Limiting Vancomycin Exposure in Pediatric Oncology Patients With Febrile Neutropenia May Be Associated With Decreased Vancomycin-Resistant Enterococcus Incidence.

BACKGROUND: Limited data exists regarding the effects of empiric antibiotic use in pediatric oncology patients with febrile neutropenia (FN) on the development of antibiotic resistance. We evaluated the impact of a change in our empiric FN guideline limiting vancomycin exposure on the development of vancomycin-resistant Enterococcus in pediatric oncology patients. METHODS: Retrospective, quasi-experimental, single-center study using interrupted timeseries analysis in oncology patients aged ≤18 years with at least 1 admission for FN between 2009 and 2015. Risk strata incorporated diagnosis, chemotherapy phase, Down syndrome, septic shock, and typhlitis. Microbiologic data and inpatient antibiotic use were obtained by chart review. Segmented Poisson regression was used to compare VRE incidence and antibiotic days of therapy (DOT) before and after the intervention. RESULTS: We identified 285 patients with 697 FN episodes pre-intervention and 309 patients with 691 FN episodes postintervention. The proportion of high-risk episodes was similar in both periods (49% vs 48%). Empiric vancomycin DOT/1000 FN days decreased from 315 pre-intervention to 164 post-intervention (P < .01) in high-risk episodes and from 199 to 115 in standard risk episodes (P < .01). Incidence of VRE/1000 patient-days decreased significantly from 2.53 pre-intervention to 0.90 post-intervention (incidence rate ratio, 0.14; 95% confidence interval, 0.04-0.47; P = .002). CONCLUSIONS: A FN guideline limiting empiric vancomycin exposure was associated with a decreased incidence of VRE among pediatric oncology patients. Antimicrobial stewardship interventions are feasible in immunocompromised patients and can impact antibiotic resistance.

Variability in antimicrobial use in pediatric ventilator-associated events.

OBJECTIVE: To assess variability in antimicrobial use and associations with infection testing in pediatric ventilator-associated events (VAEs). DESIGN: Descriptive retrospective cohort with nested case-control study. SETTING: Pediatric intensive care units (PICUs), cardiac intensive care units (CICUs), and neonatal intensive care units (NICUs) in 6 US hospitals.PatientsChildren≤18 years ventilated for≥1 calendar day. METHODS: We identified patients with pediatric ventilator-associated conditions (VACs), pediatric VACs with antimicrobial use for≥4 days (AVACs), and possible ventilator-associated pneumonia (PVAP, defined as pediatric AVAC with a positive respiratory diagnostic test) according to previously proposed criteria. RESULTS: Among 9,025 ventilated children, we identified 192 VAC cases, 43 in CICUs, 70 in PICUs, and 79 in NICUs. AVAC criteria were met in 79 VAC cases (41%) (58% CICU; 51% PICU; and 23% NICU), and varied by hospital (CICU, 20-67%; PICU, 0-70%; and NICU, 0-43%). Type and duration of AVAC antimicrobials varied by ICU type. AVAC cases in CICUs and PICUs received broad-spectrum antimicrobials more often than those in NICUs. Among AVAC cases, 39% had respiratory infection diagnostic testing performed; PVAP was identified in 15 VAC cases. Also, among AVAC cases, 73% had no associated positive respiratory or nonrespiratory diagnostic test. CONCLUSIONS: Antimicrobial use is common in pediatric VAC, with variability in spectrum and duration of antimicrobials within hospitals and across ICU types, while PVAP is uncommon. Prolonged antimicrobial use despite low rates of PVAP or positive laboratory testing for infection suggests that AVAC may provide a lever for antimicrobial stewardship programs to improve utilization.

Increased 30-Day Mortality Associated With Carbapenem-Resistant Enterobacteriaceae in Children.

In this multicenter study, we identified an increased risk of 30-day mortality among hospitalized children with carbapenem-resistant Enterobacteriaceae (CRE) isolated from clinical cultures compared with those with carbapenem-susceptible Enterobacteriaceae. We additionally report significant variation in antibiotic treatment for children with CRE infections with infrequent use of combination therapy.

