BACKGROUND:Stratification of well-appearing febrile infants into a low-risk category for invasive bacterial infections (IBI) is critical to optimizing patient care. Procalcitonin, a biomarker associated with bacterial infection, was included in the 2019 PECARN clinical prediction rule to identify febrile infants 60 days and younger at low risk for serious bacterial infection. That same year, we incorporated a modified PECARN febrile infant prediction rule into our existing febrile infant algorithm. The primary objective of the study was to evaluate the effect of the modified PECARN prediction rule on rate of lumbar puncture (LP), hospital admissions, and 30-day readmissions. METHODS:e identified febrile infants 3 to 90 days evaluated in our emergency department from November 2017 through April 2022. The pre-implementation period was from 11/2017 through 6/2019. The modified PECARN rule was incorporated into the clinical care process model between 7/2019 and 8/2019. The post-implementation period was 9/2019 through 4/2022. The primary outcomes were LP rate and hospital admissions. The primary process metric was procalcitonin obtainment. The balancing metric was 30-day readmissions. Between group comparisons were performed with Chi square tests. RESULTS:A total of 1520 febrile infants were included in the analysis, 662 in the pre-implementation period, and 858 in the post-implementation period. LP rate and hospital admissions decreased from 45.8% to 31.0% (p<0.001) and from 54.1% to 43.2% (p<0.001), respectively. The percentage of infants with a procalcitonin increased from 3.9% to 94.1% post-implementation (P<0.001). The 30-day readmission rate was 3.5% in the pre-implementation and 4.8% in the post-implementation period (p = 0.26). CONCLUSION:Incorporation of the modified PECARN prediction rule to an existing febrile infant care process model resulted in decreased lumbar punctures and hospital admissions without significantly increasing 30-day readmissions.
BACKGROUND/OBJECTIVE:National guidelines provide recommendations for first-line therapy (FLT) for acute respiratory infections (ARIs). Sociodemographic differences in FLT for ARIs have been described. This study identified and categorized reasons for non-FLT for ARIs in pediatric urgent care (PUC) and evaluated whether these reasons differ across sociodemographic groups. METHODS:We conducted a retrospective chart review of PUC encounters for patients ages 6 months to 19 years diagnosed with acute otitis media, pharyngitis, community-acquired pneumonia, or acute bacterial rhinosinusitis between April 2023 and March 2024 who received an oral antibiotic. We categorized reasons for non-FLT using predefined groups: penicillin allergy label (PAL), treatment failure, new adverse effect of FLT, recent antibiotic exposure, other clinical rationale such as additional diagnoses or concern for atypical infections, family request, or no documented reason. Sociodemographic characteristics were compared across categories. RESULTS:Among 18,507 ARI encounters, 1,506 (8.1%) received non-FLT. PALs accounted for 58.8% (n=886) of non-FLT prescribing. Recent antibiotic exposure was the second most common reason (n=265, 17.6%); however, only 9.8% of therapy escalations were guideline-concordant. Family requests accounted for 4.3% of non-FLT use. Non-FLT were more common in White children, those on Commercial insurance, and children who speak English as their primary language compared to their socioeconomic counterparts. No differences in reasons for non-FLT were observed by race, insurance type, or preferred language. Hispanic patients had a higher proportion of PAL-related non-FLT (71.4%) compared with non-Hispanic patients (58.3%). CONCLUSION:PALs and escalation of therapy were the predominant drivers of non-FLT prescribing in PUC. Family requests played a minimal role. Although we observed differences of non-FLT by race, language, and insurance as described previously, we did not observe differences in reasons for non-FLT between the different socioeconomic groups. Interventions aimed at improving PAL accuracy and guideline-concordant escalation practices may enhance appropriate FLT use.
