Theoklis E Zaoutis

University of Pennsylvania, Filadelfia, Pennsylvania, United States

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Publications (246)936.04 Total impact

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    ABSTRACT: The purpose of this statement is to reaffirm the American Academy of Pediatrics' support for a mandatory influenza immunization policy for all health care personnel. With an increasing number of organizations requiring influenza vaccination, coverage among health care personnel has risen to 75% in the 2013 to 2014 influenza season but still remains below the Healthy People 2020 objective of 90%. Mandatory influenza immunization for all health care personnel is ethical, just, and necessary to improve patient safety. It is a crucial step in efforts to reduce health care-associated influenza infections.
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    ABSTRACT: Objective: To assess the availability and source of guidelines for common infections in European paediatric hospitals and determine their content and characteristics. Design: Participating hospitals completed an online questionnaire on the availability and characteristics of antibiotic prescribing guidelines and on empirical antibiotic treatment including duration of therapy for 5 common infection syndromes: respiratory tract, urinary tract, skin and soft tissue, osteoarticular and sepsis in neonates and children. Results: 84 hospitals from 19 European countries participated in the survey of which 74 confirmed the existence of guidelines. Complete guidelines (existing guidelines for all requested infection syndromes) were reported by 20% of hospitals and the majority (71%) used a range of different sources. Guidelines most commonly available were those for urinary tract infection (UTI) (74%), neonatal sepsis (71%) and sepsis in children (65%). Penicillin and amoxicillin were the antibiotics most commonly recommended for respiratory tract infections (RTIs) (up to 76%), cephalosporin for UTI (up to 50%) and for skin and soft tissue infection (SSTI) and bone infection (20% and 30%, respectively). Antistaphylococcal penicillins were recommended for SSTIs and bone infections in 43% and 36%, respectively. Recommendations for neonatal sepsis included 20 different antibiotic combinations. Duration of therapy guidelines was mostly available for RTI and UTI (82%). A third of hospitals with guidelines for sepsis provided recommendations for length of therapy. Conclusions: Comprehensive antibiotic guideline recommendations are generally lacking from European paediatric hospitals. We documented multiple antibiotics and combinations for most infections. Considerable improvement in the quality of guidelines and their evidence base is required, linking empirical therapy to resistance rates.
    Archives of Disease in Childhood 09/2015; DOI:10.1136/archdischild-2015-308255 · 2.90 Impact Factor
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    ABSTRACT: Background Surgical site infection (SSI) prevention for children with congenital heart disease is imperative and methods to assess and evaluate the tissue concentrations of prophylactic antibiotics are important to help maximize these efforts.AimThe purposes of this study were to determine the plasma and tissue concentrations with standard of care, perioperative cefazolin dosing in an immature porcine model of pediatric cardiac surgery, and to determine the feasibility of this model.Methods Piglets (3–5 days old) underwent either median sternotomy (MS) or cardiopulmonary bypass with deep hypothermic circulatory arrest (CPB + DHCA) and received standard of care prophylactic cefazolin for the procedures. Serial plasma and microdialysis sampling of the skeletal muscle and subcutaneous tissue adjacent to the surgical site was performed. Cefazolin concentrations were measured, noncompartmental pharmacokinetic analyses were performed, and tissue penetration of cefazolin was assessed.ResultsFollowing the first intravenous dose, maximal cefazolin concentrations in the subcutaneous tissue and skeletal muscle were similar between groups with peak tissue concentrations 15–30 min after administration. After the second cefazolin dose given with the initiation of CPB, total plasma cefazolin concentrations remained relatively constant until the end of DHCA and then decreased while muscle- and subcutaneous-unbound cefazolin concentrations showed a second peak during or after rewarming. For the MS group, 60–67% of the intraoperative time showed subcutaneous and skeletal muscle concentrations of cefazolin >16 μg·ml−1 while this percentage was 78–79% for the CPB + DHCA group. There was less tissue penetration of cefazolin in the group that underwent CBP + DHCA (P = 0.03).Conclusions The cefazolin dosing used in this study achieves plasma and tissue concentrations that should be effective against methicillin-sensitive Staphylococcus aureus but may not be effective against some gram-negative pathogens. The timing of the cefazolin administration prior to incision and a second dose given during cardiopulmonary bypass may be important factors for achieving goal tissue concentrations.
    Pediatric Anesthesia 09/2015; 25(11). DOI:10.1111/pan.12756 · 1.85 Impact Factor
  • Neika Vendetti · Theoklis Zaoutis · Susan E Coffin · Julia Shaklee Sammons ·
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    ABSTRACT: OBJECTIVE The incidence of Clostridium difficile infection (CDI) has increased and has been associated with poor outcomes among hospitalized children, including increased risk of death. The purpose of this study was to identify risk factors for all-cause in-hospital mortality among children with CDI. METHODS A multicenter cohort of children with CDI, aged 1-18 years, was established among children hospitalized at 41 freestanding children's hospitals between January 1, 2006 and August 31, 2011. Children with CDI were identified using a validated case-finding tool (ICD-9-CM code for CDI plus C. difficile test charge). Only the first CDI-related hospitalization during the study period was used. Risk factors for all-cause in-hospital mortality within 30 days of C. difficile test were evaluated using a multivariable logistic regression model. RESULTS We identified 7,318 children with CDI during the study period. The median age of this cohort was 6 years [interquartile range (IQR): 2-13]; the mortality rate was 1.5% (n=109); and the median number of days between C. difficile testing and death was 12 (IQR, 7-20). Independent risk factors for death included older age [adjusted odds ratio (OR, 95% confidence interval), 2.29 (1.40-3.77)], underlying malignancy [3.57 (2.36-5.40)], cardiovascular disease [2.06 (1.28-3.30)], hematologic/immunologic condition [1.89 (1.05-3.39)], gastric acid suppression [2.70 (1.43-5.08)], and presence of >1 severity of illness marker [3.88 (2.44-6.19)]. CONCLUSION Patients with select chronic conditions and more severe disease are at increased risk of death. Identifying risk factors for in-hospital mortality can help detect subpopulations of children that may benefit from targeted CDI prevention and treatment strategies. Infect Control Hosp Epidemiol 2015;00(0):1-7.
    Infection Control and Hospital Epidemiology 07/2015; -1:1-7. DOI:10.1017/ice.2015.152 · 4.18 Impact Factor
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    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: We attempted to validate a previously derived clinical prediction rule for candidemia in the pediatric intensive care unit. This multicenter case control study did not identify significant association of candidemia with most of the previously identified predictors. Additional study in larger cohorts with other predictor variables is needed.
    04/2015; DOI:10.1093/jpids/piv024
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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:
    Journal of Antimicrobial Chemotherapy 04/2015; 70(8). DOI:10.1093/jac/dkv091 · 5.31 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; 36(07):1-8. DOI:10.1017/ice.2015.76 · 4.18 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; Publish Ahead of Print(6). DOI:10.1097/PCC.0000000000000401 · 2.34 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 · 2.01 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:
    Journal of Antimicrobial Chemotherapy 01/2015; 70(5). DOI:10.1093/jac/dku548 · 5.31 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:
    Clinical Infectious Diseases 01/2015; 60(8). DOI:10.1093/cid/civ018 · 8.89 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 · 18.43 Impact Factor
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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(s3):2-7. DOI:10.1111/myc.12249 · 2.24 Impact Factor
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    ABSTRACT: The purpose of this statement is to update recommendations for routine use of seasonal influenza vaccine and antiviral medications for the prevention and treatment of influenza in children. The American Academy of Pediatrics recommends annual seasonal influenza immunization for all people 6 months and older, including all children and adolescents. Highlights for the upcoming 2014-2015 season include the following: 1. The influenza vaccine composition for the 2014-2015 season is unchanged from the 2013-2014 season. 2. Both trivalent and quadrivalent influenza vaccines are available in the United States for the 2014-2015 season. 3. Annual universal influenza immunization is indicated with either a trivalent or quadrivalent vaccine (no preference). 4. Live attenuated influenza vaccine (LAIV) should be considered for healthy children 2 through 8 years of age who have no contraindications or precautions to the intranasal vaccine. If LAIV is not readily available, inactivated influenza vaccine (IIV) should be used; vaccination should not be delayed to obtain LAIV. 5. The dosing algorithm for administration of influenza vaccine to children 6 months through 8 years of age reflects that virus strains in the vaccine have not changed from last season. As always, pediatricians, nurses, and all other health care personnel should be immunized themselves and should promote influenza vaccine use and infection control measures. In addition, pediatricians should promptly identify clinical influenza infections to enable rapid antiviral treatment, when indicated, to reduce morbidity and mortality.
    Pediatrics 11/2014; 134(5):E1503-E1519. DOI:10.1542/peds.2014-2413 · 5.47 Impact Factor

