Donor audits in deceased organ donation: a scoping review.

PURPOSE: We sought to collate and summarize existing literature on donor audits (DA) and how they have been used to guide deceased organ donation and transplantation system performance and quality assurance. SOURCE: We searched MEDLINE, Cumulative Index of Nursing and Allied Health Literature, and Web of Science supplemented by Google to identify grey literature on 6 May 2022, to locate studies in English, French, and Spanish. The data were screened, extracted, and analyzed independently by two reviewers. We grouped the results into five categories: 1) motivation for DA, 2) DA methodology, 3) potential and actual donors, 4) missed donation opportunities, and 5) quality improvement. PRINCIPAL FINDINGS: The search yielded 2,416 unique publications and 52 were included in this review. Most studies were from the UK (n = 13) and published between 2001 and 2006 (n = 15). The methodologies described for DA were diverse. Our findings showed that the primary motivation for conducting DA was to identify potential donors and the number of potential deceased organ donors is significantly higher than the number of actual donors. Among retrieved studies, the proportion of donation opportunities following neurologic determination of death was 95/222 (43%) compared with 25/181 (14%) for donation after cardiocirculatory death (DCD), suggesting that the missed donation rate is higher for DCD. CONCLUSION: Donor audits help identify missed donation opportunities along the deceased donation pathway and can help support the evaluation of quality improvement initiatives.

RéSUMé: OBJECTIF: Nous avons cherché à colliger et résumer la documentation existante sur les vérifications des donneuses et donneurs (VD) et la façon dont elles ont été utilisées pour guider la performance et l'assurance de la qualité des systèmes de don et de transplantation d'organes de personnes décédées. SOURCES: Le 6 mai 2022, nous avons effectué des recherches dans MEDLINE, CINAHL et Web of Science, complétées par des recherches sur Google afin d'identifier la littérature grise et de localiser les études en anglais, en français et en espagnol. Les données ont été examinées, extraites et analysées de manière indépendants par deux personnes. Nous avons regroupé les résultats en cinq catégories : 1) motivation pour la VD, 2) méthodologie de la VD, 3) donneurs et donneuses potentiel·les et réel·les, 4) occasions de dons manquées, et 5) amélioration de la qualité. CONSTATATIONS PRINCIPALES: Notre recherche nous a permis de découvrir 2416 publications uniques et 52 ont été incluses dans cette revue. La plupart des études provenaient du Royaume-Uni (n = 13) et avaient été publiées entre 2001 et 2006 (n = 15). Les méthodologies décrites pour la vérification des donneuses et donneurs étaient diverses. Nos résultats ont montré que la principale motivation pour mener une VD était d'identifier des donneurs et donneuses potentiel·les et que le nombre potentiel de donneuses et donneurs d'organes après le décès était significativement plus élevé que le nombre réel. Parmi les études retenues, la proportion d'occasions de dons après un diagnostic de décès neurologique était de 95/222 (43 %), comparativement à 25/181 (14 %) pour le don après un décès cardiocirculatoire (DDC), ce qui suggère que le taux de dons manqués est plus élevé pour le DDC. CONCLUSION: Les vérifications des donneuses et donneurs aident à identifier les occasions de dons manquées le long du parcours de don après un décès et peuvent aider à soutenir l'évaluation des initiatives d'amélioration de la qualité.

Canadian organ donation organizations' donor audit processes: an environmental scan.

