Theoklis E Zaoutis

The Children's Hospital of Philadelphia, Filadelfia, Pennsylvania, United States

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Publications (232)855.11 Total impact

  • [Show abstract] [Hide abstract]
    ABSTRACT: Frontline clinicians caring for hospitalized children typically knew the indication for antimicrobial therapy but less often knew the current day or planned duration of therapy or of plans for intravenous to oral conversion. Night shift clinicians were less likely to know day of therapy and duration of therapy than day shift clinicians caring for the same patients.
    05/2015; DOI:10.1093/jpids/piv026
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    ABSTRACT: The objectives of this study were to provide a nationally representative analysis of antibiotic prescribing in outpatient paediatrics and to assess overall and class-specific antibiotic costs in Greece. Data on antibiotic prescriptions for patients aged ≤19 years old between July 2010 and June 2013 in Greece were extracted from the IMS Health Xponent database. Antibiotics were grouped into narrow- and broad-spectrum agents. The number of prescribed antibiotics and census denominators were used to calculate prescribing rates. The total costs associated with prescribed antibiotics were calculated. More than 7 million antibiotics were prescribed during the study period, with an annual rate of 1100 antibiotics/1000 persons. Prescribing rates were higher among children aged <10 years old. Acute respiratory tract infections (ARTIs) accounted for 80% of prescribed antibiotics, with acute otitis media (22.3%), acute tonsillitis (19.5%) and acute bronchitis/bronchiolitis (13.9%) being the most common clinical diagnoses. Cephalosporins (32.9%), penicillins (32.3%) and macrolides (32.1%) were the most commonly prescribed antibiotic classes. The majority (90.4%) of antibiotics were broad spectrum. Antibiotic expenditures totalled ∼€50 million. Broad-spectrum antibiotic prescribing is common in outpatient paediatric patients. These data provide important targets to inform the development of an outpatient antimicrobial stewardship programme targeting specific practices, providers and conditions. © The Author 2015. Published by Oxford University Press on behalf of the British Society for Antimicrobial Chemotherapy. All rights reserved. For Permissions, please e-mail: journals.permissions@oup.com.
    Journal of Antimicrobial Chemotherapy 04/2015; DOI:10.1093/jac/dkv091 · 5.44 Impact Factor
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    ABSTRACT: 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. Infect. Control Hosp. Epidemiol. 2015;00(0):1-8.
    Infection Control and Hospital Epidemiology 04/2015; DOI:10.1017/ice.2015.76 · 3.94 Impact Factor
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    ABSTRACT: The use of ventricular assist devices has increased dramatically in adult heart failure patients. However, the overall use, outcome, comorbidities, and resource utilization of ventricular assist devices in pediatric patients have not been well described. We sought to demonstrate that the use of ventricular assist devices in pediatric patients has increased over time and that mortality has decreased. A retrospective study of the Pediatric Health Information System database was performed for patients 20 years old or younger undergoing ventricular assist device placement from 2000 to 2010. None. Four hundred seventy-five pediatric patients were implanted with ventricular assist devices during the study period: 69 in 2000-2003 (era 1), 135 in 2004-2006 (era 2), and 271 in 2007-2010 (era 3). Median age at ventricular assist device implantation was 6.0 years (interquartile range, 0.5-13.8), and the proportion of children who were 1-12 years old increased from 29% in era 1 to 47% in era 3 (p = 0.002). The majority of patients had a diagnosis of cardiomyopathy; this increased from 52% in era 1 to 72% in era 3 (p = 0.003). Comorbidities included arrhythmias (48%), pulmonary hypertension (16%), acute renal failure (34%), cerebrovascular disease (28%), and sepsis/systemic