Showing posts with label infectious disease. Show all posts
Showing posts with label infectious disease. Show all posts

Monday, December 8, 2014

Antimicrobial Stewardship Programs: Are They Making a Difference?





We certainly know the dangers of antibiotic overuse and want to be good stewards of our antibacterial medications—especially if the odds point in the direction of a viral etiology for a child’s symptoms. Yet despite our ability to talk the talk, do we walk the walk when it comes to being good stewards of antimicrobial agents?
 

Some hospitals, to further enhance the prudent usage of antimicrobials, have instituted stewardship programs to reduce and improve antibiotic prescribing. Do these programs work?

Hersh et al. (doi:10.1542/peds.2014-2579) looked at a group of children’s hospitals with formalized antibiotic stewardship programs (ASPs) compared to hospitals without such programs and looked at antibiotic prescribing over time in those hospitals. The results are not a bitter pill to swallow but are, instead, quite promising. This is especially true for those hospitals administering certain subsets of antibiotics, including vancomycin, carbapenems, and linezolid, that both did and did not follow stewardship guidelines.

So are these stewardship programs worth the investment? Infectious disease specialist Dr. Will Mason and colleagues dose out their thoughts on this issue in an accompanying commentary also being released this week.

Does your hospital offer a stewardship program? If so, do you think it has helped reduce the frequency of usage of antibiotics? If not, why? Feel free to share your thoughts on antibiotic stewardship by posting a response to this blog, sending us an e-letter or over on Facebook or Twitter.

Related Reading:

Tuesday, November 25, 2014

The Pneumococcal Vaccine: Rates of Pneumonia and Sinusitis Before, After Implementation

By: Lewis First, MD, MS; Editor-in-Chief 
Sneeze photo by Anna Gutermuth via Flickr

I don’t think many of us would argue with the benefits of the pneumococcal vaccine in reducing rates of pneumococcal bacteremia and sepsis—but what about other manifestations of this infection—i.e. pneumonia and sinusitis?

Lindstrand et al. (doi: 10.1542/peds.2013-4177) performed a population-based study in Sweden of all hospitalizations pre- and post-introduction of the pneumococcal vaccines (PCV 7 and PCV 13) to look at hospitalizations for these two disorders. Their results are dramatic (in a very positive sense)!

If you had any doubt as to the effectiveness of immunizing against pneumococcus, this study being early released this week will do a “doubt-ectomy”—and hopefully not just for health care professionals but for families who may be less convinced about the need to vaccinate their children.

The study makes some sharp points about the reduction in hospitalizations that can be attributed to the administration of this vaccine—but read it for yourself and see what I mean.

Wednesday, November 19, 2014

The Duration of Nasal Shedding by Rhinovirus—What It Is and I(s-not)!

By: Lewis First, MD, MS; Editor-in-Chief 

Human rhinovirus-14. Photo by US Dept. of Energy.
Parents often tell us that their young child’s nose is always running. We like to say that if a child’s feet smell and her nose runs—it probably means she is upside down. But since this situation is unusual, the more common reason for rhinorrhea is a viral upper respiratory infection often caused by a strain of rhinovirus.

So just how long does rhinovirus hang around in a child’s nose? Or is it possible that children get different strains of rhinovirus mimicking a long-lasting strain?

Loeffelholz et al. (doi: 10.1542/peds. 2014-2132) set out to perform a longitudinal study of infants in their first year of life by collecting monthly nasopharyngeal samples as well as additional samples when upper respiratory infections occurred. They then ran the samples via reverse-transcription polymerase chain reaction (PCR) to look at nucleotide sequences for the strain of rhinovirus detected.

Researchers studies over 2,000 specimens from approximately 350 babies. What is most remarkable is that they identified more than 300 different rhinovirus infections involving upwards of 175 strains. Fewer than 10 infectious events represented prolonged infection more than 30 days long (i.e. found in two sequential monthly samples).

Before you start working up your patients for an immune dysfunction because their upper respiratory symptoms seem persistent, read this article. It may enable you to focus more on good URI preventive strategies of hand-washing, avoidance of second hand smoke exposure, and coughing and sneezing into an elbow rather than a hand—as time better spent than ordering a myriad of tests and cultures reflecting the spread of viral infections in otherwise healthy hosts.

The information in this article may be well worth sharing with families to avert the need for further laboratory testing and unnecessary use of antibiotics—but don’t take my word for it, you can be in the know (or in the nose) yourself if you give this study some attention.

