Increase in pediatric recurrent fever evaluations during the first year of the COVID-19 pandemic in North America.

The impact of the COVID-19 pandemic on new diagnoses of recurrent fevers and autoinflammatory diseases is largely unknown. The Childhood Arthritis and Rheumatology Research Alliance (CARRA) PFAPA/AID Working Group aimed to investigate the impact of the COVID-19 pandemic on the number of pediatric patients evaluated for recurrent fevers and autoinflammatory diseases in North America. The absolute number of new outpatient visits and the proportion of these visits attributed to recurrent fever diagnoses during the pre-pandemic period (1 March 2019-29 February 2020) and the first year of the COVID-19 pandemic (1 March 2020-28 February 2021) were examined. Data were collected from 27 sites in the United States and Canada. Our results showed an increase in the absolute number of new visits for recurrent fever evaluations in 21 of 27 sites during the COVID-19 pandemic compared to the pre-pandemic period. The increase was observed across different geographic regions in North America. Additionally, the proportion of new visits to these centers for recurrent fever in relation to all new patient evaluations was significantly higher during the first year of the pandemic, increasing from 7.8% before the pandemic to 10.9% during the pandemic year (p < 0.001). Our findings showed that the first year of the COVID-19 pandemic was associated with a higher number of evaluations by pediatric subspecialists for recurrent fevers. Further research is needed to understand the reasons behind these findings and to explore non-infectious triggers for recurrent fevers in children.

Corrigendum: Increase in pediatric recurrent fever evaluations during the first year of the COVID-19 pandemic in North America.

[This corrects the article DOI: 10.3389/fped.2023.1240242.].

Comparing the clinical severity of the first versus second wave of 2009 Influenza A (H1N1) in a New York City pediatric healthcare facility.

OBJECTIVE: We previously reported the epidemiology of 2009 Influenza A (H1N1) in our pediatric healthcare facility in New York City during the first wave of illness (May-July 2009). We hypothesized that compared with the first wave, the second wave would be characterized by increased severity of illness and mortality. DESIGN: : Case series conducted from May 2009 to April 2010. SETTING: Pediatric emergency departments and inpatient facilities of New York-Presbyterian Hospital. PATIENTS: All hospitalized patients ÷ 18 yrs of age with positive laboratory tests for influenza A. MEASUREMENTS AND MAIN RESULTS: We compared severity of illness during the first and second wave assessed by the number of hospitalized children, including those in the pediatric intensive care unit, bacterial superinfections, and mortality rate. Compared to the first wave, fewer children were hospitalized during the second wave (n = 115 vs. 76), but a comparable portion were admitted to the pediatric intensive care unit (30.4% vs. 19.7%; p = .10). Pediatric Risk of Mortality III scores, length of hospitalization in the pediatric intensive care unit, incidence of respiratory failure and pneumonia, and peak oxygenation indices were similar during both waves. Bacterial superinfections were comparable in the first vs. second wave (3.5% vs. 1.3%). During the first wave, no child received extracorporeal membrane oxygenation and one died, while during the second wave, one child received extracorporeal membrane oxygenation and there were no deaths. CONCLUSIONS: At our pediatric healthcare facility in New York City, fewer children were hospitalized with 2009 Influenza A (H1N1) during the second wave, but both waves had a similar spectrum of illness severity and low mortality rate.

Pediatric surgical site infection (SSI) following ambulatory surgery: Incidence, risk factors and patient outcomes.