inflammatory response syndrome (34%). Two hundred forty-seven patients (52%) underwent heart transplantation and 327 (69%) survived to hospital discharge. Hospital mortality decreased from 42% in era 1 to 25% in era 3 (p = 0.004). Median hospital length of stay increased (37 d [interquartile range, 12-64 d] in era 1 vs 69 d [interquartile range, 35-130] in era 3; p < 0.001) and median adjusted hospital charges increased ($630,630 [interquartile range, $227,052-$853,318] in era 1 vs $1,577,983 [interquartile range, $874,463-$2,280,435] in era 3; p < 0.001). Factors associated with increased mortality include age less than 1 year (odds ratio, 2.04; 95% CI, 1.01-3.83), acute renal failure (odds ratio, 2.1; 95% CI, 1.26-3.65), cerebrovascular disease (odds ratio, 2.1; 95% CI, 1.25-3.62), and extracorporeal membrane oxygenation (odds ratio, 3.16; 95% CI, 1.79-5.60). Ventricular assist device placement in era 3 (odds ratio, 0.3; 95% CI, 0.15-0.57) and a diagnosis of cardiomyopathy (odds ratio, 0.5; 95% CI, 0.32-0.84), were associated with decreased mortality. Large-volume centers had lower mortality (odds ratio, 0.55; 95% CI, 0.34-0.88), lower use of extracorporeal membrane oxygenation, and higher charges. The use of ventricular assist devices and survival after ventricular assist device placement in pediatric patients have increased over time, with a concomitant increase in resource utilization. Age under 1 year, certain noncardiac morbidities, and the use of extracorporeal membrane oxygenation are associated with worse outcomes. Lower mortality was seen at larger volume ventricular assist device centers.
    Pediatric Critical Care Medicine 04/2015; DOI:10.1097/PCC.0000000000000401 · 2.33 Impact Factor
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    ABSTRACT: Objectives The objectives were to estimate the frequency of pregnancy testing in emergency department (ED) visits by reproductive-aged women administered or prescribed teratogenic medications (Food and Drug Administration categories D or X) and to determine factors associated with nonreceipt of a pregnancy test.Methods This was a retrospective cross-sectional study using 2005 through 2009 National Hospital Ambulatory Medical Care Survey data of ED visits by females ages 14 to 40 years. The number of visits was estimated where teratogenic medications were administered or prescribed and pregnancy testing was not conducted. The association of demographic and clinical factors with nonreceipt of pregnancy testing was assessed using multivariable logistic regression.ResultsOf 39,859 sampled visits, representing an estimated 141.0 million ED visits by reproductive-aged females nationwide, 10.1 million (95% confidence interval [CI] = 8.9 to 11.3 million) estimated visits were associated with administration or prescription of teratogenic medications. Of these, 22.0% (95% CI = 19.8% to 24.2%) underwent pregnancy testing. The most frequent teratogenic medications administered without pregnancy testing were benzodiazepines (52.2%; 95% CI = 31.1% to 72.7%), antibiotics (10.7%; 95% CI = 5.0% to 16.3%), and antiepileptics (7.7%; 95% CI = 0.12% to 15.5%). The most common diagnoses associated with teratogenic drug prescription without pregnancy testing were psychiatric (16.1%; 95% CI = 13.6% to 18.6%), musculoskeletal (12.7%; 95% CI = 10.8% to 14.5%), and cardiac (9.5%; 95% CI = 7.6% to 11.3%). In multivariable analyses, visits by older (adjusted odds ratio [AOR] = 0.57, 95% CI = 0.42 to 0.79), non-Hispanic white females (AOR = 0.71; 95% CI = 0.54 to 0.93); visits in the Northeast region (AOR = 0.60; 95% CI = 0.42 to 0.86); and visits during which teratogenic medications were administered in the ED only (AOR = 0.74; 95% CI = 0.57 to 0.97) compared to prescribed at discharge only were less likely to have pregnancy testing.ConclusionsA minority of ED visits by reproductive-aged women included pregnancy testing when patients were prescribed category D or X medications. Interventions are needed to ensure that pregnancy testing occurs before women are prescribed potentially teratogenic medications, as a preventable cause of infant morbidity.
