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To investigate differences in the rate of firstline antibiotic prescribing for common pediatric infections in relation to different socioeconomic statuses and the impact of an antimicrobial stewardship program (ASP) in pediatric urgent-care clinics (PUCs).
Three PUCs within a Midwestern pediatric academic center.
Patients and participants:
Patients aged >60 days and <18 years with acute otitis media, group A streptococcal pharyngitis, community-acquired pneumonia, urinary tract infection, or skin and soft-tissue infections who received systemic antibiotics between July 2017 and December 2020. We excluded patients who were transferred, admitted, or had a concomitant diagnosis requiring systemic antibiotics.
We used national guidelines to determine the appropriateness of antibiotic choice in 2 periods: prior to (July 2017–July 2018) and following ASP implementation (August 2018–December 2020). We used multivariable regression analysis to determine the odds ratios of appropriate firstline agent by age, sex, race and ethnicity, language, and insurance type.
The study included 34,603 encounters. Prior to ASP implementation in August 2018, female patients, Black non-Hispanic children, those >2 years of age, and those who self-paid had higher odds of receiving recommended firstline antibiotics for all diagnoses compared to male patients, children of other races and ethnicities, other ages, and other insurance types, respectively. Although improvements in prescribing occurred after implementation of our ASP, the difference within the socioeconomic subsets persisted.
We observed socioeconomic differences in firstline antibiotic prescribing for common pediatric infections in the PUCs setting despite implementation of an ASP. Antimicrobial stewardship leaders should consider drivers of these differences when developing improvement initiatives.
To describe patterns of inappropriate antibiotic prescribing at US children’s hospitals and how these patterns vary by clinical service.
Serial, cross-sectional study using quarterly surveys.
Surveys were completed in quarter 1 2019–quarter 3 2020 across 28 children’s hospitals in the United States.
Patients at children’s hospitals with ≥1 antibiotic order at 8:00 a.m. on institution-selected quarterly survey days.
Antimicrobial stewardship physicians and pharmacists collected data on antibiotic orders and evaluated appropriateness of prescribing. The primary outcome was percentage of inappropriate antibiotics, stratified by clinical service and antibiotic class. Secondary outcomes included reasons for inappropriate use and association of infectious diseases (ID) consultation with appropriateness.
Of 13,344 orders, 1,847 (13.8%) were inappropriate; 17.5% of patients receiving antibiotics had ≥1 inappropriate order. Pediatric intensive care units (PICU) and hospitalists contributed the most inappropriate orders (n = 384 and n = 314, respectively). Surgical subspecialists had the highest percentage of inappropriate orders (22.5%), and 56.8% of these were for prolonged or unnecessary surgical prophylaxis. ID consultation in the previous 7 days was associated with fewer inappropriate orders (15% vs 10%; P < .001); this association was most pronounced for hospitalist, PICU, and surgical and medical subspecialty services.
Inappropriate antibiotic use for hospitalized children persists and varies by clinical service. Across 28 children’s hospitals, PICUs and hospitalists contributed the most inappropriate antibiotic orders, and surgical subspecialists’ orders were most often judged inappropriate. Understanding service-specific prescribing patterns will enable antimicrobial stewardship programs to better design interventions to optimize antibiotic use.
The dual process model of moral judgment (DPM; Greene et al., 2004) argues that such judgments are influenced by both emotion-laden intuition and controlled reasoning. These influences are associated with distinct neural circuitries and different response tendencies. After reanalyzing data from an earlier study, McGuire et al. (2009) questioned the level of support for the dual process model and asserted that the distinction between emotion evoking moral dilemmas (personal dilemmas) and those that do not trigger such intuitions (impersonal dilemmas) is spurious. Using similar reanalysis methods on data reported by Moore, Clark, & Kane (2008), we show that the personal/impersonal distinction is reliable. Furthermore, new data show that this distinction is fundamental to moral judgment across widely different cultures (U.S. and China) and supports claims made by the DPM.
To characterize antifungal prescribing patterns, including the indication for antifungal use, in hospitalized children across the United States.
We analyzed antifungal prescribing data from 32 hospitals that participated in the SHARPS Antibiotic Resistance, Prescribing, and Efficacy among Children (SHARPEC) study, a cross-sectional point-prevalence survey conducted between June 2016 and December 2017.
