Inappropriate Prescribing of Antibiotics to Pediatric Patients Receiving Medicaid: Comparison of High-Volume and Non-High-Volume Antibiotic Prescribers-Kentucky, 2019.

Inappropriate antibiotic prescribing to pediatric Medicaid patients was compared among high-volume and non-high-volume prescribers. High-volume prescribers had a higher percentage of inappropriate prescriptions than non-high-volume prescribers (17.2% versus 15.8%, p = 0.005). Targeting high-volume prescribers for stewardship efforts is a practical approach to reducing outpatient antibiotic prescribing that also captures inappropriate use.

Adolescent COVID-19 Cases During the SARS-CoV-2 Delta and Omicron Variant Surges in Kentucky: Association With Vaccination and Prior Infection.

PURPOSE: Effectiveness of COVID-19 mRNA vaccines is influenced by SARS-CoV-2 variant and history of prior infection. Data regarding protection against SARS-CoV-2 infection among adolescents, accounting for prior infection and time since vaccination, are limited. METHODS: SARS-CoV-2 testing and immunization data from the Kentucky Electronic Disease Surveillance System and the Kentucky Immunization Registry, August-September 2021 (Delta predominance) and January 2022 (Omicron Predominance) among adolescents aged 12-17 years, were used to assess association of SARS-CoV-2 infection with mRNA vaccination and prior SARS-CoV-2 infection. Estimated protection was derived from prevalence ratios ([1-PR] × 100%). RESULTS: During Delta predominance, 89,736 tested adolescents were evaluated. Completion of primary series (second dose of mRNA vaccine ≥ 14 days prior to testing) and history of prior infection (> 90 days prior to testing) were both protective against SARS-CoV-2 infection (primary series: 81%, 95% confidence interval [CI] 79.7-82.3; prior infection: 66%, 95% CI 62.0-69.6). Prior infection plus primary series provided the greatest protection (92.3%, 95% CI 88.0-95.1). During Omicron predominance, 67,331 tested adolescents were evaluated. Primary series alone provided no benefit against SARS-CoV-2 infection after 90 days; prior infection was protective for up to one year (24.2%, 95% CI 17.2-30.7). Prior infection plus booster vaccination provided the greatest protection against infection (82.4%, 95% CI 62.1-91.8). DISCUSSION: Strength and duration of protection against infection provided by COVID-19 vaccination and prior SARS-CoV-2 infection differed by variant. Vaccination provided additional benefit to the protection offered by prior infection alone. Remaining up to date with vaccination is recommended for all adolescents regardless of infection history.

Characteristics of Decedents With COVID-19-Related Mortality in Kentucky, July 1-August 13, 2021.

OBJECTIVE: Although vaccination reduces the risk of severe COVID-19, fatal COVID-19 cases after vaccination can occur. We examined the characteristics of decedents with COVID-19-related mortality to help inform discussions about vaccination, boosters, and mitigation strategies. METHODS: We examined COVID-19-related deaths in Kentucky resulting from infections occurring from July 1 through August 13, 2021. We used records from case investigations, medical records, the Kentucky Health Information Exchange, and the Kentucky Immunization Registry to determine demographic information, vaccination status, and underlying health conditions, including calculation of the Charlson Comorbidity Index (CCI). We calculated mortality incidence rates by vaccination status by using data for unvaccinated and fully vaccinated populations in Kentucky as of July 1, 2021. RESULTS: In total, 777 COVID-19-related deaths occurred in Kentucky during the study period; 592 (76.2%) occurred among unvaccinated people. Compared with unvaccinated decedents, fully vaccinated decedents were older (median age, 77 vs 65 years; P < .001), had higher comorbidity levels (median CCI, 3 vs 1; P < .001), and were more likely to have immunocompromised health status (26.4% vs 16.0%; P = .003). Diabetes, hypertension, heart disease, and chronic lung disease were more common among vaccinated decedents than among unvaccinated decedents. Unvaccinated adults had a significantly higher risk of death than fully vaccinated adults (incidence rate ratio for age 20-49 years: 20.5 [95% CI, 6.5-64.8]; 50-64 years: 14.6 [95% CI, 9.4-22.7]; ≥65 years: 10.2 [95% CI, 8.3-12.4]). CONCLUSIONS: Immunocompromised health status, older age, and higher comorbidity were prevalent among fully vaccinated decedents, suggesting adults with these characteristics may benefit from additional protection strategies. Further understanding of the protection of additional and booster doses is needed.

