Impact of Organism Reporting from Endotracheal Aspirate Cultures on Antimicrobial Prescribing Practices in Mechanically Ventilated Pediatric Patients.

Endotracheal aspirate cultures (EACs) help diagnose lower respiratory tract infections in mechanically ventilated patients but are limited by contamination with normal microbiota and variation in laboratory reporting. Increased use of EACs is associated with increased antimicrobial prescribing, but the impact of microbiology reporting on prescribing practices is unclear. This study was a retrospective analysis of EACs from mechanically ventilated patients at Children's Hospital Colorado (CHCO) admitted between 1 January 2019 and 31 December 2019. Chart review was performed to collect all culture and Gram stain components, as well as antibiotic use directed to organisms in culture. Reporting concordance was determined for each organism using American Society for Microbiology guidelines. Days of therapy were calculated for overreported and guideline-concordant organisms. A multivariable model was used to assess the relationship between organism reporting and total days of therapy. Overall, 448 patients with 827 EACs were included in this study. Among patients with tracheostomy, 25 (8%) organisms reported from EACs were overreported and contributed 48 days of excess therapy, while 227 (29%) organisms from the EACs of endotracheally intubated patients were overreported, contributing 472 excess days of therapy. After adjustment, organism overreporting was associated with a >2-fold-higher rate of antimicrobial therapy than guideline-concordant reporting (incident rate ratio [IRR], 2.83; 95% confidence interval [CI], 1.23, 6.53; P < 0.05). Overreported organisms from respiratory cultures contribute to excess antimicrobial therapy exposure in mechanically ventilated patients. Microbiology laboratories have an opportunity to mitigate antimicrobial overuse through standardized reporting practices.

The Pediatric Endotracheal Aspirate Culture Survey (PETACS): Examining Practice Variation across Pediatric Microbiology Laboratories in the United States.

In the absence of evidence-based laboratory guidelines, the workup and interpretation of tracheal aspirate (TA) cultures remains controversial and confusing within the fields of clinical microbiology, infectious diseases, and critical care. Between 22 January and 24 February 2020, we conducted a national, web-based survey of microbiology laboratory personnel in free-standing pediatric hospitals and adult hospitals containing pediatric facilities regarding the laboratory practices used for TA specimens. We hypothesized there would be substantial center-level variability in laboratory processing of TA cultures. The response rate for the survey was 48% (73/153). There was a high level of variability in the criteria used for all processes, including specimen receipt, Gram staining, and culture reporting. Most respondents (77%) reported they do not reject TA specimens based on Gram stain criteria, and 44% of labs do not require that a minimum number of Gram stain fields be reviewed prior to reporting results. Overall, nonacademic hospital laboratories and pediatric-only laboratories are more likely to identify, report, and perform susceptibility testing on organisms from TA cultures, regardless of organism quantity or predominance. There is a substantial amount of process variability among pediatric microbiology laboratories that affects TA culture reporting, and which guides treatment decisions. This variation within and among labs makes clinical outcome studies related to TA cultures difficult to interpret. This study serves as a pragmatic step in informing the development of robust clinical guidelines. Clinical outcome and implementation studies are necessary to determine the effectiveness of guidelines for TA cultures.

Under-immunization of pediatric transplant recipients: a call to action for the pediatric community.

Vaccine-preventable infections (VPIs) are a common and serious complication following transplantation. One in six pediatric solid organ transplant recipients is hospitalized with a VPI in the first 5 years following transplant and these hospitalizations result in significant morbidity, mortality, graft injury, and cost. Immunizations are a minimally invasive, cost-effective approach to reducing the incidence of VPIs. Despite published recommendations for transplant candidates to receive all age-appropriate immunizations, under-immunization remains a significant problem, with the majority of transplant recipients not up-to-date on age-appropriate immunizations at the time of transplant. This is extremely concerning as the rate for non-medical vaccine exemptions in the United States (US) is increasing, decreasing the reliability of herd immunity to protect patients undergoing transplant from VPIs. There is an urgent need to better understand barriers to vaccinating this population of high-risk children and to develop effective interventions to overcome these barriers and improve immunization rates. Strengthened national policies requiring complete age-appropriate immunization for non-emergent transplant candidates, along with improved multi-disciplinary immunization practices and tools to facilitate and ensure complete immunization delivery to this high-risk population, are needed to ensure that we do everything possible to prevent infectious complications in pediatric transplant recipients.