Related Reading: 

Tuesday, November 18, 2014

Otitis Media and Antibiotic Selection: Does Race Play a Role in What Drug Is Chosen?

By: Lewis First, MD, MS; Editor-in-Chief 

Photo by Eden, Janine, and Jim via Flickr
Although the AAP’s guidelines on otitis media (OM) (doi:10.1542/peds.2012-3488) frown on automatic usage of antibiotics given the high incidence of viral infections for this disorder, there are circumstances in which an antibiotic is indicated. Though the guidelines make clear recommendations on what drug to use as first line for antibiotic treatment of otitis, variations in frequency of diagnosing otitis as well as in antimicrobial treatment regimen used do exist.

To gain a better understanding of these variations and their significance, Fleming-Dutra et al. (doi: 10.1542/peds.2014-1781) used national survey data to examine OM visits between black and non-black children and then compared amoxicillin prescription with broader spectrum antibiotic use, also by race, to determine if race was an independent factor in antibiotic selection.

While the number of OM visits per 1,000 children seen in the outpatient setting were not different in terms of race, the choice of antibiotics in this study revealed that black children were receiving amoxicillin more than broad-spectrum antimicrobials compared to white children, even when controlling for confounders in a multivariate analysis.

So what does this mean? Given the dangers of antibiotic overuse, are we providing better care to black children by limiting their antibiotics to amoxicillin, or are we discriminating against them by not offering broad-spectrum agents that we give to non-black patients?

There are many questions raised by this study and to help answer them, we have called upon infectious disease expert and one of our associate editors Dr. Charles Woods and his colleague Dr. Faye Jones (doi:10.1542/peds.2014-3056) to provide an important commentary to accompany this thought-provoking article.

Both the article and commentary are worth hearing about, and better yet reading about—so please do so and share your thoughts on the findings by responding to this blog, or via an eLetter, or commenting on Facebook or Twitter.

Related Reading:

Wednesday, November 12, 2014

Infant Neurodevelopment After Congenital HHV-6 Infection

By: Lewis First, MD, MS; Editor-in-Chief 

HHV-6 Inclusion bodies. Photo via the US National Cancer Institute
While we usually think of human herpesvirus 6 (HHV-6) as being the virus responsible for roseola, there is much more to this virus than a simple viral exanthem. About 1 percent of infants are born with vertical transmission of HHV-6 and when this happens, the results are far more worrisome than just being at risk for a viral exanthem.

Dr. Mary Caserta and her colleagues in Rochester (doi: 10.1542/peds. 2014-0886) have been actively studying congenital HHV-6 and this month release their findings on early developmental outcomes of children who have received the virus through vertical transmission from mother to baby. The authors performed developmental testing in a prospective double-blind controlled study at four points between 4 months and 30 months of age.

The results suggest that by 1 year old, some detrimental effects on neurodevelopment can be seen in those infants infected congenitally with HHV-6 compared to controls.

Have you thought about HHV-6 as a cause for developmental delay in your patients? After reading this study, you will want to learn more about what this virus can potentially do if it is present at the time of birth. We suspect more studies will be forthcoming at a faster rate given what we are learning about this virus—and if you haven’t read much about it, this is a great study to start with. Check out the study and learn more!

Related Reading:

Thursday, October 30, 2014

For Treating Empyema, Which Is Better—Urokinase Drainage or Video-Assisted Thoracoscopy?

By: Lewis First, MD, MS; Editor-in-Chief 

Video-assisted thoracoscopy.
Image by Cancer Research UK  via Wikimedia Commons.
Every once in a while we have a patient who develops a parapneumonic effusion of pus (otherwise known as an empyema) as a complication of an acute bacterial pneumonia. When this happens, treatment might involve a chest tube and when that fails, the use of thoracoscopy.

Recently however, the addition of urokinase to enzymatically break apart the empyema has been suggested to make the chest-tube drainage method more effective—but is it as effective as video-assisted thoracoscopy (VATS)?

Marhuenda et al. (doi:10.1542/peds.2013-3935) approached this question by performing a prospective randomized multicenter clinical trial in children younger than 15 years old with empyema that required intervention.

The results indicate that urokinase plus drainage may be just as effective as VATS, but if you want to see for yourself, scope out this study and discuss it with your local pediatric surgeons to see if they agree the two treatments are similar. Be sure to share what you learn with us by leaving a comment here on the blog, sharing an eLetter on our journal’s website or visiting us on Facebook or Twitter.

