First name
Sarah
Middle name
B
Last name
Klieger

Title

Multifaceted but Invisible: Perceptions of the Value of a Pediatric Cognitive Specialty.

Year of Publication

2018

Date Published

2018 Jun 26

ISSN Number

2154-1663

Abstract

<p><strong>BACKGROUND: </strong>Systems for standardizing physician payment have been shown to undervalue cognitive clinical encounters. Because health care reform emphasizes value-based approaches, we need an understanding of the way pediatric cognitive specialties are used to contribute to the provision of high-value care. We sought to investigate how clinical and administrative stakeholders perceive the value of pediatric infectious disease (PID) specialists.</p>

<p><strong>METHODS: </strong>We conducted qualitative interviews with a purposive sample of physicians and administrators from 5 hospitals across the United States in which children are cared for. All interviews were transcribed and systematically analyzed for common themes.</p>

<p><strong>RESULTS: </strong>We interviewed 97 stakeholders. Analysis revealed the following 3 domains of value: clinical, organizational, and communicative. Clinically, PID specialists were perceived to be highly valuable in treating patients with unusual infections that respond poorly to therapy, in optimizing the use of antimicrobial agents and in serving as outpatient homes for complex patients. Respondents perceived that PID specialists facilitate communication with patients and their families, the health care team and the media. PID specialists were perceived to generate value by participating in systemwide activities, including antimicrobial stewardship and infection prevention. Despite this, much of the valuable work PID specialists perform is difficult to measure causing some administrative stakeholders to question how many PID specialists are necessary to achieve high-quality care.</p>

<p><strong>CONCLUSIONS: </strong>With our findings, we suggest that pediatric cognitive specialties contribute value in multiple ways to the health care delivery system. Many of these domains are difficult to capture by using current metrics, which may lead administrators to overlook valuable work and to under-allocate resources.</p>

DOI

10.1542/hpeds.2017-0240

Alternate Title

Hosp Pediatr

PMID

29946040

Title

Retrospective review of immunocompromised children undergoing skin biopsy for suspected invasive infection: Analysis of factors predictive of invasive mold.

Year of Publication

2018

Number of Pages

104-11

Date Published

2018 Jan

ISSN Number

1525-1470

Abstract

<p><strong>OBJECTIVES: </strong>Cutaneous lesions are often the first marker of invasive mold infection, which can cause substantial morbidity in immunocompromised children. The purpose of this study was to describe the evaluation and outcomes of immunocompromised children who presented with findings requiring skin biopsy because of concern about invasive infection. In children who were biopsied, we sought to determine the factors predictive of invasive mold infection.</p>

<p><strong>METHODS: </strong>A retrospective review was conducted at the Children's Hospital of Philadelphia. Patients included in the study were immunocompromised individuals younger than 26 years old who underwent skin biopsy by the inpatient dermatology consultation team between January 1, 2003, and March 15, 2015, because of development of new cutaneous lesions that were suspected of being invasive infection.</p>

<p><strong>RESULTS: </strong>One hundred five encounters met the inclusion criteria. Fifty (47.6%) biopsied individuals had an infectious pathogen identified on histopathology or culture. Mold was the most common (36%) pathogen, followed by bacteria (32%) and yeast (26%). The presence of a single lesion (P = .001) and prior occlusion at the site of the lesion (P &lt; .001) were associated with mold on biopsy. The combination of a single lesion, history of occlusion, and tissue necrosis on examination was highly predictive for invasive mold infection (86.3% [95% confidence interval 55.1-97.0%]). Of the 18 individuals with confirmed invasive mold infection, 13 (72%) underwent surgical resection, of whom 12 (92%) survived the 30-day follow-up period.</p>

<p><strong>CONCLUSION: </strong>Skin biopsy enabled the detection of a pathogen that informed directed therapeutic interventions in nearly half of participants. Institutions caring for immunocompromised children should ensure adequate staffing of clinical personnel approved to perform skin biopsies.</p>

DOI

10.1111/pde.13351

Alternate Title

Pediatr Dermatol

PMID

29231258

Title

What Parents Think About the Risks and Benefits of Antibiotics for Their Child's Acute Respiratory Tract Infection.