PURPOSE: Deceased donor audits (DAs) allow organ donation and transplantation systems to measure and analyze missed donation opportunities (MDOs). Missed donation opportunities can harm both patients/families denied the opportunity to donate and patients on transplant waitlists denied access to lifesaving organs. In Canada, there are no national standards for DAs, data analysis, nor accountability processes surrounding MDOs. Understanding DA current practice in each jurisdicton would facilitate developing a national strategy for DAs. METHOD: All provincial organ donation organizations (ODOs) were invited to participate in an environmental scan (ES) of current DA practices. The two ES phases were an electronic survey followed by semistructured interviews. We collected information about the objectives, frequency, scope, data collection methodology, resources required, definitions/metrics used, and process for reporting outcomes. RESULTS: All eleven ODOs participated in both phases of the ES (July and October 2019). The primary purposes for conducting DAs were to estimate the following: 1) donor potential (5/11, 45%); 2) system performance at the provincial level (3/11, 27%); and 3) system performance at the hospital level (3/11, 27%). Frequency of DAs varied from weekly to annually, depending on the availability of death reports, urban vs rural setting, and staffing. High variability was observed in DA methodology, donor definitions, and metrics across jurisdictions. CONCLUSION: There is significant variability across Canadian ODOs in the methodology, definitions, timeliness, data collection, and reporting of DAs. This underscores the need for a national donor audit strategy to reduce preventable harm from MDOs to patients/families at end of life and those on transplant waitlists.

RéSUMé: OBJECTIF: Les vérifications des donneurs et donneuses décédé·es permettent aux systèmes de dons et de transplantations d'organes de mesurer et d'analyser les occasions de dons manquées. Les occasions de don manquées peuvent nuire à la fois aux patient·es et aux familles qui se voient refuser la possibilité de faire un don et à la patientèle inscrite sur les listes d'attente pour une greffe qui se voit refuser l'accès à des organes vitaux. Au Canada, il n'existe pas de normes nationales pour les vérifications de donneurs et donneuses, ni pour l'analyse des données ou les processus de responsabilisation entourant les occasions de dons manquées. L'élaboration d'une stratégie nationale pour les vérifications des donneurs et donneuses serait facilitée par la compréhension des pratiques actuelles de vérification de chaque territoire. MéTHODE: Tous les organismes provinciaux de don d'organes (ODO) ont été invités à participer à une analyse environnementale des pratiques actuelles en matière de vérification des donneurs et donneuses. Les deux phases de l'analyse environnementale consistaient en un sondage électronique suivi d'entrevues semi-structurées. Nous avons recueilli des informations sur les objectifs, la fréquence, la portée, la méthodologie de collecte de données, les ressources requises, les définitions/paramètres utilisés et le processus de communication des résultats. RéSULTATS: Les onze ODO ont participé aux deux phases de l'analyse environnementale (juillet et octobre 2019). Les principaux objectifs des vérifications de donneurs et donneuses étaient d'estimer ce qui suit : 1) le potentiel de donneur ou donneuse (5/11, 45 %); 2) le rendement du système à l'échelle provinciale (3/11, 27 %); et 3) le rendement du système au niveau hospitalier (3/11, 27 %). La fréquence des vérifications variait d'une fois par semaine à une fois par année, selon la disponibilité des déclarations de décès, le milieu urbain vs rural, et la dotation en personnel. Une grande variabilité a été observée dans la méthodologie de vérification, les définitions de donneur/donneuse et les paramètres entre les territoires des ODO. CONCLUSION: Il existe une grande variabilité entre les ODO canadiens en ce qui concerne la méthodologie, les définitions, la rapidité, la collecte de données et la production de rapports sur les vérifications des donneurs et donneuses. Cela souligne la nécessité d'une stratégie nationale de vérification des donneurs et donneuses pour réduire les préjudices évitables causés par les occasions de dons manquées aux patient·es/familles en fin de vie et aux personnes sur les listes d'attente pour une transplantation.

Preventable harm in the Canadian organ donation and transplantation system: a descriptive study of missed organ donor identification and referral.