BACKGROUND: Inpatient surgical site infections (SSIs) cause morbidity in children. The SSI rate among pediatric ambulatory surgery patients is less clear. To fill this gap, we conducted a multiple-institution, retrospective epidemiologic study to identify incidence, risk factors, and outcomes. METHODS: We identified patients aged <22 years with ambulatory visits between October 2010 and September 2015 via electronic queries at 3 medical centers. We performed sample chart reviews to confirm ambulatory surgery and adjudicate SSIs. Weighted Poisson incidence rates were calculated. Separately, we used case-control methodology using multivariate backward logistical regression to assess risk-factor association with SSI. RESULTS: In total, 65,056 patients were identified by queries, and we performed complete chart reviews for 13,795 patients; we identified 45 SSIs following ambulatory surgery. The weighted SSI incidence following pediatric ambulatory surgery was 2.00 SSI per 1,000 ambulatory surgeries (95% confidence interval [CI], 1.37-3.00). Integumentary surgeries had the highest weighted SSI incidence, 3.24 per 1,000 ambulatory surgeries (95% CI, 0.32-12). The following variables carried significantly increased odds of infection: clean contaminated or contaminated wound class compared to clean (odds ratio [OR], 9.8; 95% CI, 2.0-48), other insurance type compared to private (OR, 4.0; 95% CI, 1.6-9.8), and surgery on weekend day compared to weekday (OR, 30; 95% CI, 2.9-315). Of the 45 instances of SSI following pediatric ambulatory surgery, 40% of patients were admitted to the hospital and 36% required a new operative procedure or bedside incision and drainage. CONCLUSIONS: Our findings suggest that morbidity is associated with SSI following ambulatory surgery in children, and we also identified possible targets for intervention.

Central Venous Catheter Salvage in Ambulatory Central Line-Associated Bloodstream Infections.

BACKGROUND: Guidelines for treatment of central line-associated bloodstream infection (CLABSI) recommend removing central venous catheters (CVCs) in many cases. Clinicians must balance these recommendations with the difficulty of obtaining alternate access and subjecting patients to additional procedures. In this study, we evaluated CVC salvage in pediatric patients with ambulatory CLABSI and associated risk factors for treatment failure. METHODS: This study was a secondary analysis of 466 ambulatory CLABSIs in patients <22 years old who presented to 5 pediatric medical centers from 2010 to 2015. We defined attempted CVC salvage as a CVC left in place ≥3 days after a positive blood culture result. Salvage failure was removal of the CVC ≥3 days after CLABSI. Successful salvage was treatment of CLABSI without removal of the CVC. Bivariate and multivariable logistic regression analyses were used to test associations between risk factors and attempted and successful salvage. RESULTS: A total of 460 ambulatory CLABSIs were included in our analysis. CVC salvage was attempted in 379 (82.3%) cases. Underlying diagnosis, CVC type, number of lumens, and absence of candidemia were associated with attempted salvage. Salvage was successful in 287 (75.7%) attempted cases. Underlying diagnosis, CVC type, number of lumens, and absence of candidemia were associated with successful salvage. In patients with malignancy, neutropenia within 30 days before CLABSI was significantly associated with both attempted salvage and successful salvage. CONCLUSIONS: CVC salvage was often attempted and was frequently successful in ambulatory pediatric patients presenting with CLABSI.

Pediatric Ambulatory Central Line-Associated Bloodstream Infections.

BACKGROUND: Inpatient pediatric central line-associated bloodstream infections (CLABSIs) cause morbidity and increased health care use. Minimal information exists for ambulatory CLABSIs despite ambulatory central line (CL) use in children. In this study, we identified ambulatory pediatric CLABSI incidence density, risk factors, and outcomes. METHODS: Retrospective cohort with nested case-control study at 5 sites from 2010 through 2015. Electronic queries were used to identify potential cases on the basis of administrative and laboratory data. Chart review was used to confirm ambulatory CL use and adjudicated CLABSIs. Bivariate followed by multivariable backward logistic regression was used to identify ambulatory CLABSI risk factors. RESULTS: Queries identified 4600 potentially at-risk children; 1658 (36%) had ambulatory CLs. In total, 247 (15%) patients experienced 466 ambulatory CLABSIs with an incidence density of 0.97 CLABSIs per 1000 CL days. Incidence density was highest among patients with tunneled externalized catheters versus peripherally inserted central catheters and totally implanted devices: 2.58 CLABSIs per 1000 CL days versus 1.46 vs 0.23, respectively (P < .001). In a multivariable model, clinic visit (odds ratio [OR] 2.8; 95% confidence interval [CI]: 1.4-5.5) and low albumin (OR 2.3; 95% CI: 1.2-4.3) were positively associated with CLABSI, and prophylactic antimicrobial agents for underlying conditions within the preceding 30 days (OR 0.22; 95% CI: 0.12-0.40) and operating room CL placement (OR 0.36; 95% CI: 0.16-0.79) were inversely associated with CLABSI. A total of 396 patients (85%) were hospitalized because of ambulatory CLABSI with an 8-day median length of stay (interquartile range 5-13). CONCLUSIONS: Ambulatory pediatric CLABSI incidence density is appreciable and associated with health care use. CL type, patients with low albumin, prophylactic antimicrobial agents, and placement setting may be targets for reduction efforts.

