Antimicrobial Stewardship and Improved Antibiotic Utilization in the Pediatric Cardiac Intensive Care Unit.

Background: We developed a multidisciplinary antimicrobial stewardship team to optimize antimicrobial use within the Pediatric Cardiac Intensive Care Unit. A quality improvement initiative was conducted to decrease unnecessary broad-spectrum antibiotic use by 20%, with sustained change over 12 months. Methods: We conducted this quality improvement initiative within a quaternary care center. PDSA cycles focused on antibiotic overuse, provider education, and practice standardization. The primary outcome measure was days of therapy (DOT)/1000 patient days. Process measures included electronic medical record order-set use. Balancing measures focused on alternative antibiotic use, overall mortality, and sepsis-related mortality. Data were analyzed using statistical process control charts. Results: A significant and sustained decrease in DOT was observed for vancomycin and meropenem. Vancomycin use decreased from a baseline of 198 DOT to 137 DOT, a 31% reduction. Meropenem use decreased from 103 DOT to 34 DOT, a 67% reduction. These changes were sustained over 24 months. The collective use of gram-negative antibiotics, including meropenem, cefepime, and piperacillin-tazobactam, decreased from a baseline of 323 DOT to 239 DOT, a reduction of 26%. There was no reciprocal increase in cefepime or piperacillin-tazobactam use. Key interventions involved electronic medical record changes, including automatic stop times and empiric antibiotic standardization. All-cause mortality remained unchanged. Conclusions: The initiation of a dedicated antimicrobial stewardship initiative resulted in a sustained reduction in meropenem and vancomycin usage. Interventions did not lead to increased utilization of alternative broad-spectrum antimicrobials or increased mortality. Future interventions will target additional broad-spectrum antimicrobials.

Time to Positive Blood Cultures Among Critically Ill Children Admitted to the PICU.

OBJECTIVES: Our study aimed to assess the time to positivity (TTP) of clinically significant blood cultures in critically ill children admitted to the PICU. DESIGN: Retrospective review of positive blood cultures in patients admitted or transferred to the PICU. SETTING: Large tertiary-care medical center with over 90 PICU beds. PATIENTS: Patients 0-20 years old with bacteremia admitted or transferred to the PICU. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: The primary endpoint was the TTP, defined as time from blood culture draw to initial Gram stain result. Secondary endpoints included percentage of cultures reported by elapsed time, as well as the impact of pathogen and host immune status on TTP. Host immune status was classified as previously healthy, standard risk, or immunocompromised. Linear regression for TTP was performed to account for age, blood volume, and Gram stain. Among 164 episodes of clinically significant bacteremia, the median TTP was 13.3 hours (interquartile range, 10.7-16.8 hr). Enterobacterales, Staphylococcus aureus, Streptococcus agalactiae, and Streptococcus pneumoniae were most commonly identified. By 12, 24, 36, and 48 hours, 37%, 89%, 95%, and 97% of positive cultures had resulted positive, respectively. Median TTP stratified by host immune status was 13.2 hours for previously healthy patients, 14.0 hours for those considered standard risk, and 10.6 hours for immunocompromised patients (p = 0.001). Median TTP was found to be independent of blood volume. No difference was seen in TTP for Gram-negative vs. Gram-positive organisms (12.2 vs. 13.9 hr; p = 0.2). CONCLUSIONS: Among critically ill children, 95% of clinically significant blood cultures had an initial positive result within 36 hours, regardless of host immune status. Need for antimicrobial therapy should be frequently reassessed and implementation of a shorter duration of empiric antibiotics should be considered in patients with low suspicion for infection.

Standardizing the diagnosis of necrotizing enterocolitis in infants with congenital heart disease.

OBJECTIVE: This quality improvement initiative aimed to standardize the diagnosis of necrotizing enterocolitis (NEC) in infants with congenital heart disease (CHD). STUDY DESIGN: A multidisciplinary team developed clinical practice guidelines for the diagnosis and treatment of NEC within the Cardiac Intensive Care Unit (CICU). The diagnosis rate of NEC per 100 at-risk admissions was the primary outcome measure. NEC order set usage was employed as a process measure, and the balancing measures monitored were CICU length of stay (LOS) and mortality. RESULT: After guideline development and implementation, the diagnosis rate of NEC decreased from 3% to 1%, sustained over three years. The EMR order set enabled guideline integration into daily workflow. No change was noted in CICU LOS or mortality. CONCLUSION: Guideline implementation standardized the diagnosis of NEC in infants with CHD. Establishing a standardized definition and subsequent treatment regimen has enabled us to provide more consistent and appropriate care.

