Clostridioides difficile Infection in Hospitalized Pediatric Patients: Comparisons of Epidemiology, Testing, and Treatment from 2013 to 2019.

OBJECTIVES: To compare the incidence, epidemiology, testing patterns, treatment, and outcomes of Clostridioides difficile infection (CDI) among hospitalized pediatric patients from 2013 to 2019. STUDY DESIGN: The Pediatric Health Information System database was queried for patient admissions (age 0-17 years) with International Classification of Diseases, 9th and 10th edition, codes for diagnoses of CDI with a billing code for a CDI-related antibiotic treatment. RESULTS: We identified 17 142 pediatric patients, representing 23 052 admissions, with CDI. The adjusted annual CDI incidence decreased over the study period from 7.09 cases per 10 000 patient-days (95% CI, 6.15-8.18) in 2013 to 4.89 cases per 10 000 patient-days (95% CI, 4.03-5.93) in 2019 (P < .001). C difficile-specific testing also decreased during the study period (P < .001). Chronic gastrointestinal conditions (36%) and malignancy (32%) were the most common comorbidities in CDI encounters. Oral metronidazole use decreased during the study period (P < .01) and oral vancomycin use increased (P < .001). CONCLUSIONS: Our study demonstrates a decrease in CDI incidence in hospitalized pediatric patients, a notable change from prior studies, although this may have been influenced by altered testing patterns. We found a high incidence of CDI in patients with cancer and gastrointestinal conditions: groups that warrant targeted evaluation of CDI prevention and treatment.

Implementation of a Mandatory Influenza Vaccine Policy: A 10-Year Experience.

BACKGROUND: Influenza vaccination of healthcare workers (HCWs) has been recommended for more than 30 years. In 2009, HCWs were designated as a priority group by the Centers for Disease Control and Prevention. Current HCW vaccination rates are 78% across all settings and reach approximately 92% among those employed in hospital settings. Over the last decade, it has become clear that mandatory vaccine policies result in maximal rates of HCW immunization. METHODS: In this observational 10-year study, we describe the implementation of a mandatory influenza vaccination policy in a dedicated quaternary pediatric hospital setting by a multidisciplinary team. We analyzed 10 years of available data from deidentified occupational health records from 2009-2010 through the 2018-2019 influenza seasons. Descriptive statistics were performed using Stata v15 and Excel. RESULTS: Sustained increases in HCW immunization rates above 99% were observed in the 10 years postimplementation, in addition to a reduction in exemption requests and healthcare-associated influenza. In the year of implementation, 145 (1.6%) HCWs were placed on temporary suspension for failure to receive the vaccine without documentation of an exemption, with 9 (0.06%) subsequently being terminated. Since then, between 0 and 3 HCWs are terminated yearly for failure to receive the vaccine. CONCLUSIONS: Implementation of our mandatory influenza vaccination program succeeded in successfully increasing the proportion of immunized HCWs at a quaternary care children's hospital, reducing annual exemption requests with a small number of terminations secondary to vaccine refusal. Temporal trends suggest a positive impact on the safety of our patients.

Outbreak of Adenovirus in a Neonatal Intensive Care Unit: Critical Importance of Equipment Cleaning During Inpatient Ophthalmologic Examinations.