A community divided: Post-transplant live vaccine practices among Society of Pediatric Liver Transplantation (SPLIT) centers.

BACKGROUND: Historically, the IDSA and the AST have recommended that live vaccines not be administered post-transplant due to concern for induction of vaccine-strain disease in immunocompromised hosts. However, recent prospective studies and revised AST guidelines published in April 2019 suggest that in the current era of immunosuppression minimization, live vaccines may be safely administered to select transplant recipients with resulting immunoprotection. The goal of this study was to assess current post-transplant live vaccine practices at individual pediatric liver transplant centers following the updated AST guidelines. METHODS: A six-item email survey detailing center-specific post-transplant live vaccine practices followed by up to three response-specific questions were distributed between July 2019 and May 2020 to a representative from each center participating in the SPLIT consortium. RESULTS: The overall survey response rate was 93% (41/44 centers). Only 29% (12/41) of centers offer live vaccines post-transplant; each of these 12 centers uses different eligibility criteria for live vaccines. There was no difference between large (ten or more transplants per year) and small (less than ten transplants per year) centers in likelihood to offer live vaccines post-transplant. The main reasons for a center not offering post-transplant live vaccines were safety concerns and inability to reach group consensus. CONCLUSIONS: The majority of pediatric liver transplant centers are reluctant to offer live vaccines post-transplant despite the updated AST guidelines. Prospective multicenter studies are needed to confirm safety and immunogenicity of live vaccines post-transplant.

Recommendations for Methicillin-Resistant Staphylococcus aureus Prevention in Adult ICUs: A Cost-Effectiveness Analysis.

OBJECTIVE: Patients in the ICU are at the greatest risk of contracting healthcare-associated infections like methicillin-resistant Staphylococcus aureus. This study calculates the cost-effectiveness of methicillin-resistant S aureus prevention strategies and recommends specific strategies based on screening test implementation. DESIGN: A cost-effectiveness analysis using a Markov model from the hospital perspective was conducted to determine if the implementation costs of methicillin-resistant S aureus prevention strategies are justified by associated reductions in methicillin-resistant S aureus infections and improvements in quality-adjusted life years. Univariate and probabilistic sensitivity analyses determined the influence of input variation on the cost-effectiveness. SETTING: ICU. PATIENTS: Hypothetical cohort of adults admitted to the ICU. INTERVENTIONS: Three prevention strategies were evaluated, including universal decolonization, targeted decolonization, and screening and isolation. Because prevention strategies have a screening component, the screening test in the model was varied to reflect commonly used screening test categories, including conventional culture, chromogenic agar, and polymerase chain reaction. MEASUREMENTS AND MAIN RESULTS: Universal and targeted decolonization are less costly and more effective than screening and isolation. This is consistent for all screening tests. When compared with targeted decolonization, universal decolonization is cost-saving to cost-effective, with maximum cost savings occurring when a hospital uses more expensive screening tests like polymerase chain reaction. Results were robust to sensitivity analyses. CONCLUSIONS: As compared with screening and isolation, the current standard practice in ICUs, targeted decolonization, and universal decolonization are less costly and more effective. This supports updating the standard practice to a decolonization approach.

Enterovirus D68 in Critically Ill Children: A Comparison With Pandemic H1N1 Influenza.

OBJECTIVE: In 2014, the Unites States experienced an outbreak of enterovirus D68 associated with severe respiratory illness. The clinical characteristics associated with severe illness from enterovirus D68 during this outbreak compared with those associated with the 2009 H1N1 influenza virus outbreak are unknown. DESIGN AND SETTING: In this retrospective cohort study, we characterized the clinical features of children with enterovirus D68 admitted to the PICU between August 1, 2014, and November 1, 2014, and compared them with critically ill children infected with H1N1 influenza during the pandemic admitted between May 1, 2009, and January 31, 2010. PATIENTS: PICU patients. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Ninety-seven severely ill children with enterovirus D68 infections were compared with 68 children infected with H1N1 influenza during the 2009 pandemic. Children with enterovirus D68 were more likely to have asthma (62% vs 23%; p < 0.001) and present with reactive airway disease exacerbations, with greater receipt of albuterol (94% vs 49%) and steroids (89% vs 40%; p < 0.0001 for both). Although more children with enterovirus D68 were admitted to the ICU compared with those with H1N1 influenza, they had a shorter hospital length of stay (4 vs 7 d; p < 0.0001), with lower intubation rates (7% vs 44%), vasopressor use (3% vs 32%), acute respiratory distress syndrome (3% vs 24%), shock (0% vs 16%), and death (0% vs 12%; p < 0.05 for all). Compared with children with other enteroviruses and rhinoviruses, children with enterovirus D68 were more likely to have a history of asthma (64% vs 45%) or multiple prior wheezing episodes (54% vs 34%; p < 0.01 for both). CONCLUSIONS: Critically ill children with enterovirus D68 were more likely to present with reactive airway disease exacerbations, whereas children with H1N1 influenza were more likely to present with pneumonia. Compared with the pandemic H1N1 influenza outbreak, the enterovirus D68 outbreak resulted in more children requiring admission to the ICU, but was associated with less severe outcomes.