Year of Publication

2018

Number of Pages

303-309

Date Published

2018 Dec 3

ISSN Number

2048-7207

Abstract

<p><strong>Background: </strong>Parental pressure is often cited as a reason for why pediatricians overuse antibiotics for children with acute respiratory tract infection (ARTI). We sought to capture parent perceptions of antibiotics at the time of their child's presentation with an ARTI.</p>

<p><strong>Methods: </strong>We conducted semistructured interviews with parents of children who presented with ARTI symptoms to 1 of 4 diverse practices in a large hospital-affiliated network of pediatric primary care practices. Parents were interviewed before their child was seen by the pediatrician and asked about their perceptions of antibiotics.</p>

<p><strong>Results: </strong>Interviews were conducted with 109 parents. None of the parents said they planned to ask the pediatrician for antibiotics but instead expected to gain reassurance and a plan to minimize symptoms. Three perceptions about antibiotics were identified: parents have a sense of wariness when their child is prescribed antibiotics, they have an understanding that antibiotic overuse is a problem but that it is driven by the demands of other parents, and they have a preference for alternative treatment. The majority of the parents were not concerned about antibiotic resistance. In response to closed-ended questions designed to assess their level of concern with adverse effects, parents were most concerned with their child developing an upset stomach, having an allergic reaction, and experiencing diarrhea. The parents were not concerned with antibiotic treatment failure.</p>

<p><strong>Conclusions: </strong>Parents in our study expressed a sense of caution about antibiotics and an awareness that they should be used judiciously. Our findings indicate that parents are aware of the downsides of antibiotics and might be willing to partner with healthcare providers to improve appropriate use.</p>

DOI

10.1093/jpids/pix073

Alternate Title

J Pediatric Infect Dis Soc

PMID

28992328

Title

A Case of Adenovirus Viremia in a Pediatric Liver Transplant Recipient With Neutropenia and Lymphopenia: Who and When Should We Treat?

Year of Publication

2015

Number of Pages

e1-5

Date Published

2015 Mar

ISSN Number

2048-7207

Abstract

<p>Human adenovirus (HAdV) is one of the most feared infections among immunocompromised patients. In particular, in liver transplant patients, HAdV has been implicated in acute liver failure with resultant mortality. The development of current molecular techniques and surveillance testing protocols have provided tools for early detection of HAdV infection, prior to or at the early onset of HAdV disease. Although reduction in immune suppression is the mainstay of therapy, many researchers have also advocated for early administration of antiviral therapy. In multiple reports, cidofovir treatment has been associated with declines in HAdV viral loads or clinical improvement in solid organ and bone marrow transplant recipients. However, there have also been case reports that raise questions about the effectiveness of antiviral therapy in controlling systemic HAdV disease. We report a case of a 26-month-old male recipient of a liver transplantation for hepatoblastoma who developed adenoviremia with an associated hepatitis and gastroenteritis. He recovered with reduced immune suppression but without antiviral therapy, thus avoiding potential toxicities associated with cidofovir therapy. This case a contrast to previous reports, and it highlights the ambiguity regarding which patients should receive HAdV-specific antiviral therapy. Additional knowledge regarding specific pediatric host factors and HAdV factors that predict poor outcomes are needed. Such information would allow clinicians to better stratify patients by risk at the time of adenoviremia detection so that low-risk patients are not unnecessarily exposed to medications with potential toxicities.</p>

DOI

10.1093/jpids/pit081

Alternate Title

J Pediatric Infect Dis Soc

PMID

26407369

Title

A Pragmatic Biomarker-Driven Algorithm to Guide Antibiotic Use in the Pediatric Intensive Care Unit: The Optimizing Antibiotic Strategies in Sepsis (OASIS) Study.