Related Reading:

Wednesday, October 1, 2014

Healthcare-Associated Infections in Critically Ill Children

Pediatrics Editorial Board Member Joann Schulte, DO, MPH, shares her expert perspective on a new article from our October issue. To learn more about Dr. Schulte, check out her bio on our Contributors page.

By: Joann Schulte, DO, MPH

Photo by daveynin via Flickr
Nosocomial infections have been bad news since the days of Ignaz Philipp Semmelweis who proved that washing hands drastically reduced the incidence of puerperal fever in mid-19th-century hospitals.

He has modern day counterparts in the infection control practitioners and hospital epidemiologists who combat healthcare-associated infections (HAIs) in US hospitals. There’s some good news about HAIs among children who got care in neonatal ICUs (NICUs) and pediatric ICUs (PICUs) documented in the October issue of Pediatrics (doi: 10.1542/peds.2014-0613).

A cohort study done with data reported to the US Centers for Disease Control and Prevention found the incidence rates of central-line associated blood infections and ventilator-associated pneumonia declined during a 5-year period between 2007 and 2012. The study examined data from 173 NICUs and 64 PICUs. Infections associated with central lines in NICUs declined from 4.9 to 1.5 per 1,000 central-line days and from 4.7 to 1.0 per 1,000 central line days in PICUs. Rates of pneumonia declined in NICUs from 1.6 to 0.6 per 1,000 ventilator days and in PICUs from 1.9 to 0.7 per 1,000 ventilator days. Rates of urinary tract infections associated with catheters did not change significantly in PICUs.

The team of investigators, led by Dr. Stephen Patrick at Vanderbilt University, used a time-series design to evaluate the changes in HAIs among hospitalized neonates and children. The investigators estimated the reduction in infections associated with central lines saved $131 million. The physicians and researchers who are the intellectual descendants of Semmelweis have done important work.  

Monday, September 29, 2014

If You See One Emergency Department Approach to Febrile Infants, You See Only One of Many Approaches

By: Lewis First, MD, MS; Editor-in-Chief 
Photo by Joseph Nicola via Flickr

Nothing provokes more discussion in a clinical conference than asking, “What is the best way to diagnose and manage febrile infants when you don’t want to miss a serious bacterial infection?” Do all infants under 3-months-old need a full sepsis evaluation, some, none over a month, or is the approach solely dependent on immunization status of the child, family or community?

While algorithms and guidelines exist as to best practice based on evidence to date, what really happens in emergency departments when these children are evaluated?

Aronson et al. (doi: 10.1542/peds.2014-1382) share with us the results of a retrospective cohort of more than 17,000 infants seen in 37 different emergency departments (EDs) to look at patient and hospital level variation in diagnostic testing, treatment and disposition. The variations across EDs and patients is stark and worth your attention. If there was ever a need for a well-circulated, evidence-based common approach to these young infants and their fevers, this study certainly calls for one.

So what do you do with your febrile babies under 3 months of age? Do you follow a care pathway or guideline? If so, which one? Share with us your thoughts on your approach to febrile infants seen in emergency departments or your office by sending us your comments to this blog, via an eLetter, or on Facebook or Twitter.

Related Reading:

Monday, September 22, 2014

Two Pertussis Vaccine Studies Shed More Light on Benefits vs. Risks

By: Lewis First, MD, MS; Editor-in-Chief 
Photo via the National Institute for Health

It seems that no matter how many studies we publish on the advantages of vaccinating children against pertussis with the Tdap vaccine, some families ask for even more evidence—so this week, we provide two studies to add to the published benefits of this vaccine.

The first by Quinn et al. (doi:10.1542/peds.2014-1105) focuses on the benefits of “cocooning”, the process of vaccinating close adult contacts of newborn infants against pertussis during a pertussis epidemic in Australia. This was especially effective if parents were vaccinated pre-pregnancy.

The second by Vogt et al. (doi:10.1542/peds.2014-0723) debunks the belief that pertussis immunization in infancy may increase the chances of developing asthma by adolescence as measured by asthma medication use in adolescence. Again, the data convincingly shows no association between pertussis vaccine administered in 1993-1994 and asthma medication prescribed for the study cohort of more than 80,000 children 2008-2010.

If you are looking for two nice studies to further provide vaccine-hesitant parents of your patients with added reassurance that their infant should receive this important vaccine (and parents should get a booster if they haven’t gotten one recently), then take a deep breath. The findings these two studies cough up should help you make your case.

Related Reading: