Clinical Impact of an Antibiotic Stewardship Program at a Children's Hospital.

INTRODUCTION: Antibiotic stewardship programs (ASP) improve appropriate antibiotic use. Data are limited on the clinical benefit of ASPs in children's hospitals. This study's objective was to determine the impact of an ASP on length of stay (LOS) and readmission rate among patients admitted to children's hospitals. METHODS: Data from a prospective-audit-with-feedback ASP were used to examine the ASP review characteristics, including antibiotic(s) prescribed, clinical indication, recommendations made by the ASP, and agreement with recommendations. Propensity score analysis was utilized to determine the impact of the ASP on LOS and 30-day readmission based on whether the patient received an ASP recommendation and if the clinician agreed with recommendations. Patients were stratified on if they had a complex chronic condition status (CCC) and their service line, medical or surgical. RESULTS: Of the 8038 reviews included, 1362 (16.9%) resulted in a recommendation that was agreed with in 1116 (81%) cases. Propensity score analysis demonstrated a significantly longer LOS for the non-CCC medicine group who received an ASP recommendation (80.9 vs. 67.6 h, p < 0.001). However, for CCC medicine patients that agreed with the ASP recommendation, a clinically relevant decrease in LOS (158.1 vs. 180.3 h, p = 0.095) was observed. The 30-day readmission rate was significantly greater in CCC medicine patients when comparing those who did not receive a recommendation versus those who did receive a recommendation (7.3% vs 4.2%, respectively; p = 0.005). CONCLUSION: Children without a CCC who received an ASP recommendation had a longer length of stay. For children with CCCs, the ASP appeared to decrease LOS and significantly reduce 30-day readmission rates. Overall, this study demonstrate that ASPs offer meaningful clinical benefit justifying resource allocation needed to develop and maintain ASP programs.

Prevalence and characteristics of antimicrobial stewardship programs at freestanding children's hospitals in the United States.

BACKGROUND AND OBJECTIVE: Antimicrobial stewardship programs (ASPs) are a mechanism to ensure the appropriate use of antimicrobials. The extent to which ASPs are formally implemented in freestanding children's hospitals is unknown. The objective of this study was to determine the prevalence and characteristics of ASPs in freestanding children's hospitals. METHODS: We conducted an electronic survey of 42 freestanding children's hospitals that are members of the Children's Hospital Association to determine the presence and characteristics of their ASPs. For hospitals without an ASP, we determined whether stewardship strategies were in place and whether there were barriers to implementing a formal ASP. RESULTS: We received responses from 38 (91%) of 42. Among responding institutions, 16 (38%) had a formal ASP, and 15 (36%) were in the process of implementing a program. Most ASPs (13 [81%] of 16) were started after 2007. The median number of full-time equivalents dedicated to ASPs was 0.63 (range, 0.1-1.8). The most common antimicrobials monitored by ASPs were linezolid, vancomycin, and carbapenems. Many hospitals without a formal ASP were performing stewardship activities, including elements of prospective audit and feedback (9 [41%] of 22), formulary restriction (9 [41%] of 22), and use of clinical guidelines (17 [77%] of 22). Antimicrobial outcomes were more likely to be monitored by hospitals with ASPs (100% vs 68%; P = .01), although only 1 program provided support for a data analyst. CONCLUSIONS: Most freestanding children's hospitals have implemented or are developing an ASP. These programs differ in structure and function, and more data are needed to identify program characteristics that have the greatest impact.

Linezolid use in hospitalized children.

We used the Pediatric Health Information System to evaluate linezolid use among hospitalized children. From 2003 to 2007, use increased 5-fold, including wide interhospital variation, then stabilized through 2011. Linezolid was responsible for 3% of total antibiotic expenditures. Children with respiratory, oncologic or transplant conditions were the most frequently treated with linezolid.

Antibiotic Management of Animal Bites in Children During the Methicillin-Resistant Staphylococcus aureus Era.

Children presenting to an emergency department following an animal bite were found to be at risk for infection if they had puncture wounds, crush wounds, or were bitten by a cat. Of the infected wounds that were cultured, methicillin-resistant Staphylococcus aureus was not isolated as a pathogen.

Validating deaths reported in the Foodborne Diseases Active Surveillance Network (FoodNet): are all deaths being captured?

Accurate information about deaths is important when determining the human health and economic burden of foodborne diseases. We reviewed death certificate data to assess the accuracy of deaths reported to the Foodborne Diseases Active Surveillance Network (FoodNet). Data were highly accurate, and few deaths were missed through active surveillance.

Impact of a guideline on management of children hospitalized with community-acquired pneumonia.

