First name
Rakesh
Middle name
D
Last name
Mistry

Title

Current State of Antimicrobial Stewardship in Children's Hospital Emergency Departments.

Year of Publication

2017

Number of Pages

1-7

Date Published

2017 Feb 08

ISSN Number

1559-6834

Abstract

<p>BACKGROUND Antimicrobial stewardship programs (ASPs) effectively optimize antibiotic use for inpatients; however, the extent of emergency department (ED) involvement in ASPs has not been described.</p>

<p>OBJECTIVE To determine current ED involvement in children's hospital ASPs and to assess beliefs and preferred methods of implementation for ED-based ASPs.</p>

<p>METHODS A cross-sectional survey of 37 children's hospitals participating in the Sharing Antimicrobial Resistance Practices collaboration was conducted. Surveys were distributed to ASP leaders and ED medical directors at each institution. Items assessed included beliefs regarding ED antibiotic prescribing, ED prescribing resources, ASP methods used in the ED such as clinical decision support and clinical care guidelines, ED participation in ASP activities, and preferred methods for ED-based ASP implementation.</p>

<p>RESULTS A total of 36 ASP leaders (97.3%) and 32 ED directors (86.5%) responded; the overall response rate was 91.9%. Most ASP leaders (97.8%) and ED directors (93.7%) agreed that creation of ED-based ASPs was necessary. ED resources for antibiotic prescribing were obtained via the Internet or electronic health records (EHRs) for 29 hospitals (81.3%). The main ASP activities for the ED included production of antibiograms (77.8%) and creation of clinical care guidelines for pneumonia (83.3%). The ED was represented on 3 hospital ASP committees (8.3%). No hospital ASPs actively monitored outpatient ED prescribing. Most ASP leaders (77.8%) and ED directors (81.3%) preferred implementation of ED-based ASPs using clinical decision support integrated into the EHR.</p>

<p>CONCLUSIONS Although ED involvement in ASPs is limited, both ASP and ED leaders believe that ED-based ASPs are necessary. Many children's hospitals have the capability to implement ED-based ASPs via the preferred method: EHR clinical decision support.</p>

DOI

10.1017/ice.2017.3

Alternate Title

Infect Control Hosp Epidemiol

PMID

28173888

Title

Interpretation of Cerebrospinal Fluid White Blood Cell Counts in Young Infants With a Traumatic Lumbar Puncture.

Year of Publication

2016

Date Published

2016 Dec 29

ISSN Number

1097-6760

Abstract

<p><strong>STUDY OBJECTIVE: </strong>We determine the optimal correction factor for cerebrospinal fluid WBC counts in infants with traumatic lumbar punctures.</p>

<p><strong>METHODS: </strong>We performed a secondary analysis of a retrospective cohort of infants aged 60 days or younger and with a traumatic lumbar puncture (cerebrospinal fluid RBC count ≥10,000 cells/mm(3)) at 20 participating centers. Cerebrospinal fluid pleocytosis was defined as a cerebrospinal fluid WBC count greater than or equal to 20 cells/mm(3) for infants aged 28 days or younger and greater than or equal to 10 cells/mm(3) for infants aged 29 to 60 days; bacterial meningitis was defined as growth of pathogenic bacteria from cerebrospinal fluid culture. Using linear regression, we derived a cerebrospinal fluid WBC correction factor and compared the uncorrected with the corrected cerebrospinal fluid WBC count for the detection of bacterial meningitis.</p>

<p><strong>RESULTS: </strong>Of the eligible 20,319 lumbar punctures, 2,880 (14%) were traumatic, and 33 of these patients (1.1%) had bacterial meningitis. The derived cerebrospinal fluid RBCs:WBCs ratio was 877:1 (95% confidence interval [CI] 805 to 961:1). Compared with the uncorrected cerebrospinal fluid WBC count, the corrected one had lower sensitivity for bacterial meningitis (88% uncorrected versus 67% corrected; difference 21%; 95% CI 10% to 37%) but resulted in fewer infants with cerebrospinal fluid pleocytosis (78% uncorrected versus 33% corrected; difference 45%; 95% CI 43% to 47%). Cerebrospinal fluid WBC count correction resulted in the misclassification of 7 additional infants with bacterial meningitis, who were misclassified as not having cerebrospinal fluid pleocytosis; only 1 of these infants was older than 28 days.</p>

<p><strong>CONCLUSION: </strong>Correction of the cerebrospinal fluid WBC count substantially reduced the number of infants with cerebrospinal fluid pleocytosis while misclassifying only 1 infant with bacterial meningitis of those aged 29 to 60 days.</p>

DOI

10.1016/j.annemergmed.2016.10.008

Alternate Title

Ann Emerg Med

PMID

28041826

Title

The Effect of Total Household Decolonization on Clearance of Colonization With Methicillin-Resistant Staphylococcus aureus.

