Providing value to patients and providers via a pediatric statewide antibiogram in South Carolina.

Objective: Antimicrobial stewardship has special challenges in particular populations and facilities, including pediatrics. We sought to augment the information available to antimicrobial stewardship programs (ASPs) by created a cumulative statewide antibiogram for neonatal and pediatric populations. Methods: In the Antimicrobial Stewardship Collaborative of South Carolina (ASC-SC), we created statewide antibiograms, including a separate antibiogram accounting for the pediatric and neonatal intensive care unit (NICU) populations. We collated data from the 4 pediatric and 3 NICU facilities in the state to provide a cumulative statewide antibiogram. Results: Methicillin-susceptible Staphylococcus aureus was more prevalent than methicillin-resistant Staphylococcus aureus. Pseudomonas aeruginosa, Citrobacter koserii, and Acinetobacter baumannii were isolated in only 1 NICU. Conclusions: These antibiograms should improve empiric prescribing in both the inpatient and outpatient setting, providing data in some areas that historically do not have pediatric antibiogram to inform prescribing. The antibiogram alone is not sufficient independently to improve prescribing but is one important aspect of stewardship in the pediatric population of South Carolina.

Recurrent ESBL Escherichia coli Urosepsis in a Pediatric Renal Transplant Patient Treated With Antibiotics and Bacteriophage Therapy.

INTRODUCTION: Treating recurrent multidrug resistant (MDR) urosepsis in pediatric transplant recipients can be challenging. Particularly when antibiotics fail to prevent future occurrence and the nidus is seemingly undiscoverable. While there is an increasing amount of data on phage therapy, to our knowledge, there are no published cases involving pediatric renal transplant recipients. Therefore, we present a challenging clinical case in which phage therapy was used in a pediatric renal transplant recipient who developed recurrent MDR urosepsis with an unclear source. CASE PRESENTATION: Our patient was a 17-year-old female who initially developed urosepsis caused by extended-spectrum ß-lactamase (ESBL) Escherichia coli , while being treated with an immunosuppressant regimen because of kidney rejection secondary to poor immunosuppression therapy compliance. She was admitted to our hospital intermittently for 4 months with 4 episodes of urosepsis caused by ESBL E. coli . She received multiple courses of antibiotics (mainly ertapenem) and underwent a fecal material transplant to eradicate her ESBL E. coli colonized gastrointestinal tract. Because of recurrent development of urosepsis after antibiotic treatment, she later underwent treatment with a phage cocktail consisting of 2 isolate-specific phages. After a prolonged antibiotic course and subsequent 3-week intravenous phage treatment, she had no ESBL E. coli in her urinary cultures for 4 years post-treatment. DISCUSSION: This case highlights the challenges of treating recurrent ESBL E. coli infections in a pediatric renal transplant patient and provides evidence that phage therapy may prove useful in such cases.

Deaths in Children and Adolescents Associated With COVID-19 and MIS-C in the United States.

OBJECTIVES: To describe the demographics, clinical characteristics, and hospital course among persons <21 years of age with a severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)-associated death. METHODS: We conducted a retrospective case series of suspected SARS-CoV-2-associated deaths in the United States in persons <21 years of age during February 12 to July 31, 2020. All states and territories were invited to participate. We abstracted demographic and clinical data, including laboratory and treatment details, from medical records. RESULTS: We included 112 SARS-CoV-2-associated deaths from 25 participating jurisdictions. The median age was 17 years (IQR 8.5-19 years). Most decedents were male (71, 63%), 31 (28%) were Black (non-Hispanic) persons, and 52 (46%) were Hispanic persons. Ninety-six decedents (86%) had at least 1 underlying condition; obesity (42%), asthma (29%), and developmental disorders (22%) were most commonly documented. Among 69 hospitalized decedents, common complications included mechanical ventilation (75%) and acute respiratory failure (82%). The sixteen (14%) decedents who met multisystem inflammatory syndrome in children (MIS-C) criteria were similar in age, sex, and race and/or ethnicity to decedents without MIS-C; 11 of 16 (69%) had at least 1 underlying condition. CONCLUSIONS: SARS-CoV-2-associated deaths among persons <21 years of age occurred predominantly among Black (non-Hispanic) and Hispanic persons, male patients, and older adolescents. The most commonly reported underlying conditions were obesity, asthma, and developmental disorders. Decedents with coronavirus disease 2019 were more likely than those with MIS-C to have underlying medical conditions.

Evaluation of Time to Resolution of Medical Necrotizing Enterocolitis Using Severity-Guided Management in a Neonatal Intensive Care Unit.

OBJECTIVE: No studies, to our knowledge, have determined the relationship between symptom resolution and timing of antimicrobial discontinuation in necrotizing enterocolitis (NEC). Our study seeks to determine the period to NEC resolution by using severity-guided management, based on surrogate markers used in the diagnosis of NEC. METHODS: This retrospective, observational review included patients in our NICU with NEC from June 1, 2012, to June 1, 2018. Patients were excluded for surgical NEC, a positive blood culture or transfer from an outside institution at the time of NEC, presence of a peritoneal drain, or death prior to NEC resolution. The primary outcome was time to resolution of NEC, measured by return to baseline of surrogate markers used in the diagnosis of NEC. RESULTS: The median times to resolution in days, based on our institution's NEC severity group, were as follows: mild 3 (range, 1-4); moderate 4 (range, 1-17); severe 9 (range, 5-21). No difference in NEC recurrence was found based on antibiotic duration (OR 0.803; 95% CI, 0.142-4.225). CONCLUSIONS: Time to resolution of NEC differs by severity group, suggesting a need for different treatment durations. Recurrence of NEC did not differ between groups, suggesting that shorter antibiotic durations do not lead to an increased incidence of NEC recurrence. Further exploration of the optimal antimicrobial treatment duration for NEC is warranted.

Cefiderocol for the Treatment of Adult and Pediatric Patients With Cystic Fibrosis and Achromobacter xylosoxidans Infections.

Treatment options for Achromobacter xylosoxidans are limited. Eight cystic fibrosis patients with A. xylosoxidans were treated with 12 cefiderocol courses. Pretreatment in vitro resistance was seen in 3 of 8 cases. Clinical response occurred after 11 of 12 treatment courses. However, microbiologic relapse was observed after 11 of 12 treatment courses, notably without emergence of resistance.

Combining bacteriophages with cefiderocol and meropenem/vaborbactam to treat a pan-drug resistant Achromobacter species infection in a pediatric cystic fibrosis patient.

Cystic fibrosis is associated with significant morbidity and early mortality due to recurrent acute and chronic lung infections. The chronic use of multiple antibiotics without pathogen eradication increases the possibility of extensive drug resistance or even pan-drug resistance (PDR). It is imperative that new or alternative treatment options be explored. We present a clinical case of a 10-year-old female cystic fibrosis patient, infected with a PDR Achromobacter spp. She was treated with cefiderocol, meropenem/vaborbactam, and bacteriophage therapy (Ax2CJ45ϕ2) during two separate admissions in an attempt to clear her infection and restore baseline pulmonary function. The Centers for Disease Control and Prevention confirmed antibiotic susceptibilities, which showed resistance to both cefiderocol and meropenem/vaborbactam. However, after using all three agents concomitantly during the second treatment course, our patient's pulmonary function improved dramatically, and the Achromobacter spp. could not be isolated from sputum samples obtained 8 and 16 weeks after completion of therapy. Overall, the treatment regimen consisting of cefiderocol, meropenem/vaborbactam, and bacteriophage was safe and well-tolerated in our patient.