Jennifer Lighter-Fisher

Evaluation of Tuberculosis Diagnostics in Children: 1. Proposed Clinical Case Definitions for Classification of Intrathoracic Tuberculosis Disease. Consensus From an Expert Panel

There is a critical need for improved diagnosis of tuberculosis in children, particularly in young children with intrathoracic disease as this represents the most common type of tuberculosis in children and the greatest diagnostic challenge. There is also a need for standardized clinical case definitions for the evaluation of diagnostics in prospective clinical research studies that include children in whom tuberculosis is suspected but not confirmed by culture of Mycobacterium tuberculosis. A panel representing a wide range of expertise and child tuberculosis research experience aimed to develop standardized clinical research case definitions for intrathoracic tuberculosis in children to enable harmonized evaluation of new tuberculosis diagnostic technologies in pediatric populations. Draft definitions and statements were proposed and circulated widely for feedback. An expert panel then considered each of the proposed definitions and statements relating to clinical definitions. Formal group consensus rules were established and consensus was reached for each statement. The definitions presented in this article are intended for use in clinical research to evaluate diagnostic assays and not for individual patient diagnosis or treatment decisions. A complementary article addresses methodological issues to consider for research of diagnostics in children with suspected tuberculosis.

Safety and Effectiveness of Intravenous Pentamidine for Prophylaxis of Pneumocystis jirovecii Pneumonia in Pediatric Hematology/Oncology Patients.

Background: Pneumocystis jirovecii pneumonia (PCP) is an opportunistic infection that can lead to significant morbidity and mortality in immunocompromised pediatric hematology/oncology patients. Trimethoprim/sulfamethoxazole is the gold standard for prophylaxis. Intravenous (IV) pentamidine is the preferred second-line agent for PCP prophylaxis at our institution and is used first-line under certain circumstances. The purpose of this study is to evaluate the effectiveness and safety of IV pentamidine for PCP prophylaxis in pediatric hematology/oncology patients. Materials and Methods: A retrospective analysis of pediatric hematology/oncology patients (N=121) who received ≥1 dose of IV pentamidine between January 2009 and July 2014 was conducted. Electronic health records were reviewed to determine baseline characteristics, rate of breakthrough PCP infection, characteristics of IV pentamidine use, and adverse events. The follow-up period was 6 months after the last reported IV pentamidine dose or the last recorded clinic visit/hospital admission. Results: No patients developed PCP during the entirety of their IV pentamidine course or during the follow-up period. Nineteen patients (16%) experienced adverse events and 5 of the 19 patients required discontinuation of IV pentamidine. Conclusions: IV pentamidine is a safe, tolerable, and effective agent for PCP prophylaxis in pediatric hematology/oncology patients and may be considered a reasonable therapeutic alternative when trimethoprim/sulfamethoxazole cannot be used for PCP prophylaxis.

Implementing an Inpatient Pediatric Prospective Audit and Feedback Antimicrobial Stewardship Program Within a Larger Medical Center

BACKGROUND Pediatric antimicrobial stewardship programs (ASPs) within larger institutions have unique opportunities to develop programs specialized to the needs of the pediatric program. In January 2013, our institution established a formalized pediatric ASP utilizing the prospective audit and feedback process. In an effort to standardize therapy and improve quality of care, members of the ASP developed evidence-based guidelines for management of common inpatient pediatric infections. ASP members met periodically with faculty and house staff to discuss guidelines and ways to improve prescribing. METHODS Provider adherence with clinical inpatient practice guidelines, frequency of interventions suggested by ASP, and acceptance of interventions by providers were elements used to measure process change. We measured outcome data by analyzing antimicrobial utilization (defined as days of therapy) and length of therapy. RESULTS Over a period of 2 years, institutional ASP guidelines were applicable to nearly half (44%) of all antimicrobial orders. Interventions were performed on 30% of all antimicrobial orders, of which 89% were accepted. Total antimicrobial days of therapy and length of therapy decreased significantly when comparing pre- and post-ASP. Overall, the susceptibility profiles of common bacterial pathogens to antibiotics remained stable. CONCLUSIONS Pediatric ASPs within larger institutions have opportunities to create programs specific to the needs of the population they serve. We observed high rates of adherence by providers and a subsequent reduction in antibiotic utilization when implementing an audit feedback-based process.

