Charles R Woods

University of Louisville, Louisville, Kentucky, United States

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Publications (72)147.63 Total impact

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    ABSTRACT: Hospitals vary widely in the services they offer to care for pediatric burn patients. When a hospital does not have the ability or capacity to handle a pediatric burn, the decision often is made to transfer the patient to another short-term hospital. Transfers may be based on available specialty coverage for children; which adult and non-teaching hospitals may not have available. The effect these transfers have on costs and length of stay (LOS) has on pediatric burn patients is not well established and is warranted given the prominent view that pediatric hospitals are inefficient or more costly. The authors examined inpatient admissions for pediatric burn patients in 2003, 2006, and 2009 using the Kids' Inpatient Database, which is part of the Healthcare Cost and Utilization Project. ICD-9-CM codes 940 to 947 were used to define burn injury. The authors tested if transfer status was associated with LOS and total charges for pediatric burn patients, while adjusting for traditional risk factors (eg, age, TBSA, insurance status, type of hospital [pediatric vs adult; teaching vs nonteaching]) by using generalized linear mixed-effects modeling. A total of n = 28,777 children had a burn injury. Transfer status (P < .001) and TBSA (P < .001) was independently associated with LOS, while age, insurance status, and type of hospital were not associated with LOS. Similarly, transfer status (P < .001) and TBSA (P < .001) was independently associated with total charges, while age, insurance status, and type of hospital were not associated with total charges. In addition, the data suggest that the more severe pediatric burn patients are being transferred from adult and non-teaching hospitals to pediatric and teaching hospitals, which may explain the increased costs and LOS seen at pediatric hospitals. Larger more severe burns are being transferred to pediatric hospitals with the ability or capacity to handle these conditions in the pediatric population, which has a dramatic impact on costs and LOS. As a result, unadjusted, pediatric hospitals are seen as being inefficient in treating pediatric burns. However, since pediatric hospitals see more severe cases, after adjustment, type of hospital did not influence costs and LOS. TBSA and transfer status were the predictors studied that independently affect costs and LOS.
    Journal of burn care & research: official publication of the American Burn Association 12/2014; · 1.55 Impact Factor
  • Claudia Espinosa, Charles R Woods, Gary S Marshall
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    ABSTRACT: Background: Intravenous (IV) antibiotics had been the mainstay of therapy for children with complicated para-pneumonic effusion (PPE) and pleural empyema (PE). Whereas oral antibiotics have been used to complete a prescribed course of therapy, when to switch and how long to treat are more a matter of style than a matter of evidence or official guidelines. There is also controversy regarding the use of video-assisted thoracoscopic surgery (VATS) versus chest tube insertion with fibrinolysis when drainage is indicated. Substantial practice variation exists. Methods: Retrospective chart review and descriptive analysis of children managed by the pediatric infectious diseases service at Kosair Children Hospital between 2008 and 2012. Results: A total of 59 children met inclusion criteria. All patients received IV antibiotics at admission. Sixty-seven percent of children had a surgical procedure on the day of admission or the following day; all of these were VATS, except for 2 children who had a chest tube placed and later underwent VATS. The mean time to VATS was 1.4 days [95% CI 1.08, 1.80]. In 70% of the cases that underwent drainage, no organism was identified by culture of the pleural fluid. All patients received IV antibiotics at admission and all were discharged on oral antibiotics; the mean time to switch was 7.9 days [95% CI 6.76, 9.12] and the mean duration of oral antibiotic therapy was 16.98 days [15.3, 18.64]. There were no deaths; 6 patients required repeat surgical intervention, but this was not related to use of oral antibiotic therapy. Conclusion: Children with complicated PPE and PE can be managed effectively with early VATS and early switch from IV to oral antibiotic therapy.
    IDWeek 2014 Meeting of the Infectious Diseases Society of America; 10/2014
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    ABSTRACT: Acute respiratory conditions are a leading cause of childhood morbidity and mortality. Corticosteroids are effective and established treatments in some acute respiratory infections (e.g. croup) and asthma exacerbations; however, their role is controversial in other conditions owing to inconsistent effectiveness or safety concerns (e.g. bronchiolitis, acute wheeze).
    Evidence-Based Child Health A Cochrane Review Journal 09/2014; 9(3):733-47.