PURPOSE: Deceased organ donation is predicated on timely identification and referral (IDR) of potential organ donors. Many Canadian provinces have legislated mandatory referral of potential deceased donors. Untimely or missed IDRs are safety events where best or expected practice has not occurred causing preventable harm to patients and denying families the opportunity of donation at end of life (EOL) as well as denying transplant waitlist patients access to lifesaving organs. METHODS: We requested donor definitions and data to calculate IDR, consent, and approach rates from all Canadian organ donation organizations (ODOs) for 2016-2018. We then estimated the number of missed IDR patients who were eligible for approach (safety events) and the associated preventable harm to patients at EOL and on transplant waitlists. RESULTS: Annually, there were 63-76 missed IDR patients eligible for approach (3.6-4.5 per million population [PMP]) from four ODOs-three with mandatory referral legislation. Applying each ODO's approach and consent rates for the corresponding year, there were 37-41 missed donors (2.4 donor PMP) annually. Assuming three transplants per donor, the theoretical number of missed transplants would be 111-123 (6.4-7.3 transplants PMP) annually. CONCLUSIONS: Data from four Canadian ODOs show that missed IDR safety events resulted in important preventable harm measured by a lost opportunity for donation of 2.4 donors PMP annually and 354 potentially missed transplants between 2016 and 2018. Given that 223 patients died on Canada's waitlist in 2018, national donor audits and quality improvement initiatives to optimize IDR are essential to reduce preventable harm to these vulnerable populations.

RéSUMé: OBJECTIF: Le don d'organes provenant de personnes décédées repose sur l'identification et l'aiguillage en temps opportun des donneurs d'organes potentiels. De nombreuses provinces canadiennes ont légiféré sur l'aiguillage obligatoire des donneurs potentiels décédés. Les identifications et aiguillages inopportuns ou manqués constituent des événements liés à la sécurité pour lesquels la meilleure pratique ou la pratique attendue n'a pas eu lieu, causant des préjudices évitables aux patients et privant les familles de la possibilité de faire un don en fin de vie, tout en refusant aux patients inscrits sur une liste d'attente de greffe un accès à des organes vitaux. MéTHODE: Nous avons demandé les définitions et les données sur les donneurs pour calculer les taux d'identification et d'aiguillage, de consentement et d'approche de tous les organismes canadiens de don d'organes (ODO) pour la période de 2016-2018. Nous avons ensuite estimé le nombre de patients n'ayant pas été identifiés et aiguillés mais qui étaient admis à être approchés (événements liés à la sécurité) et les préjudices évitables aux patients en fin de vie et sur les listes d'attente pour une greffe. RéSULTATS: Chaque année, l'identification et l'aiguillage a échoué pour 63 à 76 patients éligibles (3,6 à 4,5 par million d'habitants [PMH]) dans quatre ODO ­ dont trois possédant une législation rendant l'aiguillage obligatoire. En appliquant l'approche et les taux de consentement de chaque ODO pour l'année correspondante, on a constaté qu'il y avait de 37 à 41 donneurs manqués (2,4 donneurs PMH) chaque année. En supposant trois greffes par donneur, le nombre théorique de greffes manquées serait de 111 à 123 (6,4 à 7,3 greffes PMH) par an. CONCLUSION : Les données de quatre ODO canadiens montrent que les événements de sécurité liés à une identification et un aiguillage manqués ont entraîné d'importants préjudices évitables, mesurés par une occasion perdue de donner pour 2,4 donneurs PMH chaque année et 354 greffes potentiellement manquées entre 2016 et 2018. Étant donné que 223 patients sont décédés sur la liste d'attente du Canada en 2018, les vérifications nationales des donneurs et les initiatives d'amélioration de la qualité visant à optimiser l'identification et l'aiguillage sont essentielles pour réduire les préjudices évitables causés à ces populations vulnérables.

Antimicrobial Stewardship in Bronchiolitis: A Retrospective Cohort Study of Three PICUs in Canada.