PURPOSE: Outbreaks of adenovirus in neonatal intensive care units (NICUs) can lead to widespread transmission and serious adverse outcomes. We describe the investigation, response, and successful containment of an adenovirus outbreak in a NICU associated with contaminated handheld ophthalmologic equipment used during retinopathy of prematurity (ROP) screening. DESIGN: Epidemiologic outbreak investigation. PARTICIPANTS: A total of 23 hospitalized neonates, as well as NICU staff and parents of affected infants. MAIN OUTCOME MEASURES: Routine surveillance identified an adenovirus outbreak in a level IV NICU in August 2016. Epidemiologic investigation followed, including chart review, staff interviews, and observations. Cases were defined as hospital-acquired adenovirus identified from any clinical specimen (NICU patient or employee) or compatible illness in a family member. Real-time polymerase chain reaction (PCR) and partial- and whole-genome sequencing assays were used for testing of clinical and environmental specimens. RESULTS: We identified 23 primary neonatal cases and 9 secondary cases (6 employees and 3 parents). All neonatal case-patients had respiratory symptoms. Of these, 5 developed pneumonia and 12 required increased respiratory support. Less than half (48%) had ocular symptoms. All neonatal case-patients (100%) had undergone a recent ophthalmologic examination, and 54% of neonates undergoing examinations developed adenovirus infection. All affected employees and parents had direct contact with infected neonates. Observations revealed inconsistent disinfection of bedside ophthalmologic equipment and limited glove use. Sampling of 2 handheld lenses and 2 indirect ophthalmoscopes revealed adenovirus serotype 3 DNA on each device. Sequence analysis of 16 neonatal cases, 2 employees, and 2 lenses showed that cases and equipment shared 100% identity across the entire adenovirus genome. Infection control interventions included strict hand hygiene, including glove use; isolation precautions; enhanced cleaning of lenses and ophthalmoscopes between all examinations; and staff furlough. We identified no cases of secondary transmission among neonates. CONCLUSIONS: Adenovirus outbreaks can result from use of contaminated ophthalmologic equipment. Even equipment that does not directly contact patients can facilitate indirect transmission. Patient-to-patient transmission can be prevented with strict infection control measures and equipment cleaning. Ophthalmologists performing inpatient examinations should take measures to avoid adenoviral spread from contaminated handheld equipment.

Specific Viral Etiologies Are Associated With Outcomes in Pediatric Acute Respiratory Distress Syndrome.

OBJECTIVES: Infectious pneumonia is the most common cause of acute respiratory distress syndrome, with viruses frequently implicated as causative. However, the significance of viruses in pediatric acute respiratory distress syndrome is unknown. We aimed to characterize the epidemiology of viral pneumonia in pediatric acute respiratory distress syndrome and compare characteristics and outcomes between pneumonia subjects with and without viruses. Secondarily, we examined the association between specific viruses and outcomes. DESIGN: We performed a secondary analysis of a prospectively enrolled pediatric acute respiratory distress syndrome cohort. Subjects with pneumonia acute respiratory distress syndrome underwent testing of respiratory secretions for viruses and culture for bacteria and fungi and were stratified according to presence or absence of a virus. SETTING: Tertiary care children's hospital. PATIENTS: Children with acute respiratory distress syndrome. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Of 544 children with acute respiratory distress syndrome, 282 (52%) had pneumonia as their inciting etiology, of whom 212 were virus-positive. In 141 of 282 (50%) pneumonia acute respiratory distress syndrome cases, a virus was the sole pathogen identified. Virus-positive pneumonia had fewer organ failures but worse oxygenation, relative to virus-negative pneumonia, with no differences in antibiotic use, ventilator duration, or mortality. Subjects with respiratory syncytial virus-associated acute respiratory distress syndrome had lower mortality (0%), and subjects with influenza-associated acute respiratory distress syndrome had shorter ventilator duration, relative to other viral acute respiratory distress syndrome. Nonadeno herpesviruses, tested for exclusively in immunocompromised subjects, had greater than 80% mortality. CONCLUSIONS: Pneumonia was the most common cause of pediatric acute respiratory distress syndrome, and viruses were commonly isolated as the sole pathogen. Respiratory syncytial virus and influenza were associated with better outcomes relative to other viral etiologies. Viral pneumonias in immunocompromised subjects, particularly nonadeno herpesviruses, drove the mortality rate for pneumonia acute respiratory distress syndrome. Specific viral etiologies are associated with differential outcomes in pediatric acute respiratory distress syndrome and should be accounted for in future studies.

Clinical Practice Guidelines for Clostridium difficile Infection in Adults and Children: 2017 Update by the Infectious Diseases Society of America (IDSA) and Society for Healthcare Epidemiology of America (SHEA).

