Shabnam Jain

Effectiveness of Monovalent and Pentavalent Rotavirus Vaccine

OBJECTIVE: Previous US evaluations have not assessed monovalent rotavirus vaccine (RV1, a G1P[8] human rotavirus strain) effectiveness, because of its later introduction (2008). Using case-control methodology, we measured the vaccine effectiveness (VE) of the 2-dose RV1 and 3-dose pentavalent vaccine (RV5) series against rotavirus disease resulting in hospital emergency department or inpatient care. METHODS: Children were eligible for enrollment if they presented to 1 of 5 hospitals (3 in Georgia, 2 in Connecticut) with diarrhea of ≤10 days’ duration during January through June 2010 or 2011, and were born after RV1 introduction. Stools were collected; immunization records were obtained from providers and state electronic immunization information system (IIS). Case-subjects (children testing rotavirus antigen-positive) were compared with 2 control groups: children testing rotavirus negative and children selected from IIS. RESULTS: Overall, 165 rotavirus-case subjects and 428 rotavirus-negative controls were enrolled. Using the rotavirus-negative controls, RV1 VE was 91% (95% confidence interval [CI] 80 to 95) and RV5 VE was 92% (CI 75 to 97) among children aged ≥8 months. The RV1 VE against G2P[4] disease was high (94%, CI 78 to 98), as was that against G1P[8] disease (89%, CI 70 to 96). RV1 effectiveness was sustained among children aged 12 through 23 months (VE 91%; CI 75 to 96). VE point estimates using IIS controls were similar to those using rotavirus-negative controls. CONCLUSIONS: RV1 and RV5 were both highly effective against severe rotavirus disease. RV1 conferred sustained protection during the first 2 years of life and demonstrated high effectiveness against G2P[4] (heterotypic) disease.

Pneumococcal Carriage and Invasive Disease in Children Before Introduction of the 13-valent Conjugate Vaccine: Comparison With the Era Before 7-valent Conjugate Vaccine

Background: Nasopharyngeal (NP) carriage and invasive pneumococcal disease (IPD) attributable to serotypes in the 7-valent pneumococcal conjugate vaccine (PCV7) declined dramatically after vaccine introduction, whereas non-PCV7 serotypes increased modestly. Characteristics of pneumococcal carriage and IPD among children in Atlanta, GA, were compared during 2 time periods: before PCV7 introduction and before 13-valent PCV (PCV13) introduction. Methods: NP swabs from 231 and 451 children 6–59 months old receiving outpatient medical care were obtained in 1995 and 2009, respectively. A total of 202 and 47 IPD cases were identified in children younger than 5 years of age in 1995 and in 2008 to 2009, respectively, through active, population-based surveillance in Atlanta. Isolates were serotyped, sequence-typed (ST) and tested for antimicrobial susceptibility. Results: Forty percent (93/231) of children in 1995 and 31% (139/451) in 2009 were colonized with Streptococcus pneumoniae; 60% and 0.7% were PCV7 serotypes, respectively. In 1995, PCV7 serotypes accounted for 83% and 19A accounted for 5% of IPD compared with no PCV7 serotypes and 19A accounting for 49% of IPD in 2009 (P < 0.001). In 2009, PCV13 serotypes accounted for 22% of carriage (mostly 19A) and 60% of invasive isolates (P < 0.001). ST320 accounted for 66% and 52% of 19A carriage and IPD isolates in 2009, respectively; all ST320 isolates were multidrug-resistant. No ST320 NP or IPD isolates were identified before PCV7. Conclusions: Serotype distribution among NP and IPD isolates in Atlanta has shifted to non-PCV7 serotypes; 19A was the leading serotype for both. The multidrug-resistant ST320 strain was responsible for two-thirds of 19A carriage isolates and half of IPD isolates. The predominance of serotype 19A in carriage and IPD among children in Atlanta highlights the potential direct and indirect benefits anticipated by implementation of PCV13 in the community.