OBJECTIVES: To determine the association between the implementation of an antimicrobial stewardship program at a local PICU and to determine the association between the presence of an antimicrobial stewardship programs and antimicrobial use across three Canadian PICUs, among critically ill children with bronchiolitis. DESIGN: A multicenter retrospective cohort study. SETTING: Three Canadian PICUs over two winter seasons. INTERVENTIONS: An antimicrobial stewardship program was implemented at PICU 1 at the end of season 1. PATIENTS: Patients less than or equal to 2 years old admitted with bronchiolitis. MEASUREMENTS AND MAIN RESULTS: We used regression models with an interaction term between site (PICU 1 and PICU 2) and season (1 and 2) as the primary analysis to determine the association between implementation of an antimicrobial stewardship program at PICU 1 and 1) the proportion of antimicrobials discontinued 72 hours after hospital admission (logistic regression), 2) antimicrobial treatment duration (negative binomial regression), and 3) antimicrobial prescriptions within 48 hours of hospital admission (logistic regression). As a secondary analysis, we determined the association between having an antimicrobial stewardship program present and the aforementioned outcomes across the three PICUs. A total of 372 patients were included. During seasons 1 and 2, median age was 2.2 months (interquartile range, 1.2-6.2 mo) and 2.1 months (interquartile range, 1.3-6.8 mo), respectively. Among patients with viral bronchiolitis, implementation of an antimicrobial stewardship program at PICU 1 was associated with increased odds of discontinuing antimicrobials (odds ratio, 25.63; 95% CI, 2.86-326.29), but not with antimicrobial duration (odds ratio, 0.56; 95% CI, 0.31-1.02) or antimicrobial prescriptions (odds ratio, 0.33; 95% CI, 0.10-1.04). The presence of an antimicrobial stewardship program was similarly associated with antimicrobial discontinuation among patients with viral bronchiolitis (odds ratio, 20.79; 95% CI, 2.46-244.92), but not with antimicrobial duration (odds ratio, 0.57; 95% CI, 0.32-1.03) or antimicrobial prescriptions (odds ratio, 0.37; 95% CI, 0.12-1.11). CONCLUSIONS: Antimicrobial stewardship programs were associated with increased likelihood of discontinuing antimicrobial treatments in the PICU patients with viral bronchiolitis. However, larger studies are needed to further determine the role of an antimicrobial stewardship programs in reducing unnecessary antimicrobial use in this patient population.

International Survey on Determinants of Antibiotic Duration and Discontinuation in Pediatric Critically Ill Patients.

OBJECTIVES: We hypothesized that antibiotic use in PICUs is based on criteria not always supported by evidence. We aimed to describe determinants of empiric antibiotic use in PICUs in eight different countries. DESIGN: Cross-sectional survey. SETTING: PICUs in Canada, the United States, France, Italy, Saudi Arabia, Japan, Thailand, and Brazil. SUBJECTS: Pediatric intensivists. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: We used literature review and focus groups to develop the survey and its clinical scenarios (pneumonia, septic shock, meningitis, and intra-abdominal infections) in which cultures were unreliable due to antibiotic pretreatment. Data analyses included descriptive statistics and linear regression with bootstrapped SEs. Overall response rate was 39% (482/1,251), with individual country response rates ranging from 25% to 76%. Respondents in all countries prolonged antibiotic duration based on patient characteristics, disease severity, pathogens, and radiologic findings (from a median increase of 1.8 d [95% CI, 0.5-4.0 d] to 9.5 d [95% CI, 8.5-10.5 d]). Younger age, severe disease, and ventilator-associated pneumonia prolonged antibiotic treatment duration despite a lack of evidence for such practices. No variables were reported to shorten treatment duration for all countries. Importantly, more than 39% of respondents would use greater than or equal to 7 days of antibiotics for patients with a positive viral polymerase chain reaction test in all scenarios, except in France for pneumonia (29%), septic shock (13%), and meningitis (6%). The use of elevated levels of inflammatory markers to prolong antibiotic treatment duration varied among different countries. CONCLUSIONS: Antibiotic-related decisions are complex and may be influenced by cultural and contextual factors. Evidence-based criteria are necessary to guide antibiotic duration and ensure the rational use of antibiotics in PICUs.

Can biomarkers improve the rational use of antibiotics?

