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ABSTRACT: OBJECTIVE: The goals of this study were to evaluate the effectiveness of an inpatient documentation system for identifying missed vaccine opportunities and to identify parental satisfaction with their vaccination services. METHODS: A prospective descriptive study compared inpatient documentation of vaccine history with actual vaccine records, and adherence with the Advisory Committee on Immunization Practices guidelines was assessed. A parental satisfaction survey was administered. RESULTS: One hundred sixty pediatric patients ages 2 months to 17 years (mean age 8 years) were enrolled. Seventy-six percent of patients had documentation of vaccine history, and 92% were documented as receiving all age-appropriate vaccines. Actual immunization records showed that 16% percent of patients were in compliance with Advisory Committee on Immunization Practices guidelines. The most commonly missed vaccine was influenza (67%) followed by meningococcal (57%), hepatitis A (48%), and varicella (38%). Ninety percent of parents were satisfied with the vaccination services their child had received. CONCLUSION: A review of vaccine records is recommended to accurately assess status. Inpatient hospitalization represents an opportunity to assess vaccination status, address parental concerns, and provide updated vaccinations.
Journal of Pediatric Health Care 03/2013; · 1.66 Impact Factor
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New England Journal of Medicine 03/2013; 368(11):1066-7. · 53.30 Impact Factor
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American journal of infection control 08/2012; 40(6):577. · 3.01 Impact Factor
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ABSTRACT: Screening for vancomycin-resistant enterococci (VRE) is controversial, and disagreement exists on policy implementation. This study investigated the likelihood of a positive test using 1, 2, or 3 rectal screenings for VRE colonization. In this descriptive study of positive VRE screening cultures, a total of 1211 VRE screens identified 41 positive results. The mean age of these positive patients was 5.7 years. Thirty-nine of the 41 had a chronic illness, and only 2 were healthy. Diagnoses included pulmonary disease in 11 patients and chronic gastrointestinal abnormality in 7. Six patients had been born preterm, and 12 had been treated in a neonatal intensive care unit within the previous 6 months. Thirty-six of the 41 positive results were identified on the first screen. The likelihood of subsequently having a positive screen after a negative screen was 0.43% (95% confidence interval, 0.15%-1.02%). The cost of cultures plus isolation was $50,000 for the study period. Our data show that the likelihood of detecting a positive VRE culture after an initial negative was low, particularly in otherwise healthy children.
American journal of infection control 03/2012; · 3.01 Impact Factor
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ABSTRACT: We argue that personal belief exemptions to the mandate for childhood immunizations should not be allowed. Parents who choose not to immunize their children put both their own children and other children at risk. Other children are at risk because unimmunized children go to school or day care when they are contagious but asymptomatic, exposing many more children to potentially dangerous infections. The risks to children from disease are much higher than the risks of vaccines. There are, of course, some bona fide reasons why children should not be immunized. Some children have known allergies or other medical contraindications to certain immunizations. Immunization refusals based on parental beliefs, however, do not fall into this category. In those cases, children are denied the protection of immunizations without any medical or scientific justification. By eliminating personal belief exemptions to those childhood vaccines associated with contagious diseases that have high rates of childhood mortality, we would better protect children and would more fairly spread the burdens of this important public health program.
Journal of Health Politics Policy and Law 02/2012; 37(1):131-40. · 0.87 Impact Factor
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ABSTRACT: This report defines the role of Apophysomyces as an aggressive fungal pathogen seen after a tornado injury. Clinical and laboratory manifestations of infections after environmentally contaminated wounds incurred during a tornado are outlined, emphasizing mechanism of injury, comorbidities, and diagnostic and treatment challenges. Therapy with systemic antifungal therapy and aggressive serial tissue debridement was successful in achieving cure.
The Pediatric Infectious Disease Journal 02/2012; 31(6):640-2. · 3.58 Impact Factor
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Pediatrics in Review 12/2011; 32(12):522-32. · 0.55 Impact Factor
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ABSTRACT: The performance of C. Diff Quik Chek Complete (QCC), BD GeneOhm Cdiff PCR (BD), and ProGastro Cd PCR (PG) assays was evaluated in detecting Clostridium difficile infection (CDI) in children using 200 frozen stool specimens. The results of the tests were compared to the toxigenic culture (TC) as 'gold standard.' The sensitivity, specificity, positive predictive value, and negative predictive value were as follows. QCC antigen (GDH + Toxin-A/B) = 70.8%, 97.4%, 89.5%, and 91.4%; BD PCR = 89.6%, 96.7%, 89.6%, and 96.7%; PG PCR = 100%, 93.4%, 82.8%, and 100%. Polymerase chain reaction (PCR) assays detected an additional 11 positives missed by TC, 7 of which were confirmed positive by an alternate tcdB gene PCR assay. However, retrospective clinical chart review indicated CDI in only 3 of the 11 patients in whom C. difficile was detected by PCR only. A 2-step algorithm utilizing QCC antigen test as a screening test followed by confirmation of GDH-positive and toxin-negative samples with either BD or PG PCR assay will provide rapid and accurate results for majority of the samples and reduce laboratory testing cost.
