<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>

<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>

<p>Rates of invasive candidiasis (IC) in children between 2003 and 2011 were evaluated in a retrospective cross-sectional analysis. The rate of IC decreased 72% (P &lt; .001) overall and 91% in neonates (P &lt; .001). Improving infection control efforts is thought to be a contributing factor for this decrease.</p>

<p>This 13-year retrospective study investigated risk factors for candidemia secondary to Candida species with increased likelihood of fluconazole resistance. Of 344 candidemia cases, 23 were caused by C glabrata or C krusei (CGCK). Age &gt;2 years, recent fluconazole exposure, and recent surgery were independent risk factors for CGCK.</p>

<p>Among 254 patients with candidemia who had a dilated retinal examination, 8 patients (3.2%) were diagnosed with ocular disease resulting in retinal detachment in 2 patients and globe rupture in 1 patient. This study found that ocular candidiasis is an uncommon but serious sight-threatening complication in pediatric patients with candidemia.</p>

<p><strong>BACKGROUND: </strong>Outpatient respiratory tract infections are the most common reason for antibiotic prescribing to children. Although prior studies suggest that antibiotic overuse occurs, patient-specific data or data exploring the variability and determinants of variability across practices and practitioners is lacking.</p>

<p><strong>METHODS: </strong>This study was conducted from a retrospective cohort of encounters to 25 diverse pediatric practices with 222 clinicians, from January 1 to December 31, 2009. Diagnoses, medications, comorbid conditions, antibiotic allergy, and demographic data were obtained from a shared electronic health record and validated by manual review. Practice-specific antibiotic prescription and acute respiratory tract infection diagnosis rates were calculated to assess across-practice differences after adjusting for patient demographics and clustering of encounters within clinicians.</p>

<p><strong>RESULTS: </strong>A total of 102 102 (28%) of 399 793 acute visits by 208 015 patients resulted in antibiotic prescriptions. After adjusting for patient age, sex, race, and insurance type, and excluding encounters by patients with chronic conditions, antibiotic prescribing by practice ranged from 18% to 36% of acute visits, and the proportion of antibiotic prescriptions that were broad-spectrum ranged from 15% to 58% across practices, despite additional exclusion of patients with antibiotic allergies or prior antibiotic use. Diagnosis of (Dx) and broad-spectrum antibiotic prescribing (Broad) for acute otitis media (Dx: 8%-20%; Broad: 18%-60%), sinusitis (Dx: 0.5%-9%; Broad: 12%-78%), Streptococcal pharyngitis (Dx: 1.8%-6.4%; Broad: 2%-30%), and pneumonia (Dx: 0.4%-2%; Broad: 1%-70%) also varied by practice (P &lt; 0.001 for all comparisons).</p>

<p><strong>CONCLUSIONS: </strong>Antibiotic prescribing for common pediatric infections varied substantially across practices. This variability could not be explained by patient-specific factors. These data suggest the need for and provide high-impact targets for outpatient antimicrobial stewardship interventions.</p>

<p><strong>AIM: </strong>Determine predictors of support of a mandatory seasonal influenza vaccine program among health care workers (HCWs).</p>

<p><strong>SCOPE: </strong>Cross-sectional anonymous survey of 2443 (out of 8093) randomly selected clinical and non-clinical HCWs at a large pediatric network after implementation of a mandatory vaccination program in 2009-10.</p>

<p><strong>RESULTS: </strong>1388 HCWs (58.2%) completed the survey and 75.2% of respondents reported agreeing with the new mandatory policy. Most respondents (72%) believed that the policy was coercive but &gt;90% agreed that the policy was important for protecting patients and staff and was part of professional ethical responsibility. When we adjusted for attitudes and beliefs regarding influenza and the mandate, there was no significant difference between clinical and nonclinical staff in their support of the mandate (OR 1.08, 95% C.I. 0.94, 1.26).</p>

<p><strong>CONCLUSIONS: </strong>Attitudes and beliefs regarding influenza and the mandate may transcend professional role. Targeted outreach activities can capitalize on beliefs regarding patient protection and ethical responsibility.</p>

<p><strong>BACKGROUND: </strong>Variation in medical practice has identified opportunities for quality improvement in patient care. The degree of variation in the use of antibiotics in children's hospitals is unknown.</p>

<p><strong>METHODS: </strong>We conducted a retrospective cohort study of 556,692 consecutive pediatric inpatient discharges from 40 freestanding children's hospitals between January 1, 2008, and December 31, 2008. We used the Pediatric Health Information System to acquire data on antibiotic use and clinical diagnoses.</p>

<p><strong>RESULTS: </strong>Overall, 60% of the children received at least 1 antibiotic agent during their hospitalization, including &gt;90% of patients who had surgery, underwent central venous catheter placement, had prolonged ventilation, or remained in the hospital for &gt;14 days. Even after adjustment for both hospital- and patient-level demographic and clinical characteristics, antibiotic use varied substantially across hospitals, including both the proportion of children exposed to antibiotics (38%-72%) and the number of days children received antibiotics (368-601 antibiotic-days per 1000 patient-days). In general, hospitals that used more antibiotics also used a higher proportion of broad-spectrum antibiotics.</p>

<p><strong>CONCLUSIONS: </strong>Children's hospitals vary substantially in their use of antibiotics to a degree unexplained by patient- or hospital-level factors typically associated with the need for antibiotic therapy, which reveals an opportunity to improve the use of these drugs.</p>

<p><strong>OBJECTIVE: </strong>To compare practice patterns regarding the diagnosis and management of streptococcal pharyngitis across pediatric primary care practices.</p>

<p><strong>DESIGN: </strong>Retrospective cohort study.</p>

<p><strong>SETTING: </strong>All encounters to 25 pediatric primary care practices sharing an electronic health record.</p>

<p><strong>METHODS: </strong>Streptococcal pharyngitis was defined by an International Classification of Diseases, Ninth Revision code for acute pharyngitis, positive laboratory test, antibiotic prescription, and absence of an alternative bacterial infection. Logistic regression models standardizing for patient-level characteristics were used to compare diagnosis, testing, and broad-spectrum antibiotic treatment for children with pharyngitis across practices. Fixed-effects models and likelihood ratio tests were conducted to analyze within-practice variation.</p>

<p><strong>RESULTS: </strong>Of 399,793 acute encounters in 1 calendar year, there were 52,658 diagnoses of acute pharyngitis, including 12,445 diagnoses of streptococcal pharyngitis. After excluding encounters by patients with chronic conditions and standardizing for age, sex, insurance type, and race, there was significant variability across and within practices in the diagnosis and testing for streptococcal pharyngitis. Excluding patients with antibiotic allergies or prior antibiotic use, off-guideline antibiotic prescribing for confirmed group A streptococcal pharyngitis ranged from 1% to 33% across practices (P &lt; .001). At the clinician level, 13 of 25 sites demonstrated significant within-practice variability in off-guideline antibiotic prescribing (P ≤ .05). Only 18 of the 222 clinicians in the network accounted for half of all off-guideline antibiotic prescribing.</p>

<p><strong>CONCLUSIONS: </strong>Significant variability in the diagnosis and treatment of pharyngitis exists across and within pediatric practices, which cannot be explained by relevant clinical or demographic factors. Our data support clinician-targeted interventions to improve adherence to prescribing guidelines for this common condition.</p>