BACKGROUND:Children with risk conditions are vulnerable to invasive pneumococcal disease (IPD) and are targeted for routine and supplemental pneumococcal vaccination. This study aimed to quantify the incidence of IPD in US children by risk group since PCV introduction. METHODS:IPD episodes were identified in the Merative™ MarketScan® Commercial Database (1998-2023) and Multi-State Medicaid Database (2001-2023) using inpatient and outpatient claims. Annual IPD incidence rates (IRs) were calculated as episodes per 100 000 person-years (PY) for children <18 years of age, overall and by insurance type, age, and risk group. Incidence rate ratios (IRRs) were calculated to compare IR for children with chronic medical conditions (CMC) and immunocompromising conditions (IC) with those with no CMC/IC. RESULTS:A total of 3538 commercially-insured and 3268 Medicaid-insured children with ≥1 IPD episode were identified among 128.9 million (121.9 million PYs) and 71.2 million eligible children (65.0 million PYs), respectively. Across age and risk groups, IPD IRs decreased over time, regardless of insurance type. Commercially-insured children with CMC and IC had 3.1-8.6 and 19.1-74.5 times higher IPD IRs, respectively, than those without CMC/IC, with similar patterns in the Medicaid database. IPD IRs were the highest among children <2 years, while risk-group disparities were greater among older children. IRRs comparing CMC and IC vs. no CMC/IC increased over time, indicating widening disparities. CONCLUSIONS:IPD IRs among children with CMC/IC remain substantially higher than those without CMC/IC, and IRR for children with risk conditions has increased over time. The risk-group disparities were more pronounced in older children. Better prevention strategies are needed to prevent IPD in children with risk conditions.
Serum 1,3-β-D-glucan (BDG) showed high negative predictive value (~99%) for Pneumocystis jirovecii pneumonia (PJP) in 106 non-HIV immunocompromised children, but modest positive predictive value at low prevalence. These exploratory findings suggest BDG may help exclude PJP, pending prospective validation.
BACKGROUND:Children aged <12 years with coronavirus disease 2019 (COVID-19) have limited treatment options; currently approved oral antivirals are restricted by age or bodyweight. We evaluated the safety and plasma concentration-time profiles and exploratory efficacy of ensitrelvir, a once-daily oral 3C-like protease inhibitor, in children with mild-to-moderate COVID-19 in Japan. METHODS:This phase 3, double-blind, placebo-controlled study randomized (2:1) participants aged 6 to <12 years presenting ≤72 h after COVID-19 onset to receive ensitrelvir (bodyweight-based dosing) or placebo once daily for 5 days. Primary endpoints were safety and pharmacokinetics. Secondary endpoints included change in viral ribonucleic acid (RNA) and time to resolution (TTR) of key COVID-19 symptoms (stuffy or runny nose and cough) plus fever. RESULTS:Of 117 randomized participants (median age 10 years), 78 received ensitrelvir and 39 received placebo. Ensitrelvir was well tolerated with no new safety concerns. Plasma concentration-time profiles were similar across bodyweight categories (20 to <30, 30 to <40, and ≥40 kg). Ensitrelvir reduced viral RNA vs placebo on Day 4, by approximately 1.0 log10 copies/mL (95% CI, -1.45 to -0.47). Median TTR of key COVID-19 symptoms was 140.5 h with ensitrelvir and 146.2 h with placebo (median difference -5.7 h [95% CI, -73.6 to 43.4 h]). CONCLUSIONS:In children aged 6 to <12 years with mild-to-moderate COVID-19 treated with ensitrelvir, we observed a favorable safety profile, adult-matched plasma concentration-time profile, and a greater reduction in viral RNA vs placebo. Ensitrelvir represents a potential treatment option for underserved pediatric patients with mild-to-moderate COVID-19. CLINICAL TRIAL REGISTRATION:Japan Registry of Clinical Trials, jRCT2031230140 (https://jrct.mhlw.go.jp/en-latest-detail/jRCT2031230140).
