Clinical Focus


  • Pediatric Infectious Diseases

Professional Education


  • Board Certification: American Board of Pediatrics, Pediatric Infectious Diseases (2013)
  • MPH, Harvard School of Public Health, Clinical Effectiveness (2013)
  • Board Certification, Pediatric Infectious Diseases, American Board of Pediatrics (2013)
  • Fellowship: Boston Children's Hospital (2013) MA
  • Board Certification: American Board of Pediatrics, Pediatrics (2009)
  • Residency: Lucile Packard Children's Hospital (2009) CA
  • Medical Education: University of Texas Southwestern Medical Center (2006) TX

All Publications


  • EHR-based Case Identification of Pediatric Long COVID: A Report from the RECOVER EHR Cohort. medRxiv : the preprint server for health sciences Botdorf, M., Dickinson, K., Lorman, V., Razzaghi, H., Marchesani, N., Rao, S., Rogerson, C., Higginbotham, M., Mejias, A., Salyakina, D., Thacker, D., Dandachi, D., Christakis, D. A., Taylor, E., Schwenk, H., Morizono, H., Cogen, J., Pajor, N. M., Jhaveri, R., Forrest, C. B., Bailey, L. C. 2024

    Abstract

    Objective: Long COVID, marked by persistent, recurring, or new symptoms post-COVID-19 infection, impacts children's well-being yet lacks a unified clinical definition. This study evaluates the performance of an empirically derived Long COVID case identification algorithm, or computable phenotype, with manual chart review in a pediatric sample. This approach aims to facilitate large-scale research efforts to understand this condition better.Methods: The algorithm, composed of diagnostic codes empirically associated with Long COVID, was applied to a cohort of pediatric patients with SARS-CoV-2 infection in the RECOVER PCORnet EHR database. The algorithm classified 31,781 patients with conclusive, probable, or possible Long COVID and 307,686 patients without evidence of Long COVID. A chart review was performed on a subset of patients (n=651) to determine the overlap between the two methods. Instances of discordance were reviewed to understand the reasons for differences.Results: The sample comprised 651 pediatric patients (339 females, M age = 10.10 years) across 16 hospital systems. Results showed moderate overlap between phenotype and chart review Long COVID identification (accuracy = 0.62, PPV = 0.49, NPV = 0.75); however, there were also numerous cases of disagreement. No notable differences were found when the analyses were stratified by age at infection or era of infection. Further examination of the discordant cases revealed that the most common cause of disagreement was the clinician reviewers' tendency to attribute Long COVID-like symptoms to prior medical conditions. The performance of the phenotype improved when prior medical conditions were considered (accuracy = 0.71, PPV = 0.65, NPV = 0.74).Conclusions: Although there was moderate overlap between the two methods, the discrepancies between the two sources are likely attributed to the lack of consensus on a Long COVID clinical definition. It is essential to consider the strengths and limitations of each method when developing Long COVID classification algorithms.

    View details for DOI 10.1101/2024.05.23.24307492

    View details for PubMedID 38826460

  • Prescribing Patterns of Nonrecommended Medications for Children With Acute COVID-19. Pediatrics Burns, J. E., Dahlen, A., Bio, L. L., Chamberlain, L. J., Bassett, H. K., Ramaraj, R., Schwenk, H. T., Teufel, R. J., Schroeder, A. R. 2024

    Abstract

    Repurposed medications for acute coronavirus disease 2019 (COVID-19) continued to be prescribed after results from rigorous studies and national guidelines discouraged use. We aimed to describe prescribing rates of nonrecommended medications for acute COVID-19 in children, associations with demographic factors, and provider type and specialty.In this retrospective cohort of children <18 years in a large United States all-payer claims database, we identified prescriptions within 2 weeks of an acute COVID-19 diagnosis. We calculated prescription rate, performed multivariable logistic regression to identify risk factors, and described prescriber type and specialty during nonrecommended periods defined by national guidelines.We identified 3 082 626 COVID-19 diagnoses in 2 949 118 children between March 7, 2020 and December 31, 2022. Hydroxychloroquine (HCQ) and ivermectin were prescribed in 0.03% and 0.14% of COVID-19 cases, respectively, during nonrecommended periods (after September 12, 2020 for HCQ and February 5, 2021 for ivermectin) with considerable variation by state. Prescription rates were 4 times the national average in Arkansas (HCQ) and Oklahoma (ivermectin). Older age, nonpublic insurance, and emergency department or urgent care visit were associated with increased risk of either prescription. Additionally, residence in nonurban and low-income areas was associated with ivermectin prescription. General practitioners had the highest rates of prescribing.Although nonrecommended medication prescription rates were low, the overall COVID-19 burden translated into high numbers of ineffective and potentially harmful prescriptions. Understanding overuse patterns can help mitigate downstream consequences of misinformation. Reaching providers and parents with clear evidence-based recommendations is crucial to children's health.

    View details for DOI 10.1542/peds.2023-065003

    View details for PubMedID 38716573

  • Dynamics and prognostic value of plasma cell-free DNA PCR in patients with invasive aspergillosis and mucormycosis. Journal of clinical microbiology Moreno, A., Mah, J., Budvytiene, I., Ho, D. Y., Schwenk, H. T., Banaei, N. 2024: e0039424

    Abstract

    Aspergillus species and Mucorales agents are the primary etiologies of invasive fungal disease (IFD). Biomarkers that predict outcomes are needed to improve care. Patients diagnosed with invasive aspergillosis and mucormycosis using plasma cell-free DNA (cfDNA) PCR were retested weekly for 4 weeks. The primary outcome included all-cause mortality at 6 weeks and 6 months based on baseline cycle threshold (CT) values and results of follow-up cfDNA PCR testing. Forty-five patients with Aspergillus and 30 with invasive Mucorales infection were retested weekly for a total of 197 tests. Using the European Organization for Research and Treatment of Cancer and the Mycoses Study Group Education and Research Consortium (EORTC/MSG) criteria, 30.7% (23/75), 25.3% (19/75), and 38.7% (29/75) had proven, probable, and possible IFD, respectively. In addition, 97.3% (73/75) were immunocompromised. Baseline CT increased significantly starting at week 1 for Mucorales and week 2 for Aspergillus. Aspergillosis and mucormycosis patients with higher baseline CT (CT >40 and >35, respectively) had a nonsignificantly higher survival rate at 6 weeks, compared with patients with lower baseline CT. Mucormycosis patients with higher baseline CT had a significantly higher survival rate at 6 months. Mucormycosis, but not aspergillosis patients, with repeat positive cfDNA PCR results had a nonsignificantly lower survival rate at 6 weeks and 6 months compared with patients who reverted to negative. Aspergillosis patients with baseline serum Aspergillus galactomannan index <0.5 and <1.0 had significantly higher survival rates at 6 weeks when compared with those with index ≥0.5 and ≥1.0, respectively. Baseline plasma cfDNA PCR CT can potentially be used to prognosticate survival in patients with invasive Aspergillus and Mucorales infections.We show that Aspergillus and Mucorales plasma cell-free DNA PCR can be used not only to noninvasively diagnose patients with invasive fungal disease but also to correlate the baseline cycle threshold with survival outcomes, thus potentially allowing the identification of patients at risk for poor outcomes, who may benefit from more targeted therapies.

