Antimicrobial use and opportunities for antimicrobial stewardship in pediatric postacute and long-term care settings.

We performed a point-prevalence study of antimicrobial prescriptions in 9 pediatric postacute and long-term care (pPALTC) settings. Antimicrobials were prescribed for 5%-7% of residents including infectious (41%), noninfectious (24%), prophylaxis (24%), and unknown (11%) indications. Macrolides were often prescribed for noninfectious indications. Developing treatment guidelines are antimicrobial stewardship opportunities for pPALTC.

Surveillance for Acute Respiratory Illnesses in Pediatric Chronic Care Facilities.

Overall, 119 (33%) of 364 pediatric chronic care facility residents experienced 182 acute respiratory illnesses (ARIs) that met the surveillance definition which led to 31 (17%) emergency room visits, 34 (19%) acute care hospitalizations, and/or 25 (14%) ICU admissions. Continued PCR-positivity was observed in 35% of ARIs during follow-up testing.

Characteristics of the Audience Reached by the National Network of Sexually Transmitted Disease Clinical Prevention Training Centers and Correlation With Sexually Transmitted Infection Rates, 2015 to 2020.

BACKGROUND: The National Network of Sexually Transmitted Disease Clinical Prevention Training Centers (NNPTC) trains clinical providers to diagnose and treat sexually transmitted infections (STIs) in the United States. The purpose of this study was to examine the demographics of clinical providers and to correlate the number of training episodes with STI rates at the county level. METHODS: Registration data were collected between April 1, 2015, and March 31, 2020, in a custom Learning Management System from clinical providers taking NNPTC training. Using the 2018 STI surveillance data, counties were divided into quartiles based on reportable STI case rates and the number of county-level training events was compared per quartile. Univariate and multivariate analyses were conducted in IBM SPSS Statistics 23 (Armonk, NY) and SAS Enterprise Guide 7.1 (Cary, NC). RESULTS: From 2015 to 2020, the NNPTC trained 21,327 individuals, predominantly in the nursing professions and working in a public health environment. In multivariate analysis, the number of training events was significantly associated with higher STI rates at the county level (P < 0.0001) and the state where a prevention training center is located (P < 0001). CONCLUSIONS: The analysis suggests that NNPTC trainings are reaching the clinical providers working in geographic areas with higher STI rates.

Knowledge, Attitudes, and Practices of Pediatric Long-term Care Facility Staff Regarding Infection Control for Acute Respiratory Infections and Influenza Vaccination.

We surveyed clinical staff and on-site teachers working at pediatric long-term care facilities regarding prevention and control of acute respiratory infections and influenza in staff and residents. We uncovered knowledge gaps, particularly among teachers and clinical staff working <5 years at sites, thereby elucidating areas for targeted staff education.

COVID-19 in Pediatric Long-Term Care: How Infection Control and Prevention Practices Minimized the Impact of the Pandemic on Healthcare Providers and Residents.

Children in pediatric long-term care (LTC) facilities are commonly infected with respiratory tract viruses as they have many high-risk co-morbidities and require significant interactions with the healthcare team. From previous studies, we know that infected staff can often be the source of transmission of infection to the children. If instituted quickly, infection control practices can help mitigate the spread of infection. We will describe how Sunshine Children's Home and Rehabilitation Center responded to federal and state infection control and prevention mandates in LTC for COVID-19. We will report our practice changes, staff and resident screening, and testing results as well as outcomes of the COVID-19-infected cases. The outcomes for COVID-19 infection among pediatric LTC staff and residents are in stark contrast to the data available for the adult providers and residents in adult nursing homes. Implementation and change in infection control practices and procedures resulted in much fewer cases of COVID-19 infection in our pediatric LTC residents.

Active surveillance for acute respiratory infections among pediatric long-term care facility staff.

BACKGROUND: Transmission of respiratory viruses between staff and residents of pediatric long-term care facilities (pLTCFs) can occur. We assessed the feasibility of using text or email messages to perform surveillance for acute respiratory infections (ARIs) among staff. METHODS: From December 7, 2016 to May 7, 2017, 50 staff participants from 2 pLTCFs received weekly text or email requests to report the presence or absence of ARI symptoms. Those who fulfilled the ARI case definition (≥2 symptoms) had respiratory specimens collected to detect viruses by reverse transcriptase polymerase chain reaction assays. Pre- and postsurveillance respiratory specimens were collected to assess subclinical viral shedding. RESULTS: The response rate to weekly electronic messages was 93%. Twenty-one ARIs reported from 20 (40%) participants fulfilled the case definition. Respiratory viruses were detected in 29% (5/17) of specimens collected at symptom onset (influenza B, respiratory syncytial virus, coronavirus [CoV] 229E, rhinovirus [RV], and dual detection of CoV OC43 and bocavirus). Four participants had positive presurveillance (4 RV), and 6 had positive postsurveillance specimens (3 RV, 2 CoV NL63, and 1 adenovirus). CONCLUSIONS: Electronic messaging to conduct ARI surveillance among pLTCF staff was feasible.

The Potential Impact and Availability of Sexual Health Services During the COVID-19 Pandemic.