    Academic Emergency Medicine 01/2015; 22(2). DOI:10.1111/acem.12578 · 2.20 Impact Factor
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    ABSTRACT: The prevalence of high-MIC fluoroquinolone-susceptible Escherichia coli (FQSEC) has been increasing. These isolates are one step closer to full fluoroquinolone (FQ) resistance and may lead to delayed response to FQ therapy. Our study aimed to investigate the epidemiology of high-MIC FQSEC in ambulatory urinary tract infections (UTIs). A case-control study was conducted at outpatient services within the University of Pennsylvania Health System, Philadelphia. All female subjects with non-recurrent UTI caused by FQSEC (levofloxacin MIC < 4 mg/L) were enrolled. Cases were subjects with high-MIC FQSEC UTI (levofloxacin MIC >0.12 but < 4 mg/L) and controls were subjects with low-MIC FQSEC UTI (levofloxacin MIC ≤0.12 mg/L). Data on microbiology results and baseline characteristics were extracted from electronic medical records. During the 3 year study period (May 2008-April 2011), 11 287 episodes of E. coli bacteriuria were identified. The prevalence of FQSEC, FQ-intermediate susceptible E. coli and FQ-resistant E. coli was 75.0%, 0.4% and 24.6%, respectively. A total of 2001 female subjects with FQSEC UTI were enrolled into our study (165 cases and 1836 controls). Independent risk factors for high-MIC FQ susceptibility included Asian race (OR = 2.92; 95% CI = 1.29-6.58; P = 0.02), underlying renal disease (OR = 2.18; 95% CI = 1.15-4.14; P = 0.02) and previous nitrofurantoin exposure (OR = 8.86; 95% CI = 1.95-40.29; P = 0.005). Asian race, underlying renal disease and previous exposure to nitrofurantoin were identified as independent risk factors for high-MIC FQSEC. There may be some factors that are more common in Asians, which may result in the selection of high-MIC FQSEC. Further studies are necessary to explore these findings. © The Author 2015. Published by Oxford University Press on behalf of the British Society for Antimicrobial Chemotherapy. All rights reserved. For Permissions, please e-mail: journals.permissions@oup.com.
    Journal of Antimicrobial Chemotherapy 01/2015; 70(5). DOI:10.1093/jac/dku548 · 5.44 Impact Factor
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    ABSTRACT: Antimicrobial stewardship is pivotal to improving patient outcomes, reducing adverse events, decreasing healthcare costs, and preventing further emergence of antimicrobial resistance. In an era in which antimicrobial resistance is increasing, judicious antimicrobial use is the responsibility of every healthcare provider. While antimicrobial stewardship programs (ASPs) have made headway in improving antimicrobial prescribing using such "top-down" methods as formulary restriction and prospective audit with feedback, engagement of prescribers has not been fully explored. Strategies that include frontline prescribers and other unit-based healthcare providers have the potential to expand stewardship, both to augment existing centralized ASPs and to provide alternative approaches to perform stewardship at healthcare facilities with limited resources. This review discusses interventions focusing on antimicrobial prescribing at the point of prescription as well as a pilot project to engage unit-based healthcare providers in antimicrobial stewardship. © The Author 2015. Published by Oxford University Press on behalf of the Infectious Diseases Society of America. All rights reserved. For Permissions, please e-mail: journals.permissions@oup.com.
