An Observational Study of Severe Pertussis in 100 Infants ≤120 Days of Age.

BACKGROUND: Pertussis in young infants is a unique, severe, afebrile, cough illness that is frequently fatal. METHODS: All pertussis cases ≤120 days of age admitted to a pediatric intensive care unit in California between October 1, 2013, and April 25, 2015, were evaluated. RESULTS: Of 100 pertussis patients ≤120 days of age admitted to pediatric intensive care unit, there were 5 deaths. The white blood cell counts in the fatal cases were significantly higher than in the nonfatal cases. Thirty-four percent of patients were intubated, 18% received inotropic and/or vasoactive support, 22% received steroid, 4% received extracorporal membrane oxygenation, and 3% underwent exchange blood transfusion. The median age at the time of illness onset in the patients who died was 23 days. CONCLUSIONS: These data, as well as data from previous California studies, suggest updated strategies for the management of severe pertussis. These include perform serial white blood cell counts, treat all presumptive cases with azithromycin, evaluate for pulmonary hypertension, intubate and administer oxygen for apneic episodes and administer inotropic/vasoactive agents for cardiogenic shock. Do not administer steroids or nitric oxide. Criteria for exchange blood transfusion therapy for leukocytosis with lymphocytosis are suggested.

Nebulized hypertonic saline for bronchiolitis: a randomized clinical trial.

IMPORTANCE: Bronchiolitis is one of the most common and costly respiratory diseases in infants and young children. Previous studies have shown a potential benefit of nebulized hypertonic saline; however, its effect in the emergency department (ED) setting is unclear. OBJECTIVE: To compare the effect of nebulized 3% hypertonic saline vs 0.9% normal saline on admission rate and length of stay in infants with bronchiolitis. DESIGN, SETTING, AND PARTICIPANTS: We conducted a double-blind, randomized clinical trial during 3 consecutive bronchiolitis seasons from March 1, 2008, through April 30, 2011. We recruited a convenience sample of patients younger than 24 months with a primary diagnosis of viral bronchiolitis presenting to the ED of 2 urban free-standing tertiary children's hospitals. We excluded patients who were premature (gestational age, <34 weeks) or who had chronic pulmonary disease, immune deficiency, cardiac disease, or previous episodes of wheezing or inhaled bronchodilator use. Of eligible patients who were approached, 161 (26.6%) declined to participate. INTERVENTIONS: Patients received 4 mL of 3% sodium chloride (hypertonic saline [HS group]) or 0.9% sodium chloride (normal saline [NS group]) inhaled as many as 3 times in the ED. Those admitted received the assigned medication every 8 hours until discharge. All treatment solutions were premedicated with albuterol sulfate. MAIN OUTCOMES AND MEASURES: Hospital admission rate, length of stay for admitted patients, and Respiratory Distress Assessment Instrument score. RESULTS: A total of 197 patients were enrolled in the NS group and 211 in the HS group. Admission rate in the 3% HS group was 28.9% compared with 42.6% in the NS group (adjusted odds ratio from logistic regression, 0.49 [95% CI, 0.28-0.86]). Mean (SD) length of stay for hospitalized patients was 3.92 (5.24) days for the NS group and 3.16 (2.11) days for the HS group (P = .24). The Respiratory Distress Assessment Instrument score decreased after treatment in both groups; however, we found no significant difference between groups (P = .35). CONCLUSIONS AND RELEVANCE: Hypertonic saline given to children with bronchiolitis in the ED decreases hospital admissions. We can detect no significant difference in Respiratory Distress Assessment Instrument score or length of stay between the HS and NS groups. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT00619918.

Monoarticular coccidioidal synovitis in a pediatric patient.

Isolated monoarticular synovitis is a rare presentation of coccidioidal disease and has, to our knowledge, never previously been described in the English language pediatric literature. Coccidioidal seropositivity is increasing in incidence in the Southwestern United States. It is critical to rule out Coccidioides infection when evaluating arthritis in the context of residence in or travel to high prevalence areas, even in otherwise healthy patients and especially before administering biologic immunosuppressive therapy.

Exchange blood transfusion in the management of severe pertussis in young infants.

We analyzed data from 10 young infants who received exchange blood transfusions for management of severe pertussis. Our data are insufficient to address efficacy of the procedure, but our data, as well as previous reports in the literature, indicate that if the procedure is to be successful, it should be done before organ failure has occurred and immediately if shock/hypotension occur.

