Gina Weddle

Severe enterovirus 68 respiratory illness in children requiring intensive care management

BACKGROUND Enterovirus 68 (EV-D68) causes acute respiratory tract illness in epidemic cycles, most recently in Fall 2014, but clinical characteristics of severe disease are not well reported. OBJECTIVES Children with EV-D68 severe respiratory disease requiring pediatric intensive care unit (PICU) management were compared with children with severe respiratory disease from other enteroviruses/rhinoviruses. STUDY DESIGN A retrospective review was performed of all children admitted to Childrens Mercy Hospital PICU from August 1-September 15, 2014 with positive PCR testing for enterovirus/rhinovirus. Specimens were subsequently tested for the presence of EV-D68. We evaluated baseline characteristics, symptomatology, lab values, therapeutics, and outcomes of children with EV-D68 viral infection compared with enterovirus/rhinovirus-positive, EV-D68-negative children. RESULTS A total of 86 children with positive enterovirus/rhinovirus testing associated with respiratory symptoms were admitted to the PICU. Children with EV-D68 were older than their EV-D68-negative counterparts (7.1 vs. 3.5 years, P=0.01). They were more likely to have a history of asthma or recurrent wheeze (68% vs. 42%, P=0.03) and to present with cough (90% vs. 63%, P=0.009). EV-D68 children were significantly more likely to receive albuterol (95% vs. 79%, P=0.04), magnesium (75% vs. 42%, P=0.004), and aminophylline (25% vs. 4%, P=0.03). Other adjunctive medications used in EV-D68 children included corticosteroids, epinephrine, and heliox; 44% of EV-D68-positive children required non-invasive ventilatory support. CONCLUSIONS EV-D68 causes severe disease in the pediatric population, particularly in children with asthma and recurrent wheeze; children may require multiple adjunctive respiratory therapies.

Reducing blood culture contamination in a pediatric emergency department.

Background: Blood cultures (BCs) are used to diagnose bacteremia in febrile children. False-positive BCs increase costs because of further testing, longer hospital stays, and unnecessary antibiotic therapy. Data from a study at our hospital showed the emergency department consistently exceeded established guidelines of 2% to 4%. A phlebotomy policy change was made whereby BC had to be obtained by a second venipuncture and no longer obtained during insertion of intravenous catheters. Methods: A descriptive study compared preintervention and postintervention blood culture contamination (BCC) rates. A BC was considered contaminated if a single culture grew coagulase-negative staphylococci, diphtheroids, Micrococcus spp, Bacillus spp, or viridans group streptococci. Patients with indwelling central lines or who grew pathogenic bacteria were excluded. Results: Preintervention BCC was 120 (6.7% [SD, 2.3%]) of 1796. Postintervention BCC was 29 (2.3%, [SD, 0.8]) of 1229 with odds ratio of 2.96 (confidence interval, 1.96-4.57; P = 0.001). The most common contaminant was coagulase-negative staphylococcus, 21 (72%) of 120, followed by viridans streptococcus, 3 (10%) of 29, which was not significantly different between intervention periods. Before intervention, 44 patients were called back to the emergency department, and 25 were admitted because of BCC. After intervention, a total of 9 patients were called back, and 5 were admitted. The decrease in unnecessary hospitalization was statistically significant (P < 0.05). Conclusions: The new policy significantly reduced BCC rates, thereby decreasing unnecessary testing and hospitalizations. Coagulase-negative staphylococci and viridans streptococci remain the most common BC contaminants. Further research should focus on additional interventions to reduce BCC.

Apophysomyces trapeziformis infection associated with a tornado-related injury.

This report defines the role of Apophysomyces as an aggressive fungal pathogen seen after a tornado injury. Clinical and laboratory manifestations of infections after environmentally contaminated wounds incurred during a tornado are outlined, emphasizing mechanism of injury, comorbidities, and diagnostic and treatment challenges. Therapy with systemic antifungal therapy and aggressive serial tissue debridement was successful in achieving cure.