PURPOSE OF REVIEW: We aim to review recent literature about the use of biomarkers to guide the initiation and duration of antibiotic treatments for suspected bacterial infections. RECENT FINDINGS: Several good quality meta-analyses show that procalcitonin can be safely used to guide antibiotic-related decisions, especially for respiratory infections, thereby decreasing unnecessary antibiotic exposure. Furthermore, the use of CRP-based algorithms to guide antibiotic initiation in primary care patients with acute respiratory infections is associated with a reduction in antibiotic use without an increase in adverse events. Regarding neutrophil CD64 and serum amyloid A, more good-quality evidence is needed to assess their utility as biomarkers to tailor antibiotic use. Finally, transcriptomics, metabolomics and proteomics are promising tools for the development of tests to differentiate specific host responses to viral, bacterial and noninfectious stimuli, but such tests still need further validation. SUMMARY: Evidence shows that the use of biomarkers, procalcitonin and CRP, can safely reduce unnecessary antibiotic prescriptions in certain infectious syndromes. The clinical utility of host-based strategies such as transcriptomics, metabolomics and proteomics for the diagnosis of infectious diseases has yet to be evaluated, as well as considerations such as costs, technical complexity and result turnaround time.

Incidence and risk factors for recurrent Clostridioides difficile infection in pediatric at-risk groups in selected Pediatric Investigators Collaborative Network on Infections in Canada (PICNIC) hospitals.

OBJECTIVES: Incidence and risk factors for recurrent Clostridioides difficile infection (rCDI) are well established in adults, though data are lacking in pediatrics. We aimed to determine incidence of and risk factors for rCDI in pediatrics. METHODS: This retrospective cohort study of pediatric patients was conducted at 3 tertiary-care hospitals in Canada with laboratory-confirmed CDI between April 1, 2012, and March 31, 2017. rCDI was defined as an episode of CDI occurring 8 weeks or less from diagnostic test date of the primary episode. We used logistic regression to determine and quantify risk factors significantly associated with rCDI. RESULTS: In total, 286 patients were included in this study. The incidence proportion for rCDI was 12.9%. Among hospitalized patients, the incidence rate was estimated at 2.6 cases of rCDI per 1,000 hospital days at risk (95% confidence interval [CI], 1.7-3.9). Immunocompromised patients had higher incidence of rCDI (17.5%; P = .03) and higher odds of developing rCDI independently of antibiotic treatment given for the primary episode (odds ratio [OR], 2.31; 95% CI, 1.12-5.09). Treatment with vancomycin monotherapy did not show statistically significant protection from rCDI, independently of immunocompromised status (OR, 0.33; 95% CI, 0.05-1.15]). CONCLUSIONS: The identification of increased risk of rCDI in immunocompromised pediatric patients warrants further research into alternative therapies, prophylaxis, and prevention strategies to prevent recurrent disease burden within these groups. Treatment of the initial episode with vancomycin did not show statistically significant protection from rCDI.

Bronchiolitis Management and Unnecessary Antibiotic Use Across 3 Canadian PICUs.

OBJECTIVES: To describe the patient characteristics, clinical management, and infectious etiology in critically ill children with bronchiolitis. The secondary objective was to determine the association between antibiotic use and hospital length of stay among patients without concomitant bacterial infections. METHODS: Retrospective cohort study including patients ≤2 years old with bronchiolitis admitted to 3 Canadian pediatric intensive care units between 2016 and 2018. RESULTS: We included 372 patients with a median age of 2.1 months (interquartile range 1.2-6.6) and Pediatric Risk of Mortality III score 3.0 (interquartile range 0-3.0). Initial ventilatory management included high flow nasal cannula (28.2%) and noninvasive positive pressure ventilation (53.7%), of which 41.9% and 87.5%, respectively, did not require escalation of ventilatory support. Chest radiographs (81.7%) and respiratory virus testing (95.4%) were performed in most patients; 14.0% received systemic steroids. Respiratory syncytial virus was detected in 61.3% patients, and 7.5% had a culture-positive concomitant bacterial infection. Of 258 (69.4%) patients with a viral infection, only 45.3% received antibiotics. In this group, antibiotic use beyond 72 hours was not associated with hospital length of stay (ratio 1.14, 95% confidence interval 0.97-1.34). CONCLUSIONS: High flow nasal canulae and noninvasive ventilation are commonly used in severe bronchiolitis. Despite contrary evidence, steroids and antibiotics were also frequently used. Evidence-based guidelines specific to children with severe bronchiolitis are needed to improve the care delivered to this patient population.

