Pediatric asthma hospitalizations among urban minority children and the continuity of primary care.

OBJECTIVE: To examine the effect of ambulatory health care processes on asthma hospitalizations. METHODS: A retrospective cohort study using electronic health records was completed. Patients aged 2-18 years receiving health care from 1 of 5 urban practices between Jan 1, 2004 and Dec 31, 2008 with asthma documented on their problem list were included. Independent variables were modifiable health care processes in the primary care setting: (1) use of asthma controller medications; (2) regular assessment of asthma symptoms; (3) use of spirometry; (4) provision of individualized asthma care plans; (5) timely influenza vaccination; (6) access to primary healthcare; and (7) use of pay for performance physician incentives. Occurrence of one or more asthma hospitalizations was the primary outcome of interest. We used a log linear model (Poisson regression) to model the association between the factors of interest and number of asthma hospitalizations. RESULTS: 5,712 children with asthma were available for analysis. 96% of the children were African American. The overall hospitalization rate was 64 per 1,000 children per year. None of the commonly used asthma-specific indicators of high quality care were associated with fewer asthma hospitalizations. Children with documented asthma who experienced a lack of primary health care (no more than one outpatient visit at their primary care location in the 2 years preceding hospitalization) were at higher risk of hospitalization compared to those children with a greater number of visits (incidence rate ratio 1.39; 95% CI 1.09-1.78). CONCLUSIONS: In children with asthma, more frequent primary care visits are associated with reduced asthma hospitalizations.

Association of Broad- vs Narrow-Spectrum Antibiotics With Treatment Failure, Adverse Events, and Quality of Life in Children With Acute Respiratory Tract Infections.

Importance: Acute respiratory tract infections account for the majority of antibiotic exposure in children, and broad-spectrum antibiotic prescribing for acute respiratory tract infections is increasing. It is not clear whether broad-spectrum treatment is associated with improved outcomes compared with narrow-spectrum treatment. Objective: To compare the effectiveness of broad-spectrum and narrow-spectrum antibiotic treatment for acute respiratory tract infections in children. Design, Setting, and Participants: A retrospective cohort study assessing clinical outcomes and a prospective cohort study assessing patient-centered outcomes of children between the ages of 6 months and 12 years diagnosed with an acute respiratory tract infection and prescribed an oral antibiotic between January 2015 and April 2016 in a network of 31 pediatric primary care practices in Pennsylvania and New Jersey. Stratified and propensity score-matched analyses to account for confounding by clinician and by patient-level characteristics, respectively, were implemented for both cohorts. Exposures: Broad-spectrum antibiotics vs narrow-spectrum antibiotics. Main Outcomes and Measures: In the retrospective cohort, the primary outcomes were treatment failure and adverse events 14 days after diagnosis. In the prospective cohort, the primary outcomes were quality of life, other patient-centered outcomes, and patient-reported adverse events. Results: Of 30 159 children in the retrospective cohort (19 179 with acute otitis media; 6746, group A streptococcal pharyngitis; and 4234, acute sinusitis), 4307 (14%) were prescribed broad-spectrum antibiotics including amoxicillin-clavulanate, cephalosporins, and macrolides. Broad-spectrum treatment was not associated with a lower rate of treatment failure (3.4% for broad-spectrum antibiotics vs 3.1% for narrow-spectrum antibiotics; risk difference for full matched analysis, 0.3% [95% CI, -0.4% to 0.9%]). Of 2472 children enrolled in the prospective cohort (1100 with acute otitis media; 705, group A streptococcal pharyngitis; and 667, acute sinusitis), 868 (35%) were prescribed broad-spectrum antibiotics. Broad-spectrum antibiotics were associated with a slightly worse child quality of life (score of 90.2 for broad-spectrum antibiotics vs 91.5 for narrow-spectrum antibiotics; score difference for full matched analysis, -1.4% [95% CI, -2.4% to -0.4%]) but not with other patient-centered outcomes. Broad-spectrum treatment was associated with a higher risk of adverse events documented by the clinician (3.7% for broad-spectrum antibiotics vs 2.7% for narrow-spectrum antibiotics; risk difference for full matched analysis, 1.1% [95% CI, 0.4% to 1.8%]) and reported by the patient (35.6% for broad-spectrum antibiotics vs 25.1% for narrow-spectrum antibiotics; risk difference for full matched analysis, 12.2% [95% CI, 7.3% to 17.2%]). Conclusions and Relevance: Among children with acute respiratory tract infections, broad-spectrum antibiotics were not associated with better clinical or patient-centered outcomes compared with narrow-spectrum antibiotics, and were associated with higher rates of adverse events. These data support the use of narrow-spectrum antibiotics for most children with acute respiratory tract infections.

