted individual interviews and small group discussions with primary care and subspecialty clinicians, and individual interviews with caregivers of children diagnosed with TB infection. We sought to elicit facilitators and barriers to TB infection care engagement. We used applied thematic analysis to elucidate themes relating to care engagement, and organized themes using a cascade-grounded pediatric TB infection care engagement framework.

RESULTS

We enrolled 19 caregivers and 24 clinicians. Key themes pertaining to facilitators and barriers to care emerged that variably affected engagement at different steps of care. Clinic and health system themes included the application of risk identification strategies and communication of risk; care ecosystem accessibility; programs to reduce cost-related barriers; and medication adherence support. Patient- and family-level themes included TB knowledge and beliefs; trust in clinicians, tests, and medical institutions; behavioral skills; child development and parenting; and family resources.

CONCLUSIONS

Risk identification, education techniques, trust, family resources, TB stigma, and care ecosystem accessibility enabled or impeded care cascade engagement. Our results delineate an integrated pediatric TB infection care engagement framework that can inform multilevel interventions to improve retention in the pediatric TB infection care cascade.

Area-Based Sociodemographic Factors Associated with Latent Tuberculosis Infection in a Low-Prevalence Setting

Area-based sociodemographic markers, such as census tract foreign-born population, have been used to identify individuals and communities with a high risk for tuberculosis (TB) infection in the United States. However, these markers have not been evaluated as independent risk factors for TB infection in children. We evaluated associations between census tract poverty, crowding, foreign-born population, and the CDC's Social Vulnerability Index (CDC-SVI) ranking and TB infection in a population of children tested for TB infection in Boston, Massachusetts. After adjustment for age, crowding, and foreign-born percentage, increasing census tract poverty was associated with increased odds of TB infection (adjusted odds ratio [aOR] per 10% increase in population proportion living in poverty: 1.20 [95% CI, 1.04-1.40]; P = 0.01), although this association was attenuated after further adjustment for preferred language. In separate models, increasing CDC-SVI ranking was associated with increased odds of TB infection, including after adjustment for age and language preference (aOR per 10-point increase in CDC-SVI rank: 1.08 [95% CI, 1.02-1.15]; P = 0.01). Our findings suggest area-based sociodemographic factors may be valuable for characterizing TB infection risk and defining the social ecology of pediatric TB infection in low-burden settings.

Baseline stool toxin concentration is associated with risk of recurrence in children with Clostridioides difficile infection

BACKGROUND

In adults with Clostridioides difficile infection (CDI), higher stool concentrations of toxins A and B are associated with severe baseline disease, CDI-attributable severe outcomes, and recurrence. We evaluated whether toxin concentration predicts these presentations in children with CDI.

METHODS

We conducted a prospective cohort study of inpatients aged 2-17 years with CDI who received treatment. Patients were followed for 40 days after diagnosis for severe outcomes (intensive care unit admission, colectomy, or death, categorized as CDI primarily attributable, CDI contributed, or CDI not contributing) and recurrence. Baseline stool toxin A and B concentrations were measured using ultrasensitive single-molecule array assay, and 12 plasma cytokines were measured when blood was available.

RESULTS

We enrolled 187 pediatric patients (median age, 9.6 years). Patients with severe baseline disease by IDSA-SHEA criteria (n = 34) had nonsignificantly higher median stool toxin A+B concentration than those without severe disease (n = 122; 3,217.2 vs 473.3 pg/mL; P = .08). Median toxin A+B concentration was nonsignificantly higher in children with a primarily attributed severe outcome (n = 4) versus no severe outcome (n = 148; 19,472.6 vs 429.1 pg/mL; P = .301). Recurrence occurred in 17 (9.4%) of 180 patients. Baseline toxin A+B concentration was significantly higher in patients with versus without recurrence: 4,398.8 versus 280.8 pg/mL (P = .024). Plasma granulocyte colony-stimulating factor concentration was significantly higher in CDI patients versus non-CDI diarrhea controls: 165.5 versus 28.5 pg/mL (P < .001).

CONCLUSIONS

Higher baseline stool toxin concentrations are present in children with CDI recurrence. Toxin quantification should be included in CDI treatment trials to evaluate its use in severity assessment and outcome prediction.

Redefining Clostridioides difficile infection antibiotic response and clinical outcomes

With the approval and development of narrow-spectrum antibiotics for the treatment of Clostridioides difficile infection (CDI), the primary endpoint for treatment success of CDI antibiotic treatment trials has shifted from treatment response at end of therapy to sustained response 30 days after completed therapy. The current definition of a successful response to treatment (three or fewer unformed bowel movements [UBMs] per day for 1-2 days) has not been validated, does not reflect CDI management, and could impair assessments for successful treatment at 30 days. We propose new definitions to optimise trial design to assess sustained response. Primarily, we suggest that the initial response at the end of treatment be defined as (1) three or fewer UBMs per day, (2) a reduction in UBMs of more than 50% per day, (3) a decrease in stool volume of more than 75% for those with ostomy, or (4) attainment of bowel movements of Bristol Stool Form Scale types 1-4, on average, by day 2 after completion of primary CDI therapy (ie, assessed on day 11 and day 12 of a 10-day treatment course) and following an investigator determination that CDI treatment can be ceased.

How Should We Determine the Role of Bezlotoxumab for Pediatric Clostridioides difficile Infection?

The newly published MODIFY III trial established a safe pediatric dose of bezlotoxumab but did not conclusively demonstrate efficacy in decreasing the rate of recurrence of Clostridioides difficile infection in children. This editorial addresses considerations for bezlotoxumab use in pediatrics.

Interferon Gamma Release Assay Results and Testing Trends Among Patients Younger Than 2 Years Old at Two US Health Centers

BACKGROUND

Interferon-gamma release assays (IGRAs) are approved for children ≥2 years old to aid in diagnosis of Mycobacterium tuberculosis (TB) infection and disease. Tuberculin skin tests (TSTs) continue to be the recommended method for diagnosis of TB infection in children <2 years, in part due to limited data and concern for high rates of uninterpretable results.

METHODS

We performed a retrospective cohort study of IGRA use in patients <2 years old in 2 large Boston healthcare systems. The primary outcome was the proportion of valid versus invalid/indeterminate IGRA results. Secondary outcomes included concordance of IGRAs with paired TSTs and trends in IGRA usage over time.

RESULTS

A total of 321 IGRA results were analyzed; 308 tests (96%) were valid and 13 (4%) were invalid/indeterminate. Thirty-seven IGRAs were obtained in immunocompromised patients; the proportion of invalid/indeterminate results was significantly higher among immunocompromised (27%) compared with immunocompetent (1%) patients ( P < 0.001). Paired IGRAs and TSTs had a concordance rate of 64%, with most discordant results in bacille Calmette-Guérin-vaccinated patients. The proportion of total TB tests that were IGRAs increased over the study period (Pearson correlation coefficient 0.85, P < 0.001).

CONCLUSIONS

The high proportion of valid IGRA test results in patients <2 years of age in a low TB prevalence setting in combination with the known logistical and interpretation challenges associated with TSTs support the adoption of IGRAs for this age group in certain clinical scenarios. Interpretation of IGRAs, particularly in immunocompromised patients, should involve consideration of the broader clinical context.

Multicenter Analysis of Attrition from the Pediatric Tuberculosis Infection Care Cascade in Boston

OBJECTIVE

To characterize losses from the pediatric tuberculosis (TB) infection care cascade to identify ways to improve TB infection care delivery.

STUDY DESIGN

We conducted a retrospective cohort study of children (age <18 years) screened for TB within 2 Boston-area health systems between January 2017 and May 2019. Patients who received a tuberculin skin test (TST) and/or an interferon gamma release assay (IGRA) were included.