Characteristics of nursing home residents and healthcare personnel with repeated severe acute respiratory coronavirus virus 2 (SARS-CoV-2) tests positive ≥90 days after initial infection: Four US jurisdictions, July 2020-March 2021.

One in six nursing home residents and staff with positive SARS-CoV-2 tests ≥90 days after initial infection had specimen cycle thresholds (Ct) <30. Individuals with specimen Ct<30 were more likely to report symptoms but were not different from individuals with high Ct value specimens by other clinical and testing data.

Association of Severe Acute Respiratory Syndrome Coronavirus 2 Vaccination or a Prior Positive Test Result in Adolescents during the Delta Variant Surge in Kentucky.

In a cross-sectional study of 89 736 adolescents in Kentucky, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) vaccination provided an estimated protection against infection of 81% when the highly transmissible Delta variant was predominant. Vaccination provided added benefit to those with a history of prior infection. These findings support the recommendation that all adolescents receive SARS-CoV-2 vaccination.

Factors Associated With Severe Illness in Patients Aged <21 Years Hospitalized for COVID-19.

OBJECTIVES: To describe coronavirus disease 2019 (COVID-19)-related pediatric hospitalizations during a period of B.1.617.2 (Δ) variant predominance and to determine age-specific factors associated with severe illness. METHODS: We abstracted data from medical charts to conduct a cross-sectional study of patients aged <21 years hospitalized at 6 United States children's hospitals from July to August 2021 for COVID-19 or with an incidental positive severe acute respiratory syndrome coronavirus 2 test. Among patients with COVID-19, we assessed factors associated with severe illness by calculating age-stratified prevalence ratios (PR). We defined severe illness as receiving high-flow nasal cannula, positive airway pressure, or invasive mechanical ventilation. RESULTS: Of 947 hospitalized patients, 759 (80.1%) had COVID-19, of whom 287 (37.8%) had severe illness. Factors associated with severe illness included coinfection with respiratory syncytial virus (RSV) (PR 3.64) and bacteria (PR 1.88) in infants; RSV coinfection in patients aged 1 to 4 years (PR 1.96); and obesity in patients aged 5 to 11 (PR 2.20) and 12 to 17 years (PR 2.48). Having ≥2 underlying medical conditions was associated with severe illness in patients aged <1 (PR 1.82), 5 to 11 (PR 3.72), and 12 to 17 years (PR 3.19). CONCLUSIONS: Among patients hospitalized for COVID-19, factors associated with severe illness included RSV coinfection in those aged <5 years, obesity in those aged 5 to 17 years, and other underlying conditions for all age groups <18 years. These findings can inform pediatric practice, risk communication, and prevention strategies, including vaccination against COVID-19.

Protective Immunity after Natural Infection with Severe Acute Respiratory Syndrome Coronavirus-2 (SARS-CoV-2) - Kentucky, USA, 2020.