As the COVID-19 pandemic causes upheaval in New York City (NYC), 1 consequence is the accessibility of sexual health services. The NYC STD Prevention Training Center at Columbia University administered an online provider survey to understand how the COVID-19 pandemic is affecting the availability of sexual health care services regionally.

The National Network of Sexually Transmitted Disease Clinical Prevention Training Centers Turns 40-A Look Back, a Look Ahead.

Since 1979, the National Network of Sexually Transmitted Disease (STD) Clinical Prevention Training Centers (NNPTC) has provided state-of-the-art clinical and laboratory training for STD prevention across the United States. This article provides an overview of the history and activities of the NNPTC from its inception to present day, and emphasizes the important role the network continues to play in maintaining a high-quality STD clinical workforce. Over time, the NNPTC has responded to changing STD epidemiological patterns, technological advances, and increasing private-sector care-seeking for STDs. Its current structure of integrated regional and national training centers allows NNPTC members to provide dynamic, tailored responses to STD training needs across the country.

Prior antibiotic use and acquisition of multidrug-resistant organisms in hospitalized children: A systematic review.

OBJECTIVE: Multidrug-resistant organisms (MDROs) cause ~5%-10% of infections in hospitalized children, leading to an increased risk of death, prolonged hospitalization, and additional costs. Antibiotic exposure is considered a driving factor of MDRO acquisition; however, consensus regarding the impact of antibiotic factors, especially in children, is lacking. We conducted a systematic review to examine the relationship between antibiotic use and subsequent healthcare-associated infection or colonization with an MDRO in children. DESIGN: Systematic review was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guideline. METHODS: We searched PubMed and Embase for all English, peer-reviewed original research studies published before September 2018. Included studies evaluated hospitalized children, antibiotic use as an exposure, and bacterial MDRO as an outcome. RESULTS: Of the 535 studies initially identified, 29 met the inclusion criteria. Overall, a positive association was identified in most studies evaluating a specific antibiotic exposure (17 of 21, 81%), duration of antibiotics (9 of 12, 75%), and number of antibiotics received (2 of 3, 67%). Those studies that evaluated any antibiotic exposure had mixed results (5 of 10, 50%). Study sites, populations, and definitions of antibiotic use and MDROs varied widely. CONCLUSIONS: Published studies evaluating this relationship are limited and are of mixed quality. Limitations include observation bias in recall of antibiotic exposure, variations in case definitions, and lack of evaluation of antibiotic dosing and appropriateness. Additional studies exploring the impact of antibiotic use and MDRO acquisition may be needed to develop effective antibiotic stewardship programs for hospitalized children.

Physiologically-Based Pharmacokinetic Modeling of Fluconazole Using Plasma and Cerebrospinal Fluid Samples From Preterm and Term Infants.

Fluconazole is used to treat hematogenous Candida meningoencephalitis in preterm and term infants. To characterize plasma and central nervous system exposure, an adult fluconazole physiologically-based pharmacokinetic (PBPK) model was scaled to infants, accounting for age dependencies in glomerular filtration and metabolism. The model was optimized using 760 plasma samples from 166 infants (median postmenstrual age (range) 28 weeks (24-50)) and 27 cerebrospinal fluid (CSF) samples from 22 infants (postmenstrual age 28 weeks (24-33)). Simulations evaluated achievement of the surrogate efficacy target of area under the unbound concentration-time curve ≥ 400 mg • hour/L over the dosing interval in plasma and CSF using dosing guidelines. Average fold error of predicted concentrations was 0.73 and 1.14 for plasma and CSF, respectively. Target attainment in plasma and CSF was reached faster after incorporating a loading dose of 25 mg/kg. PBPK modeling can be useful in exploring CNS kinetics of drugs in children.

An Educational Intervention to Improve Provider Screening for Syphilis Among Men Who Have Sex with Men Utilizing an Urban Urgent Care Center.

Rates of syphilis are increasing in the United States especially among men who have sex with men (MSM). The purpose of this project was to implement an educational intervention based on the 2015 CDC Sexually Transmitted Diseases (STD) Treatment Guidelines for urgent care providers with an emphasis on identifying MSM sexual behavior and appropriate screening for syphilis. An urgent care center was identified as a location where men seek care and where STD testing was occurring. After a baseline provider focus group to identify barriers to STD testing, a patient survey was created and given to clients to increase identification of MSM behaviors and to prompt providers to order syphilis testing. In addition, an educational intervention was implemented to improve provider and staff screening for syphilis. The intervention occurred between September 2015-December 2015. A total of 1341 males were seen with 1067 surveys collected. The mean age was 35.6 and 57.4% were Hispanic. Overall, 72 (5.4%) males identified as MSM. Approximately 50% of all MSM identified had RPRs (n = 37) sent and of these 13.5% (n = 5) tested positive for syphilis. The focus group among urgent care providers and staff identified barriers to syphilis testing. Targeted screening of males using a self-administered questionnaire is acceptable to urgent care populations and may assist in identifying MSM which in turn may help to facilitate syphilis screening and other relevant STI testing pertinent to this population.