RESULTS

We included 13 353 tests among 11 622 patients; 93.9% of the tests were completed. Of 199 patients with positive tests for whom TB infection evaluation was clinically appropriate, 59.3% completed treatment or were recommended to not start treatment. Age 12-17 years (vs < 5 years; aOR 1.59; 95% CI, 1.32-1.92), non-English/non-Spanish language preference (vs English; aOR, 1.34; 95% CI, 1.02-1.76), and receipt of an IGRA (vs TST, aOR, 30.82; 95% CI, 21.92-43.34) were associated with increased odds of testing completion. Odds of testing completion decreased as census tract social vulnerability index quartile increased (ie, social vulnerability worsened; most vulnerable quartile vs least vulnerable quartile, aOR, 0.77; 95% CI, 0.60-0.99). Odds of completing treatment after starting treatment were higher in females (vs males; aOR, 2.35; 95% CI, 1.14-4.85) and were lower in patients starting treatment in a primary care clinic (vs TB/infectious diseases clinic; aOR, 0.44; 95% CI, 0.27-0.71).

CONCLUSIONS

Among children with a high proportion of negative TB infection tests, completion of testing was high, but completion of evaluation and treatment was moderate. Transitions toward IGRA testing will improve testing completion; interventions addressing social determinants of health are important to improve treatment completion.

Using a Human Factors Framework to Assess Clinician Perceptions of and Barriers to High Reliability in Hand Hygiene

BACKGROUND

Hand hygiene (HH) is critical to prevent healthcare-associated infections (HAIs). Clinician perspectives on maintaining high reliability are poorly defined.

METHODS

We surveyed physicians, nurse practitioners, and physician assistants to understand perceptions of and barriers to high reliability in HH. The Systems Engineering Initiative for Patient Safety 2.0 model was used to develop an electronic survey exploring six human factors engineering (HFE) domains.

RESULTS

. Among 61 respondents, 70% perceived HH as "essential" to patient safety. While 87% reported alcohol-based hand rub (ABHR) availability as very effective in improving HH reliability, 77% reported dispensers to be "sometimes" or "often" empty. Clinicians in surgery/anesthesia were more likely than those in medical specialties to note skin irritation from ABHR (OR 4.94; 95% CI 1.37-17.81) and less likely to believe feedback was effective in improving HH (OR 0.26; 95% CI 0.08-0.88). One quarter of respondents indicated the layout of patient care areas was not conducive to performing HH. Staffing shortages and the pace and demands of work precluded HH for 15% and 11% of respondents, respectively.

CONCLUSIONS

Aspects of organizational culture, environment, tasks, and tools were identified as barriers to high reliability in HH. HFE principles can be applied to more effectively promote HH.

Use of expert consensus to develop a shared list of procedures with potential for aerosol generation during the coronavirus disease 2019 (COVID-19) pandemic

The coronavirus disease 2019 (COVID-19) pandemic highlighted the lack of agreement regarding the definition of aerosol-generating procedures and potential risk to healthcare personnel. We convened a group of Massachusetts healthcare epidemiologists to develop consensus through expert opinion in an area where broader guidance was lacking at the time.

1439. Latent tuberculosis infection treatment location and association with care completion

Background

Location and type of clinic where pediatric latent TB infection (LTBI) care is provided are associated with treatment completion and retention in care. Prior research has not evaluated joint clinical management occurring between care settings. Understanding care transfer dynamics and accessibility of clinics can inform pediatric LTBI care service delivery.

Methods

We conducted a retrospective cohort study of LTBI in children 0-17 years old who were prescribed outpatient treatment in two Boston-area health systems from 2017-2019. We defined “initial clinical setting” (categorized as primary care or TB/infectious diseases clinic) as the location where the first LTBI medication was prescribed. Through chart review, we determined if care was transferred to a different (“final”) clinic setting during treatment. We calculated driving time between a child’s home address and initial and final treatment clinics. The primary outcome was frequency of care transfer after starting treatment. In a secondary analysis, we used two multivariable logistic regression models (adjusted for age, sex, and use of rifamycin-based treatment) to evaluate associations between completion and distance to and type of initial and final treatment clinic.

Results

We identified 142 children who started LTBI treatment as outpatients; 110 started treatment in primary care clinics and 32 in TB/infectious diseases clinics. Overall, 20/142 (14%) transferred TB care to a different clinic after starting treatment. A total of 101/142 (71%) patients completed treatment. Neither initial treatment location nor driving time to initial clinic were significantly associated with treatment completion (Table 1). However, final treatment in a TB clinic was associated with higher odds of treatment completion than final treatment in a primary care clinic (aOR 2.71 [95%CI 1.06-6.91], P=0.04); time to clinic was not associated with completion (Table 2). Figure 1.

221. Assessment and Proposed Revision of Clinical Trial Clostridioides difficile Infection Clinical Response and Outcomes Definitions

Background

Clostridioides difficile infection (CDI) research is limited by a lack of standardized definitions for clinical response and disease outcomes, which impacts clinical drug development and results comparison between studies. We aimed to assess outcome definitions in CDI therapeutic trials to propose new versions that are clinically relevant, discrete and objective.

Methods

A multidisciplinary group of CDI experts met monthly to review response endpoints from published clinical trials of antibiotic therapy for CDI. Previously published phase III or IV trials were assessed for outcome definitions. Discussions were held to reach a consensus on new clinical trial endpoints for adults and children to improve the accuracy and clinical relevance of measures of treatment success.

Results

Significant heterogeneity was noted amongst the primary endpoints in phase III and IV CDI antibiotic treatment trials. Initial clinical cure (ICC), strictly defined as < 3 unformed bowel movements/24 hour, and sustained clinical cure (SCC) were primary outcome measures for recent clinical trials. The strict ICC definition incompletely measures treatment success as assessed in clinical practice and, since ICC is necessary to achieve SCC, may lead to type II error for SCC. A set of proposed alternative outcome definitions was developed using the terms initial response (IR) and sustained response (SR) (Figure 1). IR allows for investigator assessment of overall improvement in CDI response more analogous to clinical practice and will lead to more patients eligible to meet SR. Achievement of SR requires both IR and no need for retreatment of CDI by day 30 after antibiotic completion and is the more relevant endpoint for CDI therapeutic development. The use of a less restrictive IR definition will more accurately capture early responses to treatment and importantly increase the validity of SR. The shortening of follow-up period by 30 days is also anticipated to reduce costs and efforts associated with conducting trials.

Timeline of CDI outcome assessments for clinical trials

Conclusion

The set of definitions proposed here will more accurately capture clinical success and standardize the approach to outcome assessment in trials of CDI therapeutics.

Disclosures

Carolyn D. Alonso, MD, Cidara Therapeutics: Advisor/Consultant|Merck: Advisor/Consultant Oliver A. Cornely, Prof. Dr., Abbott: Honoraria|Abbvie: Advisor/Consultant|Actelion: Board Member|Al-Jazeera Pharmaceuticals: Honoraria|Allecra Therapeutics: Board Member|Amplyx: Advisor/Consultant|Amplyx: Grant/Research Support|Astellas: Honoraria|Basilea: Advisor/Consultant|Basilea: Grant/Research Support|Biocon: Advisor/Consultant|Biosys: Advisor/Consultant|BMBF: Grant/Research Support|Cidara: Advisor/Consultant|Cidara: Board Member|Cidara: Expert Testimony|Cidara: Grant/Research Support|CoRe Consulting: Stocks/Bonds|Da Volterra: Advisor/Consultant|DLR: Grant/Research Support|DZIF: Grant/Research Support|Entasis: Board Member|EU Directorate-General for Resarch and Innovation: Grant/Research Support|F2G: Grant/Research Support|German Patent and Trade Mark Office: German patent (DE 10 2021 113 007.7)|Gilead: Advisor/Consultant|Gilead: Grant/Research Support|Grupo Biotoscana/United Medical/Knight: Honoraria|Hikma: Honoraria|IQVIA: Board Member|Janssen: Board Member|Matinas: Advisor/Consultant|Matinas: Grant/Research Support|MedPace: Advisor/Consultant|MedPace: Grant/Research Support|MedScape: Honoraria|MedUpdate: Honoraria|Menarini: Advisor/Consultant|Merck/MSD: Grant/Research Support|Merck/MSD: Honoraria|Molecular Partners: Advisor/Consultant|MSG-ERC: Advisor/Consultant|Mundipharma: Grant/Research Support|Mylan: Honoraria|Noxxon: Advisor/Consultant|Octapharma: Advisor/Consultant|Octapharma: Grant/Research Support|Paratek: Board Member|Pardes: Advisor/Consultant|Pfizer: Grant/Research Support|Pfizer: Honoraria|Projektträger Jülich: Grant/Research Support|PSI: Advisor/Consultant|PSI: Board Member|Pulmocide: Board Member|Scynexis: Advisor/Consultant|Scynexis: Grant/Research Support|Seres: Advisor/Consultant|Shionogi: Board Member|Wiley (Blackwell): Editor-in-Chief, Mycoses Kevin W. Garey, PharmD, MS, Acurx Pharmaceuticals: Grant/Research Support|Paratek Pharmaceuticals: Grant/Research Support|Seres Therapeutics: Grant/Research Support|Summit Pharmaceuticals: Grant/Research Support Dale N. Gerding, MD, Destiny Pharma plc.: Advisor/Consultant Stuart Johnson, M.D., Ferring Pharmaceuticals: Membership on Ferring Publication Steering Committee|Ferring Pharmaceuticals: Employee|Summit Plc: Advisor/Consultant Stacy A. Kahn, MD, Lilly: Stocks/Bonds Ciaran P. Kelly, n/a, Artugen: Advisor/Consultant|Facile Therapeutics: Advisor/Consultant|Ferring Pharma: Advisor/Consultant|Finch: Advisor/Consultant|Finch: Advisor/Consultant|First Light Biosciences: Advisor/Consultant|First Light Biosciences: Ownership Interest|Milky Way Biosciences: Advisor/Consultant|Milky Way Biosciences: Grant/Research Support|Pfizer: Advisor/Consultant|Seres Therapeutics: Advisor/Consultant|Summit Therapeutics: Advisor/Consultant Larry K. Kociolek, MD, MSCI, Merck: Grant/Research Support Thomas J. Louie, MD, Artugen: Advisor/Consultant|Artugen: Grant/Research Support|Crestone: Advisor/Consultant|Crestone: Grant/Research Support|Finch Therapeutics: Advisor/Consultant|Finch Therapeutics: Grant/Research Support|Rebiotix: Advisor/Consultant|Rebiotix: Grant/Research Support|Seres Therapeutics: Advisor/Consultant|Seres Therapeutics: Grant/Research Support|summit plc: Advisor/Consultant|summit plc: Grant/Research Support|Vedanta Biosciences: Advisor/Consultant|Vedanta Biosciences: Grant/Research Support Maria Vehreschild, Prof. Dr., 3M: speaker fee|Astellas: Advisor/Consultant|Astellas: speaker fee|biologische heilmittel heel gmbh: Grant/Research Support|BioNtech: Grant/Research Support|EUMEDICA: Advisor/Consultant|Farmak International Holding: Advisor/Consultant|Ferring: Advisor/Consultant|Ferring: Speaker fee|Gilead Sciences: Advisor/Consultant|Immunic AG: Advisor/Consultant|MaaT: Advisor/Consultant|Merck: Advisor/Consultant|Merck: speaker fee|MSD: Advisor/Consultant|MSD: Grant/Research Support|MSD: speaker fees|Pfizer: speaker fee|Roche Molecular Systems: Grant/Research Support|Roche Molecular Systems: speaker fees|SocraRTec R&D GmbH: Advisor/Consultant|Takeda California: Grant/Research Support Professor Mark H. Wilcox, MD, FRCPath, GSK: Advisor/Consultant|GSK: Board Member|GSK: Grant/Research Support|Pfizer: Advisor/Consultant|Phico Therapeutics: Board Member|Seres: Advisor/Consultant|Seres: Board Member|Seres: Grant/Research Support|Summit: Advisor/Consultant|Summit: Grant/Research Support Erik R. Dubberke, MD, MSPH, Abbott: Advisor/Consultant|Ferring: Advisor/Consultant|Ferring: Grant/Research Support|Merck: Advisor/Consultant|Pfizer: Advisor/Consultant|Pfizer: Grant/Research Support|Seres: Advisor/Consultant|Summit: Advisor/Consultant|Synthetic Biologics: Grant/Research Support.

1403. Facilitators and barriers to latent tuberculosis infection diagnosis and care in Massachusetts: a convergent mixed methods study of clinicians

Background

Understanding barriers and facilitators to latent tuberculosis infection (LTBI) diagnosis and care is needed to successfully treat children/adolescents with LTBI in the US. We explored physicians’ perspectives on pediatric LTBI diagnosis and care, and strategies to improve care.

Methods

We conducted a convergent mixed methods study with physicians in Massachusetts. Participants were purposefully sampled from primary care clinics (n=10), clinics seeing immunocompromised patients (n=2), and TB clinics (n=2). Physicians participated in individual qualitative semi-structured interviews exploring experience and comfort with LTBI care, and perceived barriers and facilitators to care. We used applied thematic analysis to analyze transcripts. Participants completed surveys to assess comfort with LTBI care and volume of LTBI patients in their care.

Results

Of the 25 physicians invited, 14 participated. Most participants reported “medium” or “high” comfort with current LTBI guidelines; volume of LTBI care varied by physician type (Table 1). Analysis revealed perceived barriers (Figure 1) at four steps of care: 1) identification of risk and testing for LTBI (e.g., family/patient risk perception, physician knowledge gaps), 2) completion of referral after a positive test (e.g., communication barriers), 3) treatment acceptance and initiation (e.g., lack of social support), and 4) treatment adherence and completion (e.g., adolescents’ emerging autonomy). Facilitators such as protocolized screening, counseling strategies, free medication, and telehealth (Figure 2) overcame some barriers. Important emergent themes included: 1) COVID-19 has induced rapid positive and negative changes in LTBI care in primary care clinics; 2) immigrant adolescents are uniquely at risk for disengagement due to lack of social support; and 3) physicians and clinics are ill-equipped to provide TB care for patients’ close contacts, despite knowledge of need for care. Table 1.

Volume of patients by clinician type (N=13 respondents)

Figure 1.

Barriers to LTBI diagnosis and care.

Figure 2.

Facilitators of LTBI care.

Conclusion

Lack of perceived risk, family and clinic resource constraints, and accessibility challenges hindered LTBI care; protocolized screening, telehealth, and free medications were among the facilitators that overcame some but not all barriers. These results will inform improvement of LTBI care within and between clinics.

Disclosures

Jessica Haberer, MD, MS, Merck: Advisor/Consultant|Natera: Stocks/Bonds.

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883. Stool Toxin Concentrations Are Higher in Children with Baseline Severe Disease, Severe Outcomes, and Recurrence

Background

In adults with C. difficile infection (CDI), higher baseline stool concentrations of toxins A and B are associated with severe baseline disease, CDI-attributable severe outcomes, and recurrence. We evaluated whether stool toxin concentration predicts these presentations in children with CDI.

Methods

We performed a prospective cohort study from 2016-2019. Participants were inpatients ≤17 years old at two pediatric hospitals with diarrhea and positive C. difficile testing who received therapy. Patients were followed for 40 days after baseline stool sample for severe outcomes (intensive care unit admission, colectomy, or death, categorized as CDI primarily attributable, CDI contributed, or CDI not contributing) and recurrence (resolution followed by new diarrhea and re-initiation of therapy). Baseline stool toxin A & B concentrations were measured using ultrasensitive single molecule array assay (cutoff for positive result = 20 pg/mL). Median baseline toxin concentrations were compared between groups using Wilcoxon tests.

