Patricia DeLaMora

Antibiotic Use in Neonatal Intensive Care Units and Adherence with Centers for Disease Control and Prevention 12 Step Campaign to Prevent Antimicrobial Resistance

Background: The Centers for Disease Control and Prevention (CDC) 12-Step Campaign to Prevent Antimicrobial Resistance was launched to educate clinicians about antimicrobial resistance and provide strategies to improve clinical practice, including antimicrobial utilization. Methods: A multicenter retrospective observational study of antibiotic use was performed in 4 tertiary care NICUs to assess adherence to the guidelines defined by the CDC 12-Step Campaign using predetermined criteria. Fifty infants per NICU were identified who received intravenous antibiotics at greater than 72 hours of age. Antibiotic regimens, clinical and microbiologic data, and indications for initiation and continuation of antibiotics (after 72 hours of use) were recorded. Inappropriate utilization was characterized at initiation, continuation, by agent, and by CDC 12-Step. Results: Two hundred neonates received 323 antibiotic courses totaling 3344 antibiotic-days. Ninety (28%) courses and 806 (24%) days were judged to be nonadherent to a CDC 12-Step. Inappropriate use was more common with continuation of antibiotics (39%) than with initiation (4%) of therapy. Vancomycin was the most commonly used drug (n = 895 antibiotic-days) of which 284 (32%) days were considered inappropriate. Carbapenems were used less frequently (n = 310 antibiotic-days), and 132 (43%) of these days were inappropriate. Common reasons for nonadherence at the time of continuation included failure to narrow antibiotic coverage after microbiologic results were known and prolonged antibiotic prophylaxis after surgery with chest tube placement. Conclusions: The CDC 12-Step Campaign can be modified for neonatal populations. Inappropriate antibiotic prescribing was common in the study NICUs. Improvement efforts should target antibiotic use 72 hours after initiation, particularly focusing on narrowing therapy and instituting protocols to limit prophylaxis.

Novel Influenza A(H1N1) in a Pediatric Health Care Facility in New York City During the First Wave of the 2009 Pandemic

OBJECTIVE To describe the burden of care experienced by our pediatric health care facility in New York, New York, from May 3, 2009, to July 31, 2009, during the novel influenza A(H1N1) pandemic that began in spring 2009. DESIGN Retrospective case series. SETTING Pediatric emergency departments and inpatient facilities of New York-Presbyterian Hospital. Patients Children presenting to the emergency departments with influenza-like illness (ILI) and children aged 18 years or younger hospitalized with positive laboratory test results for influenza A from May 3, 2009, to July 31, 2009. MAIN OUTCOME MEASURES Proportion of children with ILI who were hospitalized and proportion of hospitalized children with influenza A with respiratory failure, bacterial superinfection, and mortality. RESULTS When compared with the same period in 2008, the pediatric emergency departments experienced an excess of 3750 visits (19.9% increase). Overall, 27.7% of visits were for ILI; 2.5% of patients with ILI were hospitalized. Of the 115 hospitalized subjects with confirmed influenza A (median age, 4.3 years), 93 (80.9%) had underlying conditions. Four (3.5%) had identified bacterial superinfection, 1 (0.9%) died, and 35 (30.4%) were admitted to a pediatric intensive care unit; of these 35 patients, 11 had pneumonia and required mechanical ventilation, including high-frequency oscillatory ventilation (n = 3). CONCLUSIONS At our center, 2.5% of children with ILI presenting to the emergency departments during the first wave of the 2009 novel influenza A(H1N1) pandemic were hospitalized. Of the 115 hospitalized children with confirmed influenza A, 9.6% had respiratory failure and 0.9% died. These findings can be compared with the disease severity of subsequent waves of the 2009 novel influenza A(H1N1) pandemic.

(1→3)-β-d-Glucan in Cerebrospinal Fluid as a Biomarker for Candida and Aspergillus Infections of the Central Nervous System in Pediatric Patients

BACKGROUND Fungal infections of the central nervous system (FICNS) are important causes of morbidity and mortality among immunocompromised pediatric patients. Standard diagnostic modalities lack the sensitivity for detecting and therapeutically monitoring these life-threatening diseases. Current molecular methods remain investigational. (1→3)-β-d-glucan (BDG) is a cell wall component found in several fungal pathogens, including Candida and Aspergillus spp. Detecting BDG in cerebrospinal fluid (CSF) may be an important approach for detecting and therapeutically monitoring FICNS. To date, there has been no study that has investigated the effectiveness of CSF BDG as a diagnostic and therapeutic marker of FICNS in children. METHODS Serial BDG levels were measured in serum and CSF samples obtained from pediatric patients (aged 0-18 years) with a diagnosis of probable or proven Candida or Aspergillus CNS infection. RESULTS Nine cases of FICNS were identified in patients aged 1 month to 18 years. Two patients were infected with an Aspergillus species, and 7 patients were infected with a Candida species. All the patients at baseline had detectable BDG in their CSF. Among 7 patients who completed therapy for an FICNS, all elevated CSF BDG levels decreased to <31 pg/mL. At the time of this writing, 1 patient was still receiving therapy and continued to have elevated BDG levels. One patient died from overwhelming disseminated candidiasis. The lengths of therapy for these 9 children ranged from 2 weeks to 28 months. CONCLUSION The BDG assay is useful in diagnosing and therapeutically monitoring Candida and Aspergillus CNS infections in pediatric patients.

