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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.
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.
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.
Electrical injury (EI) is a significant, multifaceted trauma often with multi-domain cognitive sequelae, even when the expected current path does not pass through the brain. Chronic pain (CP) research suggests pain may affect cognition directly and indirectly by influencing emotional distress which then impacts cognitive functioning. As chronic pain may be critical to understanding EI-related cognitive difficulties, the aims of the current study were: examine the direct and indirect effects of pain on cognition following EI and compare the relationship between pain and cognition in EI and CP populations.
This cross-sectional study used data from a clinical sample of 50 patients with EI (84.0% male; Mage = 43.7 years) administered standardized measures of pain (Pain Patient Profile), depression, and neurocognitive functioning. A CP comparison sample of 93 patients was also included.
Higher pain levels were associated with poorer attention/processing speed and executive functioning performance among patients with EI. Depression was significantly correlated with pain and mediated the relationship between pain and attention/processing speed in patients with EI. When comparing the patients with EI and CP, the relationship between pain and cognition was similar for both clinical groups.
Findings indicate that pain impacts mood and cognition in patients with EI, and the influence of pain and its effect on cognition should be considered in the assessment and treatment of patients who have experienced an electrical injury.
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.
Conferences are designed for knowledge translation, but traditional conference evaluations are inadequate. We lack studies that explore alternative metrics to traditional evaluation metrics. We sought to determine how traditional evaluation metrics and Twitter metrics performed using data from a conference of the Canadian Association of Emergency Physicians (CAEP).
This study used a retrospective design to compare social media posts and tradition evaluations related to an annual specialty conference. A post (“tweet”) on the social media platform Twitter was included if it associated with a session. We differentiated original and discussion tweets from retweets. We weighted the numbers of tweets and retweets to comprise a novel Twitter Discussion Index. We extracted the speaker score from the conference evaluation. We performed descriptive statistics and correlation analyses.
Of a total of 3,804 tweets, 2,218 (58.3%) were session-specific. Forty-eight percent (48%) of all sessions received tweets (mean = 11.7 tweets; 95% CI of 0 to 57.5; range, 0–401), with a median Twitter Discussion Index score of 8 (interquartile range, 0 to 27). In the 111 standard presentations, 85 had traditional evaluation metrics and 71 received tweets (p > 0.05), while 57 received both. Twenty (20 of 71; 28%) moderated posters and 44% (40 of 92) posters or oral abstracts received tweets without traditional evaluation metrics. We found no significant correlation between Twitter Discussion Index and traditional evaluation metrics (R = 0.087).
We found no correlation between traditional evaluation metrics and Twitter metrics. However, in many sessions with and without traditional evaluation metrics, audience created real-time tweets to disseminate knowledge. Future conference organizers could use Twitter metrics as a complement to traditional evaluation metrics to evaluate knowledge translation and dissemination.
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.
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.
The number of pediatric antimicrobial stewardship programs (ASPs) is increasing and program evaluation is a key component to improve efficiency and enhance stewardship strategies.
To determine the antimicrobials and diagnoses most strongly associated with a recommendation provided by a well-established pediatric ASP.
DESIGN AND SETTING
Retrospective cohort study from March 3, 2008, to March 2, 2013, of all ASP reviews performed at a free-standing pediatric hospital.
ASP recommendations were classified as follows: stop therapy, modify therapy, optimize therapy, or consult infectious diseases. A multinomial distribution model to determine the probability of each ASP recommendation category was performed on the basis of the specific antimicrobial agent or disease category. A logistic model was used to determine the odds of recommendation disagreement by the prescribing clinician.
The ASP made 2,317 recommendations: stop therapy (45%), modify therapy (26%), optimize therapy (19%), or consult infectious diseases (10%). Third-generation cephalosporins (0.20) were the antimicrobials with the highest predictive probability of an ASP recommendation whereas linezolid (0.05) had the lowest probability. Community-acquired pneumonia (0.26) was the diagnosis with the highest predictive probability of an ASP recommendation whereas fever/neutropenia (0.04) had the lowest probability. Disagreement with ASP recommendations by the prescribing clinician occurred 22% of the time, most commonly involving community-acquired pneumonia and ear/nose/throat infections.