sodC-Based Real-Time PCR for Detection of Neisseria meningitidis

Real-time PCR (rt-PCR) is a widely used molecular method for detection of Neisseria meningitidis (Nm). Several rt-PCR assays for Nm target the capsule transport gene, ctrA. However, over 16% of meningococcal carriage isolates lack ctrA, rendering this target gene ineffective at identification of this sub-population of meningococcal isolates. The Cu-Zn superoxide dismutase gene, sodC, is found in Nm but not in other Neisseria species. To better identify Nm, regardless of capsule genotype or expression status, a sodC-based TaqMan rt-PCR assay was developed and validated. Standard curves revealed an average lower limit of detection of 73 genomes per reaction at cycle threshold (Ct) value of 35, with 100% average reaction efficiency and an average R2 of 0.9925. 99.7% (624/626) of Nm isolates tested were sodC-positive, with a range of average Ct values from 13.0 to 29.5. The mean sodC Ct value of these Nm isolates was 17.6±2.2 (±SD). Of the 626 Nm tested, 178 were nongroupable (NG) ctrA-negative Nm isolates, and 98.9% (176/178) of these were detected by sodC rt-PCR. The assay was 100% specific, with all 244 non-Nm isolates testing negative. Of 157 clinical specimens tested, sodC detected 25/157 Nm or 4 additional specimens compared to ctrA and 24 more than culture. Among 582 carriage specimens, sodC detected Nm in 1 more than ctrA and in 4 more than culture. This sodC rt-PCR assay is a highly sensitive and specific method for detection of Nm, especially in carriage studies where many meningococcal isolates lack capsule genes.

Management of Febrile Neonates in US Pediatric Emergency Departments

BACKGROUND: Blood, urine, and cerebrospinal fluid cultures and admission for antibiotics are considered standard management of febrile neonates (0–28 days). We examined variation in adherence to these recommendations across US pediatric emergency departments (PEDs) and incidence of serious infections (SIs) in febrile neonates. METHODS: Cross-sectional study of neonates with a diagnosis of fever evaluated in 36 PEDs in the 2010 Pediatric Health Information System database. We analyzed performance of recommended management (laboratory testing, antibiotic use, admission to hospital), 48-hour return visits to PED, and diagnoses of SI. RESULTS: Of 2253 neonates meeting study criteria, 369 (16.4%) were evaluated and discharged from the PED; 1884 (83.6%) were admitted. Recommended management occurred in 1497 of 2253 (66.4%; 95% confidence interval, 64.5–68.4) febrile neonates. There was more than twofold variation across the 36 PEDs in adherence to recommended management, recommended testing, and recommended treatment of febrile neonates. There was significant variation in testing and treatment between admitted and discharged neonates (P < .001). A total of 269 in 2253 (11.9%) neonates had SI, of whom 223 (82.9%; 95% confidence interval, 77.9–86.9) received recommended management. CONCLUSIONS: There was wide variation across US PEDs in adherence to recommended management of febrile neonates. One in 6 febrile neonates was discharged from the PED; discharged patients were less likely to receive testing or antibiotic therapy than admitted patients. A majority of neonates with SI received recommended evaluation and management. High rates of SI in admitted patients but low return rates for missed infections in discharged patients suggest a need for additional studies to understand variation from the current recommendations.

Decline in Pneumococcal Nasopharyngeal Carriage of Vaccine Serotypes After the Introduction of the 13-Valent Pneumococcal Conjugate Vaccine in Children in Atlanta, Georgia.

