Inappropriate Use of Peripherally Inserted Central Catheters in Pediatrics: A Multisite Study.

OBJECTIVES: This study aimed to describe how the current practice of peripherally inserted central catheter (PICC) use in hospitalized children aligns with the Michigan Appropriateness Guide for Intravenous Catheters (miniMAGIC) in Children recommendations, explore variation across sites, and describe the population of children who do not receive appropriate PICCs. METHODS: A retrospective study was conducted at 4 children's hospitals in the United States. Children with PICCs placed January 2019 to December 2021 were included. Patients in the NICU were excluded. PICCs were categorized using the miniMAGIC in Children classification as inappropriate, uncertain appropriateness and appropriate. RESULTS: Of the 6051 PICCs identified, 9% (n = 550) were categorized as inappropriate, 9% (n = 550) as uncertain appropriateness, and 82% (n = 4951) as appropriate. The number of PICCs trended down over time, but up to 20% of PICCs each year were not appropriate, with significant variation between sites. Within inappropriate or uncertain appropriateness PICCs (n = 1100 PICC in 1079 children), median (interquartile range) patient age was 4 (0-11) years, 54% were male, and the main reason for PICC placement was prolonged antibiotic course (56%, n = 611). The most common admitting services requesting the inappropriate/uncertain appropriateness PICCs were critical care 24%, general pediatrics 22%, and pulmonary 20%. Complications resulting in PICC removal were identified in 6% (n = 70) of inappropriate/uncertain PICCs. The most common complications were dislodgement (3%) and occlusion (2%), with infection and thrombosis rates of 1% (n = 10 and n = 13, respectively). CONCLUSIONS: Although the majority of PICCs met appropriateness criteria, a substantial proportion of PICCs were deemed inappropriate or of uncertain appropriateness, illustrating an opportunity for quality improvement.

Pediatric Orbital Cellulitis/Abscess: Microbiology and Pattern of Antibiotic Prescribing.

INTRODUCTION: The treatment for pediatric orbital cellulitis/abscess is trending towards intravenous antibiotic management alone in appropriate cases. Without cultures to guide therapy, knowing the local microbiology is of utmost importance in managing these patients. METHODS: We conducted a retrospective case series for patients age 2 months to 17 years, who were hospitalized between January 1, 2013, and December 31, 2019, to evaluate the local microbiology and pattern of antibiotic prescribing in pediatric orbital cellulitis. RESULTS AND DISCUSSION: Of 95 total patients, 69 (73%) received intravenous antibiotics only and 26 (27%) received intravenous antibiotics plus surgery. The most common organism cultured was Streptococcus anginosus, followed by Staphylococcus aureus, and group A streptococcus. Methicillin-resistant Staphylococcus aureus (MRSA) prevalence was 9%. MRSA-active antibiotics remain the most frequently used antibiotics.

A Rare Case of Acne Medication-Induced Drug Reaction With Eosinophilia and Systemic Symptoms.

INTRODUCTION: Acne vulgaris is the most common skin condition in late adolescence and frequently requires systemic treatment with antibiotics or androgen receptor blockers in moderateto- severe cases. CASE PRESENTATION: We report the case of a 17-year-old adolescent female with new onset fever, headache, and pruritic rash 1 month after she started doxycycline and spironolactone for the treatment of acne vulgaris. Later, she developed eosinophilia and transaminitis. Infectious workup was negative. DISCUSSION: This presentation was consistent with a definite case of drug reaction with eosinophilia and systemic symptoms (DRESS). DRESS is a severe, systemic hypersensitivity drug reaction that typically occurs 2 to 8 weeks following exposure to the offending medication. CONCLUSIONS: Although doxycycline and spironolactone are uncommon triggers of DRESS, they are common medications used to treat acne, and clinicians should be aware of this potential complication when counseling patients, especially adolescents.

Long peripheral catheters in children: A scoping review.

BACKGROUND AND OBJECTIVES: Long peripheral catheters (LPCs) are emerging vascular access devices used for short-medium term vascular access needs. Literature in adults suggests LPCs have longer dwell-times than peripheral intravenous catheters (PIVs) and lower rates of serious complications than peripherally inserted central catheters (PICCs). The role of LPCs in children is less established. The objective of this scoping review is to describe and synthesize the existing literature on the effectiveness and safety of LPCs in children. METHODS: This review follows the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) guidelines. Searches were done in MEDLINE (Ovid), Cochrane Central Register of Controlled Trials (CENTRAL), Web of Science Core Collection, Scopus, CINAHL (Ebsco), and Google Scholar most recently on February 22, 2022. Studies were included if published in English on or after 2000 and included patients <18 years of age. RESULTS: Twenty-one studies were included. The body of literature is variable in quality, measurements, and reported outcomes. Median dwell-time ranged from 5 to 14 days. The rate of completion of therapy ranged from 20% to 86%. Dislodgement, occlusion, and infiltration were the most common complications reported (0%-31%). Venous thromboembolism rates ranged from 0% to 13%. The rate of catheter-related bloodstream infection was 0% in 9 of 10 studies. Less than 50% of studies reported comparative outcomes. CONCLUSION: LPCs show promising outcomes in select populations, with longer dwell-time than PIVs and possibly lower rates of serious complications than PICCs. However, more research is needed to clarify the optimal use of LPCs in pediatrics.