    Clinical Infectious Diseases 01/2015; 60(8). DOI:10.1093/cid/civ018 · 9.42 Impact Factor
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    ABSTRACT: The objective of this study was to describe the diagnostic yield and complication rate of bronchoalveolar lavage (BAL) and lung biopsy in the evaluation of pulmonary lesions in patients with cancer and recipients of hematopoietic stem-cell transplantation (HSCT). We conducted a systematic literature review and performed electronic searches of Ovid MEDLINE, EMBASE, and Cochrane Central Register of Controlled Trials. Studies were included if patients had cancer or were recipients of HSCT, and if they underwent BAL or lung biopsy for the evaluation of pulmonary lesions. Only English language publications were included. In all, 14,148 studies were screened; 72 studies of BAL and 31 of lung biopsy were included. The proportion of procedures leading to any diagnosis was similar by procedure type (0.53 v 0.54; P = .94) but an infectious diagnosis was more common with BAL compared with lung biopsy (0.49 v 0.34; P < .001). Lung biopsy more commonly led to a noninfectious diagnosis (0.43 v 0.07; P < .001) and was more likely to change how the patient was managed (0.48 v 0.31; P = .002) compared with BAL. However, complications were more common with lung biopsy (0.15 v 0.08; P = .006), and procedure-related mortality was four-fold higher for lung biopsy (0.0078) compared with BAL (0.0018). BAL may be the preferred diagnostic modality for the evaluation of potentially infectious pulmonary lesions because of lower complication and mortality rates; thus, choice of procedure depends on clinical suspicion of infection. Guidelines to promote consistency in the approach to the evaluation of lung infiltrates may improve clinical care of patients. © 2015 by American Society of Clinical Oncology.
    Journal of Clinical Oncology 01/2015; 33(5). DOI:10.1200/JCO.2014.58.0480 · 17.88 Impact Factor
  • 01/2015; DOI:10.1093/jpids/piv024
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    ABSTRACT: Early diagnosis and initiation of amphotericin B (AmB) for treatment of mucormycosis increases survival from approximately 40% to 80%. The central objective of a new study of the European Confederation of Medical Mycology (ECMM) and the International Society for Human and Animal Mycology (ISHAM) Zygomycosis Working Group is to improve the clinical and laboratory diagnosis of mucormycosis. The diagnostic tools generated from this study may help to significantly improve survival from mucormycosis worldwide. The study has three major objectives: to conduct a prospective international registration of patients with mucormycosis using a well-established global network of centres; to construct a predictive risk model for patients at risk for mucormycosis; and to establish an international archive of specimens of tissues, fluids, and organisms linked from the patients enrolled into the registry that will be used for development of leading edge molecular, proteomic, metabolic and antigenic systems for mucormycosis. © 2014 Blackwell Verlag GmbH.
    Mycoses 12/2014; 57 Suppl 3:2-7. DOI:10.1111/myc.12249 · 1.81 Impact Factor
  • Infection Control and Hospital Epidemiology 11/2014; 35(11):1425-7. DOI:10.1086/678411 · 3.94 Impact Factor
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    ABSTRACT: Value-based health care is a proposed driver for reimbursement under the Affordable Care Act, with value broadly defined as outcomes divided by cost. Data on value-based health care in pediatric heart failure are scarce. A retrospective analysis of the Healthcare Cost and Utilization Project Kids' Inpatient Database and Nationwide Inpatient Sample was performed for pediatric and adult cardiomyopathy and heart failure related hospitalizations. The study included 5,689 pediatric and 473, 416 adult hospitalizations. Pediatric cardiomyopathy and heart failure hospitalizations were significantly longer than adult hospitalizations (mean ± standard error 16.2 ± 0.7 vs 6.8 ± 0.1 days, p< 0.001). Overall mortality was greater for pediatric hospitalizations (7.7% vs 5.6%, p< 0.001), though it decreased over time for both pediatric and adult hospitalizations. Charges were greater for pediatric hospitalizations, both overall ($116,483 ± $5,735 vs $40,662 ± $1,419, p < 0.001) and for all years evaluated. In a value-based model, pediatric cardiomyopathy and heart failure related hospitalizations are associated with worse outcomes and greater charges compared to adult hospitalizations. More research is needed to understand the cost effectiveness of pediatric heart failure treatment and to reduce the burden on the health care system. Copyright © 2014 Elsevier Inc. All rights reserved.