Background: Streptococcus pneumoniae (SP) serotype distribution among nasopharyngeal (NP) carriage isolates changed significantly after the introduction of the 7-valent pneumococcal conjugate vaccine (PCV7). We evaluated the impact on NP carriage and invasive disease of SP after the introduction of the 13-valent PCV (PCV13) in March 2010. Methods: NP swabs were collected from children 6–59 months of age in an emergency department from July 2010 to June 2013. After broth enrichment, samples were cultured for SP and isolates were serotyped. Clinical and immunization records were reviewed. Findings during 6 sequential 6-month study periods were compared. Surveillance isolates of invasive disease isolates were reviewed. Results: A total of 2048 children were enrolled, and 656 (32%) were SP carriers. Mean age of carriers was 27 months, 54% were males. Carriage was higher among day-care attendees (P < 0.01) and children with respiratory tract illnesses (P < 0.5) and otitis media (P < 0.01). Commonly carried serotypes included 35B (15.2%), 15B/C (14.2%), 19A (9.6%), 11A (8%), 23B (5.6%), 6C (5.3%), 21 (5%), and 15A (5%); 13.9% were PCV13 serotypes. The proportion of children with SP carriage remained stable but the serotype distribution changed during the study period. Among carriers, PCV13 serotypes declined from 29% (36/124) to 3% (3/99; P < 0.0001), predominantly because of decline of serotype 19A from 25.8% (32/124) to 3% (3/99; P < 0.0001); non-PCV13 serotypes (excluding 6C) increased from 68.4% (78/114) to 97% (95/98; P < 0.0001); serotype 35B significantly increased from 8.9% (11/124) to 25.3% (25/99; P < 0.05). Nonsusceptibility to ceftriaxone declined from 22.6% (28/124) to 0% (0/99; P < 0.0001), with a similar decline in penicillin nonsusceptibility. Conclusions: Introduction of PCV13 for universal infant use was associated with significant reductions in nasopharyngeal carriage of PCV13 serotypes and resistant strains. Carriage of non-PCV13 serotypes increased modestly, particularly serotype 35B. Further investigation is warranted to determine whether nonvaccine pneumococcal serotypes carried in the nasopharynx are associated with significant replacement disease.

Perinatally Acquired Chlamydia trachomatis Associated Morbidity in Young Infants

OBJECTIVE This study was designed to evaluate the spectrum of morbidity associated with perinatally acquired Chlamydia trachomatis in infants < or =12 weeks of age, and to determine its relationship to maternal Chlamydia trachomatis status. METHODS DESIGN Retrospective review of maternal and infant records. SETTING Large inner city teaching hospital. PATIENTS A cohort of 530 symptomatic infants < or =12 weeks of age who were tested for Chlamydia trachomatis infection in the upper respiratory tract during a 2-year period from January 1993 to December 1994. RESULTS During the study period, 70/530 (13.2%) patients tested positive for Chlamydia trachomatis from the conjunctiva and/or the nasopharynx. Complete medical records of 66 of these infants were available for review. Forty-eight of 66 (73%) infants had conjunctivitis, 13/66 (20%) had pneumonia, 5/66 (7%) had both conjunctivitis and pneumonia. Thirteen of 66 (20%) infants were hospitalized, 7 for pneumonia and 6 for ophthalmia, accounting for 68 hospital days. In 55/66 (83%), maternal records were available for review. Nineteen of 55 (35%) mothers had documented Chlamydia trachomatis infection at delivery or during pregnancy that had not been treated; 16/55 (29%) mothers tested negative for Chlamydia trachomatis sometime during pregnancy but were not retested at delivery, 8/55 (14%) were treated for Chlamydia trachomatis during pregnancy but status at delivery regarding reinfection was not evaluated. In 12/55 (22%) mothers, no prenatal testing was documented. CONCLUSIONS This study demonstrates significant morbidity in early infancy associated with perinatally acquired Chlamydia trachomatis infection. There is need for studies evaluating the importance of adequate maternal testing and treatment to reduce perinatal transmission.

Physician practice variation in the pediatric emergency department and its impact on resource use and quality of care.