Diagnostic microbiology and infectious disease 09/2011; 71(3):224-9. · 2.45 Impact Factor
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The Pediatric Infectious Disease Journal 06/2011; 30(6):542. · 3.58 Impact Factor
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ABSTRACT: Blood cultures (BCs) are used to diagnose bacteremia in febrile children. False-positive BCs increase costs because of further testing, longer hospital stays, and unnecessary antibiotic therapy. Data from a study at our hospital showed the emergency department consistently exceeded established guidelines of 2% to 4%. A phlebotomy policy change was made whereby BC had to be obtained by a second venipuncture and no longer obtained during insertion of intravenous catheters.
A descriptive study compared preintervention and postintervention blood culture contamination (BCC) rates. A BC was considered contaminated if a single culture grew coagulase-negative staphylococci, diphtheroids, Micrococcus spp, Bacillus spp, or viridans group streptococci. Patients with indwelling central lines or who grew pathogenic bacteria were excluded.
Preintervention BCC was 120 (6.7% [SD, 2.3%]) of 1796. Postintervention BCC was 29 (2.3%, [SD, 0.8]) of 1229 with odds ratio of 2.96 (confidence interval, 1.96-4.57; P = 0.001). The most common contaminant was coagulase-negative staphylococcus, 21 (72%) of 120, followed by viridans streptococcus, 3 (10%) of 29, which was not significantly different between intervention periods. Before intervention, 44 patients were called back to the emergency department, and 25 were admitted because of BCC. After intervention, a total of 9 patients were called back, and 5 were admitted. The decrease in unnecessary hospitalization was statistically significant (P < 0.05).
The new policy significantly reduced BCC rates, thereby decreasing unnecessary testing and hospitalizations. Coagulase-negative staphylococci and viridans streptococci remain the most common BC contaminants. Further research should focus on additional interventions to reduce BCC.
Pediatric emergency care 02/2011; 27(3):179-81. · 0.92 Impact Factor
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New England Journal of Medicine 05/2010; 362(21):2012. · 53.30 Impact Factor
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ABSTRACT: We surveyed healthcare workers (HCWs) about influenza vaccination and routine childhood vaccinations. We found that most HCWs' children received vaccinations, despite concerns regarding safety and efficacy. HCWs who received influenza vaccine were more likely to immunize their children against influenza, although a substantial proportion of HCWs' children did not receive influenza vaccination.
Infection Control and Hospital Epidemiology 04/2010; 31(6):643-6. · 3.67 Impact Factor
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ABSTRACT: Policies that mandate immunization have always been controversial. The controversies take different forms in different contexts. For routine childhood immunizations, many parents have fears about both short- and long-term side effects. Parental worries change as the rate of vaccination in the community changes. When most children are vaccinated, parents worry more about side effects than they do about disease. Because of these worries, immunization rates go down. As immunization rates go down, disease rates go up, and parents worry less about side effects of vaccination and more about the complications of the diseases. Immunization rates then go up. For teenagers, controversies arise about the criteria that should guide policies that mandate, rather than merely recommend and encourage, certain immunizations. In particular, policy makers have questioned whether immunizations for human papillomavirus, or other diseases that are not contagious, should be required. For healthcare workers, debates have focused on the strength of institutional mandates. For years, experts have recommended that all healthcare workers be immunized against influenza. Immunizations for other infections including pertussis, measles, mumps, and hepatitis are encouraged but few hospitals have mandated such immunizations-instead, they rely on incentives and education. Pandemics present a different set of problems as people demand vaccines that are in short supply. These issues erupt into controversy on a regular basis. Physicians and policy makers must respond both in their individual practices and as advisory experts to national and state agencies. The articles in this volume will discuss the evolution of national immunization programs in these various settings. We will critically examine the role of vaccine mandates. We will discuss ways that practitioners and public health officials should deal with vaccine refusal. We will contrast responses of the population as a whole, within the healthcare setting, and in the setting of pandemic influenza.
Current problems in pediatric and adolescent health care 03/2010; 40(3):38-58.
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ABSTRACT: To determine the attitudes, beliefs, and knowledge of children's hospital health care workers toward mandatory influenza vaccination.