Background Rocky Mountain Spotted Fever (RMSF) is a bacterial disease transmitted by infected ticks, with Northern Mexico experiencing a concerning rise in cases, particularly among children. Elevated inflammatory markers, such as C-reactive protein (CRP) and procalcitonin (PCT), indicate an acute inflammatory response but are not specific to RMSF. Monitoring these markers can guide management. A key challenge during the outbreak was delayed diagnosis, highlighting the importance of laboratory test results, clinical data, and georeferencing in outbreak response. Methods Clinical geographical data of patients under 16 with confirmed RMSF diagnosed at the Pediatric Reference Hospital (HRMI) in NL, Mexico, from August 2022 to September 2023, were analyzed. HRMI admitted most affected children during the outbreak. A descriptive analysis of clinical and laboratory tests was conducted, and QGIS® was employed to map case distribution, incorporating regional marginalization indices from official sources. Results Total of 23 subjects included, with a mean age 8 years (± 3.3). Most (82%) had positive contact with ticks. Time from symptom onset was 4.9 ± 1.8 days. There was high mortality (65.2%) despite in-hospital treatment. Laboratory test results showed CBC: lymphopenia (<2,000/mm3) in 99% of cases, neutrophilia (>8,000/mm3) in 47%, and thrombocytopenia (<150,000/mm3) in 100%. CRP elevation (>0.5 mg/dL) in 100%, hyperferritinemia (>1,000 ng/dL) in 74%, D-dimer elevation (>2,000 mg/dL) in 95%, and hypoalbuminemia (<3.5 g/dL) in 82%. GIS analysis revealed an NNI of 0.54 (z-score -4.1), statistically significant clustered distribution (p < 0.05). Mapping was performed with a KDE ratio of 8755 m, demonstrating two main geographical hotspots for Ped-RMSF. The mean case-to-hospital distance was 24.1 km (± 10.1 km), most cases located in areas with medium (65%) and high (30%) marginalization indices. The majority (95%) of cases lived more than 10 km from HRMI, where diagnosis was made. Conclusion The nature of vector-borne diseases necessitates advanced epidemiological surveillance. Using GIS-based analyses, we identified high-burden areas of Ped-RMSF and shared this data with local health authorities to implement effective vector control strategies. Clinical data indicated key points for suspecting and diagnosing RMSF, emphasizing the need for enhanced training for first-care clinicians. Laboratory tests revealed a higher incidence of lymphopenia and thrombocytopenia than previously reported. Elevated inflammatory markers, such as CRP, ferritin, and D-dimer, were common findings, aiding patient management. The clustering pattern of cases demonstrated a non-random distribution, emphasizing the impact of factors like marginalization indices. Our study underscores the importance of GIS in outbreak response strategies.
Abstract During an influenza B outbreak at a camp for children with type 1 diabetes, symptomatic testing, isolation, home recovery, and antiviral use supported response. Oseltamivir prophylaxis was associated with lower influenza B/influenza-like illness risk but did not fully prevent transmission.
Abstract Background Respiratory viruses are a significant cause of pediatric illness and healthcare utilization. Diagnostic testing for respiratory viruses is generally performed using nasopharyngeal (NP) specimens obtained by trained medical staff, limiting testing to medical settings. Evaluating additional sampling methods in children, such as anterior nasal swab (NS) specimens may expand access to diagnostic testing and aid public health surveillance. Methods Eligible children hospitalized at Children’s Mercy Hospital in Kansas City who had a standard of care NP specimen collected for nucleic acid amplification testing for respiratory viruses were enrolled. Research NS specimens were obtained through self, caregiver, or staff collection. Specimens were tested on QIAstat-Dx-Analzyer using QIAstat-Dx Respiratory SARS-Cov-2 Panel and included: adenovirus, seasonal coronavirus (229E, HKU1, NL63, OC43), SARS-CoV-2, human metapneumovirus (hMPV) A+B, influenza A/A H1/A H3/A H1N1/pdm09, influenza B, parainfluenza virus 1/2/3/4, rhinovirus/enterovirus (RV/EV), and respiratory syncytial virus (RSV) A+B. Statistical analysis for sensitivity with 95% confidence intervals was calculated with NP as the gold standard. Further sub-analysis evaluating time to NS collection and test results (NP specimens as time zero and NS specimens grouped from 1-24 hours, 25-48 hours, and 49+ hours) was performed. Pairs with both NP and NS specimens having viruses detected or the same virus(es) detected were considered completely concordant. Specimens with multiple viruses detected on NP swab but only a single virus detected on NS swab, or vice versa, were considered partially concordant. Specimens with one virus detected on NS or NP and none detected on its pair were considered discordant. Results One hundred and forty-seven pairs, each including one NP and one NS specimen, were obtained. Of the 147 pairs, 114 (77.5%) had complete concordance – 86 (58.5%) had viruses detected and 28 (19%) had no viruses detected. Fourteen (9.5%) pairs were partially concordant, and 19 (13%) were discordant. Sensitivity of NS specimens collected within 48 hours of their NP pair was ≥80% for all viruses except seasonal coronavirus (sensitivity 42.9%) (Table 1). NS specimens for adenovirus, influenza, parainfluenza, RSV, and SARS-CoV-2 were 100% sensitive when collected within 24 hours of NP specimens. Conclusion Overall, NS are a potential alternative method for respiratory virus detection in the pediatric population. This less invasive collection method allows for broader use outside of medical settings, including respiratory virus surveillance in community settings. Future studies with closely time-matched NS and NP collection are needed to evaluate individual virus type detections.
