BACKGROUND:In 2010, the World Health Organization (WHO) increased the recommended doses of first-line tuberculosis (TB) drugs for children. In this systematic review, we aimed to determine the proportion of children who developed adverse events (AEs) on first-line TB treatment and determine whether a change in toxicity was observed with WHO 2010 dosing. METHODS:We searched MEDLINE, Embase, Scopus, Cochrane Central Register of Controlled Trials, WHO Global Index Medicus, and ClinicalTrials.gov for studies that reported AEs for children and adolescents aged ≤19 years with TB disease receiving first-line medications. A meta-analysis of proportions was performed to generate pooled proportions of AEs. The protocol was registered with the International Prospective Register of Systematic Reviews. RESULTS:Of forty studies comprising 5021 participants, 682 (13.6%) participants experienced 712 AEs; 60 (1.2%) participants experienced a change in therapy due to AEs. The proportion of children with any AE was significantly higher with WHO 2010 dosing (26%; 95% confidence interval [CI], 18%-34%) compared with pre-WHO 2010 dosing (8%, 95% CI, 4%-15%), as was the proportion of children who developed severe AEs. There was no significant difference in hepatotoxicity before and after 2010 dosing recommendations; however, significant increases in hepatotoxicity were seen in several subgroups with 2010 dosing. There was substantial heterogeneity between studies; none were at high risk of bias. CONCLUSIONS:Higher-dose regimens in children were associated with increased AEs, raising caution for further dose increases and necessitating additional study of treatment tolerability. These findings are limited by publication bias in observational trials.

Levofloxacin prophylaxis during periods of neutropenia in pediatric hematopoietic stem cell transplant (HSCT) may reduce the number of febrile episodes and use of empiric intravenous antibiotics (EIA); however, the literature is conflicting. This retrospective review compared EIA use before and after implementation of levofloxacin prophylaxis at a children's hospital. Levofloxacin prophylaxis was associated with reduced use of certain EIA; however, did not reduce the number of positive blood cultures or clinical deteriorations. Therefore, levofloxacin prophylaxis may have implications for the stewardship of broad-spectrum intravenous antibiotics used in pediatric HSCT.

CMAJ | July 18, 2022 | Volume 194 | Issue 27 E939 A 21-day-old girl presented to the emergency department of an Ontario children’s hospital in early summer with a 1-day history of rash on the left arm and 3 days of decreased activity, poor feeding (not waking to feed, decreased volumes) and abdominal distension. She had no fever, weight loss, irritability, recent travel or known infectious contacts. The neonate was a dichorionic diamniotic twin whose mother had been treated for hyperthyroidism during the pregnancy. Labour was induced at 37 weeks’ gestation for intrauterine growth restriction, and the twins were born by vaginal delivery. The patient’s mother had screened positive for Streptococcus agalactiae (group B streptococcus) on perineal swab culture and had received intrapartum prophylaxis with intravenous (IV) penicillin; however, no maternal fever or prolonged rupture of membranes were noted. The patient and her twin had not required resuscitation at birth; however, both had been admitted to the neonatal intensive care unit for nasogastric tube feeding. Both infants had been discharged at 4 days of life after bottle feeding was successfully established. On presentation to the emergency department, the patient’s vital signs were normal for age (temperature 37.1°C, heart rate 180 beats/min, respiratory rate 40 breaths/min, blood pressure 86/51 mm Hg, mean arterial pressure 63 mm Hg, oxygen saturation 100% on room air). Examination showed mottled skin with preserved capillary refill at 2–3 seconds, a distended but soft abdomen, and a large, blanchable erythematous patch with partial central clearing on the left forearm (Figure 1). We found no abnormalties on cardiovascular, respiratory and neurologic examination. Bloodwork showed an elevated C-reactive protein level of 33.1 (normal 0.1–1.0) mg/L with normal complete blood count (leukocytes 6.2 × 109/L, neutrophils 2.24 × 109/L, platelets 298 × 109/L, hemoglobin 132 × 109/L), electrolytes, venous blood gas, creatinine and transaminases. We collected blood and urine samples for cultures. An electrocardiogram showed sinus tachycardia. An abdominal radiograph showed nonspecific, mildly dilated loops of bowel. The neonate’s family lived on a farm and had regularly found ticks on their dog over the preceding weeks. The parents reported finding an engorged tick on the infant’s left forearm 5 days before presentation, attached for no more than 24 hours Practice | Cases CPD