Effect of an outpatient antimicrobial stewardship intervention on broad-spectrum antibiotic prescribing by primary care pediatricians: a randomized trial.

IMPORTANCE: Antimicrobial stewardship programs have been effective for inpatients, often through prescribing audit and feedback. However, most antimicrobial use occurs in outpatients with acute respiratory tract infections (ARTIs). OBJECTIVE: To evaluate the effect of an antimicrobial stewardship intervention on antibiotic prescribing for pediatric outpatients. DESIGN: Cluster randomized trial of outpatient antimicrobial stewardship comparing prescribing between intervention and control practices using a common electronic health record. After excluding children with chronic medical conditions, antibiotic allergies, and prior antibiotic use, we estimated prescribing rates for targeted ARTIs standardized for age, sex, race, and insurance from 20 months before the intervention to 12 months afterward (October 2008-June 2011). SETTING AND PARTICIPANTS: A network of 25 pediatric primary care practices in Pennsylvania and New Jersey; 18 practices (162 clinicians) participated. INTERVENTIONS: One 1-hour on-site clinician education session (June 2010) followed by 1 year of personalized, quarterly audit and feedback of prescribing for bacterial and viral ARTIs or usual practice. MAIN OUTCOMES AND MEASURES: Rates of broad-spectrum (off-guideline) antibiotic prescribing for bacterial ARTIs and antibiotics for viral ARTIs for 1 year after the intervention. RESULTS: Broad-spectrum antibiotic prescribing decreased from 26.8% to 14.3% (absolute difference, 12.5%) among intervention practices vs from 28.4% to 22.6% (absolute difference, 5.8%) in controls (difference of differences [DOD], 6.7%; P = .01 for differences in trajectories). Off-guideline prescribing for children with pneumonia decreased from 15.7% to 4.2% among intervention practices compared with 17.1% to 16.3% in controls (DOD, 10.7%; P < .001) and for acute sinusitis from 38.9% to 18.8% in intervention practices and from 40.0% to 33.9% in controls (DOD, 14.0%; P = .12). Off-guideline prescribing was uncommon at baseline and changed little for streptococcal pharyngitis (intervention, from 4.4% to 3.4%; control, from 5.6% to 3.5%; DOD, -1.1%; P = .82) and for viral infections (intervention, from 7.9% to 7.7%; control, from 6.4% to 4.5%; DOD, -1.7%; P = .93). CONCLUSIONS AND RELEVANCE: In this large pediatric primary care network, clinician education coupled with audit and feedback, compared with usual practice, improved adherence to prescribing guidelines for common bacterial ARTIs, and the intervention did not affect antibiotic prescribing for viral infections. Future studies should examine the drivers of these effects, as well as the generalizability, sustainability, and clinical outcomes of outpatient antimicrobial stewardship. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT01806103.

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.

Risk factors and predictors for candidemia in pediatric intensive care unit patients: implications for prevention.