    View details for DOI 10.1128/jcm.00394-24

    View details for PubMedID 38602412

  • Guidance for prevention and management of COVID-19 in children and adolescents: A consensus statement from the Pediatric Infectious Diseases Society Pediatric COVID-19 Therapies Taskforce. Journal of the Pediatric Infectious Diseases Society Willis, Z. I., Oliveira, C. R., Abzug, M. J., Anosike, B. I., Ardura, M. I., Bio, L. L., Boguniewicz, J., Chiotos, K., Downes, K., Grapentine, S. P., Hersh, A. L., Heston, S. M., Hijano, D. R., Huskins, W. C., James, S. H., Jones, S., Lockowitz, C. R., Lloyd, E. C., MacBrayne, C., Maron, G. M., Hayes McDonough, M., Miller, C. M., Morton, T. H., Olivero, R. M., Orscheln, R. C., Schwenk, H. T., Singh, P., Soma, V. L., Sue, P. K., Vora, S. B., Nakamura, M. M., Wolf, J. 2024

    Abstract

    BACKGROUND: Since November 2019, the SARS-CoV-2 pandemic has created challenges for preventing and managing COVID-19 in children and adolescents. Most research to develop new therapeutic interventions or to repurpose existing ones has been undertaken in adults, and although most cases of infection in pediatric populations are mild, there have been many cases of critical and fatal infection. Understanding the risk factors for severe illness and the evidence for safety, efficacy, and effectiveness of therapies for COVID-19 in children is necessary to optimize therapy.METHODS: A panel of experts in pediatric infectious diseases, pediatric infectious diseases pharmacology, and pediatric intensive care medicine from 21 geographically diverse North American institutions was re-convened. Through a series of teleconferences and web-based surveys and a systematic review with meta-analysis of data for risk factors, a guidance statement comprising a series of recommendations for risk stratification, treatment, and prevention of COVID-19 was developed and refined based on expert consensus.RESULTS: There are identifiable clinical characteristics that enable risk stratification for patients at risk for severe COVID-19. These risk factors can be used to guide the treatment of hospitalized and non-hospitalized children and adolescents with COVID-19 and to guide preventative therapy where options remain available.

    View details for DOI 10.1093/jpids/piad116

    View details for PubMedID 38339996

  • Vaccine Effectiveness Against Long COVID in Children. Pediatrics Razzaghi, H., Forrest, C. B., Hirabayashi, K., Wu, Q., Allen, A., Rao, S., Chen, Y., Bunnell, H. T., Chrischilles, E. A., Cowell, L. G., Cummins, M. R., Hanauer, D. A., Higginbotham, M., Horne, B. D., Horowitz, C. R., Jhaveri, R., Kim, S., Mishkin, A., Muszynski, J. A., Naggie, S., Pajor, N. M., Paranjape, A., Schwenk, H. T., Sills, M. R., Tedla, Y. G., Williams, D. A., Bailey, C. 2024

    Abstract

    OBJECTIVE: Vaccination reduces the risk of acute COVID-19 in children, but it is less clear whether it protects against long COVID. We estimated vaccine effectiveness (VE) against long COVID in children aged 5-17 years.METHODS: This retrospective cohort study used data from 17 health systems in the RECOVER PCORnet electronic health record (EHR) Program for visits after vaccine availability. Conditional logistic regression was used to estimate VE against long COVID with matching on age group (5-11, 12-17) and time period and adjustment for sex, ethnicity, health system, comorbidity burden, and pre-exposure health care utilization. We examined both probable (symptom-based) and diagnosed long COVID in the year following vaccination.RESULTS: The vaccination rate was 56% in the cohort of 1,037,936 children. The incidence of probable long COVID was 4.5% among patients with COVID-19, while diagnosed long COVID was 0.7%. Adjusted vaccine effectiveness within 12 months was 35.4% (95 CI 24.5 - 44.5) against probable long COVID and 41.7% (15.0 - 60.0) against diagnosed long COVID. VE was higher for adolescents 50.3% [36.3 - 61.0]) than children aged 5-11 (23.8% [4.9 - 39.0]). VE was higher at 6 months (61.4% [51.0 - 69.6]) but decreased to 10.6% (-26.8 - 37.0%) at 18-months.DISCUSSION: This large retrospective study shows a moderate protective effect of SARS-CoV-2 vaccination against long COVID. The effect is stronger in adolescents, who have higher risk of long COVID, and wanes over time. Understanding VE mechanism against long COVID requires more study, including EHR sources and prospective data.

    View details for DOI 10.1542/peds.2023-064446

    View details for PubMedID 38225804

  • Real-World Effectiveness of BNT162b2 Against Infection and Severe Diseases in Children and Adolescents. Annals of internal medicine Wu, Q., Tong, J., Zhang, B., Zhang, D., Chen, J., Lei, Y., Lu, Y., Wang, Y., Li, L., Shen, Y., Xu, J., Bailey, L. C., Bian, J., Christakis, D. A., Fitzgerald, M. L., Hirabayashi, K., Jhaveri, R., Khaitan, A., Lyu, T., Rao, S., Razzaghi, H., Schwenk, H. T., Wang, F., Gage Witvliet, M. I., Tchetgen Tchetgen, E. J., Morris, J. S., Forrest, C. B., Chen, Y. 2024

    Abstract

    The efficacy of the BNT162b2 vaccine in pediatrics was assessed by randomized trials before the Omicron variant's emergence. The long-term durability of vaccine protection in this population during the Omicron period remains limited.To assess the effectiveness of BNT162b2 in preventing infection and severe diseases with various strains of the SARS-CoV-2 virus in previously uninfected children and adolescents.Comparative effectiveness research accounting for underreported vaccination in 3 study cohorts: adolescents (12 to 20 years) during the Delta phase and children (5 to 11 years) and adolescents (12 to 20 years) during the Omicron phase.A national collaboration of pediatric health systems (PEDSnet).77 392 adolescents (45 007 vaccinated) during the Delta phase and 111 539 children (50 398 vaccinated) and 56 080 adolescents (21 180 vaccinated) during the Omicron phase.First dose of the BNT162b2 vaccine versus no receipt of COVID-19 vaccine.Outcomes of interest include documented infection, COVID-19 illness severity, admission to an intensive care unit (ICU), and cardiac complications. The effectiveness was reported as (1-relative risk)*100, with confounders balanced via propensity score stratification.During the Delta period, the estimated effectiveness of the BNT162b2 vaccine was 98.4% (95% CI, 98.1% to 98.7%) against documented infection among adolescents, with no statistically significant waning after receipt of the first dose. An analysis of cardiac complications did not suggest a statistically significant difference between vaccinated and unvaccinated groups. During the Omicron period, the effectiveness against documented infection among children was estimated to be 74.3% (CI, 72.2% to 76.2%). Higher levels of effectiveness were seen against moderate or severe COVID-19 (75.5% [CI, 69.0% to 81.0%]) and ICU admission with COVID-19 (84.9% [CI, 64.8% to 93.5%]). Among adolescents, the effectiveness against documented Omicron infection was 85.5% (CI, 83.8% to 87.1%), with 84.8% (CI, 77.3% to 89.9%) against moderate or severe COVID-19, and 91.5% (CI, 69.5% to 97.6%) against ICU admission with COVID-19. The effectiveness of the BNT162b2 vaccine against the Omicron variant declined 4 months after the first dose and then stabilized. The analysis showed a lower risk for cardiac complications in the vaccinated group during the Omicron variant period.Observational study design and potentially undocumented infection.This study suggests that BNT162b2 was effective for various COVID-19-related outcomes in children and adolescents during the Delta and Omicron periods, and there is some evidence of waning effectiveness over time.National Institutes of Health.