    Journal of Cardiac Failure 10/2014; DOI:10.1016/j.cardfail.2014.10.011 · 3.07 Impact Factor
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    ABSTRACT: Background: Patient-level review of adult clinical trial data concluded that echinocandin therapy for treatment of candidemia was associated with a decreased mortality rate. Limited data are available comparing options for systemic antifungal therapy in children. We compared the effectiveness of fungicidal versus fungistatic agents as definitive therapy for pediatric candidemia on 30-day all-cause mortality. Methods: All pediatric inpatients (> 6 months and <19 years of age) diagnosed with candidemia between 2000 and 2012 at the Children’s Hospital of Philadelphia were retrospectively identified. Clinical and laboratory data were abstracted using a structured data collection tool. Candidemic patients were included in the final data analysis if they received the same antifungal agent for two consecutive days following candidemia onset. Amphotericin products and echinocandins were categorized as fungicidal and fluconazole as fungistatic. A propensity score model was used to generate inverse probability weights for receiving a fungicidal agent. These inverse weights were included in a weighted logistic regression model to compare 30-day mortality in fungicidal versus fungistatic recipients. Results: Among 203 children with candidemia that received the same antifungal agent for two consecutive days after culture was known positive, 151 (74.4%) received either amphotericin (n = 134) or caspofungin (n = 17) and 52 (25.6%) received fluconazole. Overall, 18 (8.9%) patients died within 30 days. In the weighted logistic regression model there was no statistically significant difference in mortality between patients that started on a fungicidal agent as compared to fungistatic therapy (OR: 2.19, 95% CI: 0.42 to 11.48). Conclusion: In a propensity score weighted model, initiation of definitive therapy with a fungicidal agent did not result in a significant decrease in 30-day mortality. These data suggest that both fungicidal and fungistatic agents can be considered as definitive therapy for pediatric candidemia. The results should be interpreted with caution given the small sample size and resultant wide confidence intervals. Larger pediatric cohort studies are needed to further compare antifungal therapeutic options and outcomes.
    IDWeek 2014 Meeting of the Infectious Diseases Society of America; 10/2014
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    ABSTRACT: Background: In January 2011, an electronic health record (EHR) based auto-stop feature, facilitated by mandatory antimicrobial order end dates, was enabled at our institution as part of an established Antimicrobial Stewardship Program (ASP). Previously, restricted antimicrobial orders remained as current medications in the EHR after the ASP-approved length of therapy (typically 48 hours) was complete. However another approval was required for the pharmacy to dispense more medication. Following the auto-stop implementation, the order expired from the current medications list after completion of the approved length of therapy. Methods: Repeated cross-sectional study to assess the impact of auto-stop on clinical outcomes of hospitalized children. Data on patients discharged between 2/1/2009 and 1/31/13 were obtained from the Pediatric Health Information System, a database containing medication billing data. A sub-cohort of patients with bacteremia was also identified using microbiology laboratory data. Outcomes included all-cause in-hospital mortality, readmission within 14-days and 30 days of discharge, and length of stay. Model-based pre-post comparisons were standardized by patient and clinical characteristics and accounted for clustering by physician. Results: During the 4-year study period, 26300 patients received restricted antibacterials. In-hospital all-cause mortality, 14-day and 30-day readmission, and length of stay were not significantly different before and after implementation of the auto-stop in all patients or the sub-cohort of children with bacteremia (Table). Conclusion: Implementation of an EHR-based antimicrobial auto-stop feature did not significantly impact clinical outcomes in hospitalized children. Future studies should examine the effects of this EHR-based tool on antimicrobial use. Table. Standardized clinical outcomes for patients receiving restricted antibiotics All Patients (n=26300) Bacteremia Patients (n=1405) Pre Post p-value Pre Post p-value Standardized Rate (%) In-hospital all-cause mortality 2.0 1.9 0.358 8.0 6.8 0.315 Readmission in 14 days 7.4 7.5 0.778 6.2 4.8 0.294 Readmission in 30 days 15.4 16.4 0.057 17.4 17.2 0.947 Standardized Length of Stay (days) 11.7 12.0 0.183 44.7 47.6 0.350
    IDWeek 2014 Meeting of the Infectious Diseases Society of America; 10/2014