BACKGROUND: Candida species are the leading cause of invasive fungal infections in hospitalized children and are the third most common isolates recovered from patients with healthcare-associated bloodstream infection in the United States. Few data exist on risk factors for candidemia in pediatric intensive care unit (PICU) patients. METHODS: We conducted a population-based case-control study of PICU patients at Children's Hospital of Philadelphia during the period from 1997 through 2004. Case patients were identified using laboratory records, and control patients were selected from PICU rosters. Control patients were matched to case patients by incidence density sampling, adjusting for time at risk. Following conditional multivariate analysis, we performed weighted multivariate analysis to determine predicted probabilities for candidemia given certain risk factor combinations. RESULTS: We identified 101 case patients with candidemia (incidence, 3.5 cases per 1000 PICU admissions). Factors independently associated with candidemia included presence of a central venous catheter (odds ratio [OR], 30.4; 95% confidence interval [CI], 7.7-119.5), malignancy (OR, 4.0; 95% CI, 1.23-13.1), use of vancomycin for >3 days in the prior 2 weeks (OR, 6.2; 95% CI, 2.4-16), and receipt of agents with activity against anaerobic organisms for >3 days in the prior 2 weeks (OR, 3.5; 95% CI, 1.5-8.4). Predicted probability of having various combinations of the aforementioned factors ranged from 10.7% to 46%. The 30-day mortality rate was 44% among case patients and 14% among control patients (OR, 4.22; 95% CI, 2.35-7.60). CONCLUSIONS: To our knowledge, this is the first study to evaluate independent risk factors and to determine a population of children in PICUs at high risk for developing candidemia. Future efforts should focus on validation of these risk factors identified in a different PICU population and development of interventions for prevention of candidemia in critically ill children.

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.

Polymicrobial bloodstream infections among children and adolescents with central venous catheters evaluated in ambulatory care.

BACKGROUND: Bloodstream infections (BSIs) are an ever-present concern for clinicians evaluating ill-appearing pediatric patients with central venous catheters (CVCs) in the ambulatory care setting. METHODS: We performed a case-control study of a cohort of 200 pediatric patients who were evaluated in the ambulatory care setting and who were found to have laboratory-confirmed BSI in the context of a CVC. This study sought to compare patients with polymicrobial versus monomicrobial BSIs to identify potential risk factors for polymicrobial BSI. RESULTS: Of the 200 patients enrolled in the study, 73 (37%) had a polymicrobial BSI. Patients with polymicrobial BSI were more likely than those with monomicrobial BSI to be younger (P=.002) and less likely to have been recently discharged from the hospital (P=.01). The odds of a polymicrobial BSI were >4 times greater for patients aged <3 years than for those aged >or=3 years (odds ratio, 4.54; 95% confidence interval, 1.68-12.29), and the odds were 50% lower for those discharged from the hospital in the prior 7 days than for those without recent hospitalization (odds ratio, 0.46; 95% confidence interval, 0.22-0.95) after controlling for an underlying cancer diagnosis and the time of year during which a patient presented. Recent antibiotic use, recent BSI, duration that the CVC had been in place, and underlying gastrointestinal dysfunction were not associated with a risk of polymicrobial BSI. CONCLUSIONS: Younger children and those who had not recently been discharged from the hospital had an increased risk of developing catheter-related polymicrobial BSI. Special consideration should be given to the increased likelihood of polymicrobial BSIs in these pediatric patients when initiating empirical antimicrobial therapy.

The clinical and molecular epidemiology of community- and healthcare-acquired rotavirus gastroenteritis.