Evaluation and Medical Management of the Pediatric Patient With Orbital Cellulitis/Abscess: A Systematic Review.

BACKGROUND AND OBJECTIVES: Pediatric orbital cellulitis/abscess (OCA) can lead to vision loss, intracranial extension of infection, or cavernous thrombosis if not treated promptly. No widely recognized guidelines exist for the medical management of OCA. The objective of this review was to summarize existing evidence regarding the role of inflammatory markers in distinguishing disease severity and need for surgery; the role of imaging in OCA evaluation; and the microbiology of OCA over the past 2 decades. METHODS: This review was reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Searches were performed in MEDLINE (Ovid), Web of Science Core Collection, Scopus, CINAHL (EBSCO), and Cochrane Central Register of Controlled Trials (CENTRAL), most recently on February 9, 2021. RESULTS: A total of 63 studies were included. Most were descriptive and assessed to have poor quality with high risk of bias. The existing publications evaluating inflammatory markers in the diagnosis of OCA have inconsistent results. Computed tomography imaging remains the modality of choice for evaluating orbital infection. The most common organisms recovered from intraoperative cultures are Streptococcus species (Streptococcus anginosus group, group A Streptococcus, and pneumococcus) and Staphylococcus aureus. Methicillin-resistant S aureus in culture-positive cases had a median prevalence of 3% (interquartile range, 0%-13%). CONCLUSION: This systematic review summarizes existing literature concerning inflammatory markers, imaging, and microbiology for OCA evaluation and management. High-quality evidence is still needed to define the optimal medical management of OCA.

The Development of a Long Peripheral Catheter Program at a Large Pediatric Academic Center: A Pilot Study.

OBJECTIVES: The purpose of this study was to evaluate the feasibility of a new long peripheral catheter (LPC) program at a large academic center in an effort to reduce the use of peripherally inserted central catheters (PICCs) and their related complications. METHODS: The pilot participants were hospitalized children, age >2 years, with a need for noncentral intravenous access for 2 to 29 days, or laboratory blood draw >5 times per day. Patients expected to discharge with intravenous access were excluded. Included in the pilot program development were a literature review, 1-year baseline data analysis, and program design and implementation. A multidisciplinary committee developed and implemented the program from December 2018 to September 2019. LPCs were placed from August to September 2019. RESULTS: Regarding the baseline data, between July 2018 and June 2019, 584 PICCs were placed in 461 patients. Of these, 139 PICCs (24%) did not meet requirements necessitating central access and, potentially, could have been avoided if an LPC alternative were available at the time. For the LPC pilot program, 20 LPCs were placed in 19 patients. The median age was 11 (interquartile range of 7-15). The insertion success rate was 83%. There were no serious complications, such as venous thrombosis or catheter-related bloodstream infection. The total rate of minor complications was 35%: the rate of occlusions was 10% (n = 2), and the rate of dislodgement was 25% (n = 5). The catheter failure rate was 74 per 1000 catheter-days. The mean line duration was 6 days. CONCLUSIONS: There is a role for LPCs in hospitalized children requiring durable vascular access. Multispecialty designed pilot implementation of an LPC program was successful at an academic pediatric hospital.

Nutritional Advancement in the Hospitalized Child After NPO: A Retrospective Cohort Study.

OBJECTIVES: A clear-liquid diet is commonly used after a nil per os (NPO) order in children recovering from acute gastrointestinal (GI) illnesses. Our purpose for this study was to compare outcomes in patients receiving a clear-liquid diet after an NPO order with outcomes in those receiving a regular diet. METHODS: In this retrospective cohort study, patients aged 1 to 18 years admitted to a tertiary care children's hospital between 2016 and 2017 were screened to identify those who had an NPO order placed for acute GI illnesses. Patients with complex medical needs, a feeding disorder, or chronic GI disorders were excluded. RESULTS: Of 39 total patients, 17 (44%) received a clear-liquid diet after an NPO order. There was no difference in diet tolerance between patients receiving a clear-liquid diet and those receiving a regular diet on the basis of emesis in the first 12 hours (P = .40), pain scores after the first oral intake (P = .86), return to clear-liquid diet (P = .57), or return to NPO status (P > .99). Patients started on a clear-liquid diet had a longer length of stay (LOS) after diet initiation compared with those receiving a regular diet (median: 43.7 hours [interquartile range: 29.8-53.4] vs median: 20.8 hours [interquartile range 6.7-47.3]), both in the univariate analysis (P = .01) and after controlling for age, diagnosis category, and pain score before and after the first oral intake (P = .03). CONCLUSIONS: Patients transitioned to a clear-liquid diet after NPO status have a longer LOS after the first oral intake independent of patient age, diagnosis, and pretransition abdominal pain. Both groups had similar diet tolerance, suggesting that transition to a regular diet after NPO status may decrease LOS without significant adverse effects.