Vaccine Eligibility in Hospitalized Children: Spotlight on a Unique Healthcare Opportunity

OBJECTIVE The goals of this study were to evaluate the effectiveness of an inpatient documentation system for identifying missed vaccine opportunities and to identify parental satisfaction with their vaccination services. METHODS A prospective descriptive study compared inpatient documentation of vaccine history with actual vaccine records, and adherence with the Advisory Committee on Immunization Practices guidelines was assessed. A parental satisfaction survey was administered. RESULTS One hundred sixty pediatric patients ages 2 months to 17 years (mean age 8 years) were enrolled. Seventy-six percent of patients had documentation of vaccine history, and 92% were documented as receiving all age-appropriate vaccines. Actual immunization records showed that 16% percent of patients were in compliance with Advisory Committee on Immunization Practices guidelines. The most commonly missed vaccine was influenza (67%) followed by meningococcal (57%), hepatitis A (48%), and varicella (38%). Ninety percent of parents were satisfied with the vaccination services their child had received. CONCLUSION A review of vaccine records is recommended to accurately assess status. Inpatient hospitalization represents an opportunity to assess vaccination status, address parental concerns, and provide updated vaccinations.

Clinical Course of Enterovirus D68 in Hospitalized Children

BACKGROUND Enterovirus D68 (EV-D68) has been sporadically reported as a cause of respiratory tract infections. In 2014, an international outbreak of EV-D68 occurred and caused severe respiratory disease in the pediatric population. METHODS A retrospective chart review was performed of children admitted to Childrens Mercy Hospital from August 1, 2014, to September 15, 2014, with positive multiplex polymerase chain reaction testing for EV/rhinovirus (RV). Specimens were subsequently tested for EV-D68, and clinical data were obtained from the medical records. Patients with EV-D68 were compared with children presenting simultaneously with other EV/RV. RESULTS Of 542 eligible specimens, children with EV-D68 were significantly older than children with other EV/RV (4.6 vs. 2.2 years, P < 0.001). Children with EV-D68 were more likely to have a history of asthma (38.6% vs. 30.0%, P = 0.04) or recurrent wheezing (22.1% vs. 14.8%, P = 0.04). EV-D68-positive children more commonly received supplemental oxygen (86.7% vs. 65.0%, P < 0.001), albuterol (91.2% vs. 65.5%, P < 0.001) and corticosteroids (82.9% vs. 58.6%, P < 0.001). Age ≥5 years was an independent risk factor for intensive care unit management in EV-D68-infected children. Children with a history of asthma or recurrent wheezing and EV-D68 received supplemental oxygen (92.7% vs. 82.4%, P = 0.007) and magnesium (42.7% vs. 29.7%, P = 0.03) at higher rates and more continuous albuterol (3 vs. 2 hours, P = 0.03) than those with other EV/RV. CONCLUSIONS EV-D68 causes severe disease in the pediatric population, particularly in children with a history of asthma or recurrent wheezing. EV-D68-positive children are more likely to require therapy for refractory bronchospasm and may need intensive care unit- level care.Background: Enterovirus D68 (EV-D68) has been sporadically reported as a cause of respiratory tract infections. In 2014, an international outbreak of EV-D68 occurred and caused severe respiratory disease in the pediatric population. Methods: A retrospective chart review was performed of children admitted to Children’s Mercy Hospital from August 1, 2014, to September 15, 2014, with positive multiplex polymerase chain reaction testing for EV/rhinovirus (RV). Specimens were subsequently tested for EV-D68, and clinical data were obtained from the medical records. Patients with EV-D68 were compared with children presenting simultaneously with other EV/RV. Results: Of 542 eligible specimens, children with EV-D68 were significantly older than children with other EV/RV (4.6 vs. 2.2 years, P < 0.001). Children with EV-D68 were more likely to have a history of asthma (38.6% vs. 30.0%, P = 0.04) or recurrent wheezing (22.1% vs. 14.8%, P = 0.04). EV-D68–positive children more commonly received supplemental oxygen (86.7% vs. 65.0%, P < 0.001), albuterol (91.2% vs. 65.5%, P < 0.001) and corticosteroids (82.9% vs. 58.6%, P < 0.001). Age ≥5 years was an independent risk factor for intensive care unit management in EV-D68–infected children. Children with a history of asthma or recurrent wheezing and EV-D68 received supplemental oxygen (92.7% vs. 82.4%, P = 0.007) and magnesium (42.7% vs. 29.7%, P = 0.03) at higher rates and more continuous albuterol (3 vs. 2 hours, P = 0.03) than those with other EV/RV. Conclusions: EV-D68 causes severe disease in the pediatric population, particularly in children with a history of asthma or recurrent wheezing. EV-D68–positive children are more likely to require therapy for refractory bronchospasm and may need intensive care unit– level care.

