Comparing the Frequency of Culture-Positive Late Onset Sepsis With the Use of Ceftazidime Versus Cefotaxime in the NICU.

OBJECTIVE: As broader spectrum antibiotics have been associated with adverse effects, our study evaluated whether the frequency of culture-positive late-onset sepsis (LOS) and multidrug resistant (MDR) infections were increased with the use of ceftazidime as compared with cefotaxime in the neonatal intensive care unit (NICU). METHODS: This was a multihospital, retrospective chart review of patients who received at least 24 hours of ceftazidime or cefotaxime in the NICU between December 1, 2012 and August 31, 2021. Patients were excluded from analysis if they expired during the admission, had an incomplete history, positive cultures for an MDR infection prior to receiving either antibiotic, or received the alternate antibiotic within the same treatment course. RESULTS: A total of 334 patients were included for analysis (ceftazidime, n = 147; cefotaxime, n = 187). The average birth weight was lower in the ceftazidime cohort compared with the cefotaxime cohort [1.46 kg (95% CI, 1.29-1.63 kg) versus 1.93 kg (95% CI, 1.75-2.11 kg), p = 0.0002] with a corresponding lower gestational age [28.9 weeks (95% CI, 28.0-29.9 weeks) versus 31.7 weeks (95% CI, 30.8-32.6 weeks), p = 0.0001]. Adjusting for baseline differences showed a protective effect for ceftazidime (OR = 0.32; 95% CI, 0.16-0.62; p = 0.0009). There was no statistically significant difference in the frequency of MDR infections between the cohorts (OR = 0.25; 95% CI, 0.053-1.14; p = 0.07), however this study was underpowered to detect the difference noted. CONCLUSIONS: Ceftazidime appears to be a safe and effective alternative treatment option compared with cefotaxime in the NICU with no increase in the risk of culture-positive LOS or MDR infections.

Reducing Overutilization of High-flow Nasal Cannula in Children with Bronchiolitis.

Background: Bronchiolitis is a leading cause of pediatric hospitalizations. A high-flow nasal cannula (HFNC) does not significantly improve clinical outcomes and is associated with increased costs and intensive care unit (ICU) utilization. Despite this, hospitals continue to overuse HFNC in children with bronchiolitis. We aimed to reduce HFNC initiation in children hospitalized with bronchiolitis by 20 percentage points within 6 months. Methods: This study included patients aged 1 month to 2 years diagnosed with bronchiolitis, excluding patients with prematurity less than 32 weeks or preexisting cardiopulmonary, genetic, congenital, or neuromuscular abnormalities. Measures included HFNC utilization, length of stay, length of oxygen supplementation (LOOS), ICU transfers, and emergency department (ED) revisits and readmissions. For our primary intervention, we implemented a HFNC initiation protocol incorporating a respiratory scoring system, a multidisciplinary care-team huddle, and an emphasis on supportive care. Staff education, electronic health record integration, and audit and feedback were used to support implementation. Statistical process control charts were used to track metrics. Results: We analyzed 325 hospitalizations (126 baseline and 199 postintervention). The proportion of children hospitalized with bronchiolitis who received HFNC decreased from a mean of 82% to 60% within 1 month of implementation. Length of stay decreased from a median of 54 to 42 hours, and length of oxygen supplementation decreased from 50 to 38 hours. There were no significant changes in ICU transfers, 7-day ED revisits, or readmissions. Conclusions: Implementing a HFNC initiation protocol can safely reduce the overutilization of HFNC in children hospitalized with bronchiolitis.

A Prospective Evaluation of Arrhythmias in a Large Tertiary Neonatal Intensive Care Unit.

Arrhythmias in the neonatal period are common and can be classified as bradyarhythmias and tachyarrhythmias and as benign or non-benign. Neonatal arrhythmias are further differentiated between those with abnormalities in generation (non-sinus) and those with abnormalities in propagation. Because the neonatal myocardium is immature and operates at the peak of the Starling curve, significant changes in heart rate can result in a decline in cardiac output and compromise end-organ perfusion. This is especially true for premature neonates, those critically ill, or those with concomitant congenital heart disease. While sustained arrhythmias are frequently witnessed and recorded in tertiary neonatal intensive care units (NICU) very little data exist on the observance of non-sustained brady- or tachyarrhythmias in this cohort. No prospective study has been performed on all neonates admitted to a large tertiary NICU throughout their entire stay. The purpose of this study was to prospectively evaluate the prevalence and type of arrhythmias in a large NICU population from admission to discharge. All neonates admitted to the NICU at Inova Children's Hospital at Inova Fairfax Medical Campus between January 1, 2021 and April 1, 2021 were prospectively evaluated from admission to hospital discharge via continuous bedside monitoring reviewed every 24 h. Concerning telemetry strips were reviewed by two team members as well as the senior electrophysiologist. Two-hundred and one neonates (mean gestational age = 344/7 weeks) were enrolled in the study. Admission length ranged from 1 to 195 days (total of 5624 patient days, median 16 days). Overall, 68% (N = 137) of admissions had one or more arrhythmias, the most common of which was sinus tachycardia (65%, N = 130), followed by sinus bradycardia (30%, N = 60). Clinically relevant arrhythmias were diagnosed in 6.5% of neonates. During the study period there were four deaths, none of which were directly attributable to a primary arrhythmia. Approximately 68% of neonates exhibited at least one arrhythmia. Although the vast majority of these arrhythmias were benign, clinically relevant arrhythmias were observed in 6.5%. Patients admitted to the NICU appear to have a relatively high burden of benign arrhythmias, but a relatively low burden of pathologic arrhythmias.

Acceptability of Deimplementing High-Flow Nasal Cannula in Pediatric Bronchiolitis.

BACKGROUND AND OBJECTIVES: High-flow nasal cannula (HFNC) in children hospitalized with bronchiolitis does not significantly improve clinical outcomes but can increase costs and intensive care unit use. Given widespread HFNC use, it is imperative to reduce use. However, there is limited information on key factors that affect deimplementation. To explore acceptability of HFNC deimplementation, perceptions of HFNC benefits, and identify barriers and facilitators to deimplementation. METHODS: We conducted a study of health care providers that included quantitative survey data supplemented by semistructured interviews. Data were analyzed using univariate tests and thematic content analysis. RESULTS: A total of 152 (39%) providers completed the survey; 9 participated in interviews. Eighty-three (55%) providers reported feeling positively about deimplementing HFNC. Reports of feeling positively increased as perceived familiarity with evidence increased (P = .04). Physicians were more likely than nurses and respiratory therapists to report feeling positively (P = .003). Hospital setting and years of clinical experience were not associated with feeling positively (P = .98 and .55, respectively). One hundred (66%) providers attributed nonevidence-based clinical benefits to HFNC. Barriers to deimplementation included discomfort with not intervening, perception that HFNC helps, and variation in risk tolerance and clinical experience. Facilitators promoting deimplementation include staff education, a culture of safely doing less, and enhanced multidisciplinary communication. CONCLUSIONS: Deimplementation of HFNC in children with bronchiolitis is acceptable among providers. Hospital leaders should educate staff, create a culture for safely doing less, and enhance multidisciplinary communication to facilitate deimplementation.