Evaluation of our pediatric ASP identified specific clinical diagnoses and antimicrobials associated with an increased likelihood of an ASP recommendation. Focused interventions targeting these high-yield areas may result in increased program efficiency and efficacy.
Outcome feedback is the process of learning patient outcomes after their care within the emergency department. We conducted a national survey of Canadian Royal College emergency medicine (EM) residents and program directors to determine the extent to which active outcome feedback and follow-up occurred. We also compared the perceived educational value of outcome feedback between residents and program directors.
We distributed surveys to all Royal College-accredited adult and pediatric EM training programs using a modified Dillman method. We analyzed the data using student’s t-test for continuous variables and Fisher’s exact test for categorical variables.
We received 210 completed surveys from 260 eligible residents (80.8%) and 21 of 24 program directors (87.5%) (overall 81.3%). Mandatory active outcome feedback was not present in any EM training program for admitted or discharged patients (0/21). Follow-up was performed electively by 89.4% of residents for patients admitted to the hospital, and by 44.2% of residents for patients discharged home. A majority of residents (76.9%) believed that patient follow-up should be mandatory compared to 42.9% of program directors (p=0.002). The perceived educational value of outcome feedback was 5.8/7 for residents and 5.1/7 for program directors (difference 0.7; p=0.002) based on a seven-point Likert scale (1=not important; 7=very important).
While Canadian EM training programs do not mandate follow-up, it is performed electively by the majority of residents surveyed. Residents place a significantly greater educational value on outcome feedback than their program directors, and believe that follow-up should be a mandatory component of EM residencies.
Emergency medicine point-of-care ultrasonography (EM-PoCUS) is a core competency for residents in the Royal College of Physicians and Surgeons of Canada and College of Family Physicians of Canada emergency medicine (EM) training programs. Although EM-PoCUS fellowships are currently offered in Canada, there is little consensus regarding what training should be included in a Canadian EM-PoCUS fellowship curriculum or how this contrasts with the training received in an EM residency.
To conduct a systematic needs assessment of major stakeholders to define the essential elements necessary for a Canadian EM-PoCUS fellowship training curriculum.
We carried out a national survey of experts in EM-PoCUS, EM residency program directors, and EM residents. Respondents were asked to identify competencies deemed either nonessential to EM practice, essential for general EM practice, essential for advanced EM practice, or essential for EM-PoCUS fellowship trained (‘‘expert’’) practice.
The response rate was 81% (351 of 435). PoCUS was deemed essential to general EM practice for basic cardiac, aortic, trauma, and procedural imaging. PoCUS was deemed essential to advanced EM practice in undifferentiated symptomatology, advanced chest pathologies, and advanced procedural applications. Expert-level PoCUS competencies were identified for administrative, pediatric, and advanced gynecologic applications. Eighty-seven percent of respondents indicated that there was a need for EM-PoCUS fellowships, with an ideal length of 6 months.
This is the first needs assessment of major stakeholders in Canada to identify competencies for expert training in EM-PoCUS. The competencies should form the basis for EM-PoCUS fellowship programs in Canada.
To estimate and compare the impact on healthcare costs of 3 alternative strategies for reducing bloodstream infections in the intensive care unit (ICU): methicillin-resistant Staphylococcus aureus (MRSA) nares screening and isolation, targeted decolonization (ie, screening, isolation, and decolonization of MRSA carriers or infections), and universal decolonization (ie, no screening and decolonization of all ICU patients).
Cost analysis using decision modeling.
We developed a decision-analysis model to estimate the health care costs of targeted decolonization and universal decolonization strategies compared with a strategy of MRSA nares screening and isolation. Effectiveness estimates were derived from a recent randomized trial of the 3 strategies, and cost estimates were derived from the literature.
In the base case, universal decolonization was the dominant strategy and was estimated to have both lower intervention costs and lower total ICU costs than either screening and isolation or targeted decolonization. Compared with screening and isolation, universal decolonization was estimated to save $171,000 and prevent 9 additional bloodstream infections for every 1,000 ICU admissions. The dominance of universal decolonization persisted under a wide range of cost and effectiveness assumptions.
A strategy of universal decolonization for patients admitted to the ICU would both reduce bloodstream infections and likely reduce healthcare costs compared with strategies of MRSA nares screening and isolation or screening and isolation coupled with targeted decolonization.