Neonatal management and outcomes during the COVID-19 pandemic: an observation cohort study.

BACKGROUND: The risk of vertical and perinatal transmission of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2, which causes COVID-19), the most appropriate management, and the neonate's risk of developing COVID-19 during the perinatal period are unknown. Therefore, we aimed to elucidate best practices regarding infection control in mother-newborn dyads, and identify potential risk factors associated with transmission. METHODS: In this observational cohort study, we identified all neonates born between March 22 and May 17, 2020, at three New York Presbyterian Hospitals in New York City (NY, USA) to mothers positive for SARS-CoV-2 at delivery. Mothers could practice skin-to-skin care and breastfeed in the delivery room, but had to wear a surgical mask when near their neonate and practice proper hand hygiene before skin-to-skin contact, breastfeeding, and routine care. Unless medically required, neonates were kept in a closed Giraffe isolette in the same room as their mothers, and were held by mothers for feeding after appropriate hand hygiene, breast cleansing, and placement of a surgical mask. Neonates were tested for SARS-CoV-2 by use of real-time PCR on nasopharyngeal swabs taken at 24 h, 5-7 days, and 14 days of life, and were clinically evaluated by telemedicine at 1 month of age. We recorded demographics, neonatal, and maternal clinical presentation, as well as infection control practices in the hospital and at home. FINDINGS: Of 1481 deliveries, 116 (8%) mothers tested positive for SARS-CoV-2; 120 neonates were identified. All neonates were tested at 24 h of life and none were positive for SARS-CoV-2. 82 (68%) neonates completed follow-up at day 5-7 of life. Of the 82 neonates, 68 (83%) roomed in with the mothers. All mothers were allowed to breastfeed; at 5-7 days of life, 64 (78%) were still breastfeeding. 79 (96%) of 82 neonates had a repeat PCR at 5-7 days of life, which was negative in all; 72 (88%) neonates were also tested at 14 days of life and none were positive. None of the neonates had symptoms of COVID-19. INTERPRETATION: Our data suggest that perinatal transmission of COVID-19 is unlikely to occur if correct hygiene precautions are undertaken, and that allowing neonates to room in with their mothers and direct breastfeeding are safe procedures when paired with effective parental education of infant protective strategies. FUNDING: None.

Costs of ambulatory pediatric healthcare-associated infections: Central-line-associated bloodstream infection (CLABSIs), catheter-associated urinary tract infection (CAUTIs), and surgical site infections (SSIs).