Clinical Vignettes Provide an Understanding of Antibiotic Prescribing Practices in Neonatal Intensive Care Units

OBJECTIVE To use clinical vignettes to understand antimicrobial prescribing practices in neonatal intensive care units (NICUs). DESIGN Vignette-based survey. SETTING Four tertiary care NICUs. PARTICIPANTS Antibiotic prescribers in NICUs. METHODS Clinicians from 4 tertiary care NICUs completed an anonymous survey containing 12 vignettes that described empiric, targeted, or prophylactic antibiotic use. Responses were compared with Centers for Disease Control and Prevention guidelines for appropriate use. RESULTS Overall, 161 (59% of 271 eligible respondents) completed the survey, 37% of whom had worked in NICUs for 7 or more years. Respondents were more likely to appropriately identify use of targeted therapy for methicillin-susceptible Staphylococcus aureus, that is, use of oxacillin rather than vancomycin, than for Escherichia coli, that is, use of first-generation rather than third-generation cephalosporin, (P < .01). Increased experience significantly predicted appropriate prescribing (P = .02). The proportion of respondents choosing appropriate duration of postsurgical prophylaxis (P < .01) and treatment for necrotizing enterocolitis differed by study site (P = .03). CONCLUSIONS The survey provides insight into antibiotic prescribing practices and informs the development of future antibiotic stewardship interventions for NICUs.

Developing Clinical Decision Support within a Commercial Electronic Health Record System to Improve Antimicrobial Prescribing in the Neonatal ICU

OBJECTIVE To develop and implement a clinical decision support (CDS) tool to improve antibiotic prescribing in neonatal intensive care units (NICUs) and to evaluate user acceptance of the CDS tool. METHODS Following sociotechnical analysis of NICU prescribing processes, a CDS tool for empiric and targeted antimicrobial therapy for healthcare-associated infections (HAIs) was developed and incorporated into a commercial electronic health record (EHR) in two NICUs. User logs were reviewed and NICU prescribers were surveyed for their perceptions of the CDS tool. RESULTS The CDS tool aggregated selected laboratory results, including culture results, to make treatment recommendations for common clinical scenarios. From July 2010 to May 2012, 1,303 CDS activations for 452 patients occurred representing 22% of patients prescribed antibiotics during this period. While NICU clinicians viewed two culture results per tool activation, prescribing recommendations were viewed during only 15% of activations. Most (63%) survey respondents were aware of the CDS tool, but fewer (37%) used it during their most recent NICU rotation. Respondents considered the most useful features to be summarized culture results (43%) and antibiotic recommendations (48%). DISCUSSION During the study period, the CDS tool functionality was hindered by EHR upgrades, implementation of a new laboratory information system, and changes to antimicrobial testing methodologies. Loss of functionality may have reduced viewing antibiotic recommendations. In contrast, viewing culture results was frequently performed, likely because this feature was perceived as useful and functionality was preserved. CONCLUSION To improve CDS tool visibility and usefulness, we recommend early user and information technology team involvement which would facilitate use and mitigate implementation challenges.

Utility of surveillance cultures for antimicrobial resistant organisms in infants transferred to the neonatal intensive care unit.

Background: Infections with antibiotic resistant organisms (AROs) are an important source of morbidity and mortality among infants hospitalized in the neonatal intensive care unit (NICU). To identify potential reservoirs of AROs in the NICU, active surveillance strategies have been adopted by many NICUs to detect infants colonized with AROs. However, the yield, risks, benefits and costs of different strategies have not been fully evaluated. Methods: We conducted a retrospective study in 2 level III NICUs from 2004 to 2010 to investigate the yield of surveillance cultures obtained from infants transferred to the NICU from other hospitals. Cultures were processed for methicillin-resistant Staphylococcus aureus, vancomycin-resistant enterococci and antibiotic-resistant gram-negative rods. Risk factors, selected outcomes and laboratory costs associated with ARO colonization were assessed. Results: Among 1751 infants studied, the rate of colonization for methicillin-resistant S. aureus, vancomycin-resistant enterococci and antibiotic-resistant gram-negative rods was 3%, 1.7% and 1%, respectively. Age at transfer was the strongest predictor of ARO colonization; infants transferred at ≥7 days of life had 5.8 increased odds of ARO colonization compared with infants <7 days of age. Transferred infants who were colonized had similar rates of mortality, ARO infection and duration of hospitalization compared with those who were not colonized. The laboratory cost of surveillance cultures during the study period was

Comparing the clinical severity of the first versus second wave of 2009 Influenza A (h1n1) in a New York City pediatric healthcare facility

58,425. Conclusions: The rate of colonization with AROs at transfer was low particularly in infants <7 days old. Future studies should examine the safety of targeted surveillance strategies focused on older infants.

A daring treatment and a successful outcome: the need for targeted therapies for pediatric respiratory viruses.