Abstract Background FN is a frequent complication of chemotherapy treatment in children with oncological diseases. It can cause serious complications due to infections, such as sepsis and septic shock. A target approach involves identifying microorganisms, understanding both documented and undocumented infections, and acting in a targeted manner. Methods Retrospective, descriptive and analytical study conducted through a review of medical records of cancer patients from 0 to 18 years old with FN episodes admitted to the PICU in Barretos Cancer Children’s Hospital, from June/2013 to January/2018, some patients had more than one episode. Epidemiological, clinical and types of infection were analyzed for survival outcome. The rates of severe sepsis, septic shock, and mortality were investigated. Results Data from 140 FN episodes were analyzed, in 120 patients. Most of the children had hematological diseases (80.8%), which were mainly Acute Lymphocytic Leukemia (ALL), and Acute Myeloid Leukemia (AML). The average age was 8.5 years old, and the main microorganisms identified in cultures were Gram negative bacteria. In the first FN episodes the most frequent bacterial microorganisms identified were Escherichia coli (14.51%), Klebsiella pneumoniae (14.51%), Staphilococcus epidermidis (6.45%), Streptococcus viridans (6.45%), and Clostridioides difficile (3.22%). The most frequent fungus were Candida tropicalis (4.83%), Candida albicans (3.22%), and Candida krusei (3.22%). In the second FN episodes the most frequent microorganisms identified were Klebsiella pneumoniae (22.25%), Acnitetobacter sp (22.25%), Streptococcus viridans (11.10), and Murcor sp (11.10%). The most frequent antimicrobial used in the first episodes were Vancomycin (77.5%), Cefepime (73.30%), Metronidazole (41.7%), Amikacin (32.5%) and Meropenem (24.2%), and the most frequent antimicrobial used in the second episodes were Vancomycin (95%), Cefepime (70%), Meropenem (30%), Metronidazole (25%), and Amikacyn (15%). The documented microorganisms and clinical infections were more frequent than foci of undetermined origin, as shown in figures number 1 and 2. In multivariate analysis variables included all other oncological diseases (Hodgkin's lymphoma, Juvenile Myelomonocytic Leukemia and solid tumors) versus hematological tumors in relapse (ALL in relapse, AML in relapse and Non-Hodgkin Lymphoma (NHL), in relapse), p=0.007, showing a 3.10 times higher risk of death for the second group. Conclusions The rate of severe sepsis was 38.57%, the rate of septic shock was 37.85%, and the rate of mortality was 25.71%, a total of 36 patients died and 84 patients were discharged. The most severe infections were in hematological malignant patients, principally in relapse. It is important an early detection of sepsis and septic shock in FN episodes as well as a prompt detection of types of infection and microorganisms to reach best outcomes and to decrease the mortality rate.
Abstract Background Since 2022, diagnostic laboratories in British Columbia (BC), Canada, have been advised to replace traditional bacterial, viral and parasitic intestinal pathogen testing with multiplex infectious diarrhea panel nucleic-acid amplification testing (IDP-NAAT), which contains a minimum of 14 common pathogens, including Clostridioides difficile. However, multiplex testing can lead to false positive results of targets which are not even in the clinicians’ differentials. The Canadian Paediatric Society has advised precautions in interpretation of Clostridioides difficile testing, especially in children <5 years of age who may have asymptomatic carriage of this bacteria. Testing for Clostridioides difficile is not routinely recommended for healthy infants younger than one year of age. LifeLabs BC implemented the IDP-NAAT in September 2023 and conducted a retrospective audit to determine whether the number of Clostridioides difficile positive results increased since the implementation, signaling a pseudo-outbreak. Methods LifeLabs BC microbiology laboratories are connected with 129 collection centres in urban and rural communities in the province and provided the laboratory data on Clostridioides difficile. An audit was conducted from September 2022 to August 2023, one year prior to implementation of IDP-NAAT in LifeLabs BC, and from October 2023 to September 2024, one year after the implementation of IDP-NAAT. Chi-square tests with Yates correction were used to compare differences before and after implementation of IDP-NAAT. Results Prior to implementation of IDP-NAAT, 149 of 1712 pediatric patient’s (age <18 years) stool specimens (8.70%) submitted for testing was positive for Clostridioides difficile. Among these positive results, 32 and 50 of them were from children <1 and 1-5 years of age, respectively. After the implementation of IDP-NAAT, 481 of 7547 of the pediatric patients’ stool specimens (6.37%; p < 0.05 vs. prior) submitted for testing was positive for Clostridioides difficile. Among these positive results, 75 and 206 of them were from children <1 and 1-5 years of age, respectively. Conclusions Although the positivity rate of Clostridioides difficile among pediatric patients’ stool specimens was significantly lower after the implementation of IDP-NAAT, the number of positive results increased more than three times, suggesting a pseudo-outbreak due to change in test methodology. This increase could mislead clinicians to overprescribe for Clostridioides difficile colonization rather than infection. More communications and educations may be warranted to remind clinicians that positive Clostridioides difficile NAAT results are not always indicative of infection, especially among pediatric patients, due to implementation of multiplex testing.