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    ABSTRACT: To better understand factors that may impact infant mortality rates (IMR), we evaluated the consistency across birth hospitals in the classification of a birth event as either a fetal death or an early neonatal (infant) death using natality data from North Carolina for the years 1995-2000. A database consisting of fetal deaths and infant deaths occurring within the first 24 hours after birth was constructed. Bivariate, followed by multivariable regression, analyses were used to control for relevant maternal and infant factors. Based upon hospital variances, adjustments were made to evaluate the impact of the classification on statewide infant mortality rate. After controlling for multiple maternal and infant factors, birth hospital remained a factor related to the classification of early neonatal versus fetal death. Reporting of early neonatal deaths versus fetal deaths consistent with the lowest or highest hospital strata would have resulted in an adjusted IMR varying from 7.5 to 10.64 compared with the actual rate of 8.95. Valid comparisons of IMR among geographic regions within and between countries require consistent classification of perinatal deaths. This study demonstrates that local variation in categorization of death events as fetal death versus neonatal death within the first 24 hours after delivery may impact a state-level IMR in a meaningful magnitude. The potential impact of this issue on IMRs should be examined in other state and national populations.
    BMC Pediatrics 04/2014; 14(1):108. · 1.92 Impact Factor
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    ABSTRACT: OBJECTIVES: The perineal and gluteal regions are the most frequent areas of skin and soft tissue infection (SSTI) in diapered children. No studies have investigated the relationship between perineal and general hygiene practices and SSTIs in this population. This study was conducted to evaluate this relationship. METHODS: A cross-sectional observational study was conducted in an urban pediatric emergency department. Subjects were recruited into 3 study groups as follows: gluteal/perineal SSTIs (SSTI), diaper dermatitis (DD), or healthy normal skin (NS). Survey responses were analyzed for significance followed by a clinically oriented staged regression to model predictors of SSTI compared with the NS and DD groups. RESULTS: There were 100 subjects in the SSTI, 206 in the NS, and 151 in the DD groups. Race was the only demographic characteristic that differed between the groups. After adjustment for race, no day care attendance, history of SSTI, household contact with SSTI history, and higher propensity for diaper rash were associated with SSTI compared with NS. Regression results comparing SSTI to DD revealed no day care attendance, history of SSTI, household contact with SSTI history, less sensitive skin, and less diaper cream use to be predictors of SSTI. CONCLUSIONS: Perineal and general hygiene practices were not significantly different between children with SSTI compared with children with NS or DD. Based on the results of this study, further prospective studies should evaluate diaper hygiene practices that prevent DD and subsequent SSTIs, the preventative role of day care attendance, and effective interventions that minimize the risk of recurrent SSTIs.
    Pediatric emergency care 04/2013; · 0.92 Impact Factor
  • Charles R Woods
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    ABSTRACT: Rocky Mountain spotted fever is typically undifferentiated from many other infections in the first few days of illness. Treatment should not be delayed pending confirmation of infection when Rocky Mountain spotted fever is suspected. Doxycycline is the drug of choice even for infants and children less than 8 years old.
    Pediatric Clinics of North America 04/2013; 60(2):455-470. · 2.20 Impact Factor
  • Charles R Woods
    PEDIATRICS 03/2013; · 5.30 Impact Factor
  • Charles R Woods, Kristina A Bryant
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    ABSTRACT: Viral pathogens are commonly isolated from children with community-acquired pneumonia (CAP). Viruses like respiratory syncytial virus, human rhinovirus, human metapneumovirus, parainfluenza viruses, and influenza may act as sole pathogens or may predispose to bacterial pneumonia by a variety of mechanisms. New, emerging, or reemerging viral pathogens occasionally cause outbreaks of severe respiratory tract infection in children. The 2009-2010 H1N1 influenza virus pandemic resulted in increased rates of influenza-related hospitalizations and deaths in children. Rapid viral diagnostic tests based on antigen detection or nucleic acid amplification are increasingly available for clinical use and confirm the importance of viral infection in children hospitalized with CAP. Recently published guidelines for the management of CAP in children note that positive viral test results can modify clinical decision making in children with suspected pneumonia by allowing antibacterial therapy to be withheld in the absence of clinical, laboratory, or radiographic findings that suggest bacterial coinfection.