Safety and Tolerability of Moxifloxacin in Children.

OBJECTIVES: Moxifloxacin is not approved by the US Food and Drug Administration for pediatric use. Although its use might be indicated under certain conditions, data regarding its safety and tolerability in pediatric patients are limited. The primary objective of this study was to evaluate the safety of systemic moxifloxacin therapy in children. METHODS: We conducted a retrospective observational study of patients aged <18 years who received oral or intravenous moxifloxacin at our institution between January 2011 and July 2016. Patient demographics, clinical characteristics, indication for moxifloxacin use, and adverse events (AEs) were extracted via chart review. The attribution of AEs to moxifloxacin use was adjudicated in consultation with a pediatric infectious disease (ID) pharmacist. RESULTS: We identified 221 patients who received 300 courses of moxifloxacin. The average age at moxifloxacin initiation was 10.4 years. One or more AEs occurred during 195 (65%) of the courses. Of the 463 distinct AEs, 46 (9.9%) were attributed to moxifloxacin. AEs attributed to moxifloxacin included corrected QT interval (QTc) prolongation (18 [6%] courses), transaminase level elevation (7 [2.3%] courses), and increased bilirubin level (3 [1%] courses). AEs led to moxifloxacin discontinuation in 18 (6%) courses. ID consultation was associated with QTc (P < .001) and transaminase (P = .002) monitoring. CONCLUSIONS: AEs that occur during pediatric moxifloxacin therapy are relatively common but rarely serious enough to require premature discontinuation. The drug might be used safely in most children with monitoring, including evaluation for QTc prolongation, and guidance from ID specialists.

Multicenter Study of the Risk Factors for Colonization or Infection with Carbapenem-Resistant Enterobacteriaceae in Children.

Carbapenem-resistant Enterobacteriaceae (CRE) are increasingly identified in children in the United States, but data on the epidemiology of CRE in this population are limited. The objectives of this study were to characterize the risk factors for colonization or infection with CRE and describe the microbiologic characteristics of pediatric CRE isolates. We performed a multicenter matched case-control study from January 2011 to October 2015 at three tertiary care pediatric centers. Case patients were hospitalized children with CRE isolated from clinical cultures and were matched in a 2:1 ratio to control patients with carbapenem-susceptible Enterobacteriaceae (CSE). Risk factors for colonization or infection with CRE were then evaluated using a multivariable conditional logistic regression. Additionally, we comprehensively reported the antimicrobial susceptibility pattern for CRE isolates. Sixty-three case patients were identified and matched to 126 control patients. On multivariable analysis, antipseudomonal antibiotic exposure within the previous 3 months (odds ratio [OR], 5.20; 95% confidence interval [CI], 1.71 to 15.9; P = 0.004), prior surgery (OR, 6.30; 95% CI, 1.83 to 21.6; P = 0.003), and mechanical ventilation (OR, 12.4; 95% CI, 1.26 to 122; P = 0.031) were identified as risk factors for colonization or infection with CRE. Pediatric CRE isolates demonstrated relatively low rates of resistance to amikacin (5%) and ciprofloxacin (25%). Our findings support an important role for antibiotic stewardship interventions limiting the unnecessary use of antipseudomonal antibiotics as a strategy to prevent widespread emergence of CRE in children. Future studies should further characterize molecular determinants of antibiotic resistance among pediatric CRE isolates.

Aeromonas as a Cause of Purulent Folliculitis: A Case Report and Review of the Literature.

Aeromonas species are rarely an identified cause of folliculitis. Here, we describe the case of a patient who had purulent folliculitis of the breast caused by an Aeromonas species and review 4 other cases presented in the literature, highlighting the commonalities observed. Aeromonas infection should be considered in patients who present with purulent folliculitis, particularly those with exposure to nonchlorinated pools or baths.