A panel of experts was convened by the Infectious Diseases Society of America (IDSA) and Society for Healthcare Epidemiology of America (SHEA) to update the 2010 clinical practice guideline on Clostridium difficile infection (CDI) in adults. The update, which has incorporated recommendations for children (following the adult recommendations for epidemiology, diagnosis, and treatment), includes significant changes in the management of this infection and reflects the evolving controversy over best methods for diagnosis. Clostridium difficile remains the most important cause of healthcare-associated diarrhea and has become the most commonly identified cause of healthcare-associated infection in adults in the United States. Moreover, C. difficile has established itself as an important community pathogen. Although the prevalence of the epidemic and virulent ribotype 027 strain has declined markedly along with overall CDI rates in parts of Europe, it remains one of the most commonly identified strains in the United States where it causes a sizable minority of CDIs, especially healthcare-associated CDIs. This guideline updates recommendations regarding epidemiology, diagnosis, treatment, infection prevention, and environmental management.

Clinical Practice Guidelines for Clostridium difficile Infection in Adults and Children: 2017 Update by the Infectious Diseases Society of America (IDSA) and Society for Healthcare Epidemiology of America (SHEA).

A panel of experts was convened by the Infectious Diseases Society of America (IDSA) and Society for Healthcare Epidemiology of America (SHEA) to update the 2010 clinical practice guideline on Clostridium difficile infection (CDI) in adults. The update, which has incorporated recommendations for children (following the adult recommendations for epidemiology, diagnosis, and treatment), includes significant changes in the management of this infection and reflects the evolving controversy over best methods for diagnosis. Clostridium difficile remains the most important cause of healthcare-associated diarrhea and has become the most commonly identified cause of healthcare-associated infection in adults in the United States. Moreover, C. difficile has established itself as an important community pathogen. Although the prevalence of the epidemic and virulent ribotype 027 strain has declined markedly along with overall CDI rates in parts of Europe, it remains one of the most commonly identified strains in the United States where it causes a sizable minority of CDIs, especially healthcare-associated CDIs. This guideline updates recommendations regarding epidemiology, diagnosis, treatment, infection prevention, and environmental management.

Factors Associated With Pediatric Ventilator-Associated Conditions in Six U.S. Hospitals: A Nested Case-Control Study.

OBJECTIVES: A newly proposed surveillance definition for ventilator-associated conditions among neonatal and pediatric patients has been associated with increased morbidity and mortality among ventilated patients in cardiac ICU, neonatal ICU, and PICU. This study aimed to identify potential risk factors associated with pediatric ventilator-associated conditions. DESIGN: Retrospective cohort. SETTING: Six U.S. hospitals PATIENTS:: Children less than or equal to 18 years old ventilated for greater than or equal to 1 day. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: We identified children with pediatric ventilator-associated conditions and matched them to children without ventilator-associated conditions. Medical records were reviewed for comorbidities and acute care factors. We used bivariate and multivariate conditional logistic regression models to identify factors associated with ventilator-associated conditions. We studied 192 pairs of ventilator-associated conditions cases and matched controls (113 in the PICU and cardiac ICU combined; 79 in the neonatal ICU). In the PICU/cardiac ICU, potential risk factors for ventilator-associated conditions included neuromuscular blockade (odds ratio, 2.29; 95% CI, 1.08-4.87), positive fluid balance (highest quartile compared with the lowest, odds ratio, 7.76; 95% CI, 2.10-28.6), and blood product use (odds ratio, 1.52; 95% CI, 0.70-3.28). Weaning from sedation (i.e., decreasing sedation) or interruption of sedation may be protective (odds ratio, 0.44; 95% CI, 0.18-1.11). In the neonatal ICU, potential risk factors included blood product use (odds ratio, 2.99; 95% CI, 1.02-8.78), neuromuscular blockade use (odds ratio, 3.96; 95% CI, 0.93-16.9), and recent surgical procedures (odds ratio, 2.19; 95% CI, 0.77-6.28). Weaning or interrupting sedation was protective (odds ratio, 0.07; 95% CI, 0.01-0.79). CONCLUSIONS: In mechanically ventilated neonates and children, we identified several possible risk factors associated with ventilator-associated conditions. Next steps include studying propensity-matched cohorts and prospectively testing whether changes in sedation management, transfusion thresholds, and fluid management can decrease pediatric ventilator-associated conditions rates and improve patient outcomes.