    Current Infectious Disease Reports 02/2013;
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    ABSTRACT: Background: Clindamycin is commonly used to treat community-acquired MRSA infections. The impact of this practice on outpatient antibiotic consumption at the national level is unknown. Methods: The National Ambulatory Medical Care Survey (NAMCS) collects data from outpatient visits to primary care offices and the National Hospital Ambulatory Medical Care Survey (NHAMCS) includes visits to hospital outpatient and emergency departments (EDs) in the United States. NAMCS and NHAMCS data from 2000-2009 were used to establish patterns of clindamycin prescription over time. A clinical encounter was defined as being associated with clindamycin if any of the eight recorded medications had a drug code consistent with clindamycin. We compared patterns of prescription between children (aged<19) and adults, outpatient settings (office, hospital clinics and EDs) and across diagnostic categories. All results were weighted to provide nationally representative estimates. Results: 13.3% of the 11 billion outpatient visits during the study period were associated with an antimicrobial prescription. Clindamycin accounted for 1.85% (± 0.08) of these visits. In adults use increased from 1.6% in 2000 to 2.9% in 2009. In children use increased from 0.5% to 2.1%. Three broad groups of diagnoses accounted for nearly 50% of clindamycin usage: skin and soft tissue infections (SSTIs) (21%), dental diagnoses (11%) and respiratory diagnoses (12%). Use of clindamycin increased in SSTIs (0.5 to 7.5%) and dental diagnoses (1.8 to 8.1%), but remained stable for respiratory diagnoses. The increased use of clindamycin for SSTIs was more pronounced in children (0.25 to 12.7%) than in adults (0.6 to 6.1%). The change in prescription for dental diagnoses was only observed in adults (2.5 to 10.2%). There was no significant change in the use of clindamycin for other diagnoses. Most clindamycin prescriptions occurred in the ED setting. This was largely due to increases seen after 2003 in both children and adults. Conclusion: The outpatient use of clindamycin use has increased over the past decade, likely due to the increased prevalence of infections with community-acquired MRSA. This increase was most pronounced in pediatric SSTIs and adult dental diagnoses, and occurred almost exclusively in the ED setting.
    IDWeek 2012 Meeting of the Infectious Diseases Society of America; 10/2012
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    ABSTRACT: Background: Encephalitis is a clinical syndrome that can be associated with infectious, post-infectious, and non-infectious causes. Infectious causes include herpes, arboviruses and many others. Specific causes often are not identified. Epidemiology and burden of encephalitis in the U.S. has not been described since 1997. Recent studies have focused on specific pathogens or smaller populations. Methods: Online versions of the Nationwide Inpatient Sample (NIS) database and the Kids' Inpatient Database (KID) from Healthcare Cost and Utilization Project (http://hcupnet.ahrq.gov/) were used to evaluate frequency of hospitalizations with International Classification of Disease, 9th revision (ICD-9) codes for all causes of encephalitis from 1997-2009. Data were stratified by all causes, known causes and unexplained causes of encephalitis based on the title of the ICD-9 code. Census data were used for population estimates. Data are presented for the 5 years for which NIS and KID are both available. Results: Total U.S. hospitalizations and hospitalization incidence with associated ICD-9 codes for encephalitis increased from 18,211 (6.72 per 100,000) in 1997 to 22,439 (7.31 per 100,000) in 2009. Hospitalization with known causes of encephalitis increased from 7,773 (2.87 per 100,000) in 1997 to 12,370 (4.03 per 100,000) in 2009. Hospitalizations with unexplained causes of encephalitis decreased (Figure). Mean hospital length of stay (LOS) remained relatively stable (9.9 d in 1997 and 10.8 d in 2009). Mean hospital charges increased 3-fold ($26,802 in 1997 and $80,555 in 2009). Data for children <17 yrs in KID were highly similar to all ages data shown in the Figure. s Conclusion: Hospitalizations associated with encephalitis diagnoses of all types increased in the U.S. from 1997 to 2009. ICD-9 codes for specific causes of encephalitis also increased over time, likely due to increased availability of molecular diagnostic tests for more microbes, as well as introduction of West Nile Virus into the U.S. during this time. LOS remained stable but hospital charges tripled over time. More detailed analyses are in progress.
    IDWeek 2012 Meeting of the Infectious Diseases Society of America; 10/2012
  • Charles Woods
    IDWeek 2012 Meeting of the Infectious Diseases Society of America; 10/2012
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    ABSTRACT: Background: Since 2006, the Advisory Committee on Immunization Practices (ACIP) has recommended that all teenagers who are eligible for a tetanus-containing vaccine (TCV) be immunized with Tdap instead of Td. However, some adolescents continue to receive Td. This study explored Tdap uptake among adolescents in the United States and assessed which patient and provider characteristics were associated with receipt of Td instead of Tdap. Methods: Data were obtained from the 2008-2010 National Immunization Survey – Teen, a publicly-available database that contains demographic and immunization information for adolescents aged 13-17 years. Survey weights were used to calculate national estimates of Td and Tdap receipt during the study period. A second set of analyses was performed including only those adolescents who had received a TCV. Bivariate analyses were performed to test for differences in demographic characteristics between teenagers who received Td and those who received Tdap, stratified by year. Multiple logistic regression techniques were then used to determine predictors of Td receipt rather than Tdap. Results: Overall Tdap uptake increased from 40.8% in 2008 to 68.7% in 2010. The proportion of Tdap receipt among TCV recipients increased from 55.1% to 83.8%. Td recipients were more likely to be older (45% receipt among 17-year-olds versus 11% of 13-year-olds, p<0.0001), from the southern region of the U.S. (32% receipt in the South versus 26% in all other regions, p<0.0001), and seen at a public facility (32% receipt at public facilities versus 26% from a mix of facilities, p<0.0001). In multivariable analyses older age (OR=8.206, 95% CI 6.255 – 10.766, p<0.0001) and living in the South (OR=1.597, 95% CI 1.313 – 1.944, p<0.0001) increased the odds a teenager received Td. Having multiple vaccination providers in 2008 (OR=1.254, 95% CI 1.013 – 1.553, p=0.0383) and 2010 (OR=1.434, 95% CI 1.161 – 1.771, p=0.0008) was also associated with Td receipt. Conclusion: Tdap uptake from 2008 to 2010 has increased, suggesting that the Tdap recommendation has been adopted more widely over time. Further education among vaccination providers may still be needed in the Southern region of the United States.
    IDWeek 2012 Meeting of the Infectious Diseases Society of America; 10/2012
  • Charles Woods
    IDWeek 2012 Meeting of the Infectious Diseases Society of America; 10/2012
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    ABSTRACT: To assess the effectiveness of guidelines and education on empirical therapy for community-acquired pneumonia. Administrative records for children with a primary diagnosis of pneumonia from January 2007 to September 2009 were reviewed. Antimicrobial use was measured monthly over 3 periods: (1) before creation of an antimicrobial stewardship task force (ASTF), (2) after ASTF formation but before release of guidelines for antimicrobial use, and (3) after guideline release. Antimicrobial use over time was assessed by using quasi-binomial logistic regression models that incorporated interrupted events, seasonality, and autocorrelation. Allowing calculation of immediate changes due to specific interventions and trends in use over each time period. The primary outcome was use of ampicillin as recommended in the guidelines versus ceftriaxone, the historical standard. Secondary outcomes included other antimicrobial use, length of stay, mortality, and readmission. One thousand two hundred forty-six children met study criteria. Ampicillin use increased from 2% at baseline to 6% after ASTF formation and 44% after guideline release. Ceftriaxone use increased slightly (from 56% to 59%) after ASTF formation but decreased to 28% after guideline release. An immediate change in prescription occurred in the month after guideline publication and remained stable over the following year. Guidelines and education can have an impact on antimicrobial use in the pediatric setting. Although the optimal strategies for pediatric antimicrobial stewardship programs still are being determined, we believe that our approach offers an inexpensive and low-risk step in the right direction.
    PEDIATRICS 04/2012; 129(5):e1326-33. · 5.30 Impact Factor
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    ABSTRACT: This study reviewed Kentucky Medicaid claims data for children with autism spectrum disorders to determine psychotropic drug (PTD) use in this population. Children with autism spectrum disorders (ICD-9 code 299.XX) in 3 different age-groups from 2005 to 2008 were identified; PTD use was defined as at least 1 prescription per year. PTD use in all age ranges was higher than in previously reported studies. High PTD use in children between 1 and 5 years is particularly of concern and may reflect perceived inadequacies of comprehensive educational/behavioral services for these children.