BACKGROUND: Rotavirus is the most common etiologic agent of healthcare-acquired diarrhea in pediatric patients. There has been little published information on healthcare-acquired rotavirus infection. METHODS: This was a retrospective cohort study of children hospitalized with rotavirus gastroenteritis at our institution between December 1999 and May 2004. Patients with community- and healthcare-acquired rotavirus gastroenteritis were compared with regards to age, time of infection, patient unit, and viral subtype as determined by reverse transcription polymerase chain reaction sequencing. RESULTS: Five hundred seventy-seven children were hospitalized with rotavirus gastroenteritis during the study period. One hundred twenty-one (21%) of these infections were healthcare-acquired. The incidence of healthcare-acquired infection was 4.2 cases per 10,000 patient-days. With the exception of 1 outbreak on an isolated patient unit, community- and healthcare-acquired disease affected similar patient populations, had the same temporal distribution, and were caused by viruses with similar subtypes. However, there was a significant difference between the geographic distribution of community- and healthcare-acquired disease within the hospital (P < 0.001). The majority (83%) of community-acquired cases were admitted to general medicine-surgery units, but only 53% of the healthcare-acquired cases occurred on these units (P = 0.005). The remaining healthcare-acquired infections occurred on units that rarely admitted patients with community-acquired disease. CONCLUSIONS: Healthcare-acquired rotavirus gastroenteritis seems to be caused by repeated introduction of community strains into the hospital setting. Heightened attention to infection control practices and rapid rotavirus identification is necessary on all units, especially those that infrequently admit children with rotavirus gastroenteritis, to prevent the spread of healthcare-acquired disease.

Risk factors for mediastinitis following median sternotomy in children.

BACKGROUND: Mediastinitis is a devastating complication of pediatric cardiothoracic surgery. However, risk factors for the development of mediastinitis are poorly characterized. The objective of this study was to identify risk factors for mediastinitis in a cohort of children undergoing cardiothoracic surgery at a tertiary care children's hospital. METHODS: This case-control study included patients who underwent median sternotomy between January 1, 1995 and December 31, 2003. Univariate analyses, logistic regression, and multinomial regression were performed to determine the association between potential risk factors and the development of mediastinitis. RESULTS: Forty-three patients with mediastinitis and 184 patients without mediastinitis were included. One hundred and twelve (49%) patients were female. The median patient age was 128 days (interquartile range: 7 days-2.0 years). A known or possible genetic syndrome was present in 53 (24%) patients. The following factors were associated with the development of mediastinitis: presence of a known or possible genetic syndrome (adjusted odds ratio, OR: 4.5; 95% confidence interval, CI: 1.8-11.4); American Society of Anesthesiologists score >3 (adjusted OR: 3.4; 95% CI: 1.1-10.3); and presence of intracardiac pacing wires for >3 days (adjusted OR: 15.8; 95% CI: 2.0-127.2). CONCLUSIONS: The presence of a known or possible genetic syndrome, American Society of Anesthesiologists score >3, and the presence of intracardiac pacing wires for >3 days were each associated with the development of mediastinitis in children after median sternotomy.

Observational trial of antibiotic-coated central venous catheters in critically ill pediatric patients.

BACKGROUND: Catheter-associated bloodstream infections (CABSI) are among the most common and serious adverse events experienced by critically ill children. Randomized trials have demonstrated that the use of central venous catheters (CVC) coated with antiseptic solutions reduces rates of CABSI in adult patients; however, their efficacy in children has not been evaluated. OBJECTIVE: To compare the incidence of CABSI, rate of complications, and microbiology of infection in critically ill children treated with antibiotic-coated or noncoated CVC (NC-CVC). METHODS: A prospective observational trial was conducted in the pediatric intensive care unit (PICU) during a 13-month period. A minocycline-rifampin-coated CVC (MR-CVC) or NC-CVC was placed by PICU physicians who nonpreferentially selected CVC type. RESULTS: We studied the outcomes associated with the first CVC placed in 225 patients, including 69 MR-CVC and 156 NC-CVC. Patients who received MR-CVC, as compared with NC-CVC, were similar in gender, age, and severity of illness at time of PICU admission. The incidence density of CABSI did not vary by catheter type [MR-CVC: 7.53 per 1000 catheter-days (95% confidence interval 2.05-19.17); NC-CVC: 8.64 CABSI per 1000 catheter-days (95% confidence interval 3.74-16.96)]. However, the median time to infection in children with MR-CVC was 3-fold longer than in children with NC-CVC [18 versus 5 days (P = 0.053)]. No difference was seen in the incidence of complications, including thrombosis and catheter site reaction, between MR- and NC-CVC. No significant difference was observed in the types of organisms recovered from patients with MR- and NC-CVC. CONCLUSIONS: The use of MR-CVC significantly delayed the onset of CABSI in PICU patients. Larger, randomized trials are needed to better define potential differences in the incidence of CABSI, rate of complications, and microbiology of infection among pediatric patients treated with antiseptic-coated CVC and NC-CVC.