Self-administered, Web-based questionnaire.
A large, tertiary children's hospital.
A random sample of 585 health care workers, including physicians, nurses, and all other hospital employees. Outcome Measure Attitudes of health care workers toward mandatory policies for annual influenza vaccination of health care workers as related to their opinions on safety, effectiveness, and knowledge about influenza and influenza vaccination.
Many employees (70%) thought influenza vaccination should be mandatory for health care workers who did not have a medical contraindication. Nearly everyone, 363 of 391 (94%), who favored mandatory immunization had been immunized themselves. Of those who opposed mandatory immunization, 45 of 81 (55.6%) had been immunized (P < .001). Individuals who supported mandatory policies were more likely to believe that the vaccine is safe for both children and adults. There was no significant difference between the percentages of promandate and antimandate employees who believed influenza was dangerous for the patients where they work (66.5% and 62%, respectively, P = .07). Only 29% of antimandate employees believed they were at high risk of contracting influenza, compared with 51% of promandate employees (P < .001).
Approval of mandatory influenza vaccine policies was high; however, attitudes about the dangers of influenza for patients were not associated with acceptance of mandatory vaccination policies for health care workers. Educational efforts targeting health care workers' fears and misconceptions about influenza vaccines might help to decrease the reservoir of unimmunized health care workers.
Archives of pediatrics & adolescent medicine 01/2010; 164(1):33-7. · 3.73 Impact Factor
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ABSTRACT: Group A beta hemolytic streptococcus (GABHS) pharyngitis is a common childhood illness. Penicillin remains the gold standard therapy, but macrolides are indicated for the penicillin allergic patient, and are often used for convenience.
We conducted a surveillance study of children with pharyngitis and positive streptococcal rapid antigen testing from 10/05 to 10/06 at 2 sites (A & B). Demographics, treatment, and resistance data was collected and compared to previous data from 2002. Erythromycin (EM) resistance was determined by disk diffusion and E-test on 500 isolates. Pulse field gel electrophoresis (PFGE) was performed to measure genetic relatedness of isolates. StatXact version 8 software (Cytel Inc., Cambridge, MA) was utilized to perform Fisher's exact test and exact confidence interval (CI) analysis.
There were no differences in resistance rates or demographic features, with the exception of race, between sites A & B. EM resistance was 0 in 2002, 3.5% in 2005-06 at site A, and 4.5% in 2005-06 at site B. 3/7 and 3/9 had inducible resistance at A and B respectively. 8 isolates had relatedness > or =80%, 5 of which were 88% homologous on PFGE.
Community macrolide resistance has increased following increased macrolide use. These results may have treatment implications if use continues to be high.
Annals of Clinical Microbiology and Antimicrobials 01/2009; 8:33. · 2.64 Impact Factor
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ABSTRACT: * Young infants who have meningitis may present with nonspecific clinical manifestations. * S. pneumoniae and N. meningitidis remain the most common causes of bacterial meningitis in the infant and child, and GBS continues to be the most common neonatal pathogen. * Empiric therapy for suspected bacterial meningitis in a non-neonate includes a combination of parenteral vancomycin and either cefotaxime or ceftriaxone. * Children whose GCS scores are less than 8, show signs of shock or respiratory compromise, and have focal neurologic findings or clinical signs of elevated intracranial pressure should be admitted to a pediatric intensive care unit. * Sensorineural hearing loss occurs in 30% of children who have pneumococcal and 10% of those who have meningococcal meningitis.
Pediatrics in Review 01/2009; 29(12):417-29; quiz 430. · 0.55 Impact Factor
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ABSTRACT: To report treatment outcomes of nontuberculous mycobacteria (NTM) cervicofacial lymphadenitis.
A retrospective study from 1995 to 2006.
Fifty-one patients (mean age, 30.3 months).
All but one patient presented with lymphadenopathy. The mean time from symptoms to diagnosis was 42.3 days. Tuberculin skin testing (TST) was performed on 21 of 51 patients and was positive on 14 of 21 patients. Imaging was ordered in 23; 19 had CT scans. Pathology confirmed caseating granuloma in 45 (88%); cultures grew Mycobacterium avium-intracellulare complex in 46 of 51. Interventions included fine-needle aspiration (5, 10%), incision and drainage +/- curettage (24, 46%), and complete excisional biopsy (20, 38%). Of those who underwent complete excisional biopsy initially, 95 percent were cured compared with 32 of 51 (63%) with nonexcisional surgery. Macrolides and rifampin were more likely to be recommended in referred cases and when nonexcisional surgical treatment was not feasible or had failed. The average total duration of antibiotic therapy was 89.1 days.