Evaluation of antibiotic treatment decisions in pediatric intensive care units in Saudi Arabia: A national survey.

OBJECTIVE: To describe variables used by Saudi pediatric intensivists to make antibiotic-related decisions for children with suspected severe bacterial infections. METHODS: We conducted a cross-sectional survey, which was developed using a multi-step methodological approach. The survey included 4 clinical scenarios of the most relevant bacterial infections in pediatric critical care (pneumonia, sepsis, meningitis and intra-abdominal infection). The potential determinants of antibiotic treatment duration addressed in all scenarios included clinical variables (patient characteristics, disease severity), laboratory infection markers, radiologic findings, and pathogens. RESULTS: The response rate was 65% (55/85). Eight variables (immunodeficiency, 3 months of age, 2 or more organ dysfunctions, Pediatric Risk of Mortality III score >10, leukocytosis, elevated C-reactive protein [CRP], elevated erythrocyte sedimentation rate [ESR], and elevated procalcitonin [PCT]) were associated with prolonging antibiotic treatment duration for all 4 clinical scenarios, with a median increase ranging from 3.0 days (95% confidence interval [CI] 0.5, 3.5, leukocytosis) to 8.8 days (95% CI 5.5, 10.5, immunodeficiency). There were no variables that were consistently associated with shortening antibiotic duration across all scenarios. Lastly, the proportion of physicians who would continue antibiotics for ≥5 days despite a positive viral polymerase chain reaction test result was 67% for pneumonia, 85% for sepsis, 63% for meningitis, and 95% for intra-abdominal infections. CONCLUSION: Antibiotic-related decisions for critically ill patients are complex and depend on several factors. Saudi pediatric intensivists will use prolonged courses of antibiotics for younger patients, patients with severe clinical picture, and patients with persistently elevated laboratory markers and hospital acquired infections, even when current literature and guidelines do not suggest such practices. Antimicrobial stewardship programs should include interventions to address these misconceptions to ensure the rational use of antibiotics in pediatric intensive care units.

Improving transparent team communication with the 'Glass Door' decal communication tool: a mixed methods analysis of family and staff perspectives.

OBJECTIVE: To determine the value and perspectives of intensive care unit (ICU) healthcare professionals (HCPs) and families about the Glass Door (GD) decal team communication tool. DESIGN: Quality improvement methodology was used to design, test and implement the GD. Uptake was measured through audit. Impact was assessed through mixed methodology (survey of ICU HCPs (n=96) and semi-structured interviews of HCPs (n=10) and families (n=7)). SETTING: Eighteen bed, closed, mixed medical-surgical-cardiac ICU in a tertiary care, university-affiliated, paediatric hospital. POPULATION: Interdisciplinary ICU HCPs and families of children admitted to the ICU. INTERVENTION: A transparent template (the GD) applied to the outside of ICU patients' doors with sections for HCPs names, physiological goals and planned tests and treatments for the day. Medical staff completed the GD in rounds (AM and PM) and any HCP caring for the patient updated it throughout the day. MEASUREMENTS AND MAIN RESULTS: After 3 months, 96% of 613 doors were employed of which 99% respected confidentiality. ICU HCPs reported improved understanding of the patient's plan (84% today vs 59% pre-GD, p<0.001) and sense that families were up-to-date (79% today vs 46% pre-GD, p<0.001). Based on semi-structured interviews, the GD promoted a shared understanding of the plan contributing to care continuity. The GD reassured families the team is working together and fostered family engagement in the care. Routine family experience surveys showed no change in families' sense of privacy during admission; families denied the GD's anticipated compromise of confidentiality. CONCLUSIONS: The GD decal communication tool, visible on the patient's door, improved ICU HCPs' perceived knowledge of their patient's plan. The GD improved the shared mental model, facilitated teaching and information transfer and fostered family engagement. Challenges included knowing the rules for use and consistent application. Concerns initially raised by HCPs about confidentiality were denied by families.