    Clinical Pediatrics 04/2012; 51(10):923-7. · 1.26 Impact Factor
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    ABSTRACT: Studies of pediatric intensive care unit (PICU) patients have shown a significant association of morbidity and mortality with hyperglycemia. We retrospectively evaluated the degree of hyperglycemia as well as its correlation with glucocorticoid and insulin use and assessed its association with hospital length of stay (LOS) and mortality. This study preceded the initiation of a standard glycemic control protocol. We examined medical records at Kosair Children's Hospital for all PICU admissions from 2008 of patients without diabetes mellitus. Critical illness hyperglycemia (CIH) was defined by having three or more peak glucose values greater than thresholds of 110, 140, 180, and 200 mg/dl. These patients were evaluated for glucocorticoid, insulin use, and outcome measures. We evaluated the eligible 1173 admissions, where 10.5% of these patients reached the highest threshold (200 mg/dl) of CIH. Glucocorticoids were used in 43% of these patients, with dexamethasone being the most common (58%). There was a significant correlation between glucocorticoids and higher peak glucose values, where 81% of the patients who were above the 200 mg/dl cutoff level were treated with glucocorticoids. Only 36.8% in that group were also treated with insulin. Patients at the 200 mg/dl cutoff had the highest median PICU and total hospital length of stays (4 and 10 days, respectfully). Mortality was associated with increasing glucose levels, reaching 18.7% among patients above the 200 mg/dl cutoff. Hyperglycemia was prevalent in the PICU and was associated with increased morbidity, as characterized by increased LOS and increased mortality. Glucocorticoid use was prevalent among patients exhibiting hyperglycemia. Insulin use was uncommon.
    Journal of diabetes science and technology 01/2012; 6(1):5-14.
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    ABSTRACT: Background: The incidence of localized skin/soft tissue infections (SSTIs) and invasive disease caused by Staphylococcus aureus (SA) have increased over the last decade. It is not known whether healthy patients with SSTI due to SA are at increased risk of invasive SA disease (ISAD), or, conversely, if having an SSTI is protective against ISAD. Methods: Children admitted to or seen in the Emergency Department of Kosair Children’s Hospital between November 2003 and April 2010 with positive cultures for SA were included in this study. Medical records of patients with a positive culture from a deep site, indicative of ISAD (blood, CSF, pleural, bone, joint, or pericardial) were reviewed in detail. NICU infants and patients with underlying/chronic disease were excluded from the ISAD group. Results: SA was isolated from 6,445 cultures obtained from 5,283 patients. Of these, 4,025 patients (76%) had at least one positive wound culture. 163 patients (3%) had a positive culture indicative of ISAD. 28 (17%) NICU infants and 59 (36%) other patients with underlying/chronic disease processes (21 cancer, 12 neuromuscular disorder, 7 congenital heart disease, 6 immunosuppressive therapies, 5 pulmonary, 5 gastrointestinal) were excluded from the invasive group. Of the remaining 76 patients with ISAD, 46 (60.5%) had methicillin susceptible (MSSA) and 30 (39.5%) had methicillin resistant (MRSA) disease. Of the 4,025 patients with a positive wound culture, only 1 (0.02%) also had microbiologic evidence of ISAD during the study period. The positive wound culture occurred 18 months after a positive pleural culture indicative of ISAD. Review of medical records revealed 3 (4%) patients with ISAD who had a documented history of SA disease, and 6 (8%) who had family members with a documented history of SA disease. However, none had microbiologic evidence of previous SA disease. Conclusion: Having a history of SSTI caused by SA does not appear to increase the risk of future ISAD in healthy children.