Year of Publication

2016

Number of Pages

1-8

Date Published

2016 Jul 28

ISSN Number

1559-6834

Abstract

<p>OBJECTIVE To determine the impact of total household decolonization with intranasal mupirocin and chlorhexidine gluconate body wash on recurrent methicillin-resistant Staphylococcus aureus (MRSA) infection among subjects with MRSA skin and soft-tissue infection. DESIGN Three-arm nonmasked randomized controlled trial. SETTING Five academic medical centers in Southeastern Pennsylvania. PARTICIPANTS Adults and children presenting to ambulatory care settings with community-onset MRSA skin and soft-tissue infection (ie, index cases) and their household members. INTERVENTION Enrolled households were randomized to 1 of 3 intervention groups: (1) education on routine hygiene measures, (2) education plus decolonization without reminders (intranasal mupirocin ointment twice daily for 7 days and chlorhexidine gluconate on the first and last day), or (3) education plus decolonization with reminders, where subjects received daily telephone call or text message reminders. MAIN OUTCOME MEASURES Owing to small numbers of recurrent infections, this analysis focused on time to clearance of colonization in the index case. RESULTS Of 223 households, 73 were randomized to education-only, 76 to decolonization without reminders, 74 to decolonization with reminders. There was no significant difference in time to clearance of colonization between the education-only and decolonization groups (log-rank P=.768). In secondary analyses, compliance with decolonization was associated with decreased time to clearance (P=.018). CONCLUSIONS Total household decolonization did not result in decreased time to clearance of MRSA colonization among adults and children with MRSA skin and soft-tissue infection. However, subjects who were compliant with the protocol had more rapid clearance Trial registration. ClinicalTrials.gov identifier: NCT00966446 Infect Control Hosp Epidemiol 2016;1-8.</p>

DOI

10.1017/ice.2016.138

Alternate Title

Infect Control Hosp Epidemiol

PMID

27465112

Title

Canadian Acute Respiratory Illness and Flu Scale (CARIFS) for clinical detection of influenza in children.

Year of Publication

2014

Number of Pages

1174-80

Date Published

2014 Oct

ISSN Number

1938-2707

Abstract

<p><strong>BACKGROUND: </strong>Validated clinical scales, such as the Canadian Acute Respiratory Illness and Flu Scale (CARIFS), have not been used to differentiate influenza (FLU) from other respiratory viruses.</p>

<p><strong>METHODS: </strong>Secondary analysis of a prospective cohort presenting to the emergency department (ED) with an influenza-like infection from 2008 to 2010. Subjects were children aged 0 to 19 years who had a venipuncture and respiratory virus polymerase chain reaction. Demographics and CARIFS items were assessed during the ED visit; comparisons were made between FLU and non-FLU subjects.</p>

<p><strong>RESULTS: </strong>The 203 subjects had median age 30.5 months; 61.6% were male. Comorbid conditions (51.2%) were common. FLU was identified in 26.6%, and were older than non-FLU patients (69.7 vs 47.9 months, P = .02). Demographic, household factors, and mean CARIFS score did not differ between FLU (33.7), and non-FLU (32.0) (mean difference 1.6, 95% CI: -2.0 to 5.2) groups.</p>

<p><strong>CONCLUSIONS: </strong>CARIFS cannot discriminate between FLU and non-FLU infection in ED children with influenza-like infection.</p>

DOI

10.1177/0009922814542608

Alternate Title

Clin Pediatr (Phila)

PMID

25009116

Title

Severe complications in influenza-like illnesses.

Year of Publication

2014

Number of Pages

e684-90

Date Published

2014 Sep

ISSN Number

1098-4275

Abstract

<p><strong>OBJECTIVE: </strong>Data on complications from upper respiratory infection are limited. We examined development of severe complications in children presenting to the emergency department (ED) for moderate to severe influenza-like illness (ILI).</p>

<p><strong>METHODS: </strong>Prospective cohort study of children 0 to 19 years presenting to a tertiary care children's hospital ED during peak respiratory viral seasons from 2008 to 2010. Subjects included had moderate to severe ILI, defined by performance of venipuncture and nasopharyngeal multiplex polymerase chain reaction for respiratory viruses. Severe complications (respiratory failure, encephalopathy, seizures, pneumonia, bacteremia, death) were prospectively determined. Risk factors for severe complications were collected, including demographics, comorbidities, and household exposures.</p>