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    ABSTRACT: Background: Colonization with methicillin-resistant Staphylococcus aureus(MRSA) is associated with development of recurrent skin and soft tissue infections (SSTI). Several decolonization strategies have been used to try to decrease the burden of MRSA colonization, but these have not been shown to decrease recurrent SSTI, perhaps related to transmission of MRSA colonization between household members. Methods: We conducted a three-arm non-blinded randomized controlled trial from November 1, 2011 to May 31, 2013 at five academic medical centers. Adults and children presenting to ambulatory care settings with acute community-onset MRSA SSTI (i.e. index cases), along with their household members, were eligible. Enrolled households were randomized to one of three intervention groups: 1) education on routine hygiene measures; 2) education plus unsupervised decolonization with intra-nasal mupirocin ointment and chlorhexidine gluconate body wash; 3) education plus supervised decolonization (i.e. daily phone call or text message reminders). The primary endpoint was time to termination of colonization in the index case. The decolonization arms were combined in the primary analysis. Intention to treat and per-protocol analyses were performed. Results: One hundred sixty-eight households were enrolled. Fifty-seven households were randomized to education alone, 54 to decolonization without supervision and 57 to supervised decolonization. Intention-to-treat analysis showed no significant difference in time to termination of colonization between the education-only and decolonization groups (log-rank test p-value=0.57). In per-protocol analysis, at least 50% compliance with the decolonization protocol was associated with more rapid clearance of colonization as compared to the group that included those with less than 50% compliance to decolonization or who received education alone (p=0.02). Conclusion: Households that were at least 50% compliant with an intra-nasal mupirocin and chlorhexidine body wash decolonization protocol achieved more rapid clearance of MRSA colonization. Further studies need to determine the threshold of compliance necessary to affect clinical outcomes and potential ways to improve compliance.
    IDWeek 2014 Meeting of the Infectious Diseases Society of America; 10/2014
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    ABSTRACT: Background: Candidemia is associated with significant morbidity and mortality and pediatric intensive care unit (PICU) patients with candidemia are at particular high risk for death. A clinical prediction rule for early detection of candidemia in the PICU was previously derived at a single center. Multi-center validation is necessary prior to routine application. Methods: Patients <19 years of age with candidemia were identified prospectively from six pediatric institutions (1/1/2005 - 12/31/2009). Cases were matched to two controls in the same PICU by incidence density sampling. Conditional logistic regression was performed to evaluate the association of candidemia with the previously derived predictor variables. Results: Ninety-six patients with candidemia were identified with a median age of 4 years (range 43 days to 18 years) and matched to similar controls. The proportion of predictors of candidemia for cases and controls varied significantly by study site (table) and only the presence of a central venous catheter was associated with candidemia (OR: 9.6; 95% CI: 3.4-27.3). Conclusion: Our multi-center study did not validate the previously derived prediction rule due to significant variability in predictors across hospitals and time. Consideration should be given to including biomarkers in future prediction rules.
    IDWeek 2014 Meeting of the Infectious Diseases Society of America; 10/2014
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    ABSTRACT: Background: Candidemia causes significant morbidity and mortality among hospitalized children. Prompt removal of a central venous catheter (CVC) is often recommended for adults with candidemia to decrease the likelihood of persistent and metastatic infection, but pediatric specific data are limited. We investigated the association of CVC retention and 30-day all cause mortality in a pediatric specific cohort. Methods: We performed a retrospective cohort study of inpatients (age 0 to <19 years) with candidemia at the Children’s Hospital of Philadelphia between 2000 and 2012 who had survived and retained their CVC at least one day beyond the blood culture being positive for yeast. A structured data collection instrument was used to retrieve clinical and laboratory data. A discrete time failure model was used to assess the association of CVC retention and 30-day all cause mortality. CVC exposure was not considered until the day after the culture was known to be positive for a Candida species. We adjusted for age and the complexity of clinical care prior to onset of candidemia. Complexity of clinical care included recent exposure to immune suppressive agents, recent requirement for parenteral nutrition, and admission to the ICU at time of blood culture. Results: Of the 436 incident cases of candidemia, 289 (64%) had a CVC in place at the time of blood culture and survived at least one day after candidemia onset. Among these 289 patients, 30 (10%) died within 30 days of candidemia diagnosis. CVC retention was significantly associated with an increased risk of death on a given day (OR: 2.53, 95% CI: 1.07 to 5.98). Conclusion: Retention of a CVC was associated with an increased risk of death after adjusting for age and complexity of care at candidemia onset. These results need to be interpreted with caution, as there is likely persistence of unmeasured confounding. However, given the negative association between catheter retention and death, our data suggest that early CVC removal should be strongly considered in pediatric patients with candidemia.