OBJECTIVES: We sought to describe the impact a clinical practice guideline (CPG) had on antibiotic management of children hospitalized with community-acquired pneumonia (CAP). PATIENTS AND METHODS: We conducted a retrospective study of discharged patients from a children's hospital with an ICD-9-CM code for pneumonia (480-486). Eligible patients were admitted from July 8, 2007, through July 9, 2009, 12 months before and after the CAP CPG was introduced. Three-stage least squares regression analyses were performed to examine hypothesized simultaneous relationships, including the impact of our institution\x{2019}s antimicrobial stewardship program (ASP). RESULTS: The final analysis included 1033 patients: 530 (51%) before the CPG (pre-CPG) and 503 (49%) after the CPG (post-CPG). Pre-CPG, ceftriaxone (72%) was the most commonly prescribed antibiotic, followed by ampicillin (13%). Post-CPG, the most common antibiotic was ampicillin (63%). The effect of the CPG was associated with a 34% increase in ampicillin use (P < .001). Discharge antibiotics also changed post-CPG, showing a significant increase in amoxicillin use (P < .001) and a significant decrease in cefdinir and amoxicillin/clavulanate (P < .001), with the combined effect of the CPG and ASP leading to 12% (P < 0.001) and 16% (P < .001) reduction, respectively. Overall, treatment failure was infrequent (1.5% vs 1%). CONCLUSIONS: A CPG and ASP led to the increase in use of ampicillin for children hospitalized with CAP. In addition, less broad-spectrum discharge antibiotics were used. Patient adverse outcomes were low, indicating that ampicillin is appropriate first-line therapy for otherwise healthy children admitted with uncomplicated CAP.

Antibiotic treatment of Escherichia coli O157 infection and the risk of hemolytic uremic syndrome, Minnesota.

BACKGROUND: Infection with Escherichia coli O157 (O157) can lead to the development of hemolytic uremic syndrome (HUS). Treating O157 infections with antibiotics is a possible risk factor for HUS development; however, previous studies evaluating this relationship have yielded conflicting results. The objective of this study was to further evaluate this issue. METHODS: An age-matched case-case comparison study comprising Minnesota residents less than 20 years of age with culture-confirmed O157 infection who did (n = 66) or did not (n = 129) subsequently develop HUS was conducted. Subjects were identified through statewide surveillance activities by the Minnesota Department of Health from 1996 to 2002. RESULTS: Overall antibiotic treatment was not associated with the development of HUS. Self-reported vomiting and female gender were significantly associated with the development of HUS. After adjustment for illness severity and gender, subjects who developed HUS were more likely to have been treated only with bactericidal antibiotics within the first 3 days (adjusted matched odds ratio [OR], 12.4; 95% confidence interval [CI], 1.4-110.3) or within the first 7 days (OR, 18.0; 95% CI, 1.9-170.9) after the onset of diarrhea. In particular, the use of ß-lactams (penicillins or cephalosporins) in the first 3 days after diarrhea onset was also significant after adjustment (OR, 11.3; 95% CI, 1.2-106.7). CONCLUSIONS: Individuals infected with O157 infection presenting with a more severe illness were at an increased risk of developing HUS. The use of bactericidal antibiotics, particularly ß-lactams, to treat O157 infection was associated with the subsequent development of HUS.

Impact of a Prospective-Audit-With-Feedback Antimicrobial Stewardship Program at a Children's Hospital.

BACKGROUND: The emergence of antibiotic-resistant organisms and the lack of development of new antimicrobials have made it imperative that additional strategies be developed to maintain the effectiveness of these existing antibiotics. The objective of this study was to describe the impact of a prospective-audit-with-feedback antimicrobial stewardship program (ASP) on antibiotic use in a children's hospital. METHOD: A quasi-experimental study design with a control group was performed to assess the impact of a prospective-audit-with-feedback ASP. The control group was the combined antibiotic use at 25 similar children's hospitals that are members of the Child Health Corporation of America. RESULTS: The ASP reviewed 10 460 broad-spectrum or select antibiotics in 8765 patients in the 30 months following the intervention. The most common select antibiotics reviewed were ceftriaxone/cefotaxime (43%), vancomycin (18%), ceftazidime (12%), and meropenem (7%). A total of 2378 recommendations were made in 1703 (19%) patients; the most common recommendation was to stop antibiotics (41%). Clinicians were compliant with agreed-upon ASP recommendations in 92% of patients. When comparing our antibiotic use with that of the control group, a monthly decline in all antibiotics of 7% (P = .045) and 8% (P = .045) was observed for days of therapy (DoT) and length of therapy (LoT) per 1000 patient-days, respectively. An even greater effect was observed in the select antibiotics as the monthly DoT per 1000 patient-days declined 17% (P < .001) and the monthly LoT per 1000 patient-days declined 18% (P < .001). CONCLUSIONS: A prospective-audit-with-feedback ASP can have a significant impact on decreasing antibiotic use at a children's hospital.