    View details for DOI 10.7326/M23-1754

    View details for PubMedID 38190711

  • Suboptimal antimicrobial discharge prescriptions at a tertiary referral children's hospital. Antimicrobial stewardship & healthcare epidemiology : ASHE Zhang, Y. W., Paturi, S., Puckett, L. M., Scheinker, D., Schwenk, H. T., Joerger, T. A. 2023; 3 (1): e223

    Abstract

    To determine the rate of and factors associated with suboptimal discharge antimicrobial prescribing at a tertiary referral children's hospital.Retrospective cohort.Tertiary referral children's hospital.All enteral antimicrobial discharge prescriptions at Lucile Packard Children's Hospital Stanford from January 1st, 2021 through December 31st, 2021.All enteral discharge antimicrobials are routinely evaluated by our antimicrobial stewardship program within 48 hours of hospital discharge. Antimicrobials are determined to be optimal or suboptimal by an antimicrobial stewardship pharmacist after evaluating the prescribed choice of antimicrobial, dose, duration, dosing frequency, and formulation. The rate and factors associated with suboptimal antimicrobial discharge prescribing were evaluated.Of 2,593 antimicrobial prescriptions ordered at discharge, 19.7% were suboptimal. Suboptimal prescriptions were due to incorrect duration (72.2%), dose (31.0%), dose frequency (23.3%), drug choice (6.5%), or formulation (5.7%). In total, 87.2% of antimicrobials for perioperative prophylaxis and 13.5% of treatment antimicrobials were suboptimal. Antimicrobials with the highest rate of suboptimal prescriptions were amoxicillin-clavulanate (40.7%), clindamycin (36.6%), and cephalexin (36.6%).Suboptimal antimicrobial discharge prescriptions are common and present an opportunity for antimicrobial stewardship programs during hospital transition of care. Factors associated with suboptimal prescriptions differ by antimicrobial and prescribed indication, indicating that multiple stewardship interventions may be needed to improve prescribing.

    View details for DOI 10.1017/ash.2023.488

    View details for PubMedID 38156234

    View details for PubMedCentralID PMC10753499

  • Successful enteral administration of crushed posaconazole delayed-release tablets in children. Pediatric blood & cancer Bio, L. L., Hiroshima, L., Schwenk, H. T., Green, S. 2023: e30782

    Abstract

    Erratic absorption of posaconazole oral suspension necessitates frequent dosing and administration with meals or supplements. Alternative enteral formulations are desirable for patients intolerant to enteral nutrition. Crushed posaconazole delayed-release tablets (POS-DRT) show promise in adults; limited evidence exists in children. We used crushed POS-DRT in 10 encounters with nine pediatric patients, achieving target POS concentrations in 90% of encounters. This highlights crushed POS-DRT as a potential enteral option for pediatric antifungal prophylaxis and treatment.

    View details for DOI 10.1002/pbc.30782

    View details for PubMedID 37990039

  • Real-world Effectiveness of BNT162b2 Against Infection and Severe Diseases in Children and Adolescents. medRxiv : the preprint server for health sciences Wu, Q., Tong, J., Zhang, B., Zhang, D., Chen, J., Lei, Y., Lu, Y., Wang, Y., Li, L., Shen, Y., Xu, J., Bailey, L. C., Bian, J., Christakis, D. A., Fitzgerald, M. L., Hirabayashi, K., Jhaveri, R., Khaitan, A., Lyu, T., Rao, S., Razzaghi, H., Schwenk, H. T., Wang, F., Witvliet, M. I., Tchetgen, E. J., Morris, J. S., Forrest, C. B., Chen, Y. 2023

    Abstract

    Background: The efficacy of the BNT162b2 vaccine in pediatrics was assessed by randomized trials before the Omicron variant's emergence. The long-term durability of vaccine protection in this population during the Omicron period remains limited.Objective: To assess the effectiveness of BNT162b2 in preventing infection and severe diseases with various strains of the SARS-CoV-2 virus in previously uninfected children and adolescents.Design: Comparative effectiveness research accounting for underreported vaccination in three study cohorts: adolescents (12 to 20 years) during the Delta phase, children (5 to 11 years) and adolescents (12 to 20 years) during the Omicron phase.Setting: A national collaboration of pediatric health systems (PEDSnet).Participants: 77,392 adolescents (45,007 vaccinated) in the Delta phase, 111,539 children (50,398 vaccinated) and 56,080 adolescents (21,180 vaccinated) in the Omicron period.Exposures: First dose of the BNT162b2 vaccine vs. no receipt of COVID-19 vaccine.Measurements: Outcomes of interest include documented infection, COVID-19 illness severity, admission to an intensive care unit (ICU), and cardiac complications. The effectiveness was reported as (1-relative risk)*100% with confounders balanced via propensity score stratification.Results: During the Delta period, the estimated effectiveness of BNT162b2 vaccine was 98.4% (95% CI, 98.1 to 98.7) against documented infection among adolescents, with no significant waning after receipt of the first dose. An analysis of cardiac complications did not find an increased risk after vaccination. During the Omicron period, the effectiveness against documented infection among children was estimated to be 74.3% (95% CI, 72.2 to 76.2). Higher levels of effectiveness were observed against moderate or severe COVID-19 (75.5%, 95% CI, 69.0 to 81.0) and ICU admission with COVID-19 (84.9%, 95% CI, 64.8 to 93.5). Among adolescents, the effectiveness against documented Omicron infection was 85.5% (95% CI, 83.8 to 87.1), with 84.8% (95% CI, 77.3 to 89.9) against moderate or severe COVID-19, and 91.5% (95% CI, 69.5 to 97.6)) against ICU admission with COVID-19. The effectiveness of the BNT162b2 vaccine against the Omicron variant declined after 4 months following the first dose and then stabilized. The analysis revealed a lower risk of cardiac complications in the vaccinated group during the Omicron variant period.Limitations: Observational study design and potentially undocumented infection.Conclusions: Our study suggests that BNT162b2 was effective for various COVID-19-related outcomes in children and adolescents during the Delta and Omicron periods, and there is some evidence of waning effectiveness over time.Primary Funding Source: National Institutes of Health.

    View details for DOI 10.1101/2023.06.16.23291515

    View details for PubMedID 38014095

  • Indication-driven order entry decreases stewardship and pharmacist interventions. Infection control and hospital epidemiology Nishiguchi, J. L., Bio, L. L., Cornell, S. T., Schwenk, H. T. 2023: 1-3

    Abstract

    Indication-driven order entry (IDOE) was implemented at our pediatric institution for cefazolin, piperacillin-tazobactam, and meropenem; the 3 most intervened upon antibiotics during prospective audit and feedback (PAF) by the antimicrobial stewardship program (ASP). IDOE was associated with a significant reduction in both ASP PAF recommendations and clinical pharmacist interventions.

    View details for DOI 10.1017/ice.2023.155

    View details for PubMedID 37529840

  • Impact of Model-Informed Precision Dosing on Achievement of Vancomycin Exposure Targets in Pediatric Patients with Cystic Fibrosis. Pharmacotherapy Frymoyer, A., Schwenk, H. T., Brockmeyer, J. M., Bio, L. 2023

    Abstract

    BACKGROUND: Vancomycin is commonly used to treat acute pulmonary exacerbations in pediatric patients with cystic fibrosis (CF) and a history of methicillin-resistant Staphylococcus aureus. Optimizing vancomycin exposure during therapy is essential and area under the curve (AUC)-guided dosing is now recommended. Model-informed precision dosing (MIPD) utilizing Bayesian forecasting is a powerful approach that can support AUC-guided dose individualization. The objective of the current study was to examine the impact of implementing an AUC-guided dose individualization approach supported via a MIPD clinical decision support (CDS) tool on vancomycin exposure, target attainment rate, and safety in pediatric patients with CF treated with vancomycin during clinical care.METHODS: Retrospective chart review was performed in patients with CF at a single children's hospital comparing pre- and post-implementation of a MIPD approach for vancomycin supported by a cloud-based, CDS tool integrated into the electronic health record (EHR). In the pre-MIPD period, vancomycin starting doses of 60 mg/kg/day (<13years) or 45 mg/kg/day (≥13years) were used. Dose adjustment was guided by therapeutic drug monitoring (TDM) with a target trough 10-20 mg/L. In the post-MIPD period, starting dose and dose-adjustment were based on the MIPD CDS tool predictions with a target 24 hour AUC (AUC24 ) 400-600 mg*hr/L. Exposure and target achievement rates were retrospectively calculated and compared. Rates of acute kidney injury (AKI) were also compared.RESULTS: Overall, 23 patient courses were included in the pre-MIPD period and 21 patient courses in the post-MIPD period. In the post-MIPD period, an individualized MIPD starting dose resulted in 71% of patients achieving target AUC24 compared to 39% in the pre-MIPD period (p<0.05). After the first TDM and dose adjustment, target AUC24 achievement was also higher post-MIPD versus pre-MIPD (86% vs 57%; p<0.05). AKI rates were low and similar between periods (pre-MIPD 8.7% vs post-MIPD 9.5%; p=0.9).CONCLUSION: An MIPD approach implemented within a cloud-based, EHR integrated CDS tool safely supported vancomycin AUC-guided dosing and resulted in high rates of target achievement.