Inpatients aged <18 years with an active systemic antifungal order were included in the analysis. We classified antifungal prescribing by indication (ie, prophylaxis, empiric, targeted), and we compared the proportion of patients in each category based on patient and antifungal characteristics.
Among 34,927 surveyed patients, 2,095 (6%) received at least 1 systemic antifungal and there were 2,207 antifungal prescriptions. Most patients had an underlying oncology or bone marrow transplant diagnosis (57%) or were premature (13%). The most prescribed antifungal was fluconazole (48%) and the most common indication for antifungal use was prophylaxis (64%). Of 2,095 patients receiving antifungals, 79 (4%) were prescribed >1 antifungal, most often as targeted therapy (48%). The antifungal prescribing rate ranged from 13.6 to 131.2 antifungals per 1,000 patients across hospitals (P < .001).
Most antifungal use in hospitalized children was for prophylaxis, and the rate of antifungal prescribing varied significantly across hospitals. Potential targets for antifungal stewardship efforts include high-risk, high-utilization populations, such as oncology and bone marrow transplant patients, and specific patterns of utilization, including prophylactic and combination antifungal therapy.
To evaluate efficiency and impact of a novel antimicrobial stewardship program (ASP) prospective-audit-with-feedback (PAF) review process using the Cerner Multi-Patient Task List (MPTL).
Retrospective cohort study.
A 367-bed free-standing, pediatric academic medical center.
The ASP PAF review process expanded to monitor all systemic and inhaled antibiotics through use of the MPTL on July 23, 2020. Average number of daily ASP reviews, absolute number of monthly interventions, and time to conduct ASP reviews were compared between the preimplementation period and the postimplementation period following expansion. Antibiotic days of therapy (DOT) per 1,000 patient days for overall and select antibiotics were compared between periods. ASP intervention characteristics were assessed.
Average daily ASP reviews significantly increased following program expansion (9 vs 14 reviews; P < .0001), and the absolute number of ASP interventions each month also increased (34 vs 52 interventions; P ≤ .0001). Time to conduct daily ASP reviews increased in the postimplementation period (1.03 vs 1.32 hours). Overall antibiotic DOT per 1,000 patient days significantly decreased in the postimplementation period (457.9 vs 427.9; P < .0001) as well as utilization of select, narrow-spectrum antibiotics such as ampicillin and clindamycin. Intervention type and antibiotics were similar between periods. The ASP documented 128 “nonantibiotic interventions” in the postimplementation period, including culture and/or susceptibility testing (32.8%), immunizations (25.8%), and additional diagnostic testing (22.7%).
Implementation of an ASP PAF review process using the MPTL allowed for efficient expansion of a pre-existing ASP and a decrease in overall antibiotic utilization. ASP documentation was enhanced to fully track the impact of the program.
We examined ampicillin dosing in pediatric patients across 3 conditions: (1) bacterial lower respiratory tract infections (LRTIs) in infants and children >3 months, (2) neonates with suspected or proven sepsis, and (3) neonates with suspected central nervous system (CNS) infections. We compared our findings to dosing guidance for these specific indications.
Retrospective cohort study.
The study included data from 32 children’s hospitals in the United States.
We reviewed prescriptions from the SHARPS study of antimicrobials, a survey of antibiotic prescribing from July 2016 to December 2017. Prescriptions were analyzed for indication, total daily dose per kilogram, and presence of antimicrobial stewardship program (ASP) review. LRTI prescriptions were compared to IDSA recommendations for community-acquired pneumonia. Neonatal prescriptions were compared to recommendations from the American Academy of Pediatrics (AAP). Prescriptions were categorized as “optimal” (80%–120% of recommended dosing), “suboptimal” (<80% of recommended dosing), or “excessive” (>120% of recommended dosing).
Among 1,038 ampicillin prescriptions, we analyzed 88 prescriptions for LRTI, 499 prescriptions for neonatal sepsis, and 27 prescriptions for neonatal CNS infection. Of the LRTI prescriptions, 77.3%were optimal. Of prescriptions for neonatal sepsis, 81.6% were excessive compared to AAP bacteremia recommendations but 78.8% were suboptimal compared to AAP meningitis guidelines. Also, 48.1% of prescriptions for neonatal CNS infection were suboptimal, and 50.6% of prescriptions were not reviewed by the ASP.