Abstract Background As we learned during the pandemic, decision-making on the actions to be taken is essential for control and can prevent disastrous effects on the population. Infectious diseases occur in a frequently complex sociopolitical, geographic, environmental and economic context, the presence of a respiratory virus emergency can overload the health system, causing more deaths and loss of quality of life for the population. Knowing the circulation at local level of respiratory viruses and bacteria, especially in a vulnerable group like children can help have a better understanding of the agents behavior. Methods We retrospectively analyzed the results of 7931 respiratory samples collected from 6900 pediatric patients between 0-18 years old as a process for inpatients of the pediatric hospital in Mexico from January 2022 to October 2024. We analyzed the distribution of the different respiratory viruses and bacteria detected including RSV, SARS-CoV-2, metapneumovirus, adenovirus, bordetella parapertussis, bordetella pertussis, for analysis purposes we grouped the parainfluenza subtypes PIV1-PIV4 in one parainfluenza group, the influenza subtypes A, A H1-A, A H1-B, A H4, B, H1-2009 in an influenza group and the Coronavirus 229E, HKU1, NL63,and OC 43 in the “ Other coronavirus”, group. Results From our study 45% of the samples were from feminine patients,55% were masculine, the study showed the extensive distribution and pattern of different respiratory virus, when comparing to the circulation of the viruses before the pandemic, the characteristics and etiology of the pattern changed, and continues changing during the years. Respiratory syncytial virus presents peaks of the infections during January, February, September, October, December. Rhinovirus and enterovirus are present all year long, Influenza subtypes and SARS-CoV-2 present a decrease in cases alongside other coronavirus. Another important factor is that some bacteria present an increase in cases, for example mycoplasma pneumoniae with an increase in during 2024. Conclusions The continuous circulation of different viruses and bacteria in pediatric patients can be a challenge for treatment and hospital saturation during the peaks in cases of the different agents. Preparedness and readiness is essential to be able to respond, not only to the respiratory infections but also to all the different diseases and conditions the patients present. Knowing the circulation and change in agents can help decision making and resource planning.
Abstract Introduction Bacteremia represents one of the major post-chemotherapy complications in oncohematological patients. Implementing appropriate empirical treatment based on local epidemiology is essential to reduce morbidity and mortality associated with these infections. Materials and Methods Retrospective, descriptive study. Included bacteremia episodes in patients under 18 years old with hematological-oncological diseases, admitted to a high-complexity pediatric hospital between September 2022 and October 2024. Transplanted patients were excluded. Objectives To evaluate clinical findings, laboratory results, microbiological characteristics, resistance patterns, and initial empirical treatment of bacteremia in oncohematological patients. Results A total of 123 bacteremia episodes in 67 patients were evaluated. The median age was 103 months, with a predominance of the male sex (51.2%). The most frequent underlying disease was Acute Lymphoblastic Leukemia (ALL) in 82 cases (66.7%). Fifty-eight patients received chemotherapy in the last 10 days, and 90% were exposed to antibiotics in the last 90 days. Eighty-seven episodes (71%) presented neutropenia. Among the clinical findings, 97.5% presented fever, 27 (22%) were primary bacteremias, and in secondary bacteremias, the main associated focus was the central venous catheter in 64 cases (52%) followed by an abdominal focus in 35 (28.5%). Regarding microbiological analysis, the most frequent bacteria were Gram-negative bacilli (GNB) 64% (78/123): enterobacteriaceae 79.5%, non-fermentative GNB 20.5%. The most frequent isolate was Klebsiella pneumoniae (22/78) followed by Escherichia coli (21/78). Gram-positive cocci (GPC) represented 36% (45/123), with 14 Staphylococcus coagulase-negative and 12 Streptococcus viridans as the most frequent isolates. In relation to enterobacteria, resistance mechanisms were detected in 25 episodes (25/62). The most frequent was ESBL 56% followed by MBL + ESBL 28%. The initial empirical treatment (IET) was adequate in 77% of all episodes. Regarding clinical evolution, 37 episodes (30%) had septic shock, 78% GNB and 22% GPC; of these, 6 patients died, of which 4 (67%) presented MBL+ESBL isolates. Conclusions Bacteremia occurred mainly in neutropenic oncohematological patients. Enterobacteriaceae were the most frequently detected microorganisms. The ESBL resistance mechanism prevailed, followed by MBL+ESBL. Local epidemiological knowledge is essential for effective IET and antimicrobial resistance control.