    Infectious Diseases Society of America 2011 Annual Meeting; 10/2011
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    ABSTRACT: Purpose: Community acquired methicillin-resistant Staphylococcus aureus (CA-MRSA) is the most frequent cause of skin and soft tissue infections (SSTI). The perineal and gluteal (diaper) regions are a common site of CA-MRSA SSTI in young children, but no studies have investigated the relationship between hygiene practices and SSTI. This study was conducted to evaluate the relationship of perineal and general hygiene practices with SSTI. Methods: A cross-sectional, age-matched observational study was conducted in an urban pediatric emergency department. Children were eligible when <36 months of age, diapered for >90% of the day, and with an adult who provided care >50% of the time. Children with immunosuppression, chronic antibiotic use, or group home residence were ineligible. Parents/guardians of eligible children completed a survey regarding the child’s perineal hygiene, a validated measure of general hygiene, other potential risk factors for SSTI, and demographic characteristics. Subjects were recruited into three study groups: gluteal or perineal skin and soft tissue infection (SSTI), diaper dermatitis (DD), or healthy normal perineal skin (NS). Survey responses were analyzed for significance between groups using chi-square or Mann-Whitney U as appropriate. Binary logistic regression was used to model predictors of the presence of SSTI in comparison to NS and DD when univariate analysis revealed a p value <0.1. Results: 100 subjects were recruited into the SSTI group, with 201 and 82 children in the NS and DD groups, respectively. Race was the only demographic characteristic that differed between SSTI and NS groups (% white: 56%, 46%, respectively, P =0.015). In univariate analysis, the propensity for diaper rash, diaper rash frequency, barrier cream use, daycare attendance, prior history of SSTI, household contact with abscess or boil, and recent antibiotic use differed between SSTI and NS groups (all P<0.05). After adjustment for race, daycare attendance (adjusted odds ratio (aOR) 0.43 [95% confidence interval (CI): 0.22, 0.82]), prior history of SSTI (aOR 6.46, [95% CI: 2.87, 14.5]), household contact with an SSTI (aOR 3.5, [95% CI; 1.75, 7.01]), and increasing frequency of diaper rash (P =0.004) were associated with SSTI when compared to NS. Regression results comparing SSTI with DD revealed prior history of SSTI and household contact with SSTI to be the best predictors of SSTI. Neither number of diapers used per day nor degree of general hygiene was significantly associated with SSTI. Conclusions: Perineal and general hygiene practices were not significantly different between children with SSTI compared to children with NS or DD. Parents of children with SSTI reported more frequent episodes of diaper rash than those of children with healthy perineal skin. The role of diaper dermatitis as a risk factor for SSTI warrants further investigation in order to develop preventative interventions.
    2011 American Academy of Pediatrics National Conference and Exhibition; 10/2011
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    ABSTRACT: The aim of this study was to characterize the practice of routinely obtaining tracheal aspirate cultures in children with tracheostomy tubes and to analyze the appropriateness of using this information to guide antibiotic selection for treatment of subsequent lower respiratory infections. Pediatric otolaryngologists and pulmonologists were surveyed regarding surveillance culture practices. Records of children with tracheostomy tubes from January 1, 2003, through December 31, 2007, were reviewed. Consecutive cultures were compared for similarity of bacteria and antibiotic sensitivity when a clinic culture preceded a culture from when the child was ill and received antibiotics and when a hospital culture preceded a hospital culture from a separate hospitalization. Seventy-nine of 146 pulmonologists and five of 33 otolaryngologists obtained routine surveillance tracheal aspirate cultures (P < .001); 97% of pulmonologists used these cultures to guide subsequent empiric therapy. There were 36 of 170 children with one or more eligible pairs of cultures. Nearly all children had a change in flora in their tracheal cultures. Limiting empiric antibiotic choices to those that would cover microbes isolated in the previous culture likely would not have been effective in covering one or more microbes isolated in the second culture in 56% of pairs with the first culture from hospitalization vs 30% with the first culture from an outpatient setting (P = .15). This study demonstrated that there are significant changes in bacteria or antibiotic sensitivity between consecutive tracheal cultures in children with tracheostomy tubes. Use of prior tracheal cultures from these children was of limited value for choosing empiric antibiotic therapy in treating acute lower respiratory exacerbations. Surveillance cultures, thus, are an unnecessary burden and expense of care.
    Chest 03/2011; 141(3):625-31. · 7.13 Impact Factor
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    Kelly A Sinclair, Charles R Woods, Sara H Sinal
    Pediatrics in Review 03/2011; 32(3):115-21; quiz 121. · 0.82 Impact Factor

Publication Stats

838 Citations
147.63 Total Impact Points

Institutions

  • 2002–2014
    • University of Louisville
      • • Department of Pediatrics
      • • Division of Infectious Diseases
      Louisville, Kentucky, United States
  • 2001–2008
    • Wake Forest School of Medicine
      • • Section on Infectious Diseases
      • • Department of Pediatrics
      Winston-Salem, North Carolina, United States
  • 2006
    • Winston-Salem State University
      Winston-Salem, North Carolina, United States
    • Harvard Medical School
      • Department of Medicine
      Boston, Massachusetts, United States