OBJECTIVE: Ambulatory healthcare-associated infections (HAIs) occur frequently in children and are associated with morbidity. Less is known about ambulatory HAI costs. This study estimated additional costs associated with pediatric ambulatory central-line-associated bloodstream infections (CLABSIs), catheter-associated urinary tract infections (CAUTI), and surgical site infections (SSIs) following ambulatory surgery. DESIGN: Retrospective case-control study. SETTING: Four academic medical centers. PATIENTS: Children aged 0-22 years seen between 2010 and 2015 and at risk for HAI as identified by electronic queries. METHODS: Chart review adjudicated HAIs. Charges were obtained for patients with HAIs and matched controls 30 days before HAI, on the day of, and 30 days after HAI. Charges were converted to costs and 2015 USD. Mixed-effects linear regression was used to estimate the difference-in-differences of HAI case versus control costs in 2 models: unrecorded charge values considered missing and a sensitivity analysis with unrecorded charge considered $0. RESULTS: Our search identified 177 patients with ambulatory CLABSIs, 53 with ambulatory CAUTIs, and 26 with SSIs following ambulatory surgery who were matched with 382, 110, and 75 controls, respectively. Additional cost associated with an ambulatory CLABSI was $5,684 (95% confidence interval [CI], $1,005-$10,362) and $6,502 (95% CI, $2,261-$10,744) in the 2 models; cost associated with a CAUTI was $6,660 (95% CI, $1,055, $12,145) and $2,661 (95% CI, -$431 to $5,753); cost associated with an SSI following ambulatory surgery at 1 institution only was $6,370 (95% CI, $4,022-$8,719). CONCLUSIONS: Ambulatory HAI in pediatric patients are associated with significant additional costs. Further work is needed to reduce ambulatory HAIs.

Pediatric ambulatory catheter-associated urinary tract infections (CAUTIs): Incidence, risk factors, and patient outcomes.

OBJECTIVE: Catheter-associated urinary tract infections (CAUTIs) occur frequently in pediatric inpatients, and they are associated with increased morbidity and cost. Few studies have investigated ambulatory CAUTIs, despite at-risk children utilizing home urinary catheterization. This retrospective cohort and case-control study determined incidence, risk factors, and outcomes of pediatric patients with ambulatory CAUTI. DESIGN: Broad electronic queries identified potential patients with ambulatory urinary catheters, and direct chart review confirmed catheters and adjudicated whether ambulatory CAUTI occurred. CAUTI definitions included clean intermittent catheterization (CIC). Our matched case-control analysis assessed risk factors. SETTING: Five urban, academic medical centers, part of the New York City Clinical Data Research Network. PATIENTS: Potential patients were age <22 years who were seen between October 2010 and September 2015. RESULTS: In total, 3,598 eligible patients were identified; 359 of these used ambulatory catheterization (representing186,616 ambulatory catheter days). Of these, 63 patients (18%) experienced 95 ambulatory CAUTIs. The overall ambulatory CAUTI incidence was 0.51 infections per 1,000 catheter days (1.35 for indwelling catheters and 0.47 for CIC; incidence rate ratio, 2.88). Patients with nonprivate medical insurance (odds ratio, 2.5; 95% confidence interval, 1.1-6.3) were significantly more likely to have ambulatory CAUTIs in bivariate models but not multivariable models. Also, 45% of ambulatory CAUTI resulted in hospitalization (median duration, 3 days); 5% resulted in intensive care admission; 47% underwent imaging; and 88% were treated with antibiotics. CONCLUSIONS: Pediatric ambulatory CAUTIs occur in 18% of patients with catheters; they are associated with morbidity and healthcare utilization. Ambulatory indwelling catheter CAUTI incidence exceeded national inpatient incidence. Future quality improvement research to reduce these harmful infections is warranted.

Consensus treatment plans for periodic fever, aphthous stomatitis, pharyngitis and adenitis syndrome (PFAPA): a framework to evaluate treatment responses from the childhood arthritis and rheumatology research alliance (CARRA) PFAPA work group.

BACKGROUND: Periodic fever, aphthous stomatitis, pharyngitis, and cervical adenitis (PFAPA) syndrome is the most common periodic fever syndrome in children. There is considerable heterogeneity in management strategies and a lack of evidence-based treatment guidelines. Consensus treatment plans (CTPs) are standardized treatment regimens that are derived based upon best available evidence and current treatment practices that are a way to enable comparative effectiveness studies to identify optimal therapy and are less costly to execute than randomized, double blind placebo controlled trials. The purpose of this project was to develop CTPs and response criteria for PFAPA. METHODS: The CARRA PFAPA Working Group is composed of pediatric rheumatologists, infectious disease specialists, allergists/immunologists and otolaryngologists. An extensive literature review was conducted followed by a survey to assess physician practice patterns. This was followed by virtual and in-person meetings between 2014 and 2018. Nominal group technique (NGT) was employed to develop CTPs, as well as inclusion criteria for entry into future treatment studies, and response criteria. Consensus required 80% agreement. RESULTS: The PFAPA working group developed CTPs resulting in 4 different treatment arms: 1. Antipyretic, 2. Abortive (corticosteroids), 3. Prophylaxis (colchicine or cimetidine) and 4. Surgical (tonsillectomy). Consensus was obtained among CARRA members for those defining patient characteristics who qualify for participation in the CTP PFAPA study. CONCLUSION: The goal is for the CTPs developed by our group to lead to future comparative effectiveness studies that will generate evidence-driven therapeutic guidelines for this periodic inflammatory disease.

Cerebellar cryptococcoma in an immunocompetent child. Case report.

This is the first report of a cerebellar cryptococcoma in a previously healthy, HIV-negative child. Cryptococcus neoformans is an opportunistic fungus that typically affects patients who are HIV-positive and other patients with compromised immune systems. Isolated cryptococcomas of the central nervous system (CNS) have been previously described in immunocompetent adults; however, this is the first report of a cryptococcoma in a child. The patient presented with progressive headaches and nausea and was found to have a large cerebellar hemispheric mass. The patient underwent excision of the mass, and analysis of frozen sections suggested the presence of an astrocytic tumor with pilocytic features; therefore gross-total resection was performed. Once the definitive diagnosis of a cryptococcal abscess was obtained, medical treatment with antifungal medications led to the resolution of all symptoms and the normalization of serum titers. Cryptococcoma is a rare cause of ring enhancing lesions in the cerebellum, even in apparently immunocompetent patients. The authors' experience with this case and the patient's postoperative care lead them to advocate resection of large isolated cryptococcomas of the CNS, especially those situated in the posterior fossa.

Blastomycosis during pregnancy: a case report and review of the literature.

The diagnosis of blastomycosis during pregnancy is rare, but can carry significant clinical questions for both the infected mother and developing fetus. Furthermore, given its rarity, providers have little available data to help manage and counsel patients in this uncommon, yet serious, scenario. We present a case of blastomycosis in a woman at 38weeks' gestation and review all published cases of blastomycosis during pregnancy. It is our hope to provide a multidisciplinary understanding of the current knowledge surrounding the presentation, diagnosis, management, and outcome of this unusual infection.

Infant Colonization With Methicillin-Resistant Staphylococcus aureus or Vancomycin-Resistant Enterococci Preceding Neonatal Intensive Care Unit Discharge.

Rates of colonization with methicillin-resistant Staphylococcus aureus (MRSA) and/or vancomycin-resistant enterococci (VRE) were determined for 1320 infants within 7 days of neonatal intensive care unit discharge. Overall, 4% and 1% of the infants were colonized with MRSA or VRE, respectively. Predictors identified in fixed-effects models were surgery during hospitalization (for MRSA colonization) and prolonged antimicrobial treatment (for VRE colonization).

Colonization With Antimicrobial-Resistant Gram-Negative Bacilli at Neonatal Intensive Care Unit Discharge.