Objective: To evaluate variation in case-mix adjusted resource use among pediatric emergency department (ED) physicians and its correlation with ED length of stay (LOS) and return rates. Methods: Resource use patterns at 2 EDs for 36 academic physicians (163,669 patients at ED1) and 45 private physicians (289,199 patients at ED2) from 2003 to 2006 were abstracted for common laboratory tests, imaging studies, intravenous therapy (fluids/antibiotics), LOS and 72-hour return rate for discharged patients, and hospital admissions for all patients. Case-mix adjustment was based on triage acuity, diagnostic category, demographics, and temporal measures. Outcome measures: (1) adjusted overall resource use for ED1 and ED2 physicians and (2) observed-to-expected ratios for ED1 physicians. Results: Case-mix adjusted hospital admission rates among physicians varied nearly 3-fold (6.3%-18%) for ED1 and 8-fold (2.5%-19.4%) for ED2. Intravenous therapy use varied 2-fold (4.9%-10.4%) at ED1 and 3-fold (3.6%-11.4%) at ED2. Emergency department 2 physicians had an almost 2-fold (10.9%-20.6%) variation in imaging use. Variation in head computed tomography use was 2-fold (1.1%-2.5%) at ED1 and 5-fold (0.9%-4.8%) at ED2. Physicians had longer than expected LOS if they had higher than expected use of laboratory tests (r, 0.41; 95% confidence interval [CI], 0.09-0.65; P < 0.05) and imaging (r, 0.48; 95% CI, 0.17-0.69; P < 0.01). Return rate was not significantly correlated with resource use in any category. Physicians with higher than expected use of laboratory tests had higher than expected use of imaging (r, 0.62; 95% CI, 0.36-0.78; P < 0.001), head computed tomography (r, 0.49; 95% CI, 0.19-0.70; P < 0.01), and intravenous therapy (r, 0.51; 95% CI, 0.20-0.71; P < 0.01). Conclusions: Significant variation exists in physician use of common ED resources. Higher resource use was associated with increased LOS but did not reduce return to ED. Practice variation such as this may represent an opportunity to improve health care quality and decrease costs.

Making the Case to Improve Quality and Reduce Costs in Pediatric Health Care

This article makes a case for the urgent need to improve health care quality and reduce costs. It provides an overview of the importance of the quality movement and the definition of quality, including the concept of clinical and operational quality. Some national drivers for quality improvement as well as drivers of escalating health care costs are discussed, along with the urgency of reducing health care costs. The link between quality and cost is reviewed using the concept of value in health care, which combines quality and cost in the same equation. The article ends with a discussion of future directions of the quality movement, including emerging concepts, such as risk-adjustment, shared responsibility for quality, measuring quality at the individual provider level, and evolving legal implications of the quality movement, as well as the concept of a shared savings model.

Quality initiatives in the emergency department.

Purpose of review To report on recent advances in quality initiatives in emergency departments (EDs), with a special focus on applicability to pediatric EDs (PED) Recent findings Although healthcare quality improvement has made great strides in the last couple of decades, quality improvement efforts in pediatrics have lagged behind. Over the last decade, as quality initiatives have matured in adult hospitals, there has been a downstream effect on general EDs, as system-wide clinical guidelines are usually initiated through the ED – such efforts are being reported in the literature. There is significant overlap in quality improvement efforts in adult and pediatric EDs. In this article, we review the recent relevant articles, with particular emphasis on pediatrics where appropriate. Summary There is an opportunity in pediatric emergency medicine to reduce practice variability, decrease cost and improve efficiency of care. There is an urgent need to report the successes and failures of these initiatives, so we can develop benchmarks and optimize services provided in the PED.

Emergency Department Return Visits Resulting in Admission: Do They Reflect Quality of Care?

Prior studies have suggested that emergency department (ED) return visits resulting in admission may be a more robust quality indicator than all 72-hour returns. The objective was to evaluate factors that contribute to admission within 72 hours of ED discharge. Each return visit resulting in admission was independently reviewed by 3 physicians. Analysis was by descriptive statistics. Of 45 071 ED discharges, 4.1% returned within 72 hours; 0.96% returned for related reasons and were admitted to wards (91.2%), intensive care units (6.5%), or operating rooms (1.2%). Management was acceptable in 92.6%, suboptimal in 7.4%. Admissions were illness (94.9%), patient (1.6%), and physician related (3.5%). Almost all admissions within 72 hours after ED discharge are illness related, including all intensive care unit admissions and the majority of operating room admissions. Deficiencies in ED care are rarely the reason for admission on return. ED return visits resulting in admission may not be reflective of ED quality of care.