Abstract Background Health-care Associated Infections (HAIs) represent a big burden on the health care system, with a subsequent increase in morbidity, hospital stay, medication/procedures, intensive care unit admissions, mortality, costs, etc. In order to avoid this important complication, a great number of Infection Prevention and Control (IPC) strategies has to be stablished daily, such as standard and transmission based precautions, the multimodal hand hygiene strategy, preventive bundles, active surveillance, etc., among others. Methods We analyzed an outbreak of Serratia marcescens infections, observed in association with surgical interventions at a tertiary care pediatric hospital. All cases that meet the outbreak definition were included and analyzed, meeting the clinical and epidemiological criteria to be included. Environmental cultures were obtained and compared with the patient’s culture results. Results A total of 6 patients that meet clinical and epidemiological criteria were included, 5 of them with identification of infection with S. marcescens. Age range varied from 1 month, to 18 years of age, 50% were male female. Initially, a pseudo-outbreak was identified due to the diversity of wards involved [Surgical Intensive Care Unit (2), Oncology Surgery (1), Orthopedics (1), Neurosurgery (1), and Gastroenterology (1)], with non-related procedures (e.g. renal transplant, tumor resection, removal of surgical prosthetics, intraventricular devices, etc.). During the intensive study of this outbreak, environmental cultures were taken in every operating room (OR) involved (5), no environmental isolate of S. marcescens were found in the ORs, however S. marcescens was found in the sink faucet in front of the ORs involved, where all the surgeons practice proper hand hygiene before surgery. Pulsed Field Electrophoresis Gel was performed to determinate clonal identity between S. marcescens isolates (pending). Conclusion We describe an outbreak related with the most important strategy to prevent HAIs: Hand Hygiene. This puts in the scope that even in a hospital with proper programs of IPC, if environmental cleaning/disinfection is affected, we can continue propagating HAIs in good clinical practice scenarios. After this outbreak, surveillance of environmental cleaning was encouraged.
Abstract Background Bloodstream infections (BSIs) are one of the most important health-care associated infections (HAIs), with great implication in prolonging hospitalizations, increase in morbidity and mortality and in costs. During March 2024, the increased occurrence of possibly related cases of BSIs was observed in the surgical therapy service, it was identified as an outbreak, and it was monitored to characterize it and take control measures. Methods A retrospective analysis was performed with data collected from electronic medical records of the detected cases. The variables studied were sex, venipuncture position, days of catheter placement, underlying disease, days of hospitalization, surgical procedure performed, symptoms and their onset, bacteriological isolation, and factors associated with surgical procedures. Results In this outbreak, 4 cases of BSIs due to Klebsiella pneumoniae were identified, 75% had enzymatic resistance mechanisms, 75% were men. The total exposed population was 45 patients, with an attack rate of 8.9%, 75% of the catheters corresponded to jugular venous accesses, the mean duration of CVC installation was 14.25 ± 7.2 days and the duration until removal was 12 ±7.8 days. The mean hospital stay was 89.75 days, (range of 26-155 days). Fever was present in 100% of cases, leukocytosis in 50%, tachycardia in 75%, diaphoresis in 25%, and erythema at the CVC placement site in 25%. The findings were: poor cleaning, failure of the laminar flow hood and autoclave, excessive foot traffic in the area, misuse of protective equipment, and accumulated unused equipment. The following interventions were carried out to control the outbreak: catheter removal, hand washing, taking environmental cultures, reinforcing adherence to hand hygiene, monitoring and training in placement and management of central access, timely removal of vascular access, implementing the “no touch” technique, paired sampling, eliminating the use of master solutions, limiting access to non-essential personnel, application of disinfection with UV-C light, periodic cleaning of the gasometer, changing the product collection cart, and monitoring the use of multidose medication. Conclusions BSIs are highly related to the days of hospital stay and the time the catheter is in place, usually occurring on day 7 of the start of its placement. Although there was not only one cause of the outbreak, but different factors were also found that were predisposing to its presence, so we deduced that they were attributable to routine room processes; therefore, the multidisciplinary actions carried out by epidemiology controlled the outbreak.