NTM infections require high levels of suspicion for timely diagnosis, and complete excisional biopsy results in least likelihood of persistent/recurrent disease.
Otolaryngology Head and Neck Surgery 06/2008; 138(5):566-71. · 1.72 Impact Factor
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Journal of pediatric gastroenterology and nutrition 12/2007; 45(5):607-10. · 2.18 Impact Factor
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Manish M Patel,
Jacqueline E Tate,
Rangaraj Selvarangan,
Irini Daskalaki, Mary Anne Jackson,
Aaron T Curns,
Susan Coffin,
Barbara Watson,
Richard Hodinka,
Roger I Glass,
Umesh D Parashar
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ABSTRACT: The recent implementation of a rotavirus vaccination program in the United States makes it imperative to assess the impact of immunization on the incidence of severe rotavirus disease leading to hospitalization. Active surveillance for laboratory-confirmed rotavirus hospitalizations is the ideal approach for surveillance, but requires substantial resources to implement. We examined laboratory and hospital discharge data for 2 tertiary care pediatric hospitals to assess the utility of routine laboratory testing data for surveillance of rotavirus gastroenteritis and to estimate rotavirus disease burden.
We obtained all discharge records of hospitalizations for acute gastroenteritis among children <5 years of age at Children's Mercy Hospital (CMH), Kansas City, from July 2000 to June 2005 and at Children's Hospital of Philadelphia (CHOP) from July 2004 to June 2006. We linked these discharge records to laboratory results of rotavirus testing to evaluate epidemiologic differences in children who were tested and not tested for rotavirus and to estimate overall rotavirus burden by extrapolating clinical testing results to the untested group.
At CMH, of the 3702 children with acute gastroenteritis, 69% (n = 2552) were discharged during the winter (January through May) months, when rotavirus is most common. Similarly, at CHOP, 62% (n = 779) of the 1261 gastroenteritis discharges occurred during the winter months. During these months, 47% (n = 1197 of 2552) of the discharges at CMH and 56% (n = 438 of 779) of the discharges at CHOP were tested for rotavirus and of those tested, 71% (n = 853 of 1197) and 55% (n = 242 of 438) were positive, respectively. At both hospitals, children with and without rotavirus testing had similar gender and race/ethnicity, but the rate of testing differed by age at CHOP and by month of admission at CMH. After adjusting for these differences, we estimate that 56%-70% of winter and 34%-48% of year-round gastroenteritis in children <5 years can be attributable to rotavirus. Overall, 3%-5% of all hospitalizations in children <5 years of age were caused by rotavirus.
Sentinel hospitals where a large proportion of children hospitalized for gastroenteritis are routinely tested for rotavirus could provide a useful and cost-efficient platform to complement ongoing active surveillance efforts to evaluate the impact of rotavirus vaccination. The data reaffirm the substantial burden of rotavirus hospitalizations in US children and the potential health benefits of vaccination.
The Pediatric Infectious Disease Journal 11/2007; 26(10):914-9. · 3.58 Impact Factor
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ABSTRACT: Human monocytic ehrlichiosis (HME) is a tick-borne illness caused by Ehrlichia chaffeensis. Data about disease in children have been largely derived from case reports or small case series.
A retrospective review of all medical and laboratory records from 6 sites located in the "tick belt" of the Southeastern United States was carried out. Demographic, history and laboratory data were abstracted from the identified medical records of patients. Bivariate statistical comparisons were performed using Fisher exact test or Wilcoxon rank sum tests.
Common clinical signs and symptoms of patients with HME (n = 32) included fever (100%), headache (69%), myalgia (69%), rash (66%), nausea/vomiting (56%), altered mental status (50%) and lymphadenopathy (47%). Only 48% had a complaint of fever, headache and rash. Common laboratory abnormalities included thrombocytopenia (94%), elevated aspartate aminotransferase (90%), elevated alanine aminotransferase (74%), hypoalbuminemia (65%), lymphopenia (57%), leukopenia (56%) and hyponatremia (55%). The median number of days of illness before the initiation of antirickettsial therapy was 6. Patients who received sulfonamides before starting doxycycline therapy developed a rash, were admitted to the hospital, and started doxycycline at a later date. Twenty-two percent of patients were admitted to the intensive care unit with 12.5% of patients requiring ventilatory and blood pressure support.
Although HME has been recognized among children for almost 20 years, there is only a limited knowledge about its clinical course. Even among physicians practicing in endemic regions, few cases are diagnosed each year. More work is needed to understand the true burden of disease and the natural history among asymptomatically and symptomatically infected children.
The Pediatric Infectious Disease Journal 07/2007; 26(6):475-9. · 3.58 Impact Factor