BACKGROUND: As vaccine supply and access remain limited in many parts of the world, understanding the duration of protection from reinfection after natural infection is important. METHODS: Distinct individuals testing positive and negative for SARS-CoV-2 between March 6, 2020, and August 31, 2020, in Kentucky, USA, were identified using the Kentucky National Electronic Disease Surveillance System. Individuals were followed for occurrence of a positive test for SARS-CoV-2 from 91 days after their initial test result through December 31, 2020. Protection from reinfection provided by a prior infection was calculated and additional analyses evaluated impact of age, sex, symptom status, long-term care facility connection, testing occurrence and frequency, and time from initial infection. RESULTS: The protective effect from prior infection was 80.3% (95% CI, 78.2%-82.2%) for those aged 20-59 years and 67.4% (95% CI, 62.8%-71.4%) for those aged ≥60 years. At 30-day time periods through 270 days (with limited exceptions), protection was estimated to be >75% for those aged 20-59 years and >65% for those aged ≥60 years. Factors associated with repeat positive testing included a connection to a long-term care facility, duration of potential exposure, and absence of symptoms during initial infection. CONCLUSIONS: Natural infection provides substantial and persistent immunologic protection for a period of several months for most individuals, although subpopulations may be at greater risk of repeat positive testing and potential poor outcomes associated with reinfection. These subgroups include individuals aged ≥60 years, residents and staff of long-term care facilities, and those who have mild or asymptomatic illness with initial infection. Continued emphasis on vaccination and infection prevention and control strategies remains critically important in reducing the risk of reinfection and associated severe outcomes for these groups.

A pseudo-outbreak of Burkholderia cepacia complex in a Kentucky hospital.

A cluster of Burkholderia cepacia complex cases from January to October 2020 among outpatients undergoing urologic procedures within a Kentucky hospital's operating rooms was investigated. This investigation included a laboratory look-back, chart reviews, exposure tracing, staff interviews, and direct observation of infection prevention and control practices. A significant protocol breach in a laboratory procedure led to contamination of surgical specimens submitted for culture with nonsterile saline. Pseudo-outbreaks often highlight gaps in infection control processes. Healthcare facilities can make substantial improvements in patient care quality and safety as they respond to identified gaps and improve systems and protocols.

Characteristics and Clinical Outcomes of Children and Adolescents Aged <18 Years Hospitalized with COVID-19 - Six Hospitals, United States, July-August 2021.

During June 2021, the highly transmissible† B.1.617.2 (Delta) variant of SARS-CoV-2, the virus that causes COVID-19, became the predominant circulating strain in the United States. U.S. pediatric COVID-19-related hospitalizations increased during July-August 2021 following emergence of the Delta variant and peaked in September 2021.§ As of May 12, 2021, CDC recommended COVID-19 vaccinations for persons aged ≥12 years,¶ and on November 2, 2021, COVID-19 vaccinations were recommended for persons aged 5-11 years.** To date, clinical signs and symptoms, illness course, and factors contributing to hospitalizations during the period of Delta predominance have not been well described in pediatric patients. CDC partnered with six children's hospitals to review medical record data for patients aged <18 years with COVID-19-related hospitalizations during July-August 2021.†† Among 915 patients identified, 713 (77.9%) were hospitalized for COVID-19 (acute COVID-19 as the primary or contributing reason for hospitalization), 177 (19.3%) had incidental positive SARS-CoV-2 test results (asymptomatic or mild infection unrelated to the reason for hospitalization), and 25 (2.7%) had multisystem inflammatory syndrome in children (MIS-C), a rare but serious inflammatory condition associated with COVID-19.§§ Among the 713 patients hospitalized for COVID-19, 24.7% were aged <1 year, 17.1% were aged 1-4 years, 20.1% were aged 5-11 years, and 38.1% were aged 12-17 years. Approximately two thirds of patients (67.5%) had one or more underlying medical conditions, with obesity being the most common (32.4%); among patients aged 12-17 years, 61.4% had obesity. Among patients hospitalized for COVID-19, 15.8% had a viral coinfection¶¶ (66.4% of whom had respiratory syncytial virus [RSV] infection). Approximately one third (33.9%) of patients aged <5 years hospitalized for COVID-19 had a viral coinfection. Among 272 vaccine-eligible (aged 12-17 years) patients hospitalized for COVID-19, one (0.4%) was fully vaccinated.*** Approximately one half (54.0%) of patients hospitalized for COVID-19 received oxygen support, 29.5% were admitted to the intensive care unit (ICU), and 1.5% died; of those requiring respiratory support, 14.5% required invasive mechanical ventilation (IMV). Among pediatric patients with COVID-19-related hospitalizations, many had severe illness and viral coinfections, and few vaccine-eligible patients hospitalized for COVID-19 were vaccinated, highlighting the importance of vaccination for those aged ≥5 years and other prevention strategies to protect children and adolescents from COVID-19, particularly those with underlying medical conditions.