Characteristics of Severe Bordetella pertussis Infection Among Infants ≤90 Days of Age Admitted to Pediatric Intensive Care Units - Southern California, September 2009-June 2011.

BACKGROUND: Bordetella pertussis infection can cause severe illness and death among young infants. METHODS: We collected demographic and clinical information from the medical records of infants who were ≤90 days of age and hospitalized for pertussis in 5 Southern California pediatric intensive care units (PICUs) from September 1, 2009 to June 30, 2011. Infants who died or were diagnosed with pulmonary hypertension were considered to have more severe pertussis. RESULTS: Thirty-one infants were admitted to a participating PICU. Eight infants had more severe infections, 6 infants had pulmonary hypertension, and 4 infants died. The 8 infants with more severe infections had white blood cell counts that exceeded 30 000, heart rates that exceeded 170, and respiratory rates that exceeded 70 more rapidly after cough onset than the 23 infants with less severe illness. CONCLUSIONS: Identifying higher-risk infants earlier might allow for more rapid implementation of interventions.

Communicating about vaccines and vaccine safety: what are medical residents learning and what do they want to learn?

OBJECTIVE: Physicians spend significant amounts of time discussing vaccine safety concerns with patients and parents. This study aimed to better understand the educational needs of US residents regarding vaccine safety communication, primarily by quantifying the vaccine safety communication training that residents currently receive and elucidating residents' preferences around education about vaccines and vaccine safety communication. DESIGN: A mixed-methods needs assessment consisting of focus groups and a survey. SETTING/PARTICIPANTS: A convenience sample of 303 medical residents in pediatrics, family medicine, and internal medicine from across the United States participated in an online, anonymous survey from March through June 2010. In addition, 9 focus groups with 47 resident participants were held. MAIN OUTCOME MEASURES/RESULTS: The sample included residents in pediatrics (239, 80.2%), internal or family medicine (30, 10.1%), and dual medicine-pediatrics (29, 9.7%); 20.6% of the residents reported "not learning" about vaccine safety communication in their residency programs. Preferred learning methods, which were also the most commonly used methods, included didactic lectures and role-modeling/cases. Electronic teaching method were not only less desired but also very rarely utilized. More than 95% of residents reported thinking that vaccine safety communication would be very or somewhat important in their careers. CONCLUSIONS: Improving education on vaccine safety communication within US residency programs, as well as offering self-learning opportunities, can better prepare physicians for their careers.

Bacterial identification by 16S rRNA gene PCR-hybridization as a supplement to negative culture results.

PCR-hybridization was compared to culture methods for evaluating suspected blood infections. A total of 231 clinical samples from blood culture bottles that were flagged positive by the BacT/Alert system or were negative 1 week after inoculation were tested. When the PCR-hybridization and culture method results were compared, the positive and negative concordance rates were 99.2% (122/123) and 89.5% (94/105), respectively. Of the negative blood cultures, 10.5% (11/105) were positive by PCR-hybridization. Supplemental testing of negative blood cultures may identify bacterial pathogens that are undetectable by culture methods.

Evaluation of Kawasaki disease risk-scoring systems for intravenous immunoglobulin resistance.

OBJECTIVES: To assess the performance of 3 risk scores from Japan that were developed to predict, in children with Kawasaki disease, resistance to intravenous immunoglobulin (IVIG) treatment. STUDY DESIGN: We used data from a randomized trial of pulsed steroids for primary treatment of Kawasaki disease to assess operating characteristics of the 3 risk scores, and we examined whether steroid therapy lowers the risk of coronary artery abnormalities in patients prospectively classified as IVIG resistant. RESULTS: For comparability with published cohorts, we analyzed the data of 99 patients who were not treated with steroids (16% IVIG-retreated) and identified male sex, lower albumin level, and higher aspartate aminotransferase level as independent risk factors for IVIG resistance. The Kobayashi score was similar in IVIG-resistant and -responsive patients, yielding a sensitivity of 33% and specificity of 87%. There was no interaction of high-risk versus low-risk status by treatment received (steroid versus placebo) with any of the 3 risk score algorithms. CONCLUSION: Risk-scoring systems from Japan have good specificity but low sensitivity for predicting IVIG resistance in a North American cohort. Primary steroid therapy did not improve coronary outcomes in patients prospectively classified as being at high-risk for IVIG resistance.

