Management of afebrile neonates with pustules and vesicles in a pediatric emergency department.

OBJECTIVES: To assess the management and outcomes of vesicles and pustules in afebrile neonates presenting to the pediatric emergency department. METHODS: Using International Classification of Diseases, Ninth Revision, codes, we identified patients 0-60 days old presenting to our pediatric emergency department from 2008 to 2015 with a possible diagnosis of pustules or vesicles. We then used natural language processing followed by manual chart review to identify afebrile neonates with pustules or vesicles. We collected clinical data from the electronic medical record. We also assessed current practice patterns for neonatal pustules or vesicles using a survey administered to attending physicians. RESULTS: Of the 971 possible cases identified using International Classification of Diseases, Ninth Revision, codes for fluid-filled lesions, only 64 patients had vesicles (n = 9) and pustules (n = 55). One-third (22/64) of afebrile neonates with pustules and vesicles were admitted to the hospital and received empiric parenteral therapy. Admission, parenteral antibiotics, and antiviral therapy were more common in neonates presenting with vesicles than in those with pustules alone. Apart from 2 presumed blood culture contaminants, there were no positive blood or cerebrospinal fluid cultures. Two patients had positive urine cultures. Institutional survey data showed practice patterns consistent with these retrospective results. CONCLUSION: Although one-third of neonates with pustules and vesicles were admitted to the hospital and received parenteral therapy, there were no cerebrospinal fluid or blood infections or any confirmed evidence of herpes simplex virus disease. These findings suggest that afebrile, well-appearing neonates presenting with pustules alone may not need a full serious bacterial infection examination. Larger studies are needed to confirm these findings and assess outcomes, especially in afebrile neonates with vesicles.

Implementation and Perceived Effectiveness of Prospective Audit and Feedback and Preauthorization by US Pediatric Antimicrobial Stewardship Programs.

BACKGROUND: Antimicrobial stewardship programs (ASPs) promote optimal antimicrobial use to prevent resistance, improve outcomes, and reduce costs. We explored how pediatric ASPs enact prospective audit and feedback (PAF) and preauthorization and characterized programs' perceptions of how these choices affected attainment of stewardship goals. METHODS: We conducted focus groups with US pediatric ASP practitioners, organized by predominant strategy: PAF, preauthorization, or a hybrid. We asked open-ended questions about organization, staffing, and operation of these strategies, as well as rationales for and perceived advantages and disadvantages of these choices. We used applied thematic analysis to analyze transcripts, organizing coded text into themes and categories. We formulated a conceptual model for how the design and performance of PAF and preauthorization affect stewardship goals and stewards' work experiences. RESULTS: Eighteen physicians and 14 pharmacists from 24 hospitals participated in five focus groups. Stewards described myriad advantages and limitations of PAF and preauthorization that support or detract from stewardship goals. For example, PAF uncovered institutional trends in antibiotic use and fostered relationship building but was time-consuming. Preauthorization efficiently reduced broad-spectrum antimicrobial use, yet offered limited educational opportunities. How these strategies facilitated or impeded appropriate antimicrobial use in turn affected stewards' professional satisfaction, creating a feedback loop that could reinforced positive or negative outcomes. CONCLUSIONS: ASPs reported differing emphasis on and implementation of PAF and preauthorization. Each strategy entailed contrasting benefits and trade-offs for steward satisfaction and perceived efficacy, suggesting that a hybrid approach could enable ASPs to maximize strengths of each to mitigate drawbacks of the other.

Epidemiology, Clinical Features, and Disease Severity in Patients With Coronavirus Disease 2019 (COVID-19) in a Children's Hospital in New York City, New York.

Importance: Descriptions of the coronavirus disease 2019 (COVID-19) experience in pediatrics will help inform clinical practices and infection prevention and control for pediatric facilities. Objective: To describe the epidemiology, clinical, and laboratory features of patients with COVID-19 hospitalized at a children's hospital and to compare these parameters between patients hospitalized with and without severe disease. Design, Setting, and Participants: This retrospective review of electronic medical records from a tertiary care academically affiliated children's hospital in New York City, New York, included hospitalized children and adolescents (≤21 years) who were tested based on suspicion for COVID-19 between March 1 to April 15, 2020, and had positive results for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Exposures: Detection of SARS-CoV-2 from a nasopharyngeal specimen using a reverse transcription-polymerase chain reaction assay. Main Outcomes and Measures: Severe disease as defined by the requirement for mechanical ventilation. Results: Among 50 patients, 27 (54%) were boys and 25 (50%) were Hispanic. The median days from onset of symptoms to admission was 2 days (interquartile range, 1-5 days). Most patients (40 [80%]) had fever or respiratory symptoms (32 [64%]), but 3 patients (6%) with only gastrointestinal tract presentations were identified. Obesity (11 [22%]) was the most prevalent comorbidity. Respiratory support was required for 16 patients (32%), including 9 patients (18%) who required mechanical ventilation. One patient (2%) died. None of 14 infants and 1 of 8 immunocompromised patients had severe disease. Obesity was significantly associated with mechanical ventilation in children 2 years or older (6 of 9 [67%] vs 5 of 25 [20%]; P = .03). Lymphopenia was commonly observed at admission (36 [72%]) but did not differ significantly between those with and without severe disease. Those with severe disease had significantly higher C-reactive protein (median, 8.978 mg/dL [to convert to milligrams per liter, multiply by 10] vs 0.64 mg/dL) and procalcitonin levels (median, 0.31 ng/mL vs 0.17 ng/mL) at admission (P < .001), as well as elevated peak interleukin 6, ferritin, and D-dimer levels during hospitalization. Hydroxychloroquine was administered to 15 patients (30%) but could not be completed for 3. Prolonged test positivity (maximum of 27 days) was observed in 4 patients (8%). Conclusions and Relevance: In this case series study of children and adolescents hospitalized with COVID-19, the disease had diverse manifestations. Infants and immunocompromised patients were not at increased risk of severe disease. Obesity was significantly associated with disease severity. Elevated inflammatory markers were seen in those with severe disease.