Mycobacterium porcinum Skin and Soft Tissue Infections After Vaccinations - Indiana, Kentucky, and Ohio, September 2018-February 2019.

During December 2018-February 2019, a multistate investigation identified 101 patients with vaccination-associated adverse events among an estimated 940 persons in Kentucky, Indiana, and Ohio who had received influenza; hepatitis A; pneumococcal; or tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis (Tdap) vaccines at the workplace during September 11-November 28, 2018. These vaccines had been administered by staff members of a third-party health care company contracted by 24 businesses. Company A provided multiple vaccine types during workplace vaccination events across 54 locations in these adjoining states. Injection-site wound isolates from patients yielded Mycobacterium porcinum, a nontuberculous mycobacteria (NTM) species in the Mycobacterium fortuitum group; subtyping using pulsed-field gel electrophoresis of all 28 available isolates identified two closely related clusters. Site visits to company A and interviews with staff members identified inadequate hand hygiene, improper vaccine storage and handling, lack of appropriate medical record documentation, and lack of reporting to the Vaccine Adverse Event Reporting System (VAERS). Vaccination-associated adverse events can be prevented by training health care workers responsible for handling or administering vaccines in safe vaccine handling, administration, and storage practices, timely reporting of any suspected vaccination-associated adverse events to VAERS, and notifying public health authorities of any adverse event clusters.

Reduced Risk of Reinfection with SARS-CoV-2 After COVID-19 Vaccination - Kentucky, May-June 2021.

Although laboratory evidence suggests that antibody responses following COVID-19 vaccination provide better neutralization of some circulating variants than does natural infection (1,2), few real-world epidemiologic studies exist to support the benefit of vaccination for previously infected persons. This report details the findings of a case-control evaluation of the association between vaccination and SARS-CoV-2 reinfection in Kentucky during May-June 2021 among persons previously infected with SARS-CoV-2 in 2020. Kentucky residents who were not vaccinated had 2.34 times the odds of reinfection compared with those who were fully vaccinated (odds ratio [OR] = 2.34; 95% confidence interval [CI] = 1.58-3.47). These findings suggest that among persons with previous SARS-CoV-2 infection, full vaccination provides additional protection against reinfection. To reduce their risk of infection, all eligible persons should be offered vaccination, even if they have been previously infected with SARS-CoV-2.

COVID-19 Outbreak Associated with a SARS-CoV-2 R.1 Lineage Variant in a Skilled Nursing Facility After Vaccination Program - Kentucky, March 2021.

Although COVID-19 mRNA vaccines demonstrated high efficacy in clinical trials (1), they were not 100% efficacious. Thus, some infections postvaccination are expected. Limited data are available on effectiveness in skilled nursing facilities (SNFs) and against emerging variants. The Kentucky Department for Public Health (KDPH) and a local health department investigated a COVID-19 outbreak in a SNF that occurred after all residents and health care personnel (HCP) had been offered vaccination. Among 83 residents and 116 HCP, 75 (90.4%) and 61 (52.6%), respectively, received 2 vaccine doses. Twenty-six residents and 20 HCP received positive test results for SARS-CoV-2, the virus that causes COVID-19, including 18 residents and four HCP who had received their second vaccine dose >14 days before the outbreak began. An R.1 lineage variant was detected with whole genome sequencing (WGS). Although the R.1 variant has multiple spike protein mutations, vaccinated residents and HCP were 87% less likely to have symptomatic COVID-19 compared with those who were unvaccinated. Vaccination of SNF populations, including HCP, is critical to reduce the risk for SARS-CoV-2 introduction, transmission, and severe outcomes in SNFs. An ongoing focus on infection prevention and control practices is also essential.

Hospital-acquired infections in paediatric medical wards at a tertiary hospital in KwaZulu-Natal, South Africa.