Common bile duct stenosis and pancreatitis in Kawasaki disease: two cases and a review of the literature.

We report 2 children with Kawasaki disease, who developed pancreatitis and common bile duct abnormalities. After reviewing the literature, we conclude that Kawasaki disease may lead to such changes as a result of the underlying vasculitis characterizing this disease, or of direct inflammation of the biliary tree.

Prevention of central venous catheter-associated bloodstream infections in pediatric intensive care units: a performance improvement collaborative.

OBJECTIVE: The goal of this effort was to reduce central venous catheter (CVC)-associated bloodstream infections (BSIs) in pediatric intensive care unit (ICU) patients by means of a multicenter evidence-based intervention. METHODS: An observational study was conducted in 26 freestanding children's hospitals with pediatric or cardiac ICUs that joined a Child Health Corporation of America collaborative. CVC-associated BSI protocols were implemented using a collaborative process that included catheter insertion and maintenance bundles, daily review of CVC necessity, and daily goals. The primary goal was either a 50% reduction in the CVC-associated BSI rate or a rate of 1.5 CVC-associated BSIs per 1,000 CVC-days in each ICU at the end of a 9-month improvement period. A 12-month sustain period followed the initial improvement period, with the primary goal of maintaining the improvements achieved. RESULTS: The collaborative median CVC-associated BSI rate decreased from 6.3 CVC-associated BSIs per 1,000 CVC-days at the start of the collaborative to 4.3 CVC-associated BSIs per 1,000 CVC-days at the end of the collaborative. Sixty-five percent of all participants documented a decrease in their CVC-associated BSI rate. Sixty-nine CVC-associated BSIs were prevented across all teams, with an estimated cost avoidance of $2.9 million. Hospitals were able to sustain their improvements during a 12-month sustain period and prevent another 198 infections. CONCLUSIONS: We conclude that our collaborative quality improvement project demonstrated that significant reduction in CVC-associated BSI rates and related costs can be realized by means of evidence-based prevention interventions, enhanced communication among caregivers, standardization of CVC insertion and maintenance processes, enhanced measurement, and empowerment of team members to enforce adherence to best practices.

Hand hygiene adherence is influenced by the behavior of role models.

OBJECTIVE: Proper hand hygiene (HH) reduces nosocomial infections. Therefore, factors that influence HH behavior of healthcare workers are of great interest. We hypothesized that strict HH adherence by supervisor role models would improve the HH behavior of junior staff. DESIGN: Prospective observational study. SETTING: Pediatric and cardiac intensive care units of a tertiary care children's hospital. SUBJECTS: Two critical care fellows and four nurse orientees. INTERVENTIONS: First, we observed and recorded HH adherence of the fellows and nurse orientees and their respective supervising attending physician or nurse preceptor during daily patient care. Subsequently, we paired the same fellows and nurse orientees with a different supervisor who maintained strict HH adherence, and again noted HH adherence. We used measures of HH opportunities and HH adherence consistent with guidelines set by the Centers for Disease Control and Prevention and Association for Professionals in Infection Control and Epidemiology. MEASUREMENTS AND MAIN RESULTS: HH adherence by fellows and nurse orientees at baseline was 22% of 200 HH opportunities, and improved to 56% of 234 opportunities as a result of role modeling--an average increase of 34% points (95% confidence interval, 18.7-51; p < 0.01 by linear regression), representing a HH adherence rate greater than 1.5 times that of the baseline. The control senior practitioners' HH adherence rate was 20% of 180 opportunities compared with the study senior practitioners' HH adherence of 94% of 187 opportunities--an average difference of 72% points higher compared with the control senior practitioners (95% confidence interval, 56-88.3; p < 0.01 by linear regression). CONCLUSIONS: HH adherence of junior practitioners improved under the supervision of adherent role models. These results suggest that HH behavior of senior practitioners plays a crucial influence on other staff. Senior healthcare practitioners should consider the important role they may play in reinforcing or weakening a culture of patient safety and proper HH.

Associated symptoms in the ten days before diagnosis of Kawasaki disease.