Efficacy and Effectiveness of the PCV-10 and PCV-13 Vaccines Against Invasive Pneumococcal Disease.

CONTEXT: Pneumococcal conjugate vaccines (PCVs) (pneumococcal 13-valent conjugate vaccine [PCV-13] and pneumococcal 10-valent conjugate vaccine [PCV-10]) are available for prevention of pneumococcal infections in children. OBJECTIVE: To determine the vaccine effectiveness (VE) of PCV-13 and PCV-10 in preventing invasive pneumococcal disease (IPD) and acute otitis media (AOM) in children <5 years. DATA SOURCES: Systematic searches of Medline, Embase, Cumulative Index to Nursing and Allied Health Literature, Web of Science, and Cochrane. STUDY SELECTION: Eligible studies examined the direct effectiveness and/or efficacy of PCV-10 and PCV-13 in reducing the incidence of disease in healthy children <5 years. DATA EXTRACTION: Two reviewers independently conducted data extraction and methodologic quality assessment. RESULTS: Significant effectiveness against vaccine-type IPD in children ≤5 years was reported for ≥1 dose of PCV-13 in the 3 + 1 (86%-96%) and 2 + 1 schedule (67.2%-86%) and for PCV-10 for the 3 + 1 (72.8%-100%) and 2 + 1 schedules (92%-97%). In children <12 months of age, PCV-13 VE against serotype 19A post-primary series was significant for the 3 + 1 but not the 2 + 1 schedule. PCV-10 crossprotection against 19A was significant in children ≤5 years with ≥1 dose (82.2% and 71%). Neither PCVs were found effective against serotype 3. PCV-13 was effective against AOM (86%; 95% confidence interval [CI]: 61 to 94). PCV-10 was effective against clinically defined (26.9%; 95% CI: 5.9 to 43.3) and bacteriologically confirmed AOM (43.3%; 95% CI: 1.7 to 67.3). LIMITATIONS: Because of the large heterogeneity in studies, a meta-analysis for pooled estimates was not done. CONCLUSIONS: Both PCVs afford protection against pneumococcal infections, with PCV-10 protecting against 19A IPD, but this VE has not been verified in the youngest age groups.

Determinants of under-immunization and cumulative time spent under-immunized in a Quebec cohort.

BACKGROUND: Under-immunization refers to a state of sub-optimal protection against vaccine preventable diseases. Vaccine coverage for age may not capture intentional or non-intentional spacing of vaccines in the recommended provincial immunization guidelines. We aimed to identify factors associated with coverage and under-immunization and to determine the number of days during which children were under-immunized during their first 24months of life. METHODS: Secondary analysis of children ≤3years recruited through active surveillance for gastroenteritis from three Quebec pediatric emergency departments from 2012 to 2014. Vaccination status for children at least 24months of age was determined using provincial immunization guidelines. Cumulative days under-immunized were calculated for DTaP-VPI-Hib, PCV, MMR, and Men-C-C. Factors associated with up-to-date (UTD) status at 24months of life and for under-immunization ≥6months were analyzed using logistic regression. RESULTS: Of 246 eligible children, 180 (73%) were UTD by 24months of life. The mean cumulative days under-immunized for MMR was 107days, for PCV 209days, for Men-C-C 145days, and for DTaP-VPI-Hib 227days. Overall, 149 children (60%) experienced delay for at least 1 vaccine. Factors associated with both an UTD status at 24months and concurrently associated with being under-immunization ≥6months, included timely initiation of immunization (OR=5.85; 95% CI: 2.80-12.22) and (OR=0.13; 95% CI: 0.07-0.24), failure to co-administer 18-month vaccines (OR=0.15; 95% CI: 0.10-0.21) and (OR=3.29; 95% CI: 2.47-4.39), and having a household with ≥3 children under 18years ((OR=0.50; 0.28-0.86) and (OR=2.99; 1.45-6.22), respectively. CONCLUSION: Paired with an unexpected low level of coverage at 24months of life, the majority of our cohort also experienced a state of under-immunization for a least one vaccine. Estimates of coverage do not capture intentional or non-intentional gaps in protection from vaccine preventable illnesses. Timely preventive care should be prioritized.