BACKGROUND: Hospital-acquired infections (HAIs) impact care and costs in hospitals across the globe. There are minimal data on HAIs in sub-Saharan Africa and data specific to paediatrics are especially limited. OBJECTIVE: To describe the incidence of HAIs in the paediatric medical units at Grey's Hospital, a tertiary government hospital in KwaZulu-Natal, South Africa. METHODS: The Infection Prevention and Control (IPC) team collects data on all laboratory-confirmed infections, including from paediatric patients in two medical units (52 beds), the paediatric intensive/high-care unit (PICU, 8 beds) and the neonatal intensive care unit (NICU, 23 beds). HAIs are defined as infections: (i) not present (active or incubating) at the time of admission, and (ii) with onset >48 h after hospital admission. Daily patient statistics allow calculation of infections per 100 admissions and infections per 1000 patient days. RESULTS: In the non-ICU setting, there were 7.1 and 7.0 HAIs per 100 admissions in 2013 and 2014, respectively. In the PICU, there were 20.4 and 15.3 HAIs per 100 admissions, while in the NICU there were 23.9 and 21.6 HAIs per 100 admissions in 2013 and 2014, respectively. In the non-ICU setting, there were 6.8 HAIs per 1000 patient days in both 2013 and 2014. In the PICU, there were 27.5 and 33.0 HAIs per 1000 patient days, while in the NICU, there were 20.3 and 21.5 HAIs per 1000 patient days in 2013 and 2014, respectively. CONCLUSION: HAIs in non-ICU paediatric wards were consistent with a number of point-prevalence studies performed outside Africa (e.g. Canada, Russia, U.K.). Rates of HAIs in the ICUs were higher than rates reported from the International Nosocomial Infection Control Consortium, and were substantially higher than rates reported in the United States. HAIs are serious and important, especially in ICUs, and may be relatively neglected in low- and middle-income settings. Improved surveillance will allow the development and evaluation of targeted interventions to improve care of patients.

Tuberculin skin testing and T-SPOT.TB in internationally adopted children.

BACKGROUND: Diagnosis of latent tuberculosis infection is a problem in children because of lack of a diagnostic standard and potential impact of previous Bacille Calmette-Guérin vaccination and exposure to environmental mycobacteria. Effectiveness and usefulness of interferon-gamma release assays in infants and younger children have yet to be clearly demonstrated. METHODS: Prospective cohort study including 109 children (4 months to 16 years) seen in an international adoption clinic at Nationwide Children's Hospital, Columbus, OH. Children were adopted from 14 countries, mostly (72.5%) from China, Russia and Ethiopia. Correspondence between tuberculin skin test (TST) and the T-SPOT.TB assay was evaluated. Factors associated with positive results on the TST and T-SPOT.TB were determined, and the impact of age on test performance was specifically addressed. RESULTS: TST was positive in 23.4% (25 of 107). T-SPOT.TB was positive in 4.6% (5 of 109). Overall agreement between TST and T-SPOT.TB was 71%, with prevalence-adjusted, bias-adjusted Kappa of 0.68. History of Mycobacterium tuberculosis exposure was associated with positive results on TST (odds ratio: 25.4, 95% confidence interval: 4.8-261.6, exact logistic regression) and T-SPOT.TB (odds ratio: 78.9, 95% confidence interval: 9.7-∞). All 5 children with positive T-SPOT.TB had TST induration ≥15 mm. No patient less than 1 year of age (n = 17) had positive TST or T-SPOT.TB. Positive TST was not associated with Bacille Calmette-Guérin vaccination or scar. CONCLUSIONS: TST was positive in a significant percentage of international adoptees. T-SPOT.TB was rarely positive and discordant results reflected negative T-SPOT.TB with positive TST. In this population latent tuberculosis infection may be over-estimated by TST. Regardless, in our context at the time of the study, treatment decisions were based upon TST results, not results of the T-SPOT.TB assay. Age was consistently associated with findings on TST and T-SPOT.TB with no positive result on either test for any child <1 year of age.

Occurrence of 3 Bordetella species during an outbreak of cough illness in Ohio: epidemiology, clinical features, laboratory findings and antimicrobial susceptibility.