LRTI dosing is generally within the IDSA-recommended range. However, dosing for neonatal sepsis often exceeds the recommendation for bacteremia but is below the recommendation for meningitis. This variability points to an important opportunity for future antimicrobial stewardship efforts.
Modular coral-like fossils occur in thrombolitic reefal beds at two stratigraphic levels within the Lower Ordovician (Floian) Barbace Cove Member of the Boat Harbour Formation, in the St. George Group of western Newfoundland. They are here assigned to Reptamsassia n. gen.; R. divergens n. gen. n. sp. is present at both levels, whereas a comparatively small-module species, R. minuta n. gen. n. sp., is confined to the upper level. Reptamsassia n. gen. resembles the Ordovician genus Amsassia in its phacelocerioid structure, back-to-back walls of adjoining modules, module increase by longitudinal fission involving infoldings of the wall, tabula-like structures that are continuous with the vertical module wall, and calices with concave-up bottoms. The new genus is differentiated by its encrusting habit, modules with highly variable growth directions and shapes throughout skeletal growth, and modules that may separate slightly or diverge from one another following fission. Together, Amsassia and Reptamsassia n. gen. are considered to represent a distinct group of calcareous algae, the Amsassiaceae n. fam., which possibly belongs to the green algae. The Early Ordovician origination of Amsassia followed by Reptamsassia n. gen. contributed to the beginning of the rise in diversity on a global scale and in reefal settings during the Great Ordovician Biodiversification Event. Reptamsassia minuta n. gen. n. sp. was an obligate symbiont that colonized living areas on its host, R. divergens n. gen. n. sp., with isolated modules of R. divergens n. gen. n. sp. able to persist in the resulting intergrowth with R. minuta n. gen. n. sp. This is the earliest known symbiotic intergrowth of macroscopic modular species, exemplifying the development of ecologic specialization and ecosystem complexity in Early Ordovician reefs.
Evidence suggests a link between smaller hippocampal volume (HV) and post-traumatic stress disorder (PTSD). However, there has been little prospective research testing this question directly and it remains unclear whether smaller HV confers risk or is a consequence of traumatization and PTSD.
U.S. soldiers (N = 107) completed a battery of clinical assessments, including structural magnetic resonance imaging pre-deployment. Once deployed they completed monthly assessments of traumatic-stressors and symptoms. We hypothesized that smaller HV would potentiate the effects of traumatic stressors on PTSD symptoms in theater. Analyses evaluated whether total HV, lateral (right v. left) HV, or HV asymmetry (right – left) moderated the effects of stressor-exposure during deployment on PTSD symptoms.
Findings revealed no interaction between total HV and average monthly traumatic-stressors on PTSD symptoms b = −0.028, p = 0.681 [95% confidence interval (CI) −0.167 to 0.100]. However, in the context of greater exposure to average monthly traumatic stressors, greater right HV was associated with fewer PTSD symptoms b = −0.467, p = 0.023 (95% CI −0.786 to −0.013), whereas greater left HV was unexpectedly associated with greater PTSD symptoms b = 0.435, p = 0.024 (95% CI 0.028–0.715).
Our findings highlight the importance of considering the complex role of HV, in particular HV asymmetry, in predicting the emergence of PTSD symptoms in response to war-zone trauma.
To assess current resources, interventions, and obstacles of pediatric outpatient antimicrobial stewardship programs (ASP).
Institutions from the Sharing Antimicrobial Reports for Pediatric Stewardship OutPatient collaborative (SHARPS-OP).
Antimicrobial stewardship leaders from the above institutions.
An investigator-developed survey was deployed online in September 2020 to antimicrobial stewardship leaders in SHARPS-OP institutions. The survey was divided into 4 sections: (1) basic information, (2) status of pediatric outpatient ASP in the institutions including financial support, (3) outpatient ASP interventions undertaken by the institutions, and (4) needs and SHARPS-OP collaborative goals.
Of 56 invited institutions, 45 participated, achieving an 80% response rate. Only 5 sites (11%) had allocated financial support for an outpatient ASP, compared to 42 (95.6%) for their inpatient ASP. The most widely used outpatient ASP interventions included antimicrobial guidance (57.8%), education (46.7%), and quality improvement projects (37.8%). Time was identified as the biggest barrier to expanding outpatient ASPs (91.1%), followed by financial support (53.3%), development of meaningful reports (51.1%), and administrative support (44.4%). Important goals of the collaborative included seeking learning opportunities and developing clear metrics for pediatric outpatient ASP benchmarking. Program needs included securing operational support (35.8%) and strengthening data analysis (31.6%).