    View details for DOI 10.1002/phar.2845

    View details for PubMedID 37401162

  • Antifungal stewardship in practice: Insights from a prospective audit and feedback program. Infection control and hospital epidemiology Bio, L. L., Weng, Y., Schwenk, H. T. 2023: 1-5

    Abstract

    To identify characteristics of antifungal prospective audit and feedback (PAF) and to compare rates of PAF recommendation and acceptance between antifungal and antibiotic agents.Retrospective cohort study of antifungal and antibiotic audits by a children's hospital antimicrobial stewardship program (ASP) from November 1, 2020, to October 31, 2022.Antimicrobial audit data were retrieved from the ASP data warehouse. We characterized antifungal PAF using descriptive statistics. We then compared the overall rates of PAF recommendation and recommendation acceptance between antifungals and antibiotics. We also compared the differences in antifungal and antibiotic PAF recommendation and acceptance rates across various factors, including infectious problem, medical service, and recommendation type.Of 10,402 antimicrobial audits identified during the study period, 8,599 (83%) were for antibiotics and 1,803 (17%) were for antifungals. The highest antifungal recommendation rates were for liposomal amphotericin B, antifungals used for sepsis or respiratory tract infection, and antifungals prescribed in the cardiovascular intensive care unit. The rate of PAF recommendation was higher for antibiotics than for antifungals (29% vs 21%; P < .001); however, the rates of recommendation acceptance were similar. Recommendations to discontinue or for medication monitoring were more common for antifungals.Our analysis of antifungal PAF identified key opportunities to improve antifungal use, including the optimized use of specific agents and targeted use by certain medical services. Moreover, antifungal PAF, despite identifying fewer recommendations compared to antibiotic PAF, were associated with similarly high rates of acceptance, highlighting a promising opportunity for antifungal stewardship.

    View details for DOI 10.1017/ice.2023.129

    View details for PubMedID 37381887

  • Benchmarking of Outpatient Pediatric Antibiotic Prescribing: Results of a Multicenter Collaborative JOURNAL OF THE PEDIATRIC INFECTIOUS DISEASES SOCIETY El Feghaly, R. E., Herigon, J. C., Kronman, M. P., Wattles, B. A., Poole, N. M., Smith, M. J., Vaughan, A. M., Olivero, R., Patel, S. J., Wirtz, A., Willis, Z., Lee, B. R. 2023: 364-371

    Abstract

    Most antibiotic use occurs in ambulatory settings. No benchmarks exist for pediatric institutions to assess their outpatient antibiotic use and compare prescribing rates to peers. We aimed to share pediatric outpatient antibiotic use reports and benchmarking metrics nationally.We invited institutions from the Sharing Antimicrobial Reports for Pediatric Stewardship OutPatient (SHARPS-OP) Collaborative to contribute quarterly aggregate reports on antibiotic use from January 2019 to June 2022. Outpatient settings included emergency departments (ED), urgent care centers (UCC), primary care clinics (PCC) and telehealth encounters. Benchmarking metrics included the percentage of: (1) all acute encounters resulting in antibiotic prescriptions; (2) acute respiratory infection (ARI) encounters resulting in antibiotic prescriptions; and among ARI encounters receiving antibiotics, (3) the percentage receiving amoxicillin ("Amoxicillin index"); and (4) the percentage receiving azithromycin ("Azithromycin index"). We collected rates of antibiotic prescriptions with durations ≤7 days and >10 days from institutions able to provide validated duration data.Twenty-one institutions submitted aggregate reports. Percent ARI encounters receiving antibiotics were highest in the UCC (40.2%), and lowest in telehealth (19.1%). Amoxicillin index was highest for the ED (76.2%), and lowest for telehealth (55.8%), while the azithromycin index was similar for ED, UCC, and PCC (3.8%, 3.7%, and 5.0% respectively). Antibiotic duration of ≤7 days varied substantially (46.4% for ED, 27.8% UCC, 23.7% telehealth, and 16.4% PCC).We developed a benchmarking platform for key pediatric outpatient antibiotic use metrics drawing data from multiple pediatric institutions nationally. These data may serve as a baseline measurement for future improvement work.

    View details for DOI 10.1093/jpids/piad039

    View details for Web of Science ID 001010948900001

    View details for PubMedID 37262431

  • Respiratory Failure in an 11-day-old Neonate. NeoReviews Aiden, A. P., Khan, A., Schwenk, H., Fuerch, J. H. 2023; 24 (1): 36-38

    View details for DOI 10.1542/neo.24-1-e36

    View details for PubMedID 36587004

  • Characteristics of antifungal utilization for hospitalized children in the United States. Antimicrobial stewardship & healthcare epidemiology : ASHE Eguiguren, L., Lee, B. R., Newland, J. G., Kronman, M. P., Hersh, A. L., Gerber, J. S., Lee, G. M., Schwenk, H. T. 2022; 2 (1): e190

    Abstract

    To characterize antifungal prescribing patterns, including the indication for antifungal use, in hospitalized children across the United States.We analyzed antifungal prescribing data from 32 hospitals that participated in the SHARPS Antibiotic Resistance, Prescribing, and Efficacy among Children (SHARPEC) study, a cross-sectional point-prevalence survey conducted between June 2016 and December 2017.Inpatients aged <18 years with an active systemic antifungal order were included in the analysis. We classified antifungal prescribing by indication (ie, prophylaxis, empiric, targeted), and we compared the proportion of patients in each category based on patient and antifungal characteristics.Among 34,927 surveyed patients, 2,095 (6%) received at least 1 systemic antifungal and there were 2,207 antifungal prescriptions. Most patients had an underlying oncology or bone marrow transplant diagnosis (57%) or were premature (13%). The most prescribed antifungal was fluconazole (48%) and the most common indication for antifungal use was prophylaxis (64%). Of 2,095 patients receiving antifungals, 79 (4%) were prescribed >1 antifungal, most often as targeted therapy (48%). The antifungal prescribing rate ranged from 13.6 to 131.2 antifungals per 1,000 patients across hospitals (P < .001).Most antifungal use in hospitalized children was for prophylaxis, and the rate of antifungal prescribing varied significantly across hospitals. Potential targets for antifungal stewardship efforts include high-risk, high-utilization populations, such as oncology and bone marrow transplant patients, and specific patterns of utilization, including prophylactic and combination antifungal therapy.