BACKGROUND: An increase in laboratory diagnosis of pertussis was noted in central Ohio during 2010. Diagnosis was made using a polymerase chain reaction assay targeting the multicopy insertion sequence IS481, which is found in both Bordetella pertussis (Bp) and Bordetella holmesii (Bh). An increase in specimens testing positive for Bordetella parapertussis (Bpp) using insertion sequence IS1001 was also noted. METHODS: Nasopharyngeal swab specimens submitted April 1, 2010, to March 31, 2011, were tested using a multiplex polymerase chain reaction assay for Bp/Bh (IS481) and Bpp followed by singleplex assays for Bp and Bh. A subgroup of specimens was also cultured for Bordetella species, and antimicrobial susceptibility testing was performed on recovered organisms. Demographic and clinical features were compared for patients with Bp, Bh and Bpp. RESULTS: Of 520 IS481-positive specimens, 214 (41.1%) were positive for Bp, 79 (15.2%) were positive for Bh and 5 (1.0%) were positive for both Bp and Bh; 222 (42.7%) were negative for both targets. An additional 220 specimens were positive for Bpp. Among a sample of 155 IS481-positive specimens, 40, 15 and 0 were culture positive for Bp, Bh and Bpp, respectively. Among a sample of 55 BparaIS1001-positive (Bpp) specimens, 22, 0 and 0 were culture positive for Bpp, Bp and Bh, respectively. All Bordetella species were susceptible to macrolide antibiotics. Patients with Bh were older than patients with Bp, who were older than those positive for Bpp (mean ages: 12.0, 8.0 and 4.2 years, respectively; P < 0.001). One or more classic signs of pertussis (ie, paroxysmal cough, whoop, post-tussive emesis) were seen in 55.9% of 263 patients (59 Bp, 24 Bh, 80 Bpp and 100 negative for Bordetella species), but did not differ statistically among the groups (χ = 5.1, P = 0.17). CONCLUSIONS: All 3 Bordetella species, Bp, Bh and Bpp, were detected during on outbreak of pertussis-like cough illness. There were noted differences in age and seasonality, but clinical features at the time of presentation did not allow clear differentiation of these infections. All Bordetella species recovered from culture and tested were susceptible in vitro to macrolide antibiotics. Additional study is necessary to further characterize epidemiologic and clinical characteristics of Bh-associated cough illness and to determine potential co-occurrence of Bordetella species with other bacterial and viral respiratory tract pathogens.

Completion of Latent Tuberculosis Therapy in Children: Impact of Country of Origin and Neighborhood Clinics.

BACKGROUND: Successful treatment of latent tuberculosis infection (LTBI) is an important objective in the United States' strategy for tuberculosis (TB) control. We review the impact of demographic variables and community treatment upon completion of medical therapy of LTBI in a large pediatric cohort. METHODS: We performed a retrospective analysis of prospectively collected data from children referred for evaluation and treatment of LTBI. Children were followed in the main hospital TB clinic or in 1 of 2 hospital-run neighborhood clinics. Those completing and not completing medical treatment were compared based on demographic and history variables, clinic location, and distance to clinic. Propensity score techniques were used to match children treated at the main hospital and neighborhood clinics on collected demographic and history variables. RESULTS: Of 1516 children evaluated, 1184 (78.1%) initiated medical therapy and returned for at least 1 visit. Of these, treatment was completed by 89.2% (166 of 186) of children in the neighborhood clinics versus 83.2% (830 of 998) of children in the main hospital TB clinic (P < .037). Neighborhood and main hospital clinic children did not differ in rates of completion when propensity score-matched groups were compared. Country of origin was the most important factor in determining both initiation and completion of therapy. CONCLUSIONS: Obstacles remain for successful initiation and treatment of children from identified geographic regions. Most of the dropout occurs early in treatment, and use of neighborhood clinics does not provide an obvious advantage when similar patient groups are compared. Emphasis upon initial education and early non-clinic follow-up may be useful in enhancing therapy completion.