Role of nursing unit factors on performance of phlebotomy and subsequent blood culture contamination rates.

Institutions have a duty to respond when blood culture contamination rates exceed the accepted national average of 3% to 4% and to identify risk factors so that interventions can be instituted. This study outlines work environment risk factors that can influence blood culture contamination rates. Development of interventions aimed at changing behaviors to improve these conditions may result in improvement in patient care, reduction in healthcare costs, and reduction in bacterial resistance.

QuantiFERON-TB Gold In-Tube Testing for Tuberculosis in Healthcare Professionals

OBJECTIVE To assess the performance of the QuantiFERON-TB Gold in-tube (QFT-GIT) assay for tuberculosis (TB) screening using a convenience sample from among a population of healthcare provider (HCP) employees of a hospital. METHODS For the individuals in our cohort, we reviewed occupational health records, including TB risk factors, and the results of QFT-GIT testing. We considered a QFT-GIT result of greater than 0.35 IU/mL to be positive; when we obtained a positive result from a specimen from a particular individual, we repeated testing on a fresh specimen from that individual. RESULTS Of the 758 HCP employees whose specimens we screened, 439 had negative QFT-GIT results with negative TB risk factors and 268 had a negative QFT-GIT result but had positive TB risk factors. QFT-GIT results were positive in 47 subjects. Of the positive participants, 12 had a mean TB antigen value (antigen minus nil stimulated concentrations [Ag-Nil]) of 0.61 on initial testing and had a negative result on repeat testing, 22 had a TB Ag-Nil of 1.19 on initial testing and had a positive result on repeat testing (P = .01). CONCLUSIONS The QFT-GIT assay is useful for screening HCPs. However, false-positive results occur, particularly in a borderline zone of less than 1 IU/ml. Re-evaluation by repeat testing of fresh specimens from the same individual should be considered in subjects whose specimens test within the low-level positive cutoff.

Utility of a focused vancomycin-resistant enterococci screening protocol to identify colonization in hospitalized children

Screening for vancomycin-resistant enterococci (VRE) is controversial, and disagreement exists on policy implementation. This study investigated the likelihood of a positive test using 1, 2, or 3 rectal screenings for VRE colonization. In this descriptive study of positive VRE screening cultures, a total of 1211 VRE screens identified 41 positive results. The mean age of these positive patients was 5.7 years. Thirty-nine of the 41 had a chronic illness, and only 2 were healthy. Diagnoses included pulmonary disease in 11 patients and chronic gastrointestinal abnormality in 7. Six patients had been born preterm, and 12 had been treated in a neonatal intensive care unit within the previous 6 months. Thirty-six of the 41 positive results were identified on the first screen. The likelihood of subsequently having a positive screen after a negative screen was 0.43% (95% confidence interval, 0.15%-1.02%). The cost of cultures plus isolation was

377Impact of an Educational Intervention to Improve Antibiotic Prescribing for Nurse Practitioners (NPs) in a Pediatric Urgent Care Centers (UCC)

50,000 for the study period. Our data show that the likelihood of detecting a positive VRE culture after an initial negative was low, particularly in otherwise healthy children.

Infections of the Central Nervous System

377. Impact of an Educational Intervention to Improve Antibiotic Prescribing for Nurse Practitioners (NPs) in a Pediatric Urgent Care Centers (UCC) Gina Weddle, DNP, RN, CPNP; Angela Myers, MD, MPH; Jason Newland, MD; Jennifer Goldman, MD; J. Christopher Day, MD; Leslie Stach, PharmD, BCPS; Diana Yu, PharmD, BCPS; Infectious Disease, The Children’s Mercy Hospital, Kc, MO; Children’s Mercy Hospitals and Clinics and University of Missouri-Kansas City, Kansas City, MO; Children’s Mercy Hospital and Clinics, Kansas City, MO; Ann and Robert H. Lurie Children’s Hospital of Chicago, Chicago, IL