    View details for DOI 10.1017/ash.2022.338

    View details for PubMedID 36505943

    View details for PubMedCentralID PMC9726632

  • Near-fatal Legionella pneumonia in a neonate linked to home humidifier by metagenomic next generation sequencing. Med (New York, N.Y.) West, P. T., Brooks, E. F., Costales, C., Moreno, A., Jensen, T. D., Budvytiene, I., Khan, A., Pham, T. H., Schwenk, H. T., Bhatt, A. S., Banaei, N. 2022

    View details for DOI 10.1016/j.medj.2022.06.004

    View details for PubMedID 35863347

  • Association of Diagnostic Stewardship for Blood Cultures in Critically Ill Children With Culture Rates, Antibiotic Use, and Patient Outcomes: Results of the Bright STAR Collaborative. JAMA pediatrics Woods-Hill, C. Z., Colantuoni, E. A., Koontz, D. W., Voskertchian, A., Xie, A., Thurm, C., Miller, M. R., Fackler, J. C., Milstone, A. M., Bright STAR Authorship Group, Agulnik, A., Albert, J. E., Auth, M. J., Bradley, E., Clayton, J. A., Coffin, S. E., Dallefeld, S., Ezetendu, C. P., Fainberg, N. A., Flaherty, B. F., Foster, C. B., Hauger, S. B., Hong, S. J., Hysmith, N. D., Kirby, A. L., Kociolek, L. K., Larsen, G. Y., Lin, J. C., Linam, W. M., Newland, J. G., Nolt, D., Priebe, G. P., Sandora, T. J., Schwenk, H. T., Smith, C. M., Steffen, K. M., Tadphale, S. D., Toltzis, P., Wolf, J., Zerr, D. M. 2022

    Abstract

    Importance: Blood culture overuse in the pediatric intensive care unit (PICU) can lead to unnecessary antibiotic use and contribute to antibiotic resistance. Optimizing blood culture practices through diagnostic stewardship may reduce unnecessary blood cultures and antibiotics.Objective: To evaluate the association of a 14-site multidisciplinary PICU blood culture collaborative with culture rates, antibiotic use, and patient outcomes.Design, Setting, and Participants: This prospective quality improvement (QI) collaborative involved 14 PICUs across the United States from 2017 to 2020 for the Bright STAR (Testing Stewardship for Antibiotic Reduction) collaborative. Data were collected from each participating PICU and from the Children's Hospital Association Pediatric Health Information System for prespecified primary and secondary outcomes.Exposures: A local QI program focusing on blood culture practices in the PICU (facilitated by a larger QI collaborative).Main Outcomes and Measures: The primary outcome was blood culture rates (per 1000 patient-days/mo). Secondary outcomes included broad-spectrum antibiotic use (total days of therapy and new initiations of broad-spectrum antibiotics ≥3 days after PICU admission) and PICU rates of central line-associated bloodstream infection (CLABSI), Clostridioides difficile infection, mortality, readmission, length of stay, sepsis, and severe sepsis/septic shock.Results: Across the 14 PICUs, the blood culture rate was 149.4 per 1000 patient-days/mo preimplementation and 100.5 per 1000 patient-days/mo postimplementation, for a 33% relative reduction (95% CI, 26%-39%). Comparing the periods before and after implementation, the rate of broad-spectrum antibiotic use decreased from 506 days to 440 days per 1000 patient-days/mo, respectively, a 13% relative reduction (95% CI, 7%-19%). The broad-spectrum antibiotic initiation rate decreased from 58.1 to 53.6 initiations/1000 patient-days/mo, an 8% relative reduction (95% CI, 4%-11%). Rates of CLABSI decreased from 1.8 to 1.1 per 1000 central venous line days/mo, a 36% relative reduction (95% CI, 20%-49%). Mortality, length of stay, readmission, sepsis, and severe sepsis/septic shock were similar before and after implementation.Conclusions and Relevance: Multidisciplinary diagnostic stewardship interventions can reduce blood culture and antibiotic use in the PICU. Future work will determine optimal strategies for wider-scale dissemination of diagnostic stewardship in this setting while monitoring patient safety and balancing measures.

    View details for DOI 10.1001/jamapediatrics.2022.1024

    View details for PubMedID 35499841

  • Updated Guidance on Use and Prioritization of Monoclonal Antibody Therapy for Treatment of COVID-19 in Adolescents. Journal of the Pediatric Infectious Diseases Society Wolf, J., Abzug, M. J., Anosike, B. I., Vora, S. B., Waghmare, A., Sue, P. K., Olivero, R. M., Oliveira, C. R., James, S. H., Morton, T. H., Maron, G. M., Young, J. L., Orscheln, R. C., Schwenk, H. T., Bio, L. L., Willis, Z. I., Lloyd, E. C., Hersh, A. L., Huskins, C. W., Soma, V. L., Ratner, A. J., Hayes, M., Downes, K., Chiotos, K., Grapentine, S. P., Wattier, R. L., Lamb, G. S., Zachariah, P., Nakamura, M. M. 1800

    Abstract

    BACKGROUND: Starting in November 2020, the US Food and Drug Administration (FDA) has issued Emergency Use Authorizations (EUAs) for multiple novel virus-neutralizing monoclonal antibody therapies, including bamlanivimab monotherapy (now revoked), bamlanivimab and etesivimab, casirivimab and imdevimab (REGEN-COV), and sotrovimab, for treatment or postexposure prophylaxis of Coronavirus disease 2019 (COVID-19) in adolescents (≥12 years of age) and adults with certain high-risk conditions. Previous guidance is now updated based on new evidence and clinical experience.METHODS: A panel of experts in pediatric infectious diseases, pediatric infectious diseases pharmacotherapy, and pediatric critical care medicine from 18 geographically diverse US institutions was convened. Through a series of teleconferences and web-based surveys, a guidance statement was developed and refined based on a review of the best available evidence and expert opinion.RESULTS: The course of COVID-19 in children and adolescents is typically mild, though more severe disease is occasionally observed. Evidence supporting risk stratification is incomplete. Randomized controlled trials have demonstrated the benefit of severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2)-specific monoclonal antibody therapies in adults, but data on safety and efficacy in children or adolescents are limited. Potential harms associated with infusion reactions or anaphylaxis are reportedly low in adults.CONCLUSIONS: Based on evidence available as of August 31, 2021, the panel suggests a risk-based approach to administration of SARS-CoV-2 monoclonal antibody therapy. Therapy is suggested for the treatment of mild to moderate COVID-19 in adolescents (≥12 years of age) at the highest risk of progression to hospitalization or severe disease. Therapeutic decision-making about those at moderate risk of severe disease should be individualized. Use as postexposure prophylaxis could be considered for those at the highest risk who have a high-risk exposure but are not yet diagnosed with COVID-19. Clinicians and health systems should ensure safe and timely implementation of these therapeutics that does not exacerbate existing healthcare disparities.

    View details for DOI 10.1093/jpids/piab124

    View details for PubMedID 35107571

  • Hidden No More: Capturing the Full Picture of Prolonged Perioperative Antibiotic Prophylaxis. Hospital pediatrics Schwenk, H. T., Bio, L. L. 1800

    View details for DOI 10.1542/hpeds.2021-006409

    View details for PubMedID 35039820

  • Leveraging antimicrobial stewardship programs in response to the coronavirus disease 2019 (COVID-19) public health emergency Antimicrobial Stewardship & Healthcare Epidemiology Joerger, T. A., Bio, L., Puckett, L., Schwenk, H. 2022; 2 (1)

    View details for DOI 10.1017/ash.2022.34

  • A National Survey of Outpatient Parenteral Antibiotic Therapy Practices. Journal of the Pediatric Infectious Diseases Society Vaz, L. E., Felder, K. K., Newland, J. G., Hersh, A. L., Rajapakse, N. S., Willis, Z. I., Banerjee, R., Gerber, J. S., Schwenk, H. T., Wang, M. E. 1800

    Abstract

    We conducted a national survey of pediatric infectious diseases (ID) clinicians on outpatient parenteral antibiotic therapy (OPAT) practices and post-discharge ID follow-up. Only 15% of sites required ID consultation for all OPAT. ID division resources for post-discharge care varied. Opportunities exist to increase ID involvement in post-discharge management of serious infections.

    View details for DOI 10.1093/jpids/piab127

    View details for PubMedID 34939654

  • Recent advances in Clostridioides difficile infection epidemiology, diagnosis and treatment in children. Current opinion in infectious diseases Kociolek, L. K., Crews, J. D., Schwenk, H. T. 2021

    Abstract

    PURPOSE OF REVIEW: The US Centers for Disease Control and Prevention (CDC) classified Clostridioides difficile as an 'urgent' public health threat that requires 'urgent and aggressive action'. This call to action has led to new discoveries that have advanced C. difficile infection (CDI) epidemiology, diagnosis and treatment, albeit predominantly in adults. In 2017, the Infectious Diseases Society of America and Society for Healthcare Epidemiology of America published clinical practice guidelines for both adults and children. At that time, recommendations in children were generally limited to relatively low-quality evidence.RECENT FINDINGS: Since publication of this guidance, there have been many advancements in the understanding of CDI in children. These include better understanding of healthcare settings as uncommon sources of C. difficile acquisition in children; risk factors for recurrent and community-associated CDI; performance of diagnostic tests in children and strategies for optimizing their use; and a more rigorous evidence base for CDI treatment in children, including the first-ever randomized controlled trial of CDI treatment in children and the largest study of fecal microbiota transplantation in children.SUMMARY: This review highlights the most recent salient advancements in paediatric CDI knowledge and practice that supplement published clinical guidance provided prior to these advancements.