BACKGROUND: The epidemiology of the colonization of infants with antimicrobial-resistant Gram-negative bacilli (GNB) at discharge from the neonatal intensive care unit (NICU) is not well understood. METHODS: A multicenter study in which rectal surveillance samples for culture were obtained at NICU discharge from infants hospitalized ≥14 days was performed. Factors associated with colonization with GNB resistant to gentamicin, third/fourth-generation cephalosporin agents, or carbapenem agents were assessed by using a fixed-effects model. RESULTS: Of these infants, 9% (119 of 1320) were colonized with ≥1 antimicrobial-resistant GNB. Prolonged treatment (≥10 days) with meropenem or third/fourth-generation cephalosporin agents or treatment for ≥5 days with a ß-lactam/ß-lactamase combination agent were associated with an increased risk of colonization with GNB resistant to gentamicin. Surgery and ≥5 days of treatment with third/fourth-generation cephalosporin agents, a ß-lactam/ß-lactamase combination agent, or metronidazole were associated with an increased risk of colonization with GNB resistant to third/fourth-generation cephalosporin agents. Female sex and prolonged treatment (≥10 days) with meropenem were associated with colonization with GNB resistant to carbapenem agents. CONCLUSIONS: Prolonged treatment with broad-spectrum antibiotics was associated with the colonization of infants with antimicrobial-resistant GNB within 7 days of NICU discharge. These findings suggest the potential for dissemination of resistant GNB from colonized infants to other NICUs, the community, or pediatric long-term care facilities. Antimicrobial stewardship efforts aimed at improving appropriate antibiotic use could have a beneficial effect on the emergence of antimicrobial-resistant GNB in the NICU population.

(1→3)-ß-d-Glucan in Cerebrospinal Fluid as a Biomarker for Candida and Aspergillus Infections of the Central Nervous System in Pediatric Patients.

BACKGROUND: Fungal infections of the central nervous system (FICNS) are important causes of morbidity and mortality among immunocompromised pediatric patients. Standard diagnostic modalities lack the sensitivity for detecting and therapeutically monitoring these life-threatening diseases. Current molecular methods remain investigational. (1→3)-ß-d-glucan (BDG) is a cell wall component found in several fungal pathogens, including Candida and Aspergillus spp. Detecting BDG in cerebrospinal fluid (CSF) may be an important approach for detecting and therapeutically monitoring FICNS. To date, there has been no study that has investigated the effectiveness of CSF BDG as a diagnostic and therapeutic marker of FICNS in children. METHODS: Serial BDG levels were measured in serum and CSF samples obtained from pediatric patients (aged 0-18 years) with a diagnosis of probable or proven Candida or Aspergillus CNS infection. RESULTS: Nine cases of FICNS were identified in patients aged 1 month to 18 years. Two patients were infected with an Aspergillus species, and 7 patients were infected with a Candida species. All the patients at baseline had detectable BDG in their CSF. Among 7 patients who completed therapy for an FICNS, all elevated CSF BDG levels decreased to <31 pg/mL. At the time of this writing, 1 patient was still receiving therapy and continued to have elevated BDG levels. One patient died from overwhelming disseminated candidiasis. The lengths of therapy for these 9 children ranged from 2 weeks to 28 months. CONCLUSION: The BDG assay is useful in diagnosing and therapeutically monitoring Candida and Aspergillus CNS infections in pediatric patients.

Multicenter Study of Hand Carriage of Potential Pathogens by Neonatal ICU Healthcare Personnel.

A multicenter surveillance study was performed to determine the rates of hand carriage of potential pathogens among healthcare personnel in four neonatal intensive care units. Staphylococcus aureus, enterococci, and gram-negative bacilli were recovered from 8%, 3%, and 2% of 1000 hand culture samples, respectively.

Utility of surveillance cultures for antimicrobial resistant organisms in infants transferred to the neonatal intensive care unit.