Clinicians' Attitudes Towards an Antimicrobial Stewardship Program at a Children's Hospital.

BACKGROUND: In pediatrics, limited data are available on how to develop and implement an antimicrobial stewardship program (ASP). In addition, no data exist on clinicians' impression of such programs. The objectives of this study were to describe the development and implementation of an ASP in a children's hospital and to describe the thoughts and attitudes of the clinicians interacting with the ASP. METHODS: A qualitative description of the development and implementation of an ASP is provided. In addition, 2 years after the implementation of a prospective-audit-with-feedback ASP, an electronic survey was administered to clinicians to assess their attitudes toward the ASP. RESULTS: A 5-step process for developing this ASP included the following: team development; selecting the stewardship strategy(ies) and antimicrobials to monitor; establishing a method to identify patients; program evaluation; and implementation. Of 365 participants surveyed, 205 (56%) responded, and 80% (160 of 199) had never worked with an ASP before its implementation. Clinicians agreed that the ASP decreased inappropriate use of antibiotics (84%, 162 of 194), improved the quality of patient care (82%, 159 of 194), and provided knowledge and education about appropriate antibiotic use (91%, 177 of 194). Negative feelings regarding the ASP included the following: 11% (22 of 194) felt a loss of autonomy; 6% (12 of 194) felt that it interfered with clinical decision-making; and 5% (9 of 194) felt threatened. Clinicians thought that to further decrease inappropriate antibiotic use, guidelines of empiric antibiotic choices (80%, 152 of 189) should be developed, and better training in medical school and residency should be provided (80%, 152 of 189). Finally, our clinicians felt that the problem of antibiotic resistance and inappropriate antibiotic use was worse nationally than at our institution. CONCLUSIONS: A prospective-audit-with-feedback ASP was successfully developed and implemented at a children's hospital. The ASP was perceived by clinicians to reduce inappropriate antibiotic use and to improve the quality of care of hospitalized children, with minimal loss of physician autonomy or interference in clinical decision-making.

2008 outbreak of Salmonella Saintpaul infections associated with raw produce.

BACKGROUND: Raw produce is an increasingly recognized vehicle for salmonellosis. We investigated a nationwide outbreak that occurred in the United States in 2008. METHODS: We defined a case as diarrhea in a person with laboratory-confirmed infection with the outbreak strain of Salmonella enterica serotype Saintpaul. Epidemiologic, traceback, and environmental studies were conducted. RESULTS: Among the 1500 case subjects, 21% were hospitalized, and 2 died. In three case-control studies of cases not linked to restaurant clusters, illness was significantly associated with eating raw tomatoes (matched odds ratio, 5.6; 95% confidence interval [CI], 1.6 to 30.3); eating at a Mexican-style restaurant (matched odds ratio, 4.6; 95% CI, 2.1 to ∞) and eating pico de gallo salsa (matched odds ratio, 4.0; 95% CI, 1.5 to 17.8), corn tortillas (matched odds ratio, 2.3; 95% CI, 1.2 to 5.0), or salsa (matched odds ratio, 2.1; 95% CI, 1.1 to 3.9); and having a raw jalapeño pepper in the household (matched odds ratio, 2.9; 95% CI, 1.2 to 7.6). In nine analyses of clusters associated with restaurants or events, jalapeño peppers were implicated in all three clusters with implicated ingredients, and jalapeño or serrano peppers were an ingredient in an implicated item in the other three clusters. Raw tomatoes were an ingredient in an implicated item in three clusters. The outbreak strain was identified in jalapeño peppers collected in Texas and in agricultural water and serrano peppers on a Mexican farm. Tomato tracebacks did not converge on a source. CONCLUSIONS: Although an epidemiologic association with raw tomatoes was identified early in this investigation, subsequent epidemiologic and microbiologic evidence implicated jalapeño and serrano peppers. This outbreak highlights the importance of preventing raw-produce contamination.

Salmonellosis outbreak due to chicken contact leading to a foodborne outbreak associated with infected delicatessen workers.