    View details for DOI 10.1097/QCO.0000000000000753

    View details for PubMedID 34232137

  • Antibiotic Stewardship for the Neonatologist and Perinatologist. Clinics in perinatology Katz, S., Banerjee, R., Schwenk, H. 2021; 48 (2): 379-391

    Abstract

    Antibiotic use is common in the neonatal intensive care unit. The density and heterogeneity of antibiotic prescribing suggests inappropriate and overuse of these agents. Potential antibiotic stewardship targets include sepsis, necrotizing enterocolitis, and perioperative prophylaxis. Diagnostic stewardship principles, including appropriately obtained cultures, may be leveraged to decrease unnecessary antibiotic prescribing. Strategies including guideline development, prospective audit and feedback, and formulary restriction have been successfully deployed in the neonatal intensive care unit to improve the quality of antibiotic prescribing. Implementation of antibiotic stewardship in the neonatal intensive care unit requires multidisciplinary collaboration between neonatologists, surgeons, infectious diseases specialists, pharmacists, and nurses.

    View details for DOI 10.1016/j.clp.2021.03.009

    View details for PubMedID 34030820

  • Toxoplasmosis in Pediatric Hematopoietic Stem Cell Transplantation Patients. Transplantation and cellular therapy Schwenk, H. T., Khan, A., Kohlman, K., Bertaina, A., Cho, S., Montoya, J. G., Contopoulos-Ioannidis, D. G. 2021; 27 (4): 292–300

    Abstract

    Infection due to the protozoa Toxoplasma gondii can be life-threatening in hematopoietic stem cell transplantation (HSCT) recipients. Most cases of toxoplasmosis in HSCT recipients result from reactivation of latent infection in individuals who were Toxoplasma-seropositive before transplantation and did not receive appropriate prophylaxis. Pretransplantation screening with Toxoplasma IgG and IgM antibodies is suggested for all allogeneic HSCT recipients and their donors and all autologous HSCT recipients. Prevention of toxoplasmosis in T. gondii-seropositive HSCT recipients requires primary prophylaxis, preemptive screening, or both. Trimethoprim-sulfamethoxazole (TMP-SMX) is the preferred agent for Toxoplasma prophylaxis and should be continued for 6 months or until the patient is no longer receiving immunosuppression, whichever is longer, assuming that immune reconstitution has occurred. Preemptive weekly screening with whole blood Toxoplasma PCR should be considered for seropositive HSCT recipients if prophylaxis cannot be given or if prophylaxis other than TMP-SMX is used. The signs, symptoms, and radiographic findings of toxoplasmosis in HSCT recipients can be nonspecific, and the diagnosis requires a high degree of suspicion. Common presentations include fever, encephalopathy with mental status changes or seizures, and pneumonia. A Toxoplasma PCR analysis from whole blood (and other body fluids/tissues according to clinical symptoms) should be obtained in patients in whom there is a concern for toxoplasmosis. Treatment with oral pyrimethamine, sulfadiazine, and leucovorin for at least 6 weeks is the first-line therapy and should be followed by secondary prophylaxis. In this article, we review the published literature regarding the epidemiology, clinical presentation, treatment, and prevention of toxoplasmosis in HSCT recipients.

    View details for DOI 10.1016/j.jtct.2020.11.003

    View details for PubMedID 33840441

  • Response to Trimethoprim-Sulfamethoxazole in a Pediatric Hematopoietic Stem Cell Transplant Recipient With Disseminated Toxoplasmosis: A Case Report. Journal of the Pediatric Infectious Diseases Society Khan, A., Schwenk, H. T., Kohlman, K., Bertaina, A., Cho, S., Montoya, J. G., Contopoulos-Ioannidis, D. 2021

    Abstract

    We describe the presentation and treatment of a patient who developed ongoing fever and diagnosed with disseminated toxoplasmosis post-hematopoietic stem cell transplantation. He was initially treated with trimethoprim-sulfamethoxazole (TMP-SMX) and there was dramatic improvement in his fever curve. He successfully completed a modified course of therapy.

    View details for DOI 10.1093/jpids/piab006

    View details for PubMedID 33693793

  • Toxoplasmosis Among 38,751 Hematopoietic Stem Cell Transplant Recipients: A Systematic Review of Disease Prevalence and a Compilation of Imaging and Autopsy Findings. Transplantation Contopoulos-Ioannidis, D. G., Cho, S. M., Bertaina, A., Leung, A. N., Fischbein, N., Lanzman, B., Schwenk, H. T., Montoya, J. G. 2021

    Abstract

    BACKGROUND: Toxoplasmosis in hematopoietic stem cell transplant-recipients (HSCT) can be life threatening if not promptly diagnosed and treated.METHODS: We performed a systematic review (PubMed last search 03/29/2020) of toxoplasmosis among HSCT-recipients and calculated the toxoplasmosis prevalence across studies. We also created a compilation list of brain imaging, chest imaging and autopsy findings of toxoplasmosis among HSCT-recipients.RESULTS: We identified 46 eligible studies (47 datasets) with 399 toxoplasmosis cases among 38751 HSCT-recipients. There was large heterogeneity in the reported toxoplasmosis prevalence across studies, thus formal meta-analysis was not attempted. The median toxoplasmosis prevalence among 38751 HSCT-recipients was 2.14% (range 0-66.67%). Data on toxoplasmosis among at-risk R+HSCT-recipients were more limited (25 studies; 2404 R+HSCT-recipients [6.2% of all HSCT-recipients]) although the median number of R+HSCT-recipients was 56.79% across all HSCT-recipients. Median toxoplasmosis prevalence across studies among 2404 R+HSCT was 7.51% (range 0-80%) vs 0% (range 0-1.23%) among 7438 R-HSCT. There were limited data to allow meaningful analyses of toxoplasmosis prevalence according to prophylaxis-status of R+HSCT-recipients.CONCLUSION: Toxoplasmosis prevalence among HSCT-recipients is underestimated. The majority of studies report toxoplasmosis prevalence among all HSCT-recipients rather than only among the at-risk R+HSCT-recipients. In fact, the median toxoplasmosis prevalence among all R+/R- HSCT-recipients is 3.5-fold lower compared to the prevalence among only the at-risk R+HSCT-recipients and the median prevalence among R+HSCT-recipients is 7.51-fold higher than among R-HSCT-recipients. The imaging findings of toxoplasmosis among HSCT-recipients can be atypical. High-index of suspicion is needed in R+HSCT-recipients with fever, pneumonia or encephalitis.