Ventilator-Associated Events in Neonates and Children--A New Paradigm.

OBJECTIVES: To identify a pediatric ventilator-associated condition definition for use in neonates and children by exploring whether potential ventilator-associated condition definitions identify patients with worse outcomes. DESIGN: Retrospective cohort study and a matched cohort analysis. SETTING: Pediatric, cardiac, and neonatal ICUs in five U.S. hospitals. PATIENTS: Children 18 years old or younger ventilated for at least 1 day. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: We evaluated the evidence of worsening oxygenation via a range of thresholds for increases in daily minimum fraction of inspired oxygen (by 0.20, 0.25, and 0.30) and daily minimum mean airway pressure (by 4, 5, 6, and 7 cm H2O). We required worsening oxygenation be sustained for at least 2 days after at least 2 days of stability. We matched patients with a ventilator-associated condition to those without and used Cox proportional hazard models with frailties to examine associations with hospital mortality, hospital and ICU length of stay, and duration of ventilation. The cohort included 8,862 children with 10,209 hospitalizations and 77,751 ventilator days. For the fraction of inspired oxygen 0.25/mean airway pressure 4 definition (i.e., increase in minimum daily fraction of inspired oxygen by 0.25 or mean airway pressure by 4), rates ranged from 2.9 to 3.2 per 1,000 ventilator days depending on ICU type; the fraction of inspired oxygen 0.30/mean airway pressure 7 definition yielded ventilator-associated condition rates of 1.1-1.3 per 1,000 ventilator days. All definitions were significantly associated with greater risk of hospital death, with hazard ratios ranging from 1.6 (95% CI, 0.7-3.4) to 6.8 (2.9-16.0), depending on thresholds and ICU type. Each definition was associated with prolonged hospitalization, time in ICU, and duration of ventilation, among survivors. The advisory board of the study proposed using the fraction of inspired oxygen 0.25/mean airway pressure 4 thresholds to identify pediatric ventilator-associated conditions in ICUs. CONCLUSIONS: Pediatric patients with ventilator-associated conditions are at substantially higher risk for mortality and morbidity across ICUs, regardless of thresholds used. Next steps include identification of risk factors, etiologies, and preventative measures for pediatric ventilator-associated conditions.

Clostridium difficile infection is associated with increased risk of death and prolonged hospitalization in children.

BACKGROUND: Clostridium difficile infection (CDI) is associated with significant morbidity and mortality among adults. However, outcomes are poorly defined among children. METHODS: A retrospective cohort study was performed among hospitalized children at 41 children's hospitals between January 2006 and August 2011. Patients with CDI (exposed) were matched 1:2 to patients without CDI (unexposed) based on the probability of developing CDI (propensity score derived from patient characteristics). Exposed subjects were stratified by C. difficile test date, suggestive of community-onset (CO) versus hospital-onset (HO) CDI. Outcomes were analyzed for matched subjects. RESULTS: We identified 5107 exposed and 693 409 unexposed subjects. Median age was 6 years (interquartile range [IQR], 2-13 years) for exposed and 8 years (IQR, 3-14 years) for unexposed subjects. Of these, 4474 exposed were successfully matched to 8821 unexposed by propensity score. In-hospital mortality differed significantly (CDI, 1.43% vs matched unexposed, 0.66%; P < .001). Mortality rates were similar between CO-CDI and matched subjects. However, mortality rates were significantly greater among HO-CDI compared with matched unexposed (odds ratio, 6.73 [95% confidence interval {CI}, 3.77-12.02]). Mean differences in length of stay (LOS) and total cost were significant: 5.55 days (95% CI, 4.54-6.56 days) and $18 900 (95% CI, $15 100-$22 700) for CO-CDI, and 21.60 days (95% CI, 19.29-23.90 days) and $93 600 (95% CI, $80 000-$107 200) for HO-CDI. CONCLUSIONS: Pediatric CDI is associated with increased mortality, longer LOS, and higher costs. These findings underscore the importance of antibiotic stewardship and infection control programs to prevent this disease in children.