Year of Publication

2016

Date Published

2016 May 4

ISSN Number

2048-7207

Abstract

<p><strong>BACKGROUND: </strong>Biomarkers that identify critically ill children with systemic inflammatory response syndrome (SIRS) at low risk for bacterial infection may help clinicians reduce unnecessary antibiotic use.</p>

<p><strong>METHODS: </strong>We conducted a prospective cohort study of children with SIRS and suspected infection admitted to a pediatric intensive care unit from January 5, 2012 to March 7, 2014. We enrolled patients upon initiation of new antibiotics (Time 0) and measured a panel of 8 serum biomarkers daily over 72 hours. Microbiology, imaging, and clinical data were reviewed to classify bacterial infections using Centers for Disease Control and Prevention definitions. We identified cut points of biomarker combinations to maximize the negative predictive value (NPV) and specificity for bacterial infection. Excess antibiotics were calculated as days of therapy beyond day 2 after SIRS onset in patients without bacterial infection.</p>

<p><strong>RESULTS: </strong>Infections were identified in 46 of 85 patients: bacterial (n = 22) and viral (24), whereas 39 patients had no infection identified. At Time 0, C-reactive protein (CRP) &lt;5 mg/dL plus serum amyloid A &lt;15.0 µg/mL had an NPV of 0.92 (95% confidence interval [CI], 0.79-1.0) and specificity of 0.54 (95% CI, 0.42-0.66) to identify patients without bacterial infection, whereas CRP &lt;4 mg/dL plus procalcitonin &lt;1.75 ng/mL had an NPV of 0.90 (95% CI, 0.79-1.0) and specificity of 0.43 (95% CI, 0.30-0.55). Patients without bacterial infection received a mean of 3.8 excess days of therapy.</p>

<p><strong>CONCLUSIONS: </strong>Early measurement of select biomarkers can identify children with SIRS in whom antibiotics might be safely discontinued when there is no other objective evidence of infection at 48 hours.</p>

DOI

10.1093/jpids/piw023

Alternate Title

J Pediatric Infect Dis Soc

PMID

27147715

Title

Invasive candidiasis in liver transplant patients: Incidence and risk factors in a pediatric cohort.

Year of Publication

2016

Number of Pages

235-40

Date Published

2016 Mar

ISSN Number

1399-3046

Abstract

<p>Prolonged OR, re-transplantation, and high-volume intraoperative transfusion have been associated with increased risk for IC in adult LT recipients. Antifungal prophylaxis is recommended for adult patients with these risk factors. There are limited data on the incidence of and risk factors for IC in pediatric LT recipients. A retrospective cohort study of all pediatric LT patients at the CHOP between 2000 and 2012 and the CHP between 2004 and 2012 was performed to define the incidence of IC within 30 days of LT. A 3:1 matched case-control study with incidence density sampling was performed. Conditional logistic regression analyses were used to explore risk factors associated with IC. Among 397 recipients, the incidence of IC was 2.5%. Bivariate analyses showed that ICU admission prior to transplant, OR &gt; 10 h, intraoperative volume infusion of &gt;300 mL/kg, and broad-spectrum antibiotics were significantly associated with IC. In a multivariate model, only ICU admission remained significantly associated with IC. Antifungal prophylaxis was not significantly protective against IC. The low incidence of IC and lack of an identified protective effect from antifungal prophylaxis suggest that prophylaxis in pediatric LT recipients should not be routinely recommended to prevent IC events in the first 30 days post-transplant.</p>

DOI

10.1111/petr.12663

Alternate Title

Pediatr Transplant

PMID

26748472

Title

Central line-associated bloodstream infections in neonates with gastrointestinal conditions: developing a candidate definition for mucosal barrier injury bloodstream infections.

Year of Publication

2014

Number of Pages

1391-9

Date Published

2014 Nov

ISSN Number

1559-6834

Abstract

<p><strong>OBJECTIVE: </strong>To develop a candidate definition for central line-associated bloodstream infection (CLABSI) in neonates with presumed mucosal barrier injury due to gastrointestinal (MBI-GI) conditions and to evaluate epidemiology and microbiology of MBI-GI CLABSI in infants.</p>

<p><strong>DESIGN: </strong>Multicenter retrospective cohort study.</p>

<p><strong>SETTING: </strong>Neonatal intensive care units from 14 US children's hospitals and pediatric facilities.</p>