<p><strong>RESULTS: </strong>There were 241 enrolled subjects with median age of 27.4 months (interquartile range 8.9-68.5); 59.3% were boys and 48.5% were black. High-risk conditions were present in 53.5%. Severe complications developed in 35.3% (95% confidence interval [CI] 29.3-41.3), most frequently pneumonia (26.1%). The risk for severe complications was increased in subjects with neurologic or neuromuscular conditions (relative risk 4.0; 95% CI 1.9-8.2). No specific respiratory virus was associated with development of severe complications. Among patients with influenza, severe complications were greater with subtype H1N1 infection (relative risk 1.45, 95% CI 0.99-2.13, P = .048), and were at highest risk for pneumonia (relative risk 4.2, 95% CI 1.2-15.9).</p>

<p><strong>CONCLUSION: </strong>In children presenting to the ED for moderate to severe ILI, those with neurologic and neuromuscular disease are at increased risk for severe complications. Development of severe complications did not differ by infecting virus; however, risk of severe complications was greater with subtype H1N1 compared with other influenza.</p>

DOI

10.1542/peds.2014-0505

Alternate Title

Pediatrics

PMID

25092942

Title

Clinical management of skin and soft tissue infections in the U.S. Emergency Departments.

Year of Publication

2014

Number of Pages

491-8

Date Published

2014 Jul

ISSN Number

1936-900X

Abstract

<p><strong>INTRODUCTION: </strong>Community-associated methicillin resistant Staphylococcus aureus (CA-MRSA) has emerged as the most common cause of skin and soft-tissue infections (SSTI) in the United States. A nearly three-fold increase in SSTI visit rates had been documented in the nation's emergency departments (ED). The objective of this study was to determine characteristics associated with ED performance of incision and drainage (I+D) and use of adjuvant antibiotics in the management of skin and soft tissue infections (SSTI).</p>

<p><strong>METHODS: </strong>Cross-sectional study of the National Hospital Ambulatory Medical Care Survey, a nationally representative database of ED visits from 2007-09. Demographics, rates of I+D, and adjuvant antibiotic therapy were described. We used multivariable regression to identify factors independently associated with use of I+D and adjuvant antibiotics.</p>

<p><strong>RESULTS: </strong>An estimated 6.8 million (95% CI: 5.9-7.8) ED visits for SSTI were derived from 1,806 sampled visits; 17% were for children &lt;18 years of age and most visits were in the South (49%). I+D was performed in 27% (95% CI 24-31) of visits, and was less common in subjects &lt;18 years compared to adults 19-49 years (p&lt;0.001), and more common in the South. Antibiotics were prescribed for 85% of SSTI; there was no relationship to performance of I+D (p=0.72). MRSA-active agents were more frequently prescribed after I+D compared to non-drained lesions (70% versus 56%, p&lt;0.001). After multivariable adjustment, I+D was associated with presentation in the South (OR 2.36; 95% CI 1.52-3.65 compared with Northeast), followed by West (OR 2.13; 1.31-3.45), and Midwest (OR 1.96; 1.96-3.22).</p>

<p><strong>CONCLUSION: </strong>Clinical management of most SSTIs in the U.S. involves adjuvant antibiotics, regardless of I+D. Although not necessarily indicated, CA-MRSA effective therapy is being used for drained SSTI.</p>

DOI

10.5811/westjem.2014.4.20583

Alternate Title

West J Emerg Med

PMID

25035757

Title

Practices, Beliefs, and Perceived Barriers to Adolescent Human Immunodeficiency Virus Screening in the Emergency Department.

Year of Publication

2015

Number of Pages

621-6

Date Published

2015 Sep

ISSN Number

1535-1815

Abstract

<p><strong>OBJECTIVE: </strong>Limited data exist regarding knowledge of and compliance to the Centers for Disease Control and Prevention's universal adolescent human immunodeficiency virus (HIV) screening recommendations. Our objective was to assess current guideline knowledge, practice, and perceived barriers to emergency department (ED)-based adolescent HIV screening.</p>

<p><strong>METHODS: </strong>We administered an anonymous Web-based cross-sectional survey from May 1, 2012, to June 30, 2012, to 1073 physicians from the American Academy of Pediatrics Section on Emergency Medicine LISTSERV. Survey participants were included if they (1) practiced as attending-level physicians, (2) practiced primarily in pediatric emergency medicine or general emergency medicine, and (3) provided clinical care for patients younger than the age of 21 years. The survey examined respondent demographics, knowledge, attitudes, beliefs, practices, and barriers to ED-based HIV screening. Standard descriptive statistics and comparative analyses were performed.</p>

<p><strong>RESULTS: </strong>A total of 220 responses were obtained; 29 responses were excluded and 191 responses were included in the study. Most of the participants were from urban, free-standing children's hospitals and had an annual ED volume of more than 61,000 patient visits. Respondent knowledge of the Centers for Disease Control and Prevention guidelines was low; less than 40% of the respondents identified correct consent requirements. Only 15.4% of the respondents reported screening for HIV more than 10 times for the prior 6 months. Most frequently cited barriers included concerns for privacy (67.4%), follow-up (67%), and cost-effectiveness (65.4%). Human immunodeficiency virus screening facilitators included availability of health educators (83%), established follow-up (74.7%), and rapid HIV tests (65.2%).</p>