An Immune Recovery-Based Revaccination Protocol for Pediatric Hematopoietic Stem Cell Transplant Recipients: Revaccination Outcomes Following Pediatric HSCT.

Following hematopoietic stem cell transplant (HSCT), patients are at increased risk of vaccine-preventable diseases (VPDs) and experience worse outcomes of VPDs compared to immunocompetent patients. Therefore, patients are routinely vaccinated post-HSCT to restore VPD immunity. Published guidelines recommend revaccination based on time post-HSCT, although optimal revaccination timing and the value of using other clinical and laboratory variables to guide revaccination remain unclear. An institutional immune recovery-based protocol to guide timing of revaccination is used at Children's Hospital Colorado. This protocol incorporates time from transplant, time off immunosuppressive therapy and intravenous immunoglobulin replacement, absence of active graft-versus-host disease (GVHD), and minimum absolute CD4 count, absolute lymphocyte count (ALC), and immunoglobulin G (IgG) levels. The objective of this study is to evaluate the performance of this immune recovery-based revaccination protocol by determining rates of seroprotective vaccine responses achieved and describing demographic, clinical, and laboratory markers associated with protective antibody titers post-revaccination. Rates of seroprotection following revaccination were retrospectively determined for patients who received autologous or allogeneic HSCTs at Children's Hospital Colorado from 2007 to 2017. Percent seropositivity after revaccination was determined for ten VPDs: measles, mumps, rubella, varicella, tetanus, diphtheria, Haemophilus influenzae type B (Hib), poliovirus, hepatitis B virus (HBV), and Streptococcus pneumoniae. The impact of covariates, including post-HSCT vaccine timing, patient demographics, clinical features (diagnosis, donor and conditioning regimen data, GVHD, cytomegalovirus disease), and laboratory parameters (CD4 count, ALC, IgG level), on rates of seroprotection post-revaccination was determined using Wilcoxon rank sum, Fisher's exact, or chi-square tests, as appropriate. One hundred-twelve unique patients among 427 HSCT recipients had available data for both revaccination timing and vaccine titers. Among these, high rates of seroprotection were achieved after revaccination for rubella (100%), diphtheria (100%), tetanus (100%), and Hib (98%). More modest rates of seroprotection were achieved after revaccination with HBV (87%) and pneumococcal conjugate (85%) vaccines. Seroprotection was lower after revaccination with measles (76%), pneumococcal polysaccharide (72%), mumps (67%), and varicella (25%) vaccines. Greater rates of seroprotection were associated with younger age (hepatitis B vaccine, P = .04), lack of prior rituximab treatment (pneumococcal conjugate vaccine, P = .005), lack of total body irradiation (pneumococcal conjugate vaccine, P = .03), and receipt of a non-cord blood transplant (pneumococcal polysaccharide vaccine, P = .04). These results suggest that a revaccination protocol that incorporates both time post-HSCT and patient-specific indicators of immunologic recovery can achieve high rates of seroprotection against most VPDs. Seroprotection rates for HBV and PCV were notably among the highest reported in children post-HSCT, suggesting that an immune recovery-based protocol may improve seroprotection for some VPDs that frequently are associated with lower vaccine responses post-HSCT. Seroprotection rates for other VPDs remained suboptimal after revaccination. Therefore, evaluation of additional strategies, such as the use of novel markers of immune competence and new vaccines, to further optimize protection against VPDs in this population is warranted.