    View details for DOI 10.1097/TP.0000000000003662

    View details for PubMedID 33654004

  • Initial Guidance on Use of Monoclonal Antibody Therapy for Treatment of COVID-19 in Children and Adolescents. Journal of the Pediatric Infectious Diseases Society Wolf, J. n., Abzug, M. J., Wattier, R. L., Sue, P. K., Vora, S. B., Zachariah, P. n., Dulek, D. E., Waghmare, A. n., Olivero, R. n., Downes, K. J., James, S. H., Pinninti, S. G., Yarbrough, A. n., Aldrich, M. L., MacBrayne, C. E., Soma, V. L., Grapentine, S. P., Oliveira, C. R., Hayes, M. n., Kimberlin, D. W., Jones, S. B., Bio, L. L., Morton, T. H., Hankins, J. S., Marόn-Alfaro, G. M., Timberlake, K. n., Young, J. L., Orscheln, R. C., Schwenk, H. T., Goldman, D. L., Groves, H. E., Huskins, W. C., Rajapakse, N. S., Lamb, G. S., Tribble, A. C., Lloyd, E. E., Hersh, A. L., Thorell, E. A., Ratner, A. J., Chiotos, K. n., Nakamura, M. M. 2021

    Abstract

    In November 2020, the US Food and Drug Administration (FDA) provided Emergency Use Authorizations (EUA) for two novel virus-neutralizing monoclonal antibody therapies, bamlanivimab, and REGN-COV2 (casirivimab plus imdevimab), for the treatment of mild to moderate COVID-19 in adolescents and adults in specified high-risk groups. This has challenged clinicians to determine the best approach to use of these products.A panel of experts in pediatric infectious diseases, pediatric infectious diseases pharmacy, pediatric intensive care medicine, and pediatric hematology from 29 geographically diverse North American institutions was convened. Through a series of teleconferences and web-based surveys, a guidance statement was developed and refined based on review of the best available evidence and expert opinion.The course of COVID-19 in children and adolescents is typically mild and there is no high-quality evidence supporting any high risk groups. There is no evidence for safety and efficacy of monoclonal antibody therapy for treatment of COVID-19 in children or adolescents, limited evidence of modest benefit in adults, and evidence for potential harm associated with infusion reactions or anaphylaxis.Based on evidence available as of December 20, 2020, the panel suggests against routine administration of monoclonal antibody therapy (bamlanivimab, or casirivimab and imdevimab), for treatment of COVID-19 in children or adolescents, including those designated by the FDA as at high risk of progression to hospitalization or severe disease. Clinicians and health systems choosing to use these agents on an individualized basis should consider risk factors supported by pediatric-specific evidence, and ensure implementation of a system for safe and timely administration that does not exacerbate existing healthcare disparities.

    View details for DOI 10.1093/jpids/piaa175

    View details for PubMedID 33388760

  • Pediatric Clostridioides difficile Infection: Diagnosis and Diagnostic Stewardship. Journal of the Pediatric Infectious Diseases Society Schwenk, H. T., Pollock, N. R., Vaughan-Malloy, A. M. 2021; 10 (Supplement_3): S16-S21

    Abstract

    Although the pathogenesis of Clostridioides difficile infection (CDI) is complex and incompletely understood, it is believed that the elaboration of C. difficile toxins is necessary for disease. There are a variety of tests available for the detection of both the C. difficile organism and its toxins; however, each has limitations and the best application of these tests to the diagnosis of CDI in children remains uncertain. Nucleic acid amplification tests are unable to reliably discriminate between CDI and C. difficile colonization, while commercially available enzyme immunoassays for toxin detection lack sensitivity. An understanding of preanalytic factors, relevant patient features, and test performance characteristics is essential to the accurate diagnosis of CDI in children. Specific diagnostic stewardship strategies can also increase the likelihood that positive tests reflect disease rather than colonization. Ultimately, CDI remains a clinical diagnosis and clinical judgment is essential when interpreting test results, regardless of the methods used.

    View details for DOI 10.1093/jpids/piab054

    View details for PubMedID 34791395

  • Pediatric antimicrobial stewardship practices at discharge: A national survey Infection Control & Hospital Epidemiology Wang, M. E., Felder, K., Newland, J. G., Hersh, A. L., Rajapakse, N. S., Willis, Z. I., Banerjee, R., Gerber, J. S., Schwenk, H. T., Vaz, L. E. 2021: 1-3

    Abstract

    We surveyed pediatric antimicrobial stewardship program (ASP) site leaders within the Sharing Antimicrobial Reports for Pediatric Stewardship collaborative regarding discharge stewardship practices. Among 67 sites, 13 (19%) reported ASP review of discharge antimicrobial prescriptions. These findings highlight discharge stewardship as a potential opportunity for improvement during the hospital-to-home transition.

    View details for DOI 10.1017/ice.2021.283

  • Clinical Accuracy and Impact of Plasma Cell-Free DNA Fungal PCR Panel for Non-Invasive Diagnosis of Fungal Infection. Clinical infectious diseases : an official publication of the Infectious Diseases Society of America Senchyna, F. n., Hogan, C. A., Murugesan, K. n., Moreno, A. n., Ho, D. Y., Subramanian, A. n., Schwenk, H. T., Budvytiene, I. n., Costa, H. A., Gombar, S. n., Banaei, N. n. 2021

    Abstract

    Invasive fungal infection (IFI) is a growing cause of morbidity and mortality in oncology and transplant patients. Diagnosis of IFI is often delayed due to need for invasive biopsy and low sensitivity of conventional diagnostic methods. Fungal cell-free DNA (cfDNA) detection in plasma is a novel testing modality for the non-invasive diagnosis of IFI.A novel bioinformatic pipeline was created to interrogate fungal genomes and identify multicopy sequences for cfDNA PCR targeting. A real-time PCR panel was developed for 12 genera and species most commonly causing IFI. Sensitivity and specificity of the fungal PCR panel were determined using plasma samples from patients with IFI and non-IFI controls. Clinical impact of fungal PCR panel was evaluated prospectively based on the treating team's interpretation of the results.Overall, the sensitivity and specificity were 56.5% (65/115, 95% confidence interval [CI], 47.4%-65.2%) and 99.5% (2064/2075; 95% CI, 99.0%-99.7%), respectively. In the subset of patients with an optimized plasma volume (2mL), sensitivity was 69.6% (48/69; 95% CI, 57.9%-79.2%). Sensitivity was 91.7% (11/12; 95% CI, 62.5%-100%) for detection of Mucorales agents, 56.3% (9/16; 95% CI, 33.2%-76.9%) for Aspergillus species, and 84.6% (11/13; 95% CI, 56.5%-96.9%) for Candida albicans. In a prospective evaluation of 226 patients with suspected IFI, cfDNA testing was positive in 47 (20.8%) patients and resulted in a positive impact on clinical management in 20/47 (42.6%).The fungal cfDNA PCR panel offers a non-invasive approach to early diagnosis of IFI, providing actionable results for personalized care.

    View details for DOI 10.1093/cid/ciab158

    View details for PubMedID 33606010

  • Standardization of Post-operative Antimicrobials Reduced Exposure While Maintaining Good Outcomes in Pediatric Liver Transplant Recipients. Transplant infectious disease : an official journal of the Transplantation Society Bio, L. L., Schwenk, H. T., Chen, S. F., Conlon, S., Gallo, A., Andy Bonham, C., Gans, H. A. 2020: e13538

    Abstract

    Infections following orthotopic liver transplant (OLT) result in significant morbidity and mortality, warranting careful consideration of risks associated with antibiotic overuse and benefits of infection prevention. In the absence of specific guidelines for antimicrobial prophylaxis in pediatric OLT, we developed a standardized approach to post-operative (post-op) antimicrobial therapy including 48 hours of antibiotics, no vancomycin for post-op fever within the first 48 hours, and caspofungin only for certain situations. The goal was to reduce antimicrobial utilization and adverse outcomes associated with longer duration of and broader treatment while maintaining good outcomes. The impact of this standardization on antimicrobial utilization and clinical outcomes at the largest pediatric liver transplant center in the United States is described. All individuals receiving an OLT from 1/1/17-9/30/17 (N=38) and 3/14/18-12/13/18 (N=27) were included in the pre-intervention (PreI) and post-intervention (PostI) groups, respectively. The intervention resulted in a significant reduction in individuals receiving post-op broad-spectrum gram-negative antibiotics for > 48 hours (76% PreI vs 44% PostI OLT recipients, P = 0.01) and post-op vancomycin use (50% PreI, vs 7.4% PostI, P < 0.001). There were no statistically significant differences between groups for post-op fever, positive pre-/post-operative cultures, receipt of massive transfusion, or hospital length of stay. In conclusion, following the implementation of a standardized approach to post-op prophylaxis, antimicrobial exposure was significantly reduced without affecting OLT recipient outcomes.