Salmonella is the most common bacterial cause of foodborne outbreaks in the United States. Starting in June 2007, investigation of a cluster of Salmonella Montevideo cases with indistinguishable pulsed-field gel electrophoresis (PFGE) patterns resulted in the identification of an outbreak associated with contact with chickens purchased from a single hatchery. Nine Minnesota cases from May through August 2007 were part of this outbreak. Cases with the outbreak PFGE pattern of Salmonella Montevideo continued to occur in Minnesota after August, but none of these cases reported chicken contact. The majority of these cases resided in the same town in rural Minnesota. Routine interviews revealed that all cases from these counties purchased groceries from the same local grocery store, with two specifically reporting consuming items from the grocery store delicatessen in the week before illness. As a result, an investigation into the delicatessen was initiated. Illness histories and stool samples were collected from all delicatessen employees, and food and environmental samples were collected. None of the employees reported experiencing recent gastrointestinal symptoms, but the outbreak PFGE subtype of Salmonella Montevideo was identified from stool from two food workers. Food and environmental samples collected tested negative for Salmonella. One of the positive employees reported having chickens at home, but the animals did not test positive for Salmonella. The positive food workers were excluded from work until they had two consecutive negative stool cultures for Salmonella. There was no evidence of ongoing transmission thereafter. This was an outbreak of Salmonella Montevideo infections that began as an animal-contact-associated outbreak which subsequently resulted in a foodborne outbreak associated with infected food workers. These outbreaks illustrate the complex epidemiology of salmonellosis.

Restaurant Salmonella Enteritidis outbreak associated with an asymptomatic infected food worker.

Salmonella is the most common bacterial cause of foodborne outbreaks in the United States; approximately half of Salmonella outbreaks occur in restaurant settings. In February 2008, investigation of a cluster of Salmonella Enteritidis cases with indistinguishable pulsed-field gel electrophoresis (PFGE) patterns revealed that five cases had eaten at the same restaurant. Cases were identified through routine surveillance activities and by contacting meal companions of culture-confirmed cases. Well meal companions and well patrons contacted via check stubs served as controls. Illness histories and stool samples were collected from all restaurant employees. Sandwiches were the only menu item or ingredient significantly associated with illness (15 of 15 cases versus 17 of 37 controls; odds ratio, undefined; P < 0.001). None of the six restaurant employees reported experiencing recent gastrointestinal symptoms. The outbreak PFGE subtype of Salmonella Enteritidis was identified in two food workers. One of the positive employees began working at the restaurant shortly before the first exposure date reported by a case, and assisted in the preparation of sandwiches and other foods consumed by cases. The other positive employee rarely, if ever, handled food. The restaurant did not have a glove use policy. There was no evidence of ongoing transmission after exclusion of the positive food workers. This was a restaurant Salmonella Enteritidis outbreak associated with an asymptomatic infected food worker. Routine PFGE subtyping of Salmonella Enteritidis isolates, routine interviewing of cases, and an iterative approach to cluster investigations allowed for timely identification of the source of an outbreak of Salmonella Enteritidis infections.

Characteristics of O157 versus non-O157 Shiga toxin-producing Escherichia coli infections in Minnesota, 2000-2006.

BACKGROUND: Escherichia coli O157:H7 (O157) is the Shiga toxin-producing E. coli (STEC) serotype most frequently isolated and most often associated with hemolytic uremic syndrome (HUS) in the United States. Non-O157 STEC serotypes can also cause serious illness, but their impact as pathogens remains undefined. We compared characteristics of non-O157 and O157 STEC infections identified through sentinel surveillance. METHODS: Sentinel sites included a metropolitan health maintenance organization laboratory and a hospital laboratory serving a small city and rural area. We received sorbitol-MacConkey agar plates from every stool culture performed at both sites during 2000-2006. Colony sweeps were screened for stx1 and stx2 by polymerase chain reaction. E. coli identity, serotype, and presence of stx1 and/or stx2 were confirmed on individual isolates. RESULTS: Two hundred six STEC isolates were identified: 108 (52%) were non-O157 serotypes, and 98 (48%) were O157. Of non-O157 cases, 54% involved bloody diarrhea, and 8% involved hospitalization. Non-O157 isolates with at least stx2 were not more likely to cause severe illness (bloody diarrhea, hospitalization, or HUS) than were non-O157 isolates with only stx1. O157 cases were more likely than non-O157 cases to involve bloody diarrhea (78% vs 54%; P < .001), hospitalization (34% vs 8%; P < .001 and HUS (7% vs 0%; P = .005). When including only isolates with at least stx2, O157 cases were still more likely to involve bloody diarrhea (78% vs 56%; P = .02) and hospitalization (33% vs 12%; P = .01) than non-O157 cases. CONCLUSIONS: Differences in severity among STEC infections could not be explained by stx2, suggesting that additional factors are important in STEC virulence.