Recent trends in the epidemiology and treatment of C. difficile infection in children.

PURPOSE OF REVIEW: Clostridium difficile is the most common cause of healthcare-associated diarrhea among adults in Western countries, and is increasingly recognized as an important pathogen in children. This review provides an update on the changing epidemiology of C. difficile infection (CDI) for pediatric providers and summarizes current knowledge regarding available therapies. RECENT FINDINGS: The incidence of CDI has more than doubled among adults over the past decade, with a particular rise in incidence among patients presenting from the community. CDI has also increased among children in both inpatient and outpatient settings and there is growing evidence that specific populations of children may be at highest risk. Antibiotic-based therapies remain the mainstay of treatment for CDI, but new therapies have been developed with potential future applications in children. Use of nonantibiotic-based therapies is limited in children, but their use has been studied among adults with intractable or recurrent disease. SUMMARY: The rise in incidence of CDI over the past decade warrants increased recognition by pediatric providers. Knowledge of the pediatric populations at highest risk for infection as well as the options for therapy will improve understanding of this changing disease.

The power of feedback: Implementing a comprehensive hand hygiene observer program.

BACKGROUND: Hand hygiene (HH) is a fundamental component of infection prevention within all healthcare settings. We implemented a hospital-wide program built on overt HH observation, real-time feedback, and thematic analysis of HH misses. METHODS: A robust observer training program was established to include foundational training in the WHO's My Five Moments of HH. Observational data from 2011 to 2019 were analyzed by unit, provider type, and thematic analyses of misses. RESULTS: During the study period, we conducted 160,917 hospital-wide observations on 29 units (monthly average of 1,490 observations). Institutional compliance remained above 95% from 2013 to 2019. Thematic analysis revealed "touching self" and "touching phone" as common, institution-wide reasons for HH misses. DISCUSSION: Overt observations facilitated communication between HH program and healthcare staff to better understand workflow and educate staff on HH opportunities. This program is an integral part of the Infection Prevention team and has been deployed to collect supplemental data during clusters and outbreaks investigations. CONCLUSIONS: In addition to having rich HH data, successes of this program, include increased awareness of IPC practices, enhanced communication about patient safety, enriched dialog and feedback around HH misses, and relationship building among program observers, unit staff and leaders.

The utility of paired upper and lower respiratory tract sampling for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) testing in patients with artificial airways.

Early in the coronavirus disease 2019 (COVID-19) pandemic, the CDC recommended collection of a lower respiratory tract (LRT) specimen for severe acute respiratory coronavirus virus 2 (SARS-CoV-2) testing in addition to the routinely recommended upper respiratory tract (URT) testing in mechanically ventilated patients. Significant operational challenges were noted at our institution using this approach. In this report, we describe our experience with routine collection of paired URT and LRT sample testing. Our results revealed a high concordance between the 2 sources, and that all children tested for SARS-CoV-2 were appropriately diagnosed with URT testing alone. There was no added benefit to LRT testing. Based on these findings, our institutional approach was therefore adjusted to sample the URT alone for most patients, with LRT sampling reserved for patients with ongoing clinical suspicion for SARS-CoV-2 after a negative URT test.

Epidemiology and Risk Factors for Healthcare-Associated Viral Infections in Children.

BACKGROUND: Healthcare-associated viral infections (HA-VIs) are common in hospitalized children and are increasingly recognized as a cause of preventable harm; however, the epidemiology and modifiable risk factors for pediatric HA-VIs are poorly understood. METHODS: We performed a retrospective case-control study to identify risk factors and outcomes associated with pediatric HA-VIs at a quaternary care children's hospital. HA-VI surveillance was performed hospital-wide using Centers for Disease Control and Prevention (CDC) definitions. We abstracted data from the electronic medical record and conducted semi-structured interviews with patient caregivers to identify potential exposures 4 days before the HA-VI onset. RESULTS: During the 20-month study period, we identified 143 eligible patients with HA-VIs and enrolled 64 matched case-control pairs. In total, 79 viruses were identified among 64 case patients. During the exposure period, case, as compared with control, patients were more frequently exposed to a sick visitor (odds ratio = 5.19; P = .05). During the 7 days after the HA-VI onset, case, as compared with control, patients had a greater length of antibacterial therapy per patient-days (mean 411 vs 159) as well as greater days of antibacterial therapy per patient-days (mean 665 vs 247). CONCLUSIONS: The results of this study show that exposure to a sick visitor is a potentially modifiable risk factor for pediatric HA-VIs. Hospitalized children with HA-VIs also have increased exposure to antibacterial agents when compared with matched controls. Our findings suggest that hospital policies may need to be revised, with emphasis on visitor screening and partnership with families, to reduce the incidence of pediatric HA-VIs during hospitalization.