The effectiveness of pneumococcal polysaccharide vaccine 23 (PPV23) in the general population of 50 years of age and older: A systematic review and meta-analysis.

UNLABELLED: Two pneumococcal vaccines currently exist and have been recommended for the prevention of pneumococcal infection in adults 65 years of age and older: the 23-valent polysaccharide (PPV23) and the conjugate 13-valent (PCV13) vaccine. OBJECTIVE: To evaluate and summarize the results from all studies reporting on the vaccine effectiveness of PPV23 in preventing invasive pneumococcal disease (IPD) and community-acquired pneumonia (CAP) in individuals over the age of 50. METHODS: Systematic database searches were completed in PubMed, Medline, Embase, CINAHL, Web of Science, and Cochrane. Google Scholar and hand searches of seminal articles and past systematic reviews were employed. Studies were included if they independently evaluated the effect of PPV23 on IPD and/or CAP in adults (50+). Data extraction and quality assessment were both completed independently by two researchers. Quality was assessed using the National Advisory Committee on Immunization methodology for quality assessment. All conflicts were resolved by consensus. RESULTS: The vaccine effectiveness for PPV23 in preventing IPD was 50% (95% CI: 21%-69%) for cohort studies and 54% (95% CI: 32%-69%) for case-control studies. The VE estimates for CAP were 4% (95% CI: -26%-26%) for trials, 17% (95% CI: -26%-45%) for cohort studies, and 7% (95% CI: -10%-21%) for case-control studies. CONCLUSIONS: The vaccine effectiveness of PPV23 in preventing IPD and all-cause CAP was consistent with past systematic reviews and similar to the estimates that were reported in the CAPiTA trial evaluating the vaccine effectiveness of PCV13. Consistent benefits were also reported across ecological studies and reports of surveillance data for the general population 50 years and older. The results suggests that the current practice of vaccinating the adults 65 years of age and older with PPV23 would have similar benefits to PCV13 in preventing potential cases of all-serotype IPD and all-cause CAP.

CLABSI Risk Factors in the NICU: Potential for Prevention: A PICNIC Study.

OBJECTIVE Central-line-associated bloodstream infections (CLABSI) are an important cause of morbidity and mortality in neonates. We aimed to determine whether intra-abdominal pathologies are an independent risk factor for CLABSI. METHODS We performed a retrospective matched case-control study of infants admitted to the neonatal intensive care units (NICUs) of the Montreal Children's Hospital (Montreal) and the Royal Alexandra Hospital, Edmonton, Canada. CLABSI cases that occurred between April 2009 and March 2014 were identified through local infection control databases. For each case, up to 3 controls were matched (National Healthcare Safety Network [NHSN] birth weight category, chronological age, and central venous catheter (CVC) dwell time at the time of CLABSI onset). Data were analyzed using conditional logistic regression. RESULTS We identified 120 cases and 293 controls. According to a matched univariate analysis, the following variables were significant risk factors for CLABSI: active intra-abdominal pathology (odds ratio [OR], 3.4; 95% confidence interval [CI], 1.8-6.4), abdominal surgery in the prior 7 days (OR, 3.5; 95% CI, 1.0-10.9); male sex (OR, 1.7; 95% CI, 1.1-2.6) and ≥3 heel punctures (OR, 4.0; 95% CI, 1.9-8.3). According to a multivariate matched analysis, intra-abdominal pathology (OR, 5.9; 95% CI, 2.5-14.1), and ≥3 heel punctures (OR, 5.4; 95% CI, 2.4-12.2) remained independent risk factors for CLABSI. CONCLUSION The presence of an active intra-abdominal pathology increased the risk of CLABSI by almost 6-fold. Similar to CLABSI in oncology patients, a subgroup of CLABSI with mucosal barrier injury should be considered for infants in the NICU with active intra-abdominal pathology. Infect Control Hosp Epidemiol 2016;1446-1452.