OBJECTIVE: To describe common associated symptoms within the 10 days before diagnosis in subjects enrolled in the Pediatric Heart Network's trial of steroid therapy in Kawasaki disease (KD). STUDY DESIGN: Patients with acute KD were enrolled between days 4 and 10 of illness at 8 centers between 2002 and 2004. We defined common associated symptoms as those occurring in >or=10% of patients. Principal clinical criteria for KD were not included in this analysis. RESULTS: Among 198 patients, irritability was reported in 98 (50%), vomiting in 88 (44%), decreased food/fluid intake in 73 (37%), cough in 55 (28%), diarrhea in 52 (26%), rhinorrhea in 37 (19%), weakness in 37 (19%), abdominal pain in 35 (18%), and joint pain (arthralgia or arthritis) in 29 (15%). One or more gastrointestinal symptom (vomiting, diarrhea, or abdominal pain) was present in 120 patients (61%) and 69 patients (35%) had >or= 1 respiratory symptom (rhinorrhea or cough). CONCLUSIONS: Nonspecific symptoms occur commonly in children with KD. To reduce delays in diagnosis, clinicians should be educated that such symptoms may comprise a significant component in the chief complaint.

Risk factors for nonresponse to therapy in Kawasaki disease.

OBJECTIVE: To study the refractory cases of Kawasaki disease (KD) and identify potential risk factors in patients in whom standard therapy fails. STUDY DESIGN: A retrospective chart review of patients with KD admitted from January 1, 2002, through December 31, 2006. Demographic, clinical, laboratory, echocardiographic, and therapeutic data were recorded. RESULTS: Of 196 patients, 40 (20%) needed re-treatment. The number of refractory cases were 7 (14.3%), 6 (17.1%), 11(28.9%), 10 (24.4%), and 6 (17.6%) for 2002 to 2006, respectively. There were no significant differences in age, sex, ethnicity, number of days with symptoms at diagnosis, white blood cell count, erythrocyte sedimentation rate (ESR), or C-reactive protein (CRP). Refractory patients had higher band counts (22.7% vs 7%), lower albumin levels (3 vs 3.4), and a higher number of abnormal echocardiography results at diagnosis (80% vs 16.1%). CONCLUSIONS: An elevated band count, low albumin level, and an abnormal initial echocardiography result can be useful tools to identify patients at risk for a more complicated clinical course.

Development, testing, and findings of a pediatric-focused trigger tool to identify medication-related harm in US children's hospitals.

OBJECTIVES: The purposes of this study were to develop a pediatric-focused tool for adverse drug event detection and describe the incidence and characteristics of adverse drug events in children's hospitals identified by this tool. METHODS: A pediatric-specific trigger tool for adverse drug event detection was developed and tested. Eighty patients from each site were randomly selected for retrospective chart review. All adverse drug events identified using the trigger tool were evaluated for severity, preventability, ability to mitigate, ability to identify the event earlier, and presence of associated occurrence report. Each trigger and the entire tool were evaluated for positive predictive value. RESULTS: Review of 960 randomly selected charts from 12 children's hospitals revealed 2388 triggers (2.49 per patient) and 107 unique adverse drug events. Mean adverse drug event rates were 11.1 per 100 patients, 15.7 per 1000 patient-days, and 1.23 per 1000 medication doses. The positive predictive value of the trigger tool was 3.7%. Twenty-two percent of all adverse drug events were deemed preventable, 17.8% could have been identified earlier, and 16.8% could have been mitigated more effectively. Ninety-seven percent of the identified adverse drug events resulted in mild, temporary harm. Only 3.7% of adverse drug events were identified in existing hospital-based occurrence reports. The most common adverse drug events identified were pruritus and nausea, the most common medication classes causing adverse drug events were opioid analgesics and antibiotics, and the most common stages of the medication management process associated with preventable adverse drug events were monitoring and prescribing/ordering. CONCLUSIONS: Adverse drug event rates in hospitalized children are substantially higher than previously described. Most adverse drug events resulted in temporary harm, and 22% were classified as preventable. Only 3.7% were identified by using traditional voluntary reporting methods. Our pediatric-focused trigger tool is effective at identifying adverse drug events in inpatient pediatric populations.

Adverse events in the neonatal intensive care unit: development, testing, and findings of an NICU-focused trigger tool to identify harm in North American NICUs.