Who to Test? A Retrospective Study of Lead Testing in High-Risk Children.

BACKGROUND: Nearly all pediatric patients in our setting meet high-risk criteria for lead exposure based on screening recommendations and guidelines. Implementation of screening and testing has been inconsistent. OBJECTIVE: To assess the utility and efficacy of performing universal lead testing between ages 1 and 5 at an urban academic pediatric practice. METHODS: Retrospective review of patients with routine lead testing between 2010 and 2015. Key variables included demographics, serum lead level, and behavioral diagnoses. RESULTS: A total of 6597 serum lead levels from 3274 patients were reviewed. Forty-seven samples (0.7%) from 24 patients (0.7%) were elevated. Of the 24 patients with elevated lead, 75% were identified at age 1 or 2. Sixty-seven percent of patients with first elevated lead level at age 3 or older had a diagnosis of developmental delay. CONCLUSION: Routine testing of high-risk patients yielded minimal specificity in identifying elevated lead levels, especially in patients older than 3 years and without developmental delay.

Primary versus secondary anastomosis in intestinal atresia.

PURPOSE: Neonates with intestinal atresia (IA) undergo either primary anastomosis (PA) or ostomy creation with secondary anastomosis (SA). Our purpose was to compare outcomes for PA and SA and to assess factors influencing procedure selection. METHODS: We conducted a retrospective cohort study of neonates with IA between 2009 and 2015. Patient characteristics, operative details, and outcomes were collected. Surgeon-level preferences (defined as performing >50% PA or SA) were assessed using logistic regression. RESULTS: Of 92 IA patients, 70 (76.1%) underwent PA and 22 (23.9%) underwent SA. Neonates with PA had shorter hospitalizations (27 days vs. 95 days, p < 0.001), shorter total parenteral nutrition duration (19 days vs. 74.5 days, p < 0.001), and fewer readmissions (33.3% vs. 63.2%, p = 0.024). On multivariable regression analysis, higher Apgar scores (Odds Ratio (OR) 4.16, 95% Confidence Interval (CI) 1.20-14.29) and uncomplicated atresia (OR 3.97, 95% CI 1.37-11.48) were associated with PA. At the surgeon-level, utilization of PA varied from 43.5% to 100%. Surgeon preference is not influenced by the demographic, presentation, or surgical findings of this patient population. CONCLUSIONS: PA has better outcomes than SA. Though procedural selection is influenced by the clinical status of the neonate, however surgeon preference plays a significant role in this clinical decision. LEVEL OF EVIDENCE: Level III Treatment Study.

Multi-technique quantitative analysis and socioeconomic considerations of lead, cadmium, and arsenic in children's toys and toy jewelry.

A wide spectrum and large number of children's toys and toy jewelry items were purchased from both bargain and retail vendors and analyzed for arsenic, cadmium, and lead metal content using multiple analytical techniques, including flame and furnace atomic absorption spectroscopy as well as X-ray fluorescence spectroscopy. Particularly dangerous for young children, metal concentrations in toys/toy jewelry were assessed for compliance with current Consumer Safety Product Commission (CPSC) regulations (F963-11). A conservative metric involving multiple analytical techniques was used to categorize compliance: one technique confirmation of metal in excess of CPSC limits indicated a "suspect" item while confirmation on two different techniques warranted a non-compliant designation. Sample matrix-based standard addition provided additional confirmation of non-compliant and suspect products. Results suggest that origin of purchase, rather than cost, is a significant factor in the risk assessment of these materials with 57% of toys/toy jewelry items from bargain stores non-compliant or suspect compared to only 15% from retail outlets and 13% if only low cost items from the retail stores are compared. While jewelry was found to be the most problematic product (73% of non-compliant/suspect samples), lead (45%) and arsenic (76%) were the most dominant toxins found in non-compliant/suspect samples. Using the greater Richmond area as a model, the discrepancy between bargain and retail children's products, along with growing numbers of bargain stores in low-income and urban areas, exemplifies an emerging socioeconomic public health issue.