    IDWeek 2014 Meeting of the Infectious Diseases Society of America; 10/2014
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    ABSTRACT: Background: We completed a successful outpatient antimicrobial stewardship intervention combining education with prescribing audit and feedback across a large, pediatric primary care network. The intervention significantly reduced broad-spectrum antibiotic prescribing in intervention sites relative to controls. To assess durability of this intervention, we followed antibiotic prescribing across intervention and control sites for 18 months after termination of clinician audit and feedback. Methods: We conducted a cluster-randomized trial of outpatient antimicrobial stewardship within 18 community-based pediatric primary care practices using a common EHR. The intervention included clinician education with audit and feedback of antibiotic prescribing to children with sinusitis, streptococcal pharyngitis, and pneumonia. The primary outcome was broad-spectrum (off-guideline) antibiotic prescribing. Twelve months after initiating the intervention, we stopped providing antibiotic prescribing audit and feedback to providers in the intervention arm and extended our observation period for 18 months. Using a piecewise generalized linear model with knots at month 0 (intervention start) and 12 (end of audit and feedback), we modeled the trajectory of the log odds of prescribing between treatment and control practices standardized for patient-level covariates. Results: There were 1,259,938 office visits by 185,868 unique patients to 180 clinicians at 18 practices during the 50-month study period. During the 12-month intervention, the overall proportion of antibiotic prescriptions that were broad-spectrum decreased from 26.8% to 14.3% in the intervention group and from 28.4% to 22.6% in control practices, which was a statistically significant difference in trajectories between groups (p=0.01). Following termination of audit and feedback, however, broad-spectrum antibiotic prescribing reverted to near baseline levels for both the intervention group (28%) and control group (30%) (Figure). Conclusion: The initial benefits of an outpatient antimicrobial stewardship intervention were reversed after discontinuation of audit and feedback of clinician prescribing.
    JAMA The Journal of the American Medical Association 10/2014; DOI:10.1001/jama.2014.14042 · 30.39 Impact Factor
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    ABSTRACT: Background: Factors associated with duration of methicillin-resistant Staphylococcus aureus (MRSA) colonization in the community setting are unknown. The objective of this study was to assess the duration of MRSA colonization and factors associated with termination of colonization among subjects presenting with MRSA acute skin and soft tissue infection (SSTI). Methods: A prospective cohort study was conducted from January 1, 2010 through December 31, 2012 at five academic medical centers. Patients presenting with acute SSTI (i.e. index cases) and their household members were followed with serial surveillance cultures for MRSA colonization every two weeks for six months. Duration of colonization was calculated using a Kaplan-Meier estimate. A Cox proportional hazards regression model was developed to identify factors associated with termination of colonization with MRSA. Results: Median duration of MRSA colonization among index cases was 36 days (inter-quartile range [IQR] 21-91 days). Fifty-three index cases (19.4%) remained colonized with MRSA at the end of the study period. Factors associated with more rapid termination of MRSA colonization included: treatment of the MRSA SSTI with clindamycin (adjusted hazard ratio (HR), 1.55; 95% confidence interval (CI), 1.16-2.07; P=0.003) and non-white race (HR, 1.43; 95% CI, 1.08-1.89; P=0.01). Neither presence of family members under the age of 18 nor MRSA colonization in household members at study entry were associated with duration of MRSA colonization (HR, 1.17; 95% CI, 0.87-1.56; P=0.30 and HR, 0.91 95% CI, 0.74-1.10; P=0.33, respectively). Conclusion: Among individuals with an acute MRSA SSTI, duration of colonization with MRSA was shorter than has been reported in other studies, due perhaps to a more systematic sampling approach; however, approximately 20% of subjects remained colonized at the end of six months. The association between clindamycin and shorter duration of MRSA colonization may indicate a unique role for this antibiotic in treatment of MRSA SSTI. Interestingly, presence of colonization in a household member was not significantly associated with duration of colonization. Future studies of household decolonization should look at the impact of this on duration of colonization in the index case.