Risk adjustment for surgical site infection after median sternotomy in children.

OBJECTIVE: To determine whether the National Nosocomial Infections Surveillance (NNIS) System risk index adequately stratified a population of pediatric patients undergoing cardiac surgery according to the risk of developing surgical site infection (SSI). DESIGN: A retrospective, case-control study. SETTING: An urban tertiary care children's hospital. PATIENTS: Patients who had a median sternotomy performed between January 1, 1995, and December 31, 2003, were eligible for inclusion in the study. For all case patients, medical records were reviewed to verify that all patients met the case definition for SSI. Control subjects were chosen randomly from among all patients who underwent median sternotomy during the study period who did not develop SSI. RESULTS: Thirty-eight patients with SSI and 172 patients without SSI were included. One hundred six patients (50%) were male. The median patient age was 4 months. The sensitivity of the NNIS risk index with cutoff scores of 0 to 1 and 2 to 3 was 20%. The distribution of patients with SSI for an NNIS risk index score of 0 was 0%; for a score of 1, 80%; for a score of 2, 20%; and for a score of 3, 0%. The distribution of patients without SSI for a scores of 0 was 4%; for a score of 1, 87%; for a score of 2, 9%; and for a score of 3, 0%. The area under the receiver-operating characteristic curve (AUC) of the original NNIS risk index was 0.57. The modified risk indices did not perform significantly better, with an AUC range of 0.58 to 0.73. CONCLUSIONS: The NNIS risk index did not adequately stratify pediatric patients undergoing median sternotomy according to their risk of developing an SSI. Various modifications to the risk index yielded only slightly higher AUC values.

Strengthening the academic base of general pediatrics fellowship programs: a national program and curriculum development project.

OBJECTIVE: To improve academic general pediatrics (AGP) fellowship programs by 1) developing curriculum guidelines and program standards and 2) creating a process for program review and consultation that might later be used for accreditation of AGP fellowship programs. METHODS: This project of the Ambulatory Pediatric Association (APA) created 4 documents: AGP fellowship program requirements, core curriculum, educational goals and objectives, and a standardized form to describe required program characteristics. Site visits were conducted at 7 volunteer AGP fellowship programs, selected for diversity of content, structure, and location. Evaluations were conducted using a uniform checklist of requirements that combined numerical ratings with a written evaluation summary. Feedback from programs on the review process enabled refinement of the documents. RESULTS: The site visits revealed great variety in emphasis among the 7 programs. In general, faculty were dedicated and capable, and programs showed considerable educational strengths. Typical problems were lack of integration of the program within departmental structures, overburdened faculty, and uncertain funding. Many programs demonstrated suboptimal curriculum planning and weak evaluation methods. Most program leaders felt that the project materials helped to improve the quality of their programs, and 5 of 7 programs expressed willingness to be involved in formal accreditation review in the future. CONCLUSIONS: AGP fellowship programs that volunteered for piloting of an accreditation process were diverse and vital, with rich educational offerings despite a lack of optimal curriculum structure, minimal evaluation, limited faculty resources, and tenuous funding. An APA accreditation process appears to be feasible and may enhance AGP fellowship programs.

Academic general pediatric fellowships: curriculum design and educational goals and objectives.

Academic generalists are unique and important members of the pediatric landscape.(1) Academic general pediatrics (AGP) is not considered a subspecialty, because it adheres to generalist values and embraces a wide range of clinical activities. Nonetheless, academic generalists engage in important scholarly efforts, contribute extensively to the education of new pediatricians, and must be prepared to survive in academia. Academic general pediatric faculty positions are subject to the same appointment and promotion requirements as those of subspecialist faculty.