[Voir la version anglaise de l’article ici: www.cmaj.ca/lookup/doi/10.1503/cmaj.220112][1] [Pour le témoignage des parents, voir www.cmaj.ca/lookup/doi/10.1503/cmaj.220945-f][2] Points clés Un poupon de sexe féminin de 21 jours a été amené aux urgences d’un hôpital pédiatrique ontarien

BACKGROUND AND OBJECTIVES Urinary tract infection (UTI) is a common diagnosis in the emergency department (ED), often resulting in empirical antibiotic treatment before culture results. Diagnosis of a UTI, particularly in children, can be challenging and misdiagnosis is common. The aim of this initiative was to decrease the misdiagnosis of uncomplicated pediatric UTIs by 50% while improving antimicrobial stewardship in the ED over 4 years. METHODS By using the Model for Improvement, 3 interventions were developed: (1) an electronic UTI diagnostic algorithm, (2) a callback system, and (3) a standardized discharge antibiotic prescription. Outcome measures included the percentage of patients with UTI misdiagnosis (prescribed antibiotics, but urine culture results negative) and antibiotic days saved. As a balancing measure, positive urine culture results without a UTI diagnosis were reviewed for ED return visits or hospitalization. Statistical process control and run charts were used for analysis. RESULTS From 2017 to 2021, the mean UTI misdiagnosis decreased from 54.6% to 26.4%. The adherence to the standardized antibiotic duration improved from 45.1% to 84.6%. With the callback system, 2128 antibiotic days were saved with a median of 89% of patients with negative culture results contacted to discontinue antibiotics. Of 186 patients with positive urine culture results with an unremarkable urinalysis, 14 returned to the ED, and 2 were hospitalized for multiresistant organism UTI treatment. CONCLUSIONS A UTI diagnostic algorithm coupled with a callback system safely reduced UTI misdiagnoses and antibiotic usage. Embedding these interventions electronically as a decision support tool, targeted audit and feedback, reminders, and education all supported long-term sustainability.

The COVID-19 pandemic has had dramatic effects on the lives of children globally. However, socially vulnerable children have been particularly impacted. Certain populations have increased vulnerabilities, including children and youth experiencing homelessness. Increased infection risk due to congregant living and challenges with physical distancing are contributing factors. An urgent need exists for a wholistic approach to care with unique cross-sectoral partnerships across disciplines. A recognition of the unintended consequence of the COVID-19 pandemic on this population is urgently required by all those supporting children. Families should receive direct support in clinical settings to identify their social needs. Partnership with community agencies and advocacy for appropriate isolation facilities for patients experiencing homelessness are critical.

Journal Article An adolescent male with respiratory illness and severe mucositis Get access Michael Prodanuk, MD, Michael Prodanuk, MD Department of Paediatrics, University of Toronto The Hospital for Sick Children, Toronto, Ontario https://orcid.org/0000-0002-2706-5301 Search for other works by this author on: Oxford Academic Google Scholar Hassan Jamal, MD, Hassan Jamal, MD Department of Paediatrics, University of Toronto The Hospital for Sick Children, Toronto, Ontario Search for other works by this author on: Oxford Academic Google Scholar Janaki Vallipuram, MD Janaki Vallipuram, MD Department of Paediatrics, University of Toronto The Hospital for Sick Children, Toronto, Ontario Correspondence: Janaki Vallipuram, Department of Paediatrics, University of Toronto, 555 University Avenue, Toronto, Ontario M5G 1X8. Telephone 416-813-8422, fax 416-813-8345, e-mail janaki.vallipuram@sickkids.ca Search for other works by this author on: Oxford Academic Google Scholar Paediatrics & Child Health, Volume 26, Issue 4, July 2021, Pages 200–201, https://doi.org/10.1093/pch/pxaa055 Published: 27 May 2020 Article history Received: 01 October 2019 Accepted: 24 March 2020 Published: 27 May 2020