OBJECTIVES: Currently there are few practical methods to identify and measure harm to hospitalized children. Patients in NICUs are at high risk and warrant a detailed assessment of harm to guide patient safety efforts. The purpose of this work was to develop a NICU-focused tool for adverse event detection and to describe the incidence of adverse events in NICUs identified by this tool. METHODS: A NICU-focused trigger tool for adverse event detection was developed and tested. Fifty patients from each site with a minimum 2-day NICU stay were randomly selected. All adverse events identified using the trigger tool were evaluated for severity, preventability, ability to mitigate, ability to identify the event earlier, and presence of associated occurrence report. Each trigger, and the entire tool, was evaluated for positive predictive value. Study chart reviewers, in aggregate, identified 88.0% of all potential triggers and 92.4% of all potential adverse events. RESULTS: Review of 749 randomly selected charts from 15 NICUs revealed 2218 triggers or 2.96 per patient, and 554 unique adverse events or 0.74 per patient. The positive predictive value of the trigger tool was 0.38. Adverse event rates were higher for patients <28 weeks' gestation and <1500 g birth weight. Fifty-six percent of all adverse events were deemed preventable; 16% could have been identified earlier, and 6% could have been mitigated more effectively. Only 8% of adverse events were identified in existing hospital-based occurrence reports. The most common adverse events identified were nosocomial infections, catheter infiltrates, and abnormal cranial imaging. CONCLUSIONS: Adverse event rates in the NICU setting are substantially higher than previously described. Many adverse events resulted in permanent harm and the majority were classified as preventable. Only 8% were identified using traditional voluntary reporting methods. Our NICU-focused trigger tool appears efficient and effective at identifying adverse events.

At-home recovery following hospitalization for bronchiolitis.

OBJECTIVES: To characterize the at-home recovery of infants after hospitalization for bronchiolitis, the impact of recovery from this illness on the family, and the association between delayed infant recovery and parental satisfaction with hospital care. METHODS: Otherwise healthy infants less than 1 year of age admitted to 6 children's hospitals were eligible. Telephone interviews with 486 parents (85% of sampled), 1-2 weeks following discharge, addressed functional recovery, lingering symptoms, family disruption, returns to the emergency department, and parental recall of satisfaction with care. RESULTS: Two thirds of infants experienced difficulties with normal routines (feeding, sleeping, contentedness, liveliness) on the day of discharge. By 5 days at home, 22% continued to experience disruption in sleeping, and 16% in feeding routines. Coughing (56%) and wheezing (27%) were common 4 to 6 days after discharge. Parents who reported longer delays in return to normal family routines took additional time off work, kept their infants out of day care twice as many days, and were more likely to take their infants to the doctor or hospital for repeat medical care. Parents from families slower to return to a normal routine recalled the hospital stay less favorably. CONCLUSIONS: A small but important proportion of infants have a protracted recovery period following hospitalization for bronchiolitis. Delayed recovery is associated with parental work time loss and less favorable parental impressions of care in the hospital. Anticipatory guidance about home recovery could allow parents to plan for extended home care and improve satisfaction with hospital care.

Infliximab treatment for refractory Kawasaki syndrome.

OBJECTIVE: To evaluate the use of tumor necrosis factor (TNF)-alpha blockade for treatment of patients with Kawasaki syndrome (KS) who fail to become afebrile or who experience persistent arthritis after treatment with intravenous gamma globulin (IVIG) and high-dose aspirin. STUDY DESIGN: Cases were retrospectively collected from clinicians throughout the United States who had used infliximab, a chimeric murine/human immunoglobulin (Ig)G1 monoclonal antibody that binds specifically to human TNF-alpha-1, for patients with KS who had either persistent arthritis or persistent or recrudescent fever > or =48 hours following infusion of 2 g/kg of IVIG. RESULTS: Response to therapy with cessation of fever occurred in 13 of 16 patients. C-reactive protein (CRP) level was elevated in all but one patient before infliximab infusion, and the level was lower following infusion in all 10 patients in whom it was re-measured within 48 hours of treatment. There were no infusion reactions to infliximab and no complications attributed to infliximab administration in any of the patients. CONCLUSION: The success of TNF-alpha blockade in this small series of patients suggests a central role of TNF-alpha in KS pathogenesis. Controlled, randomized clinical trials are warranted to determine the role of anti-TNF-alpha therapy in KS.

Right atrial mass in a child with disseminated coccidioidomycosis.

A 10-year-old patient with known coccidioidomycosis relapsed and had dysrrhythmias and a right atrial mass. Histopathology and culture after surgical removal revealed that this was a vegetative mass infected with Coccidioides spp. We believe that this is the first case of coccidioidal endocarditis to be reported.