A strategy for expanding infection prevention resources to support organizational growth.

BACKGROUND: The field of infection prevention is rapidly evolving and becoming increasingly complex, as resource-intensive responses to device-associated outbreaks, global epidemics, and regulatory requirements continue to grow. This increasing complexity coupled with changing health care systems present important challenges to infection prevention staffing and resources. We describe the development of a novel infection prevention and control (IPC) staffing structure that includes both infection preventionists (IPs) and role-specific support staff to meet the evolving IPC needs and challenges of an expanding health care network. METHODS: The IPC department at Children's Hospital of Philadelphia underwent iterative modifications to its staffing structure between 2014 and 2018, including the development of revised job descriptions and promotional criteria, career ladders, and supporting roles. Data on key infection prevention activities, including rounding frequency and performance of audits and observations, growth metrics and infection data was evaluated for trends before and after departmental restructuring. An overall health care associated infection (HAI) index was calculated based on existing surveillance data and used to monitor patient outcomes over time. In addition, departmental employee engagement was assessed via a standard survey instrument to evaluate improvements in teamwork and professional growth opportunities over time. RESULTS: Between 2014 and 2018, the number of unique job descriptions for IPs and support staff increased from 4 to 9, creating a 3-tier career ladder for IPs and increasing full time equivalents from 8.2 to 11.6. Additional support roles included a Hand Hygiene Program Manager, Infection Prevention Associates and a Clinical Practice Analyst; these roles, along with increased IP staffing, expanded the education and consultative range of the department, as measured by a 33% increase in environmental rounding and a 7-fold increase in performance of isolation audits. Team diversity also expanded, changing from a team with predominantly nursing backgrounds, to one with an equal distribution of nursing, public health, and laboratory scientists. Results from serial engagement surveys showed an increase in teamwork and professional growth by 7.4% and 5.4%, respectively. Over this time period, the total HAI index decreased by 23%, while patient days, central line days, and ventilator days increased each year, and there was a statistically significant reduction in rates of harm across 5 key HAI indicators. CONCLUSIONS: Role diversity and varying professional backgrounds within IPC programs offer a complement of strengths and increase capacity to support patient care activities, improving patient outcomes. This strategy leads to a more cost-effective, robust IPC program that supports the growing needs and evolving challenges of the field.

Novel risk factors for central-line associated bloodstream infections in critically ill children.

OBJECTIVE: Central-line-associated bloodstream infections (CLABSI) cause morbidity and mortality in critically ill children. We examined novel and/or modifiable risk factors for CLABSI to identify new potential targets for infection prevention strategies. METHODS: This single-center retrospective matched case-control study of pediatric intensive care unit (PICU) patients was conducted in a 60-bed PICU from April 1, 2013, to December 31, 2017. Case patients were in the PICU, had a central venous catheter (CVC), and developed a CLABSI. Control patients were in the PICU for ≥2 days, had a CVC for ≥3 days, and did not develop a CLABSI. Cases and controls were matched 1:4 on age, number of complex chronic conditions, and hospital length of stay. RESULTS: Overall, 72 CLABSIs were matched to 281 controls. Univariate analysis revealed 14 risk factors, and 4 remained significant in multivariable analysis: total number of central line accesses in the 3 days preceding CLABSI (80+ accesses: OR, 4.8; P = .01), acute behavioral health needs (OR, 3.2; P = .02), CVC duration >7 days (8-14 days: OR, 4.2; P = .01; 15-29 days: OR, 9.8; P < .01; 30-59 days: OR, 17.3; P < .01; 60-89 days: OR, 39.8; P < .01; 90+ days: OR, 4.9; P = .01), and hematologic/immunologic disease (OR, 1.5; P = .05). CONCLUSIONS: Novel risk factors for CLABSI in PICU patients include acute behavioral health needs and >80 CVC accesses in the 3 days before CLABSI. Interventions focused on these factors may reduce CLABSIs in this high-risk population.