Abstract Background Urinary tract infection (UTI) is a common diagnosis in the pediatric emergency department (ED) that often results in empiric antibiotic treatment prior to culture results. A 2016 cohort study from our centre found that 47% of children diagnosed with a UTI and prescribed antibiotics had a negative urine culture. None of these patients were notified of the misdiagnosis or told to discontinue antibiotics. Figure 1: Choosing Wisely pediatric urinary tract infection diagnostic algorithm Figure 2: Patients included/excluded with exclusion criteria Methods Institutional approval was obtained for a quality improvement project in our quaternary pediatric ED. For uncomplicated pediatric UTIs, the aim was to reduce misdiagnosis by 50% and promote antimicrobial stewardship over a 24-month period. Using the Model for Improvement, two interventions were implemented using PDSA cycles: (1) a UTI diagnostic algorithm embedded in the electronic medical record, (2) a urine culture callback system. Outcome measures included the percentage of patients with UTI misdiagnosis (urine culture negative) and antibiotic-days saved. Process measures included adherence to the UTI algorithm and callback system as well as antibiotic duration standardization. As a balancing measure, patients developing positive urine cultures without UTI diagnosis were reviewed for potential harm. Figure 3: Run chart of urinary tract infection misdiagnosis rate Figure 4: Callback system - Percent patients contacted and antibiotics-days saved Results From June 2017-April 2020, 2,183 children (0.97% of all visits) were diagnosed with a UTI in the ED. 1,381 (63.3%) met inclusion criteria for analysis. Following UTI algorithm launch, median UTI misdiagnosis decreased by 20% (52.5% vs. 32.5%), median correct antibiotic duration increased by 30% (45.2% vs. 75.1%), and algorithm adherence was 78.9%. With implementation of the callback system, 1,678 antibiotic-days were saved as mean patients contacted to discontinue antibiotics increased from 0% to 76.8%. Of 106 patients with positive urine cultures with missed UTI diagnosis over a 29-month period, 8 patients returned to the ED within 72 hours and 2 patients required admission for intravenous antibiotics. Conclusion Implementation of a UTI diagnostic algorithm and urine culture callback system for uncomplicated pediatric UTIs reduced UTI misdiagnosis and promoted antimicrobial and resource stewardship in the ED. Future directions include improving UTI algorithm adherence through targeted clinician audit and feedback, plus sustainability planning. Disclosures Olivia Ostrow, MD, Choosing Wisely Canada (Advisor or Review Panel member)

OBJECTIVE Determining pediatric severity of illness in referring centers may be useful for establishing appropriate patient disposition and interfacility transport. For this retrospective review, the authors evaluated the Canadian Paediatric Triage and Acuity Scale (PaedCTAS) tool in regards to individual patient disposition and outcomes. METHODS A disposition score using the PaedCTAS algorithm was retrospectively calculated from referring center data at the time our transport team was consulted. Data included children < 17 years transported to our tertiary pediatric center between April 2013 and March 2014. Patients were excluded if transported because of elective or planned interventions, investigations, and/or treatment. RESULTS A total of 194 pediatric patients were identified, with 49 requiring a pediatric intensive care unit (PICU) admission. A PaedCTAS assessment of 1 was the only transport characteristic evaluated that was significantly associated (odds ratio [OR] 6.15; p < 0.0001) with PICU admissions, with an area under the receiver-operating characteristic curve of 0.72 (95% CI 0.64, 0.77). On multivariate analysis, a PaedCTAS assessment of 1 was also associated with a length of hospital stay greater than 3 days (OR 1.81; 95% CI 0.99, 3.31; p = 0.05). CONCLUSIONS A PaedCTAS assessment of 1 may be a reasonable predictor for PICU admissions and longer hospitalizations when calculated in referral centers at time of pediatric transport consultation. PaedCTAS assessments may provide useful adjuvant information for specialized pediatric transport programs.