    IDWeek 2014 Meeting of the Infectious Diseases Society of America; 10/2014
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    ABSTRACT: Background: In adult liver transplant recipients, candidemia is of significant concern in the post transplant period. Prophylaxis is recommended in adult high-risk patients, such as those with prolonged operative time, retransplantation or high-volume transfusion requirement. There are limited data on the incidence of candidemia in pediatric liver transplant recipients. We aimed to describe the incidence of candidemia in the 30 days post-liver transplant and frequency of perioperative antifungal therapy at a large pediatric institution. Methods: All liver transplant patients from 2000 to 2011 at the Children’s Hospital of Philadelphia were retrospectively reviewed. Data on perioperative antifungal therapy and blood culture results were collected. Patients were followed for 30 days post-transplant to evaluate for the onset of candidemia. Results: 134 patients underwent liver transplantation over the 12-year study period. Candidemia was diagnosed in the first 30 days post transplant in 10 (7.1%) patients. Rates of candidemia varied with each three-year period with the lowest rate being in the last three years of the study (Table). Perioperative antifungal therapy was infrequently used. Rates increased between the periods of 2000 to 2002 and 2003 to 2005 but then remained stable (Table). Conclusion: The incidence of candidemia among pediatric liver transplant patients appears to have decreased over time in this single center cohort. The overall rate of perioperative antifungal therapy remained low and did not increase in accordance with the decrease in candidemia. Further investigation in multicenter cohorts is warranted to determine sources for decreasing candidemia rates such as improved infection control practices and operating room factors. Table. Rates of candidemia and perioperative antifungal therapy by 3 year time periods Liver transplant patients Candidemia (n, %) Perioperative antifungal therapy (n, %) 2000-02 30 2, 6.7% 2, 6.7% 2003-05 24 4, 16.6% 3, 12.5% 2006-08 35 3, 8.6% 4, 11.4% 2009-11 45 1, 2.2% 5, 11.1% Total 134 10, 7.4% 14, 10.4%
    IDWeek 2014 Meeting of the Infectious Diseases Society of America; 10/2014

Publication Stats

6k Citations
855.11 Total Impact Points

Institutions

  • 2003–2015
    • The Children's Hospital of Philadelphia
      • • Division of Infectious Diseases
      • • Department of Pediatrics
      • • Division of General Pediatrics
      Filadelfia, Pennsylvania, United States
    • University of Pennsylvania
      • • Center for Clinical Epidemiology and Biostatistics
      • • Division of Infectious Disease
      • • Center for Therapeutic Effectiveness Research
      Filadelfia, Pennsylvania, United States
  • 2014
    • Harokopion University of Athens
      Athínai, Attica, Greece
  • 2012
    • Wayne State University
      • Department of Pharmacy Practice
      Detroit, Michigan, United States
    • Seattle Children's Hospital
      • Division of Infectious Diseases
      Seattle, Washington, United States
  • 2007–2012
    • Aristotle University of Thessaloniki
      • Department of Pediatrics II
      Saloníki, Central Macedonia, Greece
  • 2003–2012
    • William Penn University
      Filadelfia, Pennsylvania, United States
  • 2009
    • University of Washington Seattle
      Seattle, Washington, United States
    • SickKids
      • Division of Hematology/Oncology
      Toronto, Ontario, Canada
  • 2008
    • National Cancer Institute (USA)
      • Pediatric Oncology Branch
      Maryland, United States
  • 2006
    • University of Arkansas at Little Rock
      Little Rock, Arkansas, United States