Emily A. Thorell

Economic Analysis of Rapid and Sensitive Polymerase Chain Reaction Testing in the Emergency Department for Influenza Infections in Children

Background: Rapid multiplex polymerase chain reaction (PCR) assays simultaneously detect several respiratory viral pathogens with high sensitivity. Maximizing detection of influenza at the point of care has the potential to reduce unnecessary antibiotic use, laboratory tests and hospitalizations. However, the cost-effectiveness of rapid multiplex PCR assays for influenza has not been compared with other diagnostic methods in children. Methods: For children presenting to the emergency department with influenza-like illness, we compared costs and outcomes using 4 different testing strategies for detection of influenza: (1) a rapid multiplex PCR platform (FilmArray); (2) traditional PCR; (3) direct-fluorescent antibody and (4) rapid antigen tests. Costs were assessed from the hospital perspective, and effectiveness was defined as quality-adjusted life years (QALYs). Input parameters were obtained from previous studies, and the model was run separately for children aged 3–36 months and 3–18 years. Results: Rapid multiplex PCR testing was the most effective testing strategy for children in both age groups. The incremental cost-effectiveness when compared with rapid antigen tests was

Treatment and microbiology of repeated cerebrospinal fluid shunt infections in children

115,556 per QALY for children aged 3–36 months and from

Considerations in the Pharmacologic Treatment and Prevention of Neonatal Sepsis

228,000 per QALY for children aged 3–18 years. The cost-effectiveness of rapid multiplex PCR was sensitive to estimates for influenza prevalence, the proportion of patients treated with antivirals and the cost per test. Conclusions: Our model identifies scenarios in which identification of influenza in the emergency department using rapid multiplex PCR testing is a cost-effective strategy for infants and children 3 months through 18 years. Including detection of other respiratory viruses in the analysis would further improve cost-effectiveness.

Response-based therapy for ruptured appendicitis reduces resource utilization

Background: A small group of children have second and even more cerebrospinal fluid (CSF) shunt infections (SIs). We sought to describe the treatment approaches used for, and the microbiology of, repeated SIs. Methods: The study population included 31 children with second shunt infection (SI-2) among those undergoing initial CSF shunt placement and treatment for initial infection at Primary Childrens Medical Center. CSF SI was defined as follows: (1) presence of bacteria in Gram stain and/or culture of CSF, wound, and/or pseudocyst; (2) visible hardware; (3) abdominal pseudocyst; or (4) presence of bacteria in a blood culture in children with a ventriculoatrial shunt. Infection rates were generated using per-patient denominators, and the concordance of organisms across infections was summarized. Results: Of the 31 children with SI-2, most were less than 6 months of age at initial shunt placement (81%), male (77%), and with ventriculoperitoneal shunts (71%). Of total, 18 developed SI-3 and 8 developed SI-4. Infection rates were 60% (95% confidence interval [CI]: 42%–75%, n = 18/30) for SI-3 and 47% (95% CI: 26%–69%, n = 8/17) for SI-4. The median time to SI-3 was 477 days (range, 5–828) and to SI-4 it was 2137 days (range, 9–2137). Gram-positive organisms predominated (93% of SI-2, 94% of SI-3). The majority of SI-2 demonstrated Gram-stain concordance with both the initial (first) SI (58%, 95% CI: 41%–74%) and with the following (third) SI (78%, 95% CI: 55%–91%). Conclusions: Children with SI-2 experience high subsequent reinfection rates with a long time to reinfection.

Disseminated nontuberculous mycobacterial infections in sickle cell anemia patients.

The management of neonatal sepsis is challenging owing to complex developmental and environmental factors that contribute to inter-individual variability in the pharmacokinetics and pharmacodynamics of many antimicrobial agents. In this review, we describe (i) the changing epidemiology of early- and late-onset neonatal sepsis; (ii) the pharmacologic considerations that influence the safety and efficacy of antibacterials, antifungals, and immunomodulatory adjuvants; and (iii) the recommended dosing regimens for pharmacologic agents commonly used in the treatment and prevention of neonatal sepsis. Neonatal sepsis is marked by high morbidity and mortality, such that prompt initiation of antimicrobial therapy is essential following culture collection. Before culture results are available, combination therapy with ampicillin and an aminoglycoside is recommended. When meningitis is suspected, ampicillin and cefotaxime may be considered. Following identification of the causative organism and in vitro susceptibility testing, antimicrobial therapy may be narrowed to provide targeted coverage. Therapeutic drug monitoring should be considered for neonates receiving vancomycin or aminoglycoside therapies. For neonates with invasive fungal infections, the development of new antifungal agents has significantly improved therapeutic outcomes in recent years. Liposomal amphotericin B has been found to be safe and efficacious in patients with renal impairment or toxicity caused by conventional amphotericin B. Antifungal prophylaxis with fluconazole has also been reported to dramatically reduce rates of neonatal invasive fungal infections and to improve long-term neurodevelopmental outcomes among treated children. Additionally, several large multicenter studies are currently investigating the safety and efficacy of oral lactoferrin as an immunoprophylactic agent for the prevention of neonatal sepsis.

A dynamic postoperative protocol provides efficient care for pediatric patients with non-ruptured appendicitis.

PURPOSE We examined the effectiveness of a postoperative ruptured appendicitis protocol that eliminated Pseudomonas coverage and based the duration of IV antibiotic treatment and length of hospital stay on the patients clinical response. METHODS In our new protocol, IV antibiotics were administered until the patient met discharge criteria: adequate oral intake, pain control with oral medications, and afebrile for 24h. We collected data on all patients with ruptured appendicitis at our institution following protocol implementation (May 1, 2012, to April 30, 2013) and compared them to a control group. RESULTS 306 patients were treated (154 prior protocol, 152 new protocol). The new clinical response-based protocol led to a decrease in hospital stay from 134h (SD 66.1) to 94.5h (SD 61.7) (p<0.001) and total cost of care per patient also decreased from

Outpatient parenteral antimicrobial therapy in pediatrics: an opportunity to expand antimicrobial stewardship.

13,610 (SD

Incidence, morbidity, and costs of human metapneumovirus infection in hospitalized children

6859) to

Pediatric vancomycin dosing: Trends over time and the impact of therapeutic drug monitoring

9870 (SD

Few Patient, Treatment, and Diagnostic or Microbiological Factors, Except Complications and Intermittent Negative Cerebrospinal Fluid (CSF) Cultures During First CSF Shunt Infection, Are Associated With Reinfection

5670) (p<0.001). CONCLUSION Our clinical response-based protocol for pediatric patients with ruptured appendicitis decreased LOS, cost, and IV antibiotics use without significant changes in adverse events.