Results

We enrolled 206 patients [median age 8.9 years (IQR, 4.7–13.2)]. Children with severe baseline disease by IDSA-SHEA criteria (n = 39) had higher median stool toxin A+B concentration than those without severe disease (n = 131) (2,912.6 vs. 500.5 pg/mL, P=0.05). Of the cohort, 40 (19%) had a severe outcome (4 primarily attributed to CDI, 19 with contribution from CDI, and 17 unrelated to CDI). Median toxin A+B concentration was non-significantly higher in children with a primarily-attributed severe outcome versus those without severe outcome (19,473 vs. 429.1 pg/mL, P=0.317) (Figure 1). Of 197 children with eligible data, recurrence occurred in 18 (9.1%); baseline toxin A+B concentration was significantly higher in patients with versus without recurrence (3,946.7 vs. 283.3 pg/mL, P=0.026) (Figure 2).

Conclusion

Higher stool toxin concentrations are present in children with baseline severe CDI, a CDI-attributable severe outcome, or recurrence compared with children without these presentations. Quantification of stool toxin concentration may be helpful in identifying severe CDI and predicting CDI outcomes, which could help guide decisions about clinical management.

Disclosures

Larry K. Kociolek, MD, MSCI, Merck: Grant/Research Support Timothy J. Savage, MD, MPH, MSc, UCB: Contract to Brigham and Women's Hospital Alice Banz, PhD, biomerieux: Simoa assays were performed by bioMerieux, and A.B. is an employee of bioMerieux Kevin W. Garey, PharmD, MS, Acurx: Grant/Research Support|cidara: Advisor/Consultant|cidara: Grant/Research Support|Paratek: Grant/Research Support|Seres Health: Grant/Research Support|Summit: Grant/Research Support Ciaran P. Kelly, n/a, Artugen: Advisor/Consultant|Facile Therapeutics: Advisor/Consultant|Ferring Pharma: Advisor/Consultant|Finch: Advisor/Consultant|Finch: Advisor/Consultant|First Light Biosciences: Advisor/Consultant|First Light Biosciences: Ownership Interest|Milky Way Biosciences: Advisor/Consultant|Milky Way Biosciences: Grant/Research Support|Pfizer: Advisor/Consultant|Seres Therapeutics: Advisor/Consultant|Summit Therapeutics: Advisor/Consultant.

Preventing pediatric catheter-associated urinary tract infections utilizing urinary catheter Kamishibai cards (K-cards)

BACKGROUND

We instituted Kamishibai (K-card rounding) with the goals of improving indwelling urinary catheter maintenance bundle reliability and decreasing catheter-associated urinary tract infection (CAUTI) rates.

METHOD

In a free-standing children's hospital, we undertook a hospital-wide quality improvement project from January 2019 to June 2021 after developing a K-card based on our urinary catheter maintenance bundle. Auditors used K-cards to ask standardized questions during weekly rounds. Bundle reliability and CAUTI rates were analyzed prospectively.

RESULTS

During the study period, 826 K-card audits were performed for 657 unique patients. While overall maintenance bundle reliability remained stable at 84%, there was a statistically significant improvement in reliability to the bundle element "medical discussion of need for the urinary catheter" from 88% to 94% (P = .01). The hospital-wide CAUTI rate significantly decreased (incidence rate ratio, 0.38; 95% CI, 0.15-0.93; P = .04).

DISCUSSION

Hospital-wide urinary catheter K-card rounding facilitated standardized data collection, discussion of reliability and real-time feedback to nurses. Maintenance bundle reliability remained stable after implementation, accompanied by a significant decrease in the CAUTI rate.

CONCLUSIONS

Implementation of hospital-wide urinary catheter K-card rounding was associated with reduction in CAUTI rates. The project demonstrated likelihood of reproducibility with support of a multidisciplinary team.

Increasing Use Of Interferon Gamma Release Assays Among Children ≥2 Years of Age in a Setting With Low Tuberculosis Prevalence

US guidelines recommend interferon gamma release assays (IGRAs) for diagnosis of tuberculosis infection in children. In this retrospective cohort study, IGRA use in children 2-17 years of age increased substantially between 2015 and 2021. Testing in inpatient/subspecialty settings (vs. primary care), public (vs. private) insurance, lower age and non-English preferred language were associated with increased odds of receiving an IGRA.

Stool Toxin Concentration Does Not Distinguish Clostridioides difficile Infection from Colonization in Children Less Than 3 Years of Age

In a prospective cohort study, stools from children <3 years with and without diarrhea who were Clostridioides difficile nucleic acid amplification test-positive underwent ultrasensitive and quantitative toxin measurement. Among 37 cases and 46 controls, toxin concentration distributions overlapped substantially. Toxin concentration alone does not distinguish C. difficile infection from colonization in young children.

Clostridioides difficile Infection in Children: The Role of Infection Prevention and Antimicrobial Stewardship

There are 2 primary approaches to prevent Clostridioides difficile infection (CDI) in children: prevent transmission and acquisition of the organism and prevent the progression from colonization to disease. The most important interventions to reduce the risk of transmission include contact precautions, hand hygiene, and environmental disinfection. Glove use minimizes contamination of the hands by spores and is associated with reductions in CDI incidence. Hand hygiene with soap and water and disinfection with a sporicidal agent are recommended as the best approaches in hyperendemic settings. Because antibiotic exposure is the most important modifiable risk factor for CDI, antimicrobial stewardship focused on identified high-risk antibiotic classes (including clindamycin, fluoroquinolones, and third- and fourth-generation cephalosporins) is critical to preventing progression from colonization to infection. Despite clear evidence that antimicrobial stewardship programs (ASPs) are associated with reduced CDI rates in adults, data demonstrating the ASP impact on pediatric CDI are lacking.

Novel Deployment of Pediatric Biocontainment Unit Nurses in Response to COVID-19

ABSTRACT

Most existing biocontainment units (BCUs) in U.S. hospitals are designed to care for a limited number of patients infected with epidemiologically significant pathogens. The COVID-19 pandemic presented substantial challenges to hospital preparedness and operations because of its high incidence rate and the high risk of transmission to staff members. This article describes a novel practice innovation: a hospital-wide deployment of nurses on a trained BCU team to support hospital staff in safely caring for patients with COVID-19. Their responsibilities included assisting in the development of guidelines and providing training on safety protocols and the appropriate use of personal protective equipment. The authors show how this deployment contributed significantly to staff education and support during the pandemic.

Mycobacterium chimaera Outbreak Management and Outcomes at a Large Pediatric Cardiac Surgery Center

BACKGROUND

In 2012, a global outbreak of invasive Mycobacterium chimaera (M. chimaera) infection was identified in patients post-cardiopulmonary bypass (CPB) surgery. Investigations revealed the source to be heater-cooler unit (HCU) exhaust, with point-source contamination discovered at the LivaNova HCU manufacturing plant. We report our experience with affected HCUs at a high-volume pediatric cardiac surgery center in the United States.

METHODS

A multi-disciplinary task force was established for outbreak management, including removing contaminated HCUs from service. Patients identified as exposed to affected HCUs were systematically contacted. A call center was created for patient/family inquiries, and symptomatic patients were assessed using an institutional triage protocol, including lab/culture data and infectious diseases consultation.

RESULTS

CPB surgeries were performed in 4,276 patients (median age 2.1 years, range 0-48.4) between October 2010 and October 2016. Call center volume was highest in the first 6 weeks following patient notification, totaling 307 calls and yielding 70 clinical patient assessments. Presenting symptoms included fatigue (60%), fever (49%), night sweats (46%), myalgias (34%), and weight loss (24%). Among the 70 assessed patients, echocardiogram (n=30), cardiac CT (n=2), cardiac MRI (n=1), and pulmonary CT (n=1) did not reveal abnormalities suggestive of active infection. Infectious diseases consultation occurred in 23 (33%) patients. Acid fast bacilli blood cultures were obtained in 30 patients; all were negative.

CONCLUSIONS

Through a highly coordinated outreach effort, no patients have been found to have M. chimaera infection in the six years after exposure to contaminated HCUs. Ongoing vigilance for cases that may yet manifest is needed.

Leadership Training in Pediatric Residency Programs: Identifying Content, Characterizing Practice, and Planning for the Future

OBJECTIVE

Physicians serve as leaders in varying roles, but often with minimal dedicated training. Existing pediatric residency competencies may not completely describe all leadership skills that should be valued. We sought to identify a set of high-value leadership skills and evaluate current training in these skills in pediatric residency programs.

METHODS

A modified Delphi process was used to inform a national survey of pediatric residency program directors. Programs were asked to rate the perceived importance of identified leadership skills and the presence of dedicated teaching. Skills identified as extremely or quite important by ≥90% of respondents were classified as high-value.

RESULTS

Our modified Delphi process generated 16 core leadership skills to evaluate. A total of 67/204 residency programs responded. Six skills were identified as high-value: managing time effectively, receiving feedback, communicating effectively through speaking, embodying professionalism, demonstrating emotional intelligence, and addressing conflict. Only 19% of responding programs reported providing dedicated teaching time for all high-value skills.

CONCLUSIONS

Despite a high degree of national agreement among program directors about the importance of specific leadership skills, few pediatric residency programs dedicate time to teaching residents about these skills. The identified high-value leadership skills could help to inform future educational efforts.

Predictive Value of Direct Disk Diffusion Testing from Positive Blood Cultures in a Children's Hospital and Its Utility in Antimicrobial Stewardship

Accurate and early susceptibility results could reduce overuse of broad-spectrum antibiotics for empirical treatment of bacteremia. Direct disk diffusion testing (dDD) using nonstandardized inocula directly from blood cultures could facilitate earlier narrowing of antibiotics. To determine the predictive value of dDD compared with standardized antimicrobial susceptibility testing (AST), we performed a retrospective cohort study of 582 blood cultures from 495 pediatric patients with bacteremia. Positive and negative predictive value (PPV: number of isolates susceptible by both dDD and AST divided by the total number of isolates susceptible by dDD; NPV: number of isolates not susceptible [either intermediate or resistant] by both dDD and AST divided by the total number of isolates not susceptible by dDD), sensitivity, specificity, and 95% confidence interval were calculated for each bacterium-antibiotic combination. We evaluated the Antibiotic Spectrum Index of prescribed antibiotics to assess change in antibiotic prescribing after availability of Gram stain, dDD, and AST results. dDD results were available a median of 21 h before AST results. dDD had PPVs of ≥96% for most organism-antibiotic pairs, including 100% (CI 96 to 100%) for Staphylococcus aureus with oxacillin and 99% (CI 93 to 100%) for Enterobacterales with ceftriaxone. NPVs of dDD were variable and frequently lower than the PPV. Very major errors and major errors occurred in 31/5,454 (0.6%) and 231/5,454 (4.2%) organism-antibiotic combinations, respectively. Antibiotics were narrowed in 30% of cases after a dDD result and a further 25% of cases after AST result. dDD is highly predictive of susceptibility for many common organism-antibiotic combinations and provides actionable information one day earlier than standard susceptibility approaches. dDD has the potential to facilitate earlier deescalation to narrow-spectrum antibiotic treatment.

A scoping review of paediatric latent tuberculosis infection care cascades: initial steps are lacking

BACKGROUND AND OBJECTIVES

Identifying and treating children with latent tuberculosis infection (TB infection) is critical to prevent progression to TB disease and to eliminate TB globally. Diagnosis and treatment of TB infection requires completion of a sequence of steps, collectively termed the TB infection care cascade. There has been no systematic attempt to comprehensively summarise literature on the paediatric TB infection care cascade.

METHODS

We performed a scoping review of the paediatric TB infection care cascade. We systematically searched PubMed, Cumulative Index to Nursing and Allied Health Literature, Cochrane and Embase databases. We reviewed articles and meeting abstracts that included children and adolescents ≤21 years old who were screened for or diagnosed with TB infection, and which described completion of at least one step of the cascade. We synthesised studies to identify facilitators and barriers to retention, interventions to mitigate attrition and knowledge gaps.

RESULTS

We identified 146 studies examining steps in the paediatric TB infection care cascade; 31 included children living in low-income and middle-income countries. Most literature described the final cascade step (treatment initiation to completion). Studies identified an array of patient and caregiver-related factors associated with completion of cascade steps. Few health systems factors were evaluated as potential predictors of completion, and few interventions to improve retention were specifically tested.

CONCLUSIONS

We identified strengths and gaps in the literature describing the paediatric TB infection care cascade. Future research should examine cascade steps upstream of treatment initiation and focus on identification and testing of at-risk paediatric patients. Additionally, future studies should focus on modifiable health systems factors associated with attrition and may benefit from use of behavioural theory and implementation science methods to improve retention.

Risk factors for pediatric surgical site infection following neurosurgical procedures for hydrocephalus: a retrospective single-center cohort study

Background

Infection is a major complication following cerebral spinal fluid (CSF) diversion procedures for hydrocephalus. However, pediatric risk factors for surgical site infection (SSI) are currently not well defined. Because a SSI prevention bundle is increasingly introduced, the purpose of this study was to evaluate risk factors associated with SSIs following CSF diversion surgeries following a SSI bundle at a single quaternary care pediatric hospital.

Methods

We performed a retrospective cohort study of patients undergoing CSF diversion procedures from 2017 to 2019. SSIs were identified prospectively through continuous surveillance. We performed unadjusted logistic regression analyses and univariate analyses to determine an association between SSIs and patient demographics, comorbidities and perioperative factors to identify independent risk factors for SSI.

Results

We identified a total of 558 CSF diversion procedures with an overall SSI rate of 3.4%. The SSI rates for shunt, external ventricular drain (EVD) placement, and endoscopic third ventriculostomy (ETV) were 4.3, 6.9 and 0%, respectively. Among 323 shunt operations, receipt of clindamycin as perioperative prophylaxis and presence of cardiac disease were significantly associated with SSI (O.R. 4.99, 95% C.I. 1.27–19.70, p = 0.02 for the former, and O.R. 7.19, 95% C.I. 1.35–38.35, p = 0.02 for the latter). No risk factors for SSI were identified among 72 EVD procedures.

Conclusion

We identified receipt of clindamycin as perioperative prophylaxis and the presence of cardiac disease as risk factors for SSI in shunt procedures. Cefazolin is recommended as a standard antibiotic for perioperative prophylaxis. Knowing that unsubstantiated beta-lactam allergy label is a significant medical problem, efforts should be made to clarify beta-lactam allergy status to maximize the number of patients who can receive cefazolin for prophylaxis before shunt placement. Further research is needed to elucidate the mechanism by which cardiac disease may increase SSI risk after shunt procedures.

Non-SARS-CoV-2 Infections Among Patients Evaluated for MIS-C Associated With COVID-19

Clinical features of Multisystem Inflammatory Syndrome in Children (MIS-C) associated with COVID-19 are nonspecific. In this retrospective cohort study of 39 patients evaluated for MIS-C, 11 had non-SARS-CoV-2 infections, 3 of whom were also diagnosed with MIS-C. Clinical features were similar in patients with MIS-C and patients with non-SARS-CoV-2 infections. Clinicians should consider non-SARS-CoV-2 infections in patients undergoing MIS-C evaluation.

Trends in Pediatric Candidemia: Epidemiology, Anti-Fungal Susceptibility, and Patient Characteristics in a Children's Hospital

Candida bloodstream infections (CBSIs) have decreased among pediatric populations in the United States, but remain an important cause of morbidity and mortality. Species distributions and susceptibility patterns of CBSI isolates diverge widely between children and adults. The awareness of these patterns can inform clinical decision-making for empiric or pre-emptive therapy of children at risk for candidemia. CBSIs occurring from 2006-2016 among patients in a large children's hospital were analyzed for age specific trends in incidence rate, risk factors for breakthrough-CBSI, and death, as well as underlying conditions. Candida species distributions and susceptibility patterns were evaluated in addition to the anti-fungal agent use. The overall incidence rate of CBSI among this complex patient population was 1.97/1000 patient-days. About half of CBSI episodes occurred in immunocompetent children and 14% in neonatal intensive care unit (NICU) patients. Anti-fungal resistance was minimal: 96.7% of isolates were fluconazole, 99% were micafungin, and all were amphotericin susceptible. Liposomal amphotericin was the most commonly prescribed anti-fungal agent included for NICU patients. Overall, CBSI-associated mortality was 13.7%; there were no deaths associated with CBSI among NICU patients after 2011. Pediatric CBSI characteristics differ substantially from those in adults. The improved management of underlying diseases and antimicrobial stewardship may further decrease morbidity and mortality from CBSI, while continuing to maintain low resistance rates among Candida isolates.

Facilitators and barriers to a family empowerment strategy to improve healthcare worker hand hygiene in a resource-limited setting

OBJECTIVES

The World Health Organization recommends empowering patients/families to remind healthcare workers (HCWs) to perform hand hygiene (HH). We sought to understand acceptability of a family empowerment strategy in a Vietnamese pediatric intensive care unit (PICU).

METHODS

With end-user input, we designed a tool to help families in a PICU in Vietnam to remind HCWs to perform HH. We conducted 3 preliminary focus group discussions (FGDs) with patients' family members (n = 8), physicians (n = 9), and nurses (n = 8) to understand acceptability of preliminary tools, attitudes towards HH and barriers to HH. Tools were then modified and implemented in a 5-week intervention study. We then conducted 3 more FGDs with families (n = 7), physicians (n = 7), and nurses (n = 8). Discussions were analyzed using qualitative directed content analysis. Families who used the tool were asked to complete written surveys.

FINDINGS

Both family members and HCWs felt that HCWs had a responsibility to perform HH. Barriers to performing HH were identified, including forgetfulness and time constraints. Family members felt shy reminding HCWs to perform HH. However, the HH reminder tool was acceptable, and some felt it could overcome barriers to reminding HCWs to perform HH. HCWs felt embarrassed when reminded to perform HH, but felt that the reminder was useful. Nearly all (99%) survey respondents felt that family members should speak up if they noticed HCWs omitting HH.

CONCLUSIONS

A tool given to families to remind HCWs to perform HH was largely acceptable in a pediatric ICU in Vietnam. Perceived benefits of improving HH were felt to surmount barriers to tool use.

The Role of Anesthetic Management in Surgical Site Infections After Pediatric Intestinal Surgery

BACKGROUND

Although surgical site infections (SSIs) remain a significant health care issue, a limited number of studies have analyzed risk factors for SSIs in children, particularly the role of intraoperative anesthetic management. Pediatric patients are less likely to have major adult risk factors for SSIs such as smoking and diabetes. Thus children may be more suitable as a cohort for examining the role of intraoperative anesthetics in SSIs.

AIM

We examined an association between SSI incidence and anesthetic management in children who underwent elective intestinal surgery in a single institution.

METHODS

We performed a retrospective study of 621 patients who underwent elective intestinal surgery under general anesthesia between January 2017 and September 2019, with primary outcome as the incidence of SSIs. We compared patients who were dichotomized in accordance with the median of the sevoflurane dose. We used propensity score (PS) pairwise matching of these patients to avoid selection biases. PS matching yielded 204 pairs of patients.

RESULTS

We found that higher doses of sevoflurane were associated with a higher incidence of SSIs (9.8% versus 3.9%, P = 0.019). We adjusted for intraoperative factors that were not included in the PS adjustment factors, and multivariate regression analysis after PS matching showed compatible results (odds ratio: 2.58, 95% confidence interval: 1.11-6.04, P = 0.028).

CONCLUSIONS

Higher doses of sevoflurane are associated with increased odds of SSIs after pediatric elective intestinal surgery. A randomized controlled study of volatile anesthetic-based versus intravenous anesthetic-based anesthesia will be needed to further determine the role of anesthetic drugs in SSI risk.

Genomic and epidemiological evidence of bacterial transmission from probiotic capsule to blood in ICU patients

Probiotics are routinely administered to hospitalized patients for many potential indications1 but have been associated with adverse effects that may outweigh their potential benefits2-7. It is particularly alarming that probiotic strains can cause bacteremia8,9, yet direct evidence for an ancestral link between blood isolates and administered probiotics is lacking. Here we report a markedly higher risk of Lactobacillus bacteremia for intensive care unit (ICU) patients treated with probiotics compared to those not treated, and provide genomics data that support the idea of direct clonal transmission of probiotics to the bloodstream. Whole-genome-based phylogeny showed that Lactobacilli isolated from treated patients' blood were phylogenetically inseparable from Lactobacilli isolated from the associated probiotic product. Indeed, the minute genetic diversity among the blood isolates mostly mirrored pre-existing genetic heterogeneity found in the probiotic product. Some blood isolates also contained de novo mutations, including a non-synonymous SNP conferring antibiotic resistance in one patient. Our findings support that probiotic strains can directly cause bacteremia and adaptively evolve within ICU patients.

Clinical Practice Guidelines for Clostridium difficile Infection in Adults and Children: 2017 Update by the Infectious Diseases Society of America (IDSA) and Society for Healthcare Epidemiology of America (SHEA)

A panel of experts was convened by the Infectious Diseases Society of America (IDSA) and Society for Healthcare Epidemiology of America (SHEA) to update the 2010 clinical practice guideline on Clostridium difficile infection (CDI) in adults. The update, which has incorporated recommendations for children (following the adult recommendations for epidemiology, diagnosis, and treatment), includes significant changes in the management of this infection and reflects the evolving controversy over best methods for diagnosis. Clostridium difficile remains the most important cause of healthcare-associated diarrhea and has become the most commonly identified cause of healthcare-associated infection in adults in the United States. Moreover, C. difficile has established itself as an important community pathogen. Although the prevalence of the epidemic and virulent ribotype 027 strain has declined markedly along with overall CDI rates in parts of Europe, it remains one of the most commonly identified strains in the United States where it causes a sizable minority of CDIs, especially healthcare-associated CDIs. This guideline updates recommendations regarding epidemiology, diagnosis, treatment, infection prevention, and environmental management.

Clinical Practice Guidelines for Clostridium difficile Infection in Adults and Children: 2017 Update by the Infectious Diseases Society of America (IDSA) and Society for Healthcare Epidemiology of America (SHEA)

A panel of experts was convened by the Infectious Diseases Society of America (IDSA) and Society for Healthcare Epidemiology of America (SHEA) to update the 2010 clinical practice guideline on Clostridium difficile infection (CDI) in adults. The update, which has incorporated recommendations for children (following the adult recommendations for epidemiology, diagnosis, and treatment), includes significant changes in the management of this infection and reflects the evolving controversy over best methods for diagnosis. Clostridium difficile remains the most important cause of healthcare-associated diarrhea and has become the most commonly identified cause of healthcare-associated infection in adults in the United States. Moreover, C. difficile has established itself as an important community pathogen. Although the prevalence of the epidemic and virulent ribotype 027 strain has declined markedly along with overall CDI rates in parts of Europe, it remains one of the most commonly identified strains in the United States where it causes a sizable minority of CDIs, especially healthcare-associated CDIs. This guideline updates recommendations regarding epidemiology, diagnosis, treatment, infection prevention, and environmental management.