Abstract Background Healthcare-associated infections (HAIs) continue to be a public health problem, impacting morbidity and mortality and costs for the health system. Due to the increased risk of transmission of communicable and preventable infectious diseases between patients and healthcare workers, there is a need for the development of preventive actions. Protective insulation aims to defend immunocompromised patients who are vulnerable and at high risk of infections that can be acquired. The objective was to demonstrate whether a modification of the protective insulation strategy had an impact on the number of HAIs and to evaluate the effectiveness and safety of these changes as adaptations to existing protocols. Methods This was an observational, descriptive, ambispective, unicentric study that included HAIs from 2022 and 2023, along with retrospective HAI data from January to March 2024, and prospective HAI cases from April to June 2024 in a pediatric oncology center in Queretaro including patients under 18 years of age. Protective insulation was defined as a single patient room, hand hygiene, masks, along with the removal of disposable gloves and coats to reduce healthcare costs. A descriptive analysis of the number of HAIs was conducted and reported in proportions and percentages. Results A total of 38 HAIs were found in 2022 and 2023, with rates of 3.03/100 discharges in 2022 and 2.67/100 in 2023. From January to March, there were a total of 7 HAIs, with rates of 4.8/100 in January, 2.5/100 in February, and 1.2/100 in March. After implementing the modification in protective insulation, the rates of HAIs were 2.08/100 in April, 6.38/100 in May, and 3.03/100 in June as part of the pilot trial of the measure. Following an observational and descriptive analysis showing no increase in HAIs, the modified measure continued until September 2024, with rates of 3.03/100 in June, 4.9/100 in July, 1.56/100 in August, and 4.4/100 in September. The total rate of HAIs over the six months with the modification was 3.3/100 discharges. Conclusions We observed no increase in the number of HAIs following the modification of the protective insulation. This measure emphasizes that hand hygiene, standard precautions and environmental safety continue to be key points in the prevention of HAIs, and that reducing the use of single-use health materials like gloves and coats may positively impact healthcare costs. This study encourages further research into adaptations in definitions of pediatric insulation, including analytic studies in larger populations to determine statistical significance.
Abstract Background When determining whether the presence of bacteremia indicates infection, clinicians and laboratorians could compare the results in multiple blood culture bottles drawn; consistent presence of the same microorganisms in multiple bottles are suggestive of infection rather than contamination. However, in pediatrics, it is common practice to draw minimum required volume of blood to avoid iatrogenic cause of anemia. When there is only one bottle of blood culture drawn, it could be difficult to interpret the clinical significance. One may rely on time-to-positivity (TTP) of blood culture, as true pathogens tend to be signaled positive in the blood culture continuous-monitoring blood culture systems (CMBCS) within 24 hours. The current study compared the TTP of Staphylococcus aureus, commonly a true pathogen, and coagulase-negative staphylococci (CoNS), commonly a contaminant, in blood culture, to hypothesize whether TTP is a good predictor of pathogenicity of bacteremia. Methods Children’s Hospital of Eastern Ontario (CHEO), a tertiary pediatric hospital, and Eastern Ontario Regional Laboratory Association (EORLA) microbiology laboratory provided the positive blood cultures data from patients at CHEO from 1 November 2019 to 31 October 2020. TTP was defined as the time from collection to a positive signal from the automated incubators. Only the first positive blood culture of a patient was included in the data analysis. Two-tailed Fisher’s exact test was used to compare TTP between Staphylococcus aureus and CoNS bacteremia. Results A mean transport time of 2.93 hours and a mean TTP of 28.73 hours were calculated from the 20 episodes of first positive blood culture from the patients with Staphylococcus aureus bacteremia (mean age 8.05 years). A mean transport time of 2.85 hours and a mean TTP of 27.81 hours were calculated from the 44 episodes of first positive blood culture from the patients with CoNS bacteremia (mean age 6.63 years). No statistical difference was found between the two groups. Conclusions TTP within 24 hours may not be a good predictor of pathogenicity of staphylococcus bacteremia in pediatric patients because Staphylococcus aureus and CoNS bacteremia were shown to have similar TTP and can both appear as gram-positive cocci cluster in Gram stain.