Objective: We previously reported the epidemiology of 2009 Influenza A (H1N1) in our pediatric healthcare facility in New York City during the first wave of illness (May–July 2009). We hypothesized that compared with the first wave, the second wave would be characterized by increased severity of illness and mortality. Design: Case series conducted from May 2009 to April 2010. Setting: Pediatric emergency departments and inpatient facilities of New York-Presbyterian Hospital. Patients: All hospitalized patients ÷18 yrs of age with positive laboratory tests for influenza A. Measurements and Main Results: We compared severity of illness during the first and second wave assessed by the number of hospitalized children, including those in the pediatric intensive care unit, bacterial superinfections, and mortality rate. Compared to the first wave, fewer children were hospitalized during the second wave (n = 115 vs. 76), but a comparable portion were admitted to the pediatric intensive care unit (30.4% vs. 19.7%; p = .10). Pediatric Risk of Mortality III scores, length of hospitalization in the pediatric intensive care unit, incidence of respiratory failure and pneumonia, and peak oxygenation indices were similar during both waves. Bacterial superinfections were comparable in the first vs. second wave (3.5% vs. 1.3%). During the first wave, no child received extracorporeal membrane oxygenation and one died, while during the second wave, one child received extracorporeal membrane oxygenation and there were no deaths. Conclusions: At our pediatric healthcare facility in New York City, fewer children were hospitalized with 2009 Influenza A (H1N1) during the second wave, but both waves had a similar spectrum of illness severity and low mortality rate.

Transmission of scabies in a newborn nursery.

The report by Stankova et al. in this issue tells the fascinating and inspiring story of a child with SCID who underwent two sequential human stem cell transplantations (HSCT), a myeloablative pre-conditioning regimen, and many posttransplant complications, all while she was actively infected with human parainfluenza virus type 3 (HPIV3). The child never developed severe respiratory disease, and three yr later had no evidence of damage to the respiratory tract. The child’s physicians had elected to initiate aerosolized ribavirin two wk before HSCT, and continued this medication for 10 months in an effort to prevent the HPIV3 infection from progressing in severity; the report cautiously suggests that this therapy may have contributed to the gratifying outcome. This brave physicians report begs the question: Why are we relying on untested, unproven, partially active agents for a virus that is so important in children? The valiant attempt to treat parainfluenza viral respiratory tract disease with ribavirin points to our more general dilemma for pediatric respiratory viral diseases; we are often guessing, trying therapies based upon thin evidence for their use for a different pathogen, or on inadequate in vitro data. Even for RSV, ribavirin is a nucleoside analog that has good activity against RSV in vitro but has produced conflicting clinical data and uncertainty with regard to its utility in most cases. As far as ribavirin use in cases of HPIV3 infection, most reports have focused on early diagnosis and treatment. The authors of this piece seem to have been the first to treat active HPIV3 infection, in anticipation of transplant. Published reports do not suggest a strong link between ribavirin use in cases of HPIV infection and improved outcome. In one large series, ribavirin was used to treat nine of 27 HPIVinfected stem cell transplant patients, without effect on mortality rate (18). In a small pilot study designed to address preemptive therapy in HSCT patients, Chakrabar et al. treated five patients with HPIV3 infection – one asymptomatic and four symptomatic with URTI – with oral ribavirin. Three of these individuals, including the patient who had been asymptomatic at the initiation of therapy, had no virologic response. One of those three died; the other two (including the person with no symptoms of respiratory disease) were placed on IV ribavirin and resolved. The role of ribavirin in preventing progression of URTI is uncertain, at best. In the patient treated by Stankova et al., the question of the significance of risk factors makes interpretation even more difficult. Known risks for increased mortality from HPIV3 after transplantation include graft vs. host disease, steroid use, and the presence of copathogens (2, 11, 17); the child had none of these. However, infection with HPIV3 within the first 100 days after transplant has also been associated with increased mortality (2), and this patient was certainly infected throughout the high-impact period. This combination of high and low risk factors makes it even more difficult to evaluate the role of ribavirin in the positive outcome. The child in this case was treated for upper respiratory tract infection (URTI), in an effort to prevent progression to lower respiratory tract disease (LRTI). LRTI is a well-known consequence of URTI infection with HPIV3; in one study of 228 patients who underwent bone marrow transplantation and acquired HPIV3 infection, 198 individuals presented with symptoms of URTI, and 24% of these progressed to LRTI (11). Although the authors of that study Pediatr Transplantation 2007: 11: 121–123. Copyright 2007 Blackwell Munksgaard

Colonization With Antimicrobial-Resistant Gram-Negative Bacilli at Neonatal Intensive Care Unit Discharge

Author(s): Barbara G. Ross, RN, CIC, BSN, Jennifer K. Wright-McCarthy, MD, Patricia A. DeLaMora, MD and Philip L. Graham III, MD, MSc Source: Infection Control and Hospital Epidemiology, Vol. 32, No. 5 (May 2011), pp. 516-517 Published by: The University of Chicago Press on behalf of The Society for Healthcare Epidemiology of America Stable URL: http://www.jstor.org/stable/10.1086/659954 . Accessed: 16/05/2014 15:18