Limiting Vancomycin Exposure in Pediatric Oncology Patients With Febrile Neutropenia May Be Associated With Decreased Vancomycin-Resistant Enterococcus Incidence

BACKGROUND

Limited data exists regarding the effects of empiric antibiotic use in pediatric oncology patients with febrile neutropenia (FN) on the development of antibiotic resistance. We evaluated the impact of a change in our empiric FN guideline limiting vancomycin exposure on the development of vancomycin-resistant Enterococcus in pediatric oncology patients.

METHODS

Retrospective, quasi-experimental, single-center study using interrupted timeseries analysis in oncology patients aged ≤18 years with at least 1 admission for FN between 2009 and 2015. Risk strata incorporated diagnosis, chemotherapy phase, Down syndrome, septic shock, and typhlitis. Microbiologic data and inpatient antibiotic use were obtained by chart review. Segmented Poisson regression was used to compare VRE incidence and antibiotic days of therapy (DOT) before and after the intervention.

RESULTS

We identified 285 patients with 697 FN episodes pre-intervention and 309 patients with 691 FN episodes postintervention. The proportion of high-risk episodes was similar in both periods (49% vs 48%). Empiric vancomycin DOT/1000 FN days decreased from 315 pre-intervention to 164 post-intervention (P < .01) in high-risk episodes and from 199 to 115 in standard risk episodes (P < .01). Incidence of VRE/1000 patient-days decreased significantly from 2.53 pre-intervention to 0.90 post-intervention (incidence rate ratio, 0.14; 95% confidence interval, 0.04-0.47; P = .002).

CONCLUSIONS

A FN guideline limiting empiric vancomycin exposure was associated with a decreased incidence of VRE among pediatric oncology patients. Antimicrobial stewardship interventions are feasible in immunocompromised patients and can impact antibiotic resistance.

Reducing Redundant Anaerobic Therapy Through Spaced Education and Antimicrobial Stewardship Interventions

BACKGROUND

Decreasing the use of redundant anaerobic therapy is a key target for antimicrobial stewardship. Education techniques that optimize knowledge retention could be an important component of reducing these regimens.

METHODS

We implemented a quality improvement project that incorporated spaced education to reduce the use of redundant anaerobic therapy. The initial interventions (November through December 2015) included education in a hospital-wide newsletter and review of redundant anaerobic regimens by the antimicrobial stewardship program. A spaced education module was then developed with the gastroenterology (GI) service, which had a relatively high rate of redundant anaerobic therapy use. Ten questions with teaching points were delivered to GI physicians at spaced intervals over 2 to 4 weeks (February through March 2016). Knowledge scores were compared at initial and final question presentation using generalized estimating equations. Interrupted time-series analysis was used to compare the rates of redundant-metronidazole-days per 1000 patient-days among patients in the patients admitted to the GI service and those in the non-GI group before and after the intervention.

RESULTS

Of 66 GI physicians, 56 (85%) participated in the spaced education activity. After the intervention, their knowledge scores on all the questions improved, and their mean knowledge score increased from 57% to 86% (P < .001). Nearly all (91%) of the participants were very or generally satisfied with the activity. In the GI group, the rate of redundant-metronidazole-days decreased from 26.2 to 13.0 per 1000 patient-days (relative risk [RR], 0.45 [95% confidence interval (CI), 0.27-0.73]; P = .001). This rate in the non-GI group also decreased from 5.47 to 2.18 per 1000 patient-days (RR, 0.47 [95% CI, 0.36-0.60]; P < .001) after our interventions.

CONCLUSIONS

Spaced education is an effective approach for teaching antimicrobial stewardship topics. Focused provider education was associated with a sustained reduction in the use of redundant anaerobic therapy.

280. The Impact of a Revised Neutropenic Fever Guideline on Vancomycin-Resistant Enterococcus Rates in Pediatric Oncology Patients

Background

Data on the impact of empiric febrile neutropenia (FN) guidelines on resistant bacteria in pediatric oncology patients are limited. We implemented a risk-stratified guideline for empiric FN antibiotics, limiting vancomycin use to high-risk patients for 48 hours if cultures were negative. Our aim was to assess the impact of this intervention on rates of vancomycin-resistant Enterococcus (VRE) and vancomycin use.

Methods

We conducted a retrospective, quasi-experimental study of oncology patients ≤ 18 years with FN admitted from 2010 to 2014. Microbiologic data and inpatient antibiotic use were obtained by chart review. Risk strata incorporated diagnosis, chemotherapy phase, Down syndrome, septic shock, and typhlitis. The primary outcome was VRE incidence; all VRE isolates were included but active surveillance was only performed in intensive care units (ICUs) in both periods. We compared VRE incidence and antibiotic days of therapy (DOT) before and after the intervention using interrupted time-series analysis with segmented Poisson regression with auto-correlation.

Results

We identified 183 patients with 765 admissions and 382 FN episodes pre-intervention, and 185 patients with 830 admissions and 385 FN episodes post-intervention. The proportion of high-risk patients was 51% pre vs. 45% post (P = 0.06). Median length of stay for FN admissions was 7 days (IQR: 4–22) preintervention and 5 days (IQR: 3–15) postintervention (P ≤ 0.01). Median duration of empiric vancomycin decreased from 5 days (IQR: 3–9) pre- to 3 days (IQR: 3–4) postintervention (P ≤ 0.01). Empiric vancomycin DOT/1,000 FN days decreased from 287 preintervention to 199 postintervention (P ≤ 0.01). Incidence of VRE/1,000 patient-days decreased significantly from 1.71 preintervention to 0.45 postintervention (IRR=0.26, 95% CI 0.09–0.80; P = 0.02). The proportion of VRE isolates representing colonization did not differ significantly pre- and postintervention (50% vs. 67%).

Conclusion

Implementation of an FN guideline limiting vancomycin exposure was associated with decreased incidence of VRE among pediatric oncology patients. Antimicrobial stewardship interventions are feasible in immunocompromised patients and can impact antibiotic resistance.

Disclosures

All authors: No reported disclosures.

Promoting Resident Professional Development Using Scholarly Academies

Promoting professional development is a challenging but vital component of residency training. We created resident academies (scholarly homes) that aimed to develop academic skills, enhance mentorship, and create a sense of community based on scholarly interest.

Adherence to guidelines for testing and treatment of children with pharyngitis: a retrospective study

BACKGROUND

Group A streptococcus (GAS) is the most common bacterial etiology of pharyngitis but is difficult to distinguish clinically from viral pharyngitis. There are benefits to early antibacterial treatment of GAS pharyngitis, but administering antibiotics to children with viral pharyngitis is ineffective and costly. We evaluated adherence to guidelines that were developed to help clinicians distinguish between viral and GAS pharyngitis and guide management.

METHODS

Retrospective cohort study of patients ages 3-18 who had a rapid streptococcal test and/or throat culture performed in an outpatient setting. We collected data on documentation of components of the McIsaac score and classified tests as indicated if the score was ≥2. Based on McIsaac score and GAS test results, we determined whether each antibiotic course prescribed was indicated according to the Infectious Diseases Society of America guideline.

RESULTS

Among 291 eligible children, 87 (30%) had all five components of the McIsaac score documented. There was sufficient data to classify the score as either < 2 or ≥2 in 234 (80%); among these, 96% of tests were indicated. Twenty-nine patients (10%) were prescribed antibiotics. Eight (28%) of these prescriptions were not indicated according to guidelines.

CONCLUSIONS

The majority of GAS tests in children with pharyngitis are indicated, although providers do not regularly document all elements of a validated pharyngitis scoring tool. Over one quarter of children prescribed antibiotics for pharyngitis did not require antibiotics according to guidelines. There remains a role for targeted antimicrobial stewardship education regarding pharyngitis management in pediatric outpatient settings.