  • Infection Control and Hospital Epidemiology 11/2014; 35(11):1425-7. DOI:10.1086/678411 · 4.18 Impact Factor
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    ABSTRACT: Background 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.
    10/2014; 4(4). DOI:10.1093/jpids/piu086
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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; 21(1). DOI:10.1016/j.cardfail.2014.10.011 · 3.05 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
  • hael Ross · Talene A. Metjian · Jonathan Beus · Theoklis Zaoutis ·
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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

Publication Stats

7k Citations
936.04 Total Impact Points


  • 2006-2015
    • University of Pennsylvania
      • • Center for Clinical Epidemiology and Biostatistics
      • • Division of Infectious Disease
      • • Center for Therapeutic Effectiveness Research
      • • Department of Medicine
      Filadelfia, Pennsylvania, United States
  • 2003-2015
    • The Children's Hospital of Philadelphia
      • • Division of Infectious Diseases
      • • Department of Pediatrics
      • • Division of General Pediatrics
      Filadelfia, Pennsylvania, United States
    • William Penn University
      Filadelfia, Pennsylvania, United States
  • 2014
    • Harokopion University of Athens
      Athínai, Attica, Greece
  • 2012
    • 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
  • 2009
    • SickKids
      • Division of Hematology/Oncology
      Toronto, Ontario, Canada
    • University of Washington Seattle
      Seattle, Washington, United States
  • 1999
    • Thomas Jefferson University
      Philadelphia, Pennsylvania, United States