<p><strong>CONCLUSIONS: </strong>Emergency department clinicians exhibit poor knowledge of adolescent HIV screening recommendations. Current universal screening practices remain low; barriers to screening are numerous. Future efforts should disseminate guideline knowledge, increase rapid HIV testing and health educator availability, as well as reduce adolescent-specific barriers.</p>

DOI

10.1097/PEC.0000000000000370

Alternate Title

Pediatr Emerg Care

PMID

25834965

Title

Risk factors for recurrent colonization with methicillin-resistant Staphylococcus aureus in community-dwelling adults and children.

Year of Publication

2015

Number of Pages

786-93

Date Published

07/2015

ISSN Number

1559-6834

Abstract

<p>OBJECTIVE To identify risk factors for recurrent methicillin-resistant Staphylococcus aureus (MRSA) colonization. DESIGN Prospective cohort study conducted from January 1, 2010, through December 31, 2012. SETTING Five adult and pediatric academic medical centers. PARTICIPANTS Subjects (ie, index cases) who presented with acute community-onset MRSA skin and soft-tissue infection. METHODS Index cases and all household members performed self-sampling for MRSA colonization every 2 weeks for 6 months. Clearance of colonization was defined as 2 consecutive sampling periods with negative surveillance cultures. Recurrent colonization was defined as any positive MRSA surveillance culture after clearance. Index cases with recurrent MRSA colonization were compared with those without recurrence on the basis of antibiotic exposure, household demographic characteristics, and presence of MRSA colonization in household members. RESULTS The study cohort comprised 195 index cases; recurrent MRSA colonization occurred in 85 (43.6%). Median time to recurrence was 53 days (interquartile range, 36-84 days). Treatment with clindamycin was associated with lower risk of recurrence (odds ratio, 0.52; 95% CI, 0.29-0.93). Higher percentage of household members younger than 18 was associated with increased risk of recurrence (odds ratio, 1.01; 95% CI, 1.00-1.02). The association between MRSA colonization in household members and recurrent colonization in index cases did not reach statistical significance in primary analyses. CONCLUSION A large proportion of patients initially presenting with MRSA skin and soft-tissue infection will have recurrent colonization after clearance. The reduced rate of recurrent colonization associated with clindamycin may indicate a unique role for this antibiotic in the treatment of such infection.</p>

DOI

10.1017/ice.2015.76

Alternate Title

Infect Control Hosp Epidemiol

PMID

25869756

Title

Duration of Colonization and Determinants of Earlier Clearance of Colonization With Methicillin-Resistant Staphylococcus aureus.

Year of Publication

2015

Number of Pages

1489-96

Date Published

05/2015

ISSN Number

1537-6591

Abstract

<p><strong>BACKGROUND: </strong>The duration of colonization and factors associated with clearance of methicillin-resistant Staphylococcus aureus (MRSA) after community-onset MRSA skin and soft-tissue infection (SSTI) remain unclear.</p>

<p><strong>METHODS: </strong>We conducted a prospective cohort study of patients with acute MRSA SSTI presenting to 5 adult and pediatric academic hospitals from 1 January 2010 through 31 December 2012. Index patients and household members performed self-sampling for MRSA colonization every 2 weeks for 6 months. Clearance of colonization was defined as negative MRSA surveillance cultures during 2 consecutive sampling periods. A Cox proportional hazards regression model was developed to identify determinants of clearance of colonization.</p>

<p><strong>RESULTS: </strong>Two hundred forty-three index patients were included. The median duration of MRSA colonization after SSTI diagnosis was 21 days (95% confidence interval [CI], 19-24), and 19.8% never cleared colonization. Treatment of the SSTI with clindamycin was associated with earlier clearance (hazard ratio [HR], 1.72; 95% CI, 1.28-2.30; P &lt; .001). Older age (HR, 0.99; 95% CI, .98-1.00; P = .01) was associated with longer duration of colonization. There was a borderline significant association between increased number of household members colonized with MRSA and later clearance of colonization in the index patient (HR, 0.85; 95% CI, .71-1.01; P = .06).</p>

<p><strong>CONCLUSIONS: </strong>With a systematic, regular sampling protocol, duration of MRSA colonization was noted to be shorter than previously reported, although 19.8% of patients remained colonized at 6 months. The association between clindamycin and shorter duration of colonization after MRSA SSTI suggests a possible role for the antibiotic selected for treatment of MRSA infection.</p>

DOI

10.1093/cid/civ075

Alternate Title

Clin. Infect. Dis.

PMID

25648237

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