Very few pediatric institutions with robust inpatient ASPs have devoted time and financial support to advance outpatient efforts. To promote appropriate antibiotic prescribing in the outpatient arena, time and resource funding by administrative leaders are necessary to develop a robust, sustainable stewardship infrastructure.
Modular coral-like fossils from Lower Ordovician (Tremadocian) thrombolitic mounds in the St. George Group of western Newfoundland were initially identified as Lichenaria and thought to include the earliest tabulate corals. They are here assigned to Amsassia terranovensis n. sp. and Amsassia? sp. A from the Watts Bight Formation, and A. diversa n. sp. and Amsassia? sp. B from the overlying Boat Harbour Formation. Amsassia terranovensis n. sp. and A. argentina from the Argentine Precordillera are the earliest representatives of the genus. Amsassia is considered to be a calcareous alga, possibly representing an extinct group of green algae. The genus originated and began to disperse in the Tremadocian, during the onset of the Great Ordovician Biodiversification Event, on the southern margin of Laurentia and the Cuyania Terrane. It inhabited small, shallow-marine reefal mounds constructed in association with microbes. The paleogeographic range of Amsassia expanded in the Middle Ordovician (Darriwilian) to include the Sino-Korean Block, as well as Laurentia, and its environmental range expanded to include non-reefal, open- and restricted-marine settings. Amsassia attained its greatest diversity and paleogeographic extent in the Late Ordovician (Sandbian–Katian), during the culmination of the Great Ordovician Biodiversification Event. Its range included the South China Block, Tarim Block, Kazakhstan, and Siberia, as well as the Sino-Korean Block and Laurentia, and its affinity for small microbial mounds continued during that time. In the latest Ordovician (Hirnantian), the diversity of Amsassia was reduced, its distribution was restricted to non-reefal environments in South China, and it finally disappeared during the end-Ordovician mass extinction.
We identified quality indicators (QIs) for care during transitions of older persons (≥ 65 years of age). Through systematic literature review, we catalogued QIs related to older persons’ transitions in care among continuing care settings and between continuing care and acute care settings and back. Through two Delphi survey rounds, experts ranked relevance, feasibility, and scientific soundness of QIs. A steering committee reviewed QIs for their feasible capture in Canadian administrative databases. Our search yielded 326 QIs from 53 sources. A final set of 38 feasible indicators to measure in current practice was included. The highest proportions of indicators were for the emergency department (47%) and the Institute of Medicine (IOM) quality domain of effectiveness (39.5%). Most feasible indicators were outcome indicators. Our work highlights a lack of standardized transition QI development in practice, and the limitations of current free-text documentation systems in capturing relevant and consistent data.
Antimicrobial stewardship programs typically use days of therapy to assess antimicrobial use. However, this metric does not account for the antimicrobial spectrum of activity. We applied an antibiotic spectrum index to a population of very-low-birth-weight infants to assess its utility to evaluate the impact of antimicrobial stewardship interventions.
To evaluate the clinical impact of an antimicrobial stewardship program (ASP) on high-risk pediatric patients.
Retrospective cohort study.
Free-standing pediatric hospital.
This study included patients who received an ASP review between March 3, 2008, and March 2, 2017, and were considered high-risk, including patients receiving care by the neonatal intensive care (NICU), hematology/oncology (H/O), or pediatric intensive care (PICU) medical teams.
The ASP recommendations included stopping antibiotics; modifying antibiotic type, dose, or duration; or obtaining an infectious diseases consultation. The outcomes evaluated in all high-risk patients with ASP recommendations were (1) hospital-acquired Clostridium difficile infection, (2) mortality, and (3) 30-day readmission. Subanalyses were conducted to evaluate hospital length of stay (LOS) and tracheitis treatment failure. Multivariable generalized linear models were performed to examine the relationship between ASP recommendations and each outcome after adjusting for clinical service and indication for treatment.