Abstract Background In the initial management of fever in neutropenic children with cancer, the collection of blood cultures (BC) helps guide antimicrobial therapy and identify blood stream infections (BSI). Most pediatric oncology patients possess central venous catheters, and the utility of obtaining concurrent peripheral and central BC is unclear in this population. The aim of this study was to examine the role of peripheral BC in identifying BSI in pediatric neutropenic oncology patients. Methods A retrospective chart review was performed to identify hospitalized pediatric oncology patients with a central venous access device (CVAD) recorded who were treated for febrile neutropenia over a 10-year period. Per institutional practices paired central and peripheral blood cultures (BC) sets were drawn upon recognition of FN and before empiric antibiotics were administered. Episodes with at least one positive BC and that were considered true BSI were grouped according to whether the set had concordant positive central and peripheral BCs, an isolated positive central BC, or an isolated positive peripheral BC. The volume and time to positivity of the samples was recorded. Results A total of 419 FN episodes were captured, of which 55 episodes (13.1%) met the criteria for true BSI, as indicated by at least one positive BC from a paired set of peripheral and central BC. Of the 55 episodes, 27 (49.1%) exhibited concordant positive blood cultures, 15 (27.3%) had isolated positive central blood cultures, and 13 (23.6%) had isolated positive peripheral blood cultures. Conclusions The proportion of bloodstream infections identified solely through peripheral draws was 23.6%, surpassing previous reports. This highlights the critical importance of obtaining paired blood cultures in the initial management of fever in neutropenic children with cancer, underscoring the need for vigilant diagnostic practices to ensure timely and effective treatment.
Abstract Background Biomerieux VITEK2 system is a fast, automated instrument for microbial identification and antibiotic susceptibility testing (AST) and commonly used in clinical laboratories. However, Clinical & Laboratory Standards Institute (CLSI) recommends verification of commercial AST with selected microorganism-antimicrobial combinations prior to diagnostic use in clinical laboratories. Tobramycin is an aminoglycoside antimicrobial which is generally effective against Enterobacterales and commonly used for infections in pediatrics. Our clinical laboratory incidentally found a Enterobacterales clinical isolate with tobramycin susceptible result (minimum inhibitory concentration or MIC = 2 mg/L) on VITEK2 (with AST-N391 card) but intermediate result on traditional Etest, indicating a minor error. In both the EUCAST and CLSI 2024 guidance, MIC <=2 would indicate susceptible. We subsequently carried out an ad-hoc verification study in hope of reassuring the validity of tobramycin AST results on VITEK2. Methods The current study was conducted in LifeLabs microbiology regional laboratories, connected with 129 collection centers in urban and rural communities in in British Columbia, Canada. Thirty consecutive Enterobacterales clinical isolates with MIC of 2 mg/L on VITEK2 were selected to undergo AST by traditional Etest, using the recommended methods in CLSI M100 (2024) and M52 (2015). The MIC breakpoints used were as per CLSI (2024): susceptible <=2 mg/L; intermediate = 4 mg/L; resistant => 8 mg/L. Results Despite achieving MIC of 2 mg/L on VITEK2, 16 and 3 of the isolates showed intermediate (MIC = 4 mg/L) and resistant (MIC => 8 mg/L) AST results with tobramycin Etest. respectively, equivalent to 53.3% minor error and 27.3% major error rates. Conclusions Our laboratory decided not to automatically release VITEK2 tobramycin AST results for Enterobacterales and will perform Etest when tobramycin AST is requested. Other microbiology laboratories are encouraged to perform their internal verification study to confirm the validity of tobramycin AST results on VITEK2. Pediatricians should be cautious when they encounter tobramycin MIC of 2 mg/L from the automated VITEK2 system.