The Epidemiology of Severe Acute Respiratory Syndrome Coronavirus 2 in a Pediatric Healthcare Network in the United States.

BACKGROUND: Understanding the prevalence and clinical presentation of coronavirus disease 2019 in pediatric patients can help healthcare providers and systems prepare and respond to this emerging pandemic. METHODS: This was a retrospective case series of patients tested for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) across a pediatric healthcare network, including clinical features and outcomes of those with positive test results. RESULTS: Of 7256 unique children tested for SARS-CoV-2, 424 (5.8%) tested positive. Patients aged 18-21 years had the highest test positive rate (11.2%), while those aged 1-5 years had the lowest (3.9%). By race, 10.6% (226/2132) of black children tested positive vs 3.3% (117/3592) of white children. By indication for testing, 21.1% (371/1756) of patients with reported exposures or clinical symptoms tested positive vs 3.8% (53/1410) of those undergoing preprocedural or preadmission testing. Of 424 patients who tested positive for SARS-CoV-2, 182 (42.9%) had no comorbidities, 87 (20.5%) had asthma, and 55 (13.0%) were obese. Overall, 52.1% had cough, 51.2% fever, and 14.6% shortness of breath. Seventy-seven (18.2%) SARS-CoV-2-positive patients were hospitalized, of whom 24 (31.2%) required respiratory support. SARS-CoV-2-targeted antiviral therapy was given to 9 patients, and immunomodulatory therapy to 18 patients. Twelve (2.8%) SARS-CoV-2-positive patients required mechanical ventilation, and 2 patients required extracorporeal membrane oxygenation. Two patients died. CONCLUSIONS: In this large cohort of pediatric patients tested for SARS-CoV-2, the rate of infection was low but varied by testing indication. The majority of cases were mild and few children had critical illness.

Variability in antimicrobial use in pediatric ventilator-associated events.

OBJECTIVE: To assess variability in antimicrobial use and associations with infection testing in pediatric ventilator-associated events (VAEs). DESIGN: Descriptive retrospective cohort with nested case-control study. SETTING: Pediatric intensive care units (PICUs), cardiac intensive care units (CICUs), and neonatal intensive care units (NICUs) in 6 US hospitals.PatientsChildren≤18 years ventilated for≥1 calendar day. METHODS: We identified patients with pediatric ventilator-associated conditions (VACs), pediatric VACs with antimicrobial use for≥4 days (AVACs), and possible ventilator-associated pneumonia (PVAP, defined as pediatric AVAC with a positive respiratory diagnostic test) according to previously proposed criteria. RESULTS: Among 9,025 ventilated children, we identified 192 VAC cases, 43 in CICUs, 70 in PICUs, and 79 in NICUs. AVAC criteria were met in 79 VAC cases (41%) (58% CICU; 51% PICU; and 23% NICU), and varied by hospital (CICU, 20-67%; PICU, 0-70%; and NICU, 0-43%). Type and duration of AVAC antimicrobials varied by ICU type. AVAC cases in CICUs and PICUs received broad-spectrum antimicrobials more often than those in NICUs. Among AVAC cases, 39% had respiratory infection diagnostic testing performed; PVAP was identified in 15 VAC cases. Also, among AVAC cases, 73% had no associated positive respiratory or nonrespiratory diagnostic test. CONCLUSIONS: Antimicrobial use is common in pediatric VAC, with variability in spectrum and duration of antimicrobials within hospitals and across ICU types, while PVAP is uncommon. Prolonged antimicrobial use despite low rates of PVAP or positive laboratory testing for infection suggests that AVAC may provide a lever for antimicrobial stewardship programs to improve utilization.