The ASP made 2,088 recommendations, and 50% of these recommendations were to stop antibiotics. Recommendation agreement occurred in 70% of these cases. Agreement with an ASP recommendation was not associated with higher odds of mortality or hospital readmission. Patients with a single ASP review and agreed upon recommendation had a shorter median LOS (10.2 days vs 13.2 days; P < .05). The ASP recommendations were not associated with high rates of tracheitis treatment failure.
ASP recommendations do not result in worse clinical outcomes among high-risk pediatric patients. Most ASP recommendations are to stop or to narrow antimicrobial therapy. Further work is needed to enhance stewardship efforts in high-risk pediatric patients.
We retrospectively evaluated the effect of penicillin adverse drug reaction (ADR) labeling on surgical antibiotic prophylaxis. Cefazolin was administered in 86% of penicillin ADR-negative (−) and 28% penicillin ADR-positive (+) cases. Broad-spectrum antibiotic use was more common in ADR(+) cases and was more commonly associated with perioperative adverse drug events.
We observed pediatric S. aureus hospitalizations decreased 36% from 26.3 to 16.8 infections per 1,000 admissions from 2009 to 2016, with methicillin-resistant S. aureus (MRSA) decreasing by 52% and methicillin-susceptible S. aureus decreasing by 17%, among 39 pediatric hospitals. Similar decreases were observed for days of therapy of anti-MRSA antibiotics.
There is remarkably little documented information in the scientific literature on any of the 18 species of buttonquail as they are very difficult to observe in the wild. This lack of information has hampered informed conservation decision making. We undertook the first biome-wide survey for the fynbos endemic Hottentot Buttonquail Turnix hottentottus, using flush transect surveys covering 275 km. We used location data for sightings as well as from records reported by the bird-watching community and modelled distribution using MaxEnt. Encounters were restricted to the fynbos biome, and the top contributors to our prediction of suitable habitat were habitat transformation, slope and time since fire. We obtained a density estimate of 0.032 individuals per hectare which, across an estimated median range of 27,855 km2, provides a population estimate of 89,136 individuals. Given the extent of the range and the population estimate we suggest the IUCN Red List status could be ‘Vulnerable’, rather than ‘Endangered’. Agricultural and alien-vegetation encroachment means that the future of the species is certainly under threat and further studies are needed to inform conservation management.
We analyzed antifungal and antiviral prescribing among high-risk children across freestanding children’s hospitals. Antifungal and antiviral days of therapy varied across hospitals. Benchmarking antifungal and antiviral use and developing antimicrobial stewardship strategies to optimize use of these high cost agents is needed.
Giant miscanthus is under consideration as a biofuel crop in the United States; however, there is little information on weed management for the establishment and survival of this crop. Therefore, greenhouse and field studies using ornamental pots were conducted in summer 2011 at Tifton, GA, with the objective of screening potential PPI, PRE, and POST herbicides and herbicide combinations for giant miscanthus when establishing from vegetative rhizomes. For the POST treatments, giant miscanthus was established from rhizomes in 7.6-L containers in the field and treated with 27 POST herbicides to evaluate efficacy. Thifensulfuron, metsulfuron, tribenuron, chlorimuron, halosulfuron, rimsulfuron, cloransulam, pinoxaden, bentazon, and metribuzin did not significantly lower shoot height, reduce shoot dry weight, or increase injury compared with nontreated control (NTC) when evaluated at 4 wk after treatment. Nicosulfuron, trifloxysulfuron, sulfometuron, clodinafop, fluazifop, and pyrithiobac caused the greatest injury, reduced plant height, and reduced dry weights compared with the NTC. Sethoxydim, diclofop, flumioxazin, imazamox, imazapic, and imazethapyr decreased plant heights or resulted in increased injury. PPI and PRE treatments included 21 herbicides and herbicide combinations applied at two rates. Results indicated that most treatments containing atrazine, metribuzin, pendimethalin, acetochlor, metolachlor, and mesotrione did not injure or stunt growth; however, EPTC at 4.5 kg ai ha−1 significantly reduced height and dry weight and oxadiazon resulted in greater injury compared with NTC at both rates. These results indicate that PPI, PRE, and POST herbicides can be utilized for establishment of giant miscanthus from vegetative rhizomes. Considering the invasive potential of giant miscanthus, several POST herbicides evaluated in this study such as fluazifop, pyrithiobac, and sulfometuron may be viable options to control this species if it becomes invasive.