BACKGROUNDProviding acutely ill children in isolated communities access to specialized care is challenging. This study aimed to evaluate remote presence robotic technology (RPRT) for enhancing pediatric remote assessments, expediting initiation of treatment, refining triaging, and reducing the need for transport.METHODSWe conducted a pilot prospective observational study at a primary/urgent care clinic in an isolated northern community. Participants (n = 38) were acutely ill children <17 years presenting to the clinic, whom local healthcare professionals had considered for interfacility transportation (IFT). Participants were assessed and managed by a tertiary center pediatric intensivist through a remote presence robot. The intensivist triaged participants to either remain at the clinic or be transported to regional/tertiary care. Controls from a pre-existing local transport database were matched using propensity scoring. The primary outcome was the number of IFTs among participants versus controls.RESULTSFourteen of 38 (37%) participants required transport, whereas all controls were transported (p < 0.0001). Six of 14 (43%) transported participants were triaged to a nearby regional hospital, while no controls were regionalized (p = 0.0001). All participants who remained at the clinic stayed <24 h, and were matched to controls who stayed 4.9 days in tertiary care (p < 0.001). There was no statistically significant difference in hospital length of stay between transported participants and controls (6.0 vs. 5.7 days).CONCLUSIONSRPRT reduced the need for specialized pediatric IFT, while enabling regionalization when appropriate. This study may have implications for the broader implementation of RPRT, while reducing costs to the healthcare system.

Purpose Universal and timely access to pediatric critical care and specialized transportation is a substantial challenge, particularly in rural and remote areas. This study evaluates the utilization of the FDA-approved RP7i remote presence device (InTouch Technology Inc.) to assess, manage, and triage pediatric patients in determining need for inter-facility transportation. The primary objective of this study is to compare the number of transports that occur in the cases (with RP7i) …

Abstract Objective: Determining care disposition for pediatric patients during interfacility transport is often challenging. Severity of illness scoring can assist with this process. The purpose of this retrospective study was to compare currently utilized scoring systems and their ability to reliably match pediatric transport patients’ severity of illness with the level of care necessary. Methods: The retrospective transport registry review for our region included 209 patients <18 years, transported between 2015 and 2016 and admitted to tertiary care. The Pediatric RISk of Mortality III (PRISM III); Canadian Pediatric Triage and Acuity Scale (PedCTAS); Transport Pediatric Early Warning Scores (TPEWS); and Transport Risk Assessment in Pediatrics (TRAP) scores were calculated. Descriptive statistics and binomial logistic regression were utilized to compare the scoring tools. Interrater reliability was calculated using kappa statistics. All analyses were computed using IBM SPSS Statistics for Windows, version 24. Results: Patients were more likely to be admitted to pediatric intensive care unit (PICU) with PedCTAS = 1 (odds ratio [OR] = 37.2; 95% confidence interval [CI], 12.4, 111.4; p < 0.0001), TPEWS = 3 in one category or total score ≥6 (OR = 42.2; 95% CI, 17.0, 104.9; p < 0.0001), and TRAP ≥4 (OR = 7.2; 95% CI, 3.8, 13.5; p < 0.0001). PRISM scores were not predictive for PICU admissions. Conclusion: Elevated PedCTAS, TPEWS, and TRAP scores are strongly associated with PICU admission within the interfacility transport setting.