Clinical Utility of Preimplantation Homograft Cultures in Patients Undergoing Congenital Cardiac Surgery

Institutional practice at our hospital (Boston Children's Hospital) is to culture homografts before implantation during congenital cardiac surgery. Over a 4-year period, 5% (73 of 1376) of these cultures were positive, but the results had minimal clinical impact. Our experience demonstrates that there is limited utility in preimplantation cultures of cardiac homografts.

A qualitative study to identify reasons for Clostridium difficile testing in pediatric inpatients receiving laxatives or stool softeners

To understand why clinicians send Clostridium difficile tests from hospitalized children receiving laxatives or stool softeners, we performed a mixed-methods study. We prospectively identified tested patients and surveyed their clinicians by e-mail. Reasons for testing included changes in stooling pattern on baseline bowel regimen, other changes in clinical status, and risk factors for C difficile infection. Education targeting discontinuing bowel medications before C difficile testing could improve the specificity of pediatric C difficile infection diagnosis.

National Variability and Appropriateness of Surgical Antibiotic Prophylaxis in US Children's Hospitals

IMPORTANCE

Appropriate use of surgical antibiotic prophylaxis (AP) reduces surgical site infection rates, but prior data suggest variability in use patterns.

OBJECTIVE

To assess national variability and appropriateness of AP in pediatric surgical patients.

DESIGN, SETTING, AND PARTICIPANTS

Retrospective cohort study of 31 freestanding children's hospitals in the United States using administrative data from 2010-2013. The study included 603 734 children younger than 18 years who underwent one of the 45 most commonly performed operations.

EXPOSURES

Receipt of surgical AP.

MAIN OUTCOMES AND MEASURES

Primary outcomes included procedure- and hospital-specific rates of AP use and appropriateness of use based on clinical guidelines and consensus statements. We also assessed rates of Clostridium difficile infection and potential allergic reactions (using epinephrine administration as a surrogate event) after AP receipt.

RESULTS

Of the 603 734 eligible patients, the mean (SD) patient age was 4.8 (4.4) years and 384 571 (63.7%) were boys. For the 671 255 operations evaluated, AP was administered for 348 119 (52%) of procedures. Intrahospital variation in AP use by procedure ranged from 11.5% to 100% (median, 78.1%). Overall, AP use was considered appropriate for 64.6% of cases. Appropriate use of AP by hospital varied from 47.3% to 84.4% with large variability by procedure within each hospital. For procedures for which AP was indicated, the median rate of appropriate use by hospital was 93.8%; however, for procedures for which AP was not indicated, the median rate of appropriate use by hospital was 52.0%. The odds of C difficile infection and epinephrine administration were significantly higher among children who received AP (odds ratio, 3.34; 95% CI, 1.66-6.73 and odds ratio 1.97; 95% CI, 1.92-2.02; respectively).

CONCLUSIONS AND RELEVANCE

There is substantial national variability in the overall and appropriate use of AP for the most commonly performed operations in children both at a procedure and hospital level. A high proportion of AP use is inappropriate, potentially exposing many children to avoidable adverse events. Urgent attention should be directed to efforts to standardize the use of surgical AP in pediatrics.

Ventilator-Associated Events in Neonates and Children--A New Paradigm

OBJECTIVES

To identify a pediatric ventilator-associated condition definition for use in neonates and children by exploring whether potential ventilator-associated condition definitions identify patients with worse outcomes.

DESIGN

Retrospective cohort study and a matched cohort analysis.

SETTING

Pediatric, cardiac, and neonatal ICUs in five U.S. hospitals.

PATIENTS

Children 18 years old or younger ventilated for at least 1 day.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

We evaluated the evidence of worsening oxygenation via a range of thresholds for increases in daily minimum fraction of inspired oxygen (by 0.20, 0.25, and 0.30) and daily minimum mean airway pressure (by 4, 5, 6, and 7 cm H2O). We required worsening oxygenation be sustained for at least 2 days after at least 2 days of stability. We matched patients with a ventilator-associated condition to those without and used Cox proportional hazard models with frailties to examine associations with hospital mortality, hospital and ICU length of stay, and duration of ventilation. The cohort included 8,862 children with 10,209 hospitalizations and 77,751 ventilator days. For the fraction of inspired oxygen 0.25/mean airway pressure 4 definition (i.e., increase in minimum daily fraction of inspired oxygen by 0.25 or mean airway pressure by 4), rates ranged from 2.9 to 3.2 per 1,000 ventilator days depending on ICU type; the fraction of inspired oxygen 0.30/mean airway pressure 7 definition yielded ventilator-associated condition rates of 1.1-1.3 per 1,000 ventilator days. All definitions were significantly associated with greater risk of hospital death, with hazard ratios ranging from 1.6 (95% CI, 0.7-3.4) to 6.8 (2.9-16.0), depending on thresholds and ICU type. Each definition was associated with prolonged hospitalization, time in ICU, and duration of ventilation, among survivors. The advisory board of the study proposed using the fraction of inspired oxygen 0.25/mean airway pressure 4 thresholds to identify pediatric ventilator-associated conditions in ICUs.

CONCLUSIONS

Pediatric patients with ventilator-associated conditions are at substantially higher risk for mortality and morbidity across ICUs, regardless of thresholds used. Next steps include identification of risk factors, etiologies, and preventative measures for pediatric ventilator-associated conditions.

Beyond the Bundle: A Survey of Central Line–Associated Bloodstream Infection Prevention Practices Used in US and Canadian Pediatric Hospitals

We surveyed US and Canadian pediatric hospitals about their use of central line-associated bloodstream infection (CLABSI) prevention strategies beyond typical insertion and maintenance bundles. We found wide variation in supplemental strategies across hospitals and in their penetration within hospitals. Future studies should assess specific adjunctive prevention strategies and CLABSI rates.

Risk Factors for Central Line–Associated Bloodstream Infection in Pediatric Intensive Care Units

Objective.

We sought to identify risk factors for central line-associated bloodstream infection (CLABSI) to describe children who might benefit from adjunctive interventions.

Design.

Case-control study of children admitted to the medical-surgical intensive care unit (ICU) or cardiac ICU from January 1, 2004, through December 31, 2007.

Setting.

Children's Hospital Boston is a freestanding, 396-bed quaternary care pediatric hospital with a 29-bed medical-surgical ICU and a 24-bed cardiac ICU.

Patients.

Case patients were patients with CLABSI who were identified by means of prospective surveillance. Control subjects were patients with a central venous catheter who were matched by ICU admission date.

Methods.

Multivariate conditional logistic regression models were used to identify independent risk factors for CLABSI and to derive and to validate a prediction rule.

Results.

Two hundred three case patients were matched with 406 control subjects. Independent predictors of CLABSI included duration of ICU central access (odds ratio [OR] for 15 or more days, 18.41 [95% confidence interval {CI} 4.10-82.56]; P < .001), central venous catheter placement in the ICU (OR for 2 or more ICU-placed catheters, 8.63 [95% CI, 2.63-28.38]; P = .001), nonoperative cardiovascular disease (OR, 7.44 [95% CI, 2.13-25.98]; P = .012), presence of gastrostomy tube (OR, 3.48 [95% CI, 1.55-7.79]; P = .003), receipt of parenteral nutrition (OR, 3.12 [95% CI, 1.55-6.32]; P= .002), and receipt of blood transfusion (OR, 2.55 [95% CI, 1.21-5.36]; P = .014). By use of risk factors known before central venous catheter placement, our model predicted CLABSI with a positive predictive value of 54% and a negative predictive value of 79%.

Conclusions.

Duration of central access, receipt of parenteral nutrition, and receipt of blood transfusion were confirmed as risk factors for CLABSI among children in the ICU. Newly identified risk factors include presence of gastrostomy tube, nonoperative cardiovascular disease, and ICU placement of central venous catheter. Children with these risk factors may be candidates for adjunctive interventions for CLABSI prevention.