Patient-Delivered Expedited Partner Therapy for Chlamydia trachomatis Infection Among Female Adolescents Using School-Based Health Centers.

INTRODUCTION: Expedited partner therapy (EPT) may reduce Chlamydia trachomatis reinfection. This pilot study was conducted to determine if female adolescents with C. trachomatis accept and deliver EPT to male sexual partners and whether it is associated with decreased C. trachomatis reinfection rates at 3 and 6 months. METHOD: Forty-six female adolescents, aged 13 to 19years and diagnosed with C. trachomatis at two urban school-based health centers, participated in four visits over 6 months. Participants completed a self-administered self-efficacy scale and a sexual risk behavior and EPT questionnaire and were retested for C. trachomatis 3 and 6 months after treatment. RESULTS: Overall, 65% accepted EPT, and 73% of those who accepted EPT delivered EPT to their partners. Eighty percent completed the 3-month visit, of these, 30% tested positive for C. trachomatis; 57% completed the 6-month visit, and of these, 15% tested positive for C. trachomatis. Acceptance of EPT was associated with reductions in C.trachomatis reinfection at 3 months (p = .04) but not at 6 months (p = .10). Delivery of EPT was not associated with reductions in C. trachomatis reinfection at 3 or 6 months (p = .08 and p = .44, respectively). Self-efficacy scales did not predict acceptance and delivery of EPT. DISCUSSION: Although two-thirds of participants accepted EPT and acceptance of EPT was associated with reductions in C. trachomatis reinfection at 3 months, rates of reinfection were high. Implications of these findings are limited by the small sample size. Larger studies are needed to understand potential barriers to delivery of EPT.

Meropenem time above the MIC exposure is predictive of response in cystic fibrosis children with acute pulmonary exacerbations.

Meropenem exposures from 15 children (8-17 years old) with cystic fibrosis (CF) acute pulmonary exacerbation were analyzed to define the pharmacodynamic threshold required for a positive response. The primary endpoint was the relative increase in forced expiratory volume in 1 s (↑FEV1) between pre- and posttreatment. Meropenem pharmacodynamic indices (fT > MIC, fAUC/MIC, fCmin/MIC) over the first 24 h were estimated for each participant based on their individual parameter estimates and the isolated pathogen with the highest meropenem MIC. Pseudomonas aeruginosa was the most common pathogen (n = 11/15). The mean ± SD ↑FEV1 was 18.8% ± 11.3% posttreatment. The mean (range) fT > MIC exposure was 63% (0-100%). An Emax model determined a significant relationship between fT > MIC and ↑FEV1 (r2 = 0.8, P < 0.0004). 65% fT > MIC was a significant predictor of response; the median (25th, 75th %) ↑FEV1 was 28.5% (22.2%, 31.7%) in those patients who achieved above 65% fT > MIC and 7.8% (1.1%, 12.6%) in those at or below 65% fT > MIC (P = 0.001). This is the first study in CF children to link meropenem exposure with a positive response as measured by ↑FEV1. Larger studies are required to confirm this exposure threshold.

Antimicrobial stewardship in pediatric post-acute care facilities.

Providers in pediatric post-acute care facilities were surveyed about knowledge of and resources for antimicrobial stewardship. All agreed that antibiotics were overused in such pediatric facilities, but 60% had not implemented stewardship strategies. Lack of treatment guidelines (47%) was identified as the most common barrier to antimicrobial stewardship.

Behavioral Interventions to Reduce Infections in Pediatric Long-term Care Facilities: The Keep It Clean for Kids Trial.

Children in pediatric long-term care facilities (pLTCF) represent a highly vulnerable population and infectious outbreaks occur frequently, resulting in significant morbidity, mortality, and resource use. The purpose of this quasi-experimental trial using time series analysis was to assess the impact of a 4-year theoretically based behavioral intervention on infection prevention practices and clinical outcomes in three pLTCF (288 beds) in New York metropolitan area including 720 residents, ages 1 day to 26 years with mean lengths of stay: 7.9-33.6 months. The 5-pronged behavioral intervention included explicit leadership commitment, active staff participation, work flow assessments, training staff in the World Health Organization "'five moments of hand hygiene (HH)," and electronic monitoring and feedback of HH frequency. Major outcomes were HH frequency, rates of infections, number of hospitalizations associated with infections, and outbreaks. Mean infection rates/1000 patient days ranged from 4.1-10.4 pre-intervention and 2.9-10.0 post-intervention. Mean hospitalizations/1000 patient days ranged from 2.3-9.7 before and 6.4-9.8 after intervention. Number of outbreaks/1000 patient days per study site ranged from 9-24 pre- and 9-18 post-intervention (total = 95); number of cases/outbreak ranged from 97-324 (total cases pre-intervention = 591 and post-intervention = 401). Post-intervention, statistically significant increases in HH trends occurred in one of three sites, reductions in infections in two sites, fewer hospitalizations in all sites, and significant but varied changes in the numbers of outbreaks and cases/outbreak. Modest but inconsistent improvements occurred in clinically relevant outcomes. Sustainable improvements in infection prevention in pLTCF will require culture change; increased staff involvement; explicit administrative support; and meaningful, timely behavioral feedback.