BACKGROUND: Infections with antibiotic resistant organisms (AROs) are an important source of morbidity and mortality among infants hospitalized in the neonatal intensive care unit (NICU). To identify potential reservoirs of AROs in the NICU, active surveillance strategies have been adopted by many NICUs to detect infants colonized with AROs. However, the yield, risks, benefits and costs of different strategies have not been fully evaluated. METHODS: We conducted a retrospective study in 2 level III NICUs from 2004 to 2010 to investigate the yield of surveillance cultures obtained from infants transferred to the NICU from other hospitals. Cultures were processed for methicillin-resistant Staphylococcus aureus, vancomycin-resistant enterococci and antibiotic-resistant gram-negative rods. Risk factors, selected outcomes and laboratory costs associated with ARO colonization were assessed. RESULTS: Among 1751 infants studied, the rate of colonization for methicillin-resistant S. aureus, vancomycin-resistant enterococci and antibiotic-resistant gram-negative rods was 3%, 1.7% and 1%, respectively. Age at transfer was the strongest predictor of ARO colonization; infants transferred at ≥ 7 days of life had 5.8 increased odds of ARO colonization compared with infants <7 days of age. Transferred infants who were colonized had similar rates of mortality, ARO infection and duration of hospitalization compared with those who were not colonized. The laboratory cost of surveillance cultures during the study period was $58,425. CONCLUSIONS: The rate of colonization with AROs at transfer was low particularly in infants <7 days old. Future studies should examine the safety of targeted surveillance strategies focused on older infants.

Clinical vignettes provide an understanding of antibiotic prescribing practices in neonatal intensive care units.

OBJECTIVE: To use clinical vignettes to understand antimicrobial prescribing practices in neonatal intensive care units (NICUs). DESIGN: Vignette-based survey. SETTING: Four tertiary care NICUs. PARTICIPANTS: Antibiotic prescribers in NICUs. METHODS: Clinicians from 4 tertiary care NICUs completed an anonymous survey containing 12 vignettes that described empiric, targeted, or prophylactic antibiotic use. Responses were compared with Centers for Disease Control and Prevention guidelines for appropriate use. RESULTS: Overall, 161 (59% of 271 eligible respondents) completed the survey, 37% of whom had worked in NICUs for 7 or more years. Respondents were more likely to appropriately identify use of targeted therapy for methicillin-susceptible Staphylococcus aureus, that is, use of oxacillin rather than vancomycin, than for Escherichia coli, that is, use of first-generation rather than third-generation cephalosporin, (P < .01). Increased experience significantly predicted appropriate prescribing (P = .02). The proportion of respondents choosing appropriate duration of postsurgical prophylaxis (P < .01) and treatment for necrotizing enterocolitis differed by study site (P = .03). CONCLUSIONS: The survey provides insight into antibiotic prescribing practices and informs the development of future antibiotic stewardship interventions for NICUs.

Novel influenza A(H1N1) in a pediatric health care facility in New York City during the first wave of the 2009 pandemic.

OBJECTIVE: To describe the burden of care experienced by our pediatric health care facility in New York, New York, from May 3, 2009, to July 31, 2009, during the novel influenza A(H1N1) pandemic that began in spring 2009. DESIGN: Retrospective case series. SETTING: Pediatric emergency departments and inpatient facilities of New York-Presbyterian Hospital. Patients Children presenting to the emergency departments with influenza-like illness (ILI) and children aged 18 years or younger hospitalized with positive laboratory test results for influenza A from May 3, 2009, to July 31, 2009. MAIN OUTCOME MEASURES: Proportion of children with ILI who were hospitalized and proportion of hospitalized children with influenza A with respiratory failure, bacterial superinfection, and mortality. RESULTS: When compared with the same period in 2008, the pediatric emergency departments experienced an excess of 3750 visits (19.9% increase). Overall, 27.7% of visits were for ILI; 2.5% of patients with ILI were hospitalized. Of the 115 hospitalized subjects with confirmed influenza A (median age, 4.3 years), 93 (80.9%) had underlying conditions. Four (3.5%) had identified bacterial superinfection, 1 (0.9%) died, and 35 (30.4%) were admitted to a pediatric intensive care unit; of these 35 patients, 11 had pneumonia and required mechanical ventilation, including high-frequency oscillatory ventilation (n = 3). CONCLUSIONS: At our center, 2.5% of children with ILI presenting to the emergency departments during the first wave of the 2009 novel influenza A(H1N1) pandemic were hospitalized. Of the 115 hospitalized children with confirmed influenza A, 9.6% had respiratory failure and 0.9% died. These findings can be compared with the disease severity of subsequent waves of the 2009 novel influenza A(H1N1) pandemic.