<p><strong>METHODS: </strong>A multidisciplinary focus group developed a candidate MBI-GI CLABSI definition based on presence of an MBI-GI condition, parenteral nutrition (PN) exposure, and an eligible enteric organism. CLABSI surveillance data from participating hospitals were supplemented by chart review to identify MBI-GI conditions and PN exposure.</p>

<p><strong>RESULTS: </strong>During 2009-2012, 410 CLABSIs occurred in 376 infants. MBI-GI conditions and PN exposure occurred in 149 (40%) and 324 (86%) of these 376 neonates, respectively. The distribution of pathogens was similar among neonates with versus without MBI-GI conditions and PN exposure. Fifty-nine (16%) of the 376 initial CLABSI episodes met the candidate MBI-GI CLABSI definition. Subsequent versus initial CLABSIs were more likely to be caused by an enteric organism (22 of 34 [65%] vs 151 of 376 [40%]; P = .009) and to meet the candidate MBI-GI CLABSI definition (19 of 34 [56%] vs 59 of 376 [16%]; P &lt; .01).</p>

<p><strong>CONCLUSIONS: </strong>While MBI-GI conditions and PN exposure were common, only 16% of initial CLABSIs met the candidate definition of MBI-GI CLABSI. The high proportion of MBI-GI CLABSIs among subsequent infections suggests that infants with MBI-GI CLABSI should be a population targeted for further surveillance and interventional research.</p>

DOI

10.1086/678410

Alternate Title

Infect Control Hosp Epidemiol

PMID

25333434

Title

Reducing catheter-associated urinary tract infections: a quality-improvement initiative.

Year of Publication

2014

Number of Pages

e857-64

Date Published

2014 Sep

ISSN Number

1098-4275

Abstract

<p><strong>BACKGROUND: </strong>Catheter-associated urinary tract infections (CAUTIs) are among the most common health care-associated infections in the United States, yet little is known about the prevention and epidemiology of pediatric CAUTIs.</p>

<p><strong>METHODS: </strong>An observational study was conducted to assess the impact of a CAUTI quality improvement prevention bundle that included institution-wide standardization of and training on urinary catheter insertion and maintenance practices, daily review of catheter necessity, and rapid review of all CAUTIs. Poisson regression was used to determine the impact of the bundle on CAUTI rates. A retrospective cohort study was performed to describe the epidemiology of incident pediatric CAUTIs at a tertiary care children's hospital over a 3-year period (June 2009 to June 2012).</p>

<p><strong>RESULTS: </strong>Implementation of the CAUTI prevention bundle was associated with a 50% reduction in the mean monthly CAUTI rate (95% confidence interval: -1.28 to -0.12; P = .02) from 5.41 to 2.49 per 1000 catheter-days. The median monthly catheter utilization ratio remained unchanged; ∼90% of patients had an indication for urinary catheterization. Forty-four patients experienced 57 CAUTIs over the study period. Most patients with CAUTIs were female (75%), received care in the pediatric or cardiac ICUs (70%), and had at least 1 complex chronic condition (98%). Nearly 90% of patients who developed a CAUTI had a recognized indication for initial catheter placement.</p>

<p><strong>CONCLUSIONS: </strong>CAUTI is a common pediatric health care-associated infection. Implementation of a prevention bundle can significantly reduce CAUTI rates in children.</p>

DOI

10.1542/peds.2013-3470

Alternate Title

Pediatrics

PMID

25113293

Title

Beyond the bundle: a survey of central line-associated bloodstream infection prevention practices used in US and Canadian pediatric hospitals.

Year of Publication

2013

Number of Pages

1208-10

Date Published

2013 Nov

ISSN Number

1559-6834

Abstract

<p>We surveyed US and Canadian pediatric hospitals about their use of central line-associated bloodstream infection (CLABSI) prevention strategies beyond typical insertion and maintenance bundles. We found wide variation in supplemental strategies across hospitals and in their penetration within hospitals. Future studies should assess specific adjunctive prevention strategies and CLABSI rates.</p>

DOI

10.1086/673447

Alternate Title

Infect Control Hosp Epidemiol

PMID

24113607

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