Intracranial Mycobacterium abscessus infection in a healthy toddler

We present the first case of pediatric intracranial Mycobacterium abscessus infection in a 16-month-old female with neurofibromatosis type 1. We describe a successful treatment regimen including excisional biopsy combined with high-dose steroids and 16 weeks of triple antimicrobial therapy that resulted in clinical cure and an excellent neurologic outcome.

Preventing Infections in Children with Cancer.

1. Jennifer Lighter-Fisher, MD* 2. Kaitlin Stanley, MD* 3. Michael Phillips, MD† 4. Vinh Pham, MD, PhD† 5. Liana M. Klejmont, PharmD, BCPS‡ 1. *Department of Pediatrics, New York University Langone Medical Center, New York, NY. 2. †Department of Medicine, New York University Langone Medical Center, New York, NY. 3. ‡Department of Pharmacy, New York University Langone Medical Center, New York, NY. After completing this article, the reader should be able to: 1. Provide recommendations for bacterial prophylaxis for children experiencing severe and prolonged neutropenia. 2. Screen and recommend prophylaxis against Mycobacterium tuberculosis for children receiving immunosuppressive regimens. 3. Provide recommendations for secondary prophylaxis against Clostridium difficile infection, a common infection causing morbidity in the pediatric oncology population. 4. Recommend appropriate antifungal prophylaxis for pediatric patients who have high-risk cancers. 5. Review primary and second-line options for Pneumocystis jiroveci (carinii) pneumonia prophylaxis in children who fail trimethoprim/sulfamethoxazole therapy. 6. Prevent reactivation of viral infections in children receiving cancer treatment. 7. Screen for latent parasitic infections in newly diagnosed pediatric oncology patients. 8. Review vaccination regimens for patients receiving oncology treatment as suggested by the Infectious Diseases Society of America. Clear guidelines exist for the prevention of infections in patients undergoing hematopoietic stem cell transplantation (HSCT), (1)(2) but there is no guidance regarding prophylactic antimicrobial therapy for pediatric cancer patients receiving systemic chemotherapy. Infection, whether due to bacterial, fungal, viral, or parasitic pathogens, is a leading cause of morbidity and mortality in this patient population. (3)( 4)( 5) For example, more than 60% of children being treated for acute myeloid leukemia (AML) experienced at least 1 microbiologically documented infection during therapy, and the cumulative infectious mortality rate was 11%. (5) Therefore, infection prevention is of the utmost importance. Due to the lack of standard guidelines for infection prevention in most children being treated for cancer, current …

A novel approach to leveraging electronic health record data to enhance pediatric surgical quality improvement bundle process compliance

PURPOSE Quality improvement (QI) bundles have been widely adopted to reduce surgical site infections (SSI). Improvement science suggests when organizations achieve high-reliability to QI processes, outcomes dramatically improve. However, measuring QI process compliance is poorly supported by electronic health record (EHR) systems. We developed a custom EHR tool to facilitate capture of process data for SSI prevention with the aim of increasing bundle compliance and reducing adverse events. METHODS Ten SSI prevention bundle processes were linked to EHR data elements that were then aggregated into a snapshot display superimposed on weekly case-log reports. The data aggregation and user interface facilitated efficient review of all SSI bundle elements, providing an exact bundle compliance rate without random sampling or chart review. RESULTS Nine months after implementation of our custom EHR tool, we observed centerline shifts in median SSI bundle compliance (46% to 72%). Additionally, as predicted by high reliability principles, we began to see a trend toward improvement in SSI rates (1.68 to 0.87 per 100 operations), but a discrete centerline shift was not detected. CONCLUSION Simple informatics solutions can facilitate extraction of QI process data from the EHR without relying on adjunctive systems. Analyses of these data may drive reductions in adverse events. Pediatric surgical departments should consider leveraging the EHR to enhance bundle compliance as they implement QI strategies.