    View details for DOI 10.1111/tid.13538

    View details for PubMedID 33252820

  • Use of Prospective Audit and Feedback to Reduce Antibiotic Exposure in a Pediatric Cardiac ICU. Pediatric critical care medicine : a journal of the Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies Schwenk, H. T., Kruger, J. F., Sacks, L. D., Wood, M. S., Qureshi, L., Bio, L. L. 2020

    Abstract

    OBJECTIVES: We sought to determine whether a prospective audit and feedback intervention decreased antibiotic utilization in a pediatric cardiac ICU and to describe the characteristics of prospective audit and feedback audits and recommendations.DESIGN: Before-after study.SETTING: Pediatric cardiac ICU of a freestanding children's hospital.PATIENTS: All patients admitted to the cardiac ICU.INTERVENTIONS: A prospective audit and feedback program was established in our hospital's pediatric cardiac ICU on December 7, 2015. The antimicrobial stewardship program audited IV antibiotics, communicated prospective audit and feedback recommendations to the cardiac ICU, and regularly reviewed recommendation adherence. Mean monthly antibiotic utilization 18 months before ("preprospective audit and feedback"; from June 1, 2014 to November 30, 2015) and 24 months after ("prospective audit and feedback"; from January 1, 2016 to December 31, 2017) prospective audit and feedback implementation was compared. Antibiotic audit data during the prospective audit and feedback period were reviewed to capture the characteristics of prospective audit and feedback audits, recommendations, and adherence.MEASUREMENTS AND MAIN RESULTS: Mean cardiac ICU IV antibiotic use decreased 20% (701 vs 880 days of therapy per 1,000 patient days, p = 0.001) during the prospective audit and feedback period compared with the preprospective audit and feedback period. There was no difference in mean cardiac ICU length of stay (p = 0.573), mean hospital length of stay (p = 0.722), or the rate of discharge due to death (p = 0.541). There were 988 antibiotic audits and 370 prospective audit and feedback recommendations (37% recommendation rate) during the study period. The most commonly audited antibiotic category was broad-spectrum gram-negative agents and the most common indication for use was sepsis. Broad-spectrum gram-positive agents were more likely to be associated with a recommendation.CONCLUSIONS: There was a significant reduction in antibiotic use following implementation of a prospective audit and feedback program in our pediatric cardiac ICU. Over one-third of antibiotics audited in our cardiac ICU were associated with a prospective audit and feedback recommendation, revealing important targets for future antimicrobial stewardship efforts in this population.

    View details for DOI 10.1097/PCC.0000000000002608

    View details for PubMedID 33258575

  • The current state of antifungal stewardship among pediatric antimicrobial stewardship programs. Infection control and hospital epidemiology Eguiguren, L., Newland, J. G., Kronman, M. P., Hersh, A. L., Gerber, J. S., Lee, G. M., Schwenk, H. T. 2020: 1–6

    Abstract

    OBJECTIVE: To characterize the current state of antifungal stewardship practices and perceptions of antifungal use among pediatric antimicrobial stewardship programs (ASPs).DESIGN: We developed and distributed an electronic survey, which included 17 closed-ended questions about institutional antifungal stewardship practices and perceptions, among pediatric ASPs.PARTICIPANTS: ASP physicians and pharmacists of 74 hospitals participating in the multicenter Sharing Antimicrobial Reports for Pediatric Stewardship (SHARPS) Collaborative.RESULTS: We sent surveys to 74 hospitals and received 68 unique responses, for a response rate of 92%. Overall, 63 of 68 the respondent ASPs (93%) reported that they conduct 1 or more antifungal stewardship activities. Of these 68 hospital ASPs, 43 (63%) perform prospective audit and feedback (PAF) of antifungals. The most common reasons reported for not performing PAF of antifungals were not enough time or resources (19 of 25, 76%) and minimal institutional antifungal use (6 of 25, 24%). Also, 52 hospitals (76%) require preauthorization for 1 or more antifungal agents. The most commonly restricted antifungals were isavuconazole (42 of 52 hospitals, 80%) and posaconazole (39 of 52 hospitals, 75%). Furthermore, 33 ASPs (48%) agreed or strongly agreed that antifungals are inappropriately used at their institution, and only 25 of 68 (37%) of ASPs felt very confident making recommendations about antifungals.CONCLUSIONS: Most pediatric ASPs steward antifungals, but the strategies employed are highly variable across surveyed institutions. Although nearly half of respondents identified inappropriate antifungal use as a problem at their institution, most ASPs do not feel confident making recommendations about antifungals. Future studies are needed to determine the rate of inappropriate antifungal use and the best antifungal stewardship strategies.

    View details for DOI 10.1017/ice.2020.306

    View details for PubMedID 32662383

  • Inpatient Observation After Transition From Intravenous to Oral Antibiotics. Hospital pediatrics Stromberg, T. L., Robison, A. D., Kruger, J. F., Bentley, J. P., Schwenk, H. T. 2020

    Abstract

    OBJECTIVES: Children hospitalized with infections are commonly transitioned from intravenous (IV) to enteral (per os [PO]) antibiotics before discharge, after which they may be observed in the hospital to ensure tolerance of PO therapy and continued clinical improvement. We sought to describe the frequency and predictors of in-hospital observation after transition from IV to PO antibiotics in children admitted for skin and soft tissue infections (SSTIs).METHODS: We conducted a retrospective cohort study of children with SSTIs discharged between January 1, 2016, and June 30, 2018, using the Pediatric Health Information System database. Children were classified as observed if hospitalized ≥1 day after transitioning from IV to PO antibiotics. We calculated the proportion of observed patients and used logistic regression with random intercepts to identify predictors of in-hospital observation.RESULTS: Overall, 15% (558 of 3704) of hospitalizations for SSTIs included observation for ≥1 hospital day after the transition from IV to PO antibiotics. The proportion of children observed differed significantly between hospitals (range of 4%-27%; P < .001). Observation after transition to PO antibiotics was less common in older children (adjusted odds ratio [aOR] = 0.69; 95% confidence interval [CI] 0.52-0.90; P = .045). Children initially prescribed vancomycin (aOR = 1.36; 95% CI 1.03-1.79; P = .032) or with infections located on the neck (aOR = 1.72; 95% CI 1.32-2.24; P < .001) were more likely to be observed.CONCLUSIONS: Children hospitalized for SSTIs are frequently observed after transitioning from IV to PO antibiotics, and there is substantial variability in the observation rate between hospitals. Specific factors predict in-hospital observation and should be investigated as part of future studies aimed at improving the care of children hospitalized with SSTIs.

    View details for DOI 10.1542/hpeds.2020-0047

    View details for PubMedID 32532795

  • Reporting and Categorization of Blood Culture Contaminants in Infants and Young Children: A Scoping Review JOURNAL OF THE PEDIATRIC INFECTIOUS DISEASES SOCIETY Chappell-Campbell, L., Schwenk, H. T., Capdarest-Arest, N., Schroeder, A. R. 2020; 9 (2): 110–17
  • Clinical Impact of Clostridium difficile PCR Cycle Threshold-Predicted Toxin Reporting in Pediatric Patients JOURNAL OF THE PEDIATRIC INFECTIOUS DISEASES SOCIETY Schwenk, H. T., Bio, L. L., Kruger, J. F., Banaei, N. 2020; 9 (1): 44–50
  • A 10-Month-Old Female With Complicated Mastoiditis Due to Fusobacterium necrophorum: A Case Report and Literature Review. Journal of the Pediatric Infectious Diseases Society Rosenthal, A. n., Gans, H. n., Schwenk, H. T. 2020

    View details for DOI 10.1093/jpids/piaa059

    View details for PubMedID 32531061

  • Multicenter initial guidance on use of antivirals for children with COVID-19/SARS-CoV-2. Journal of the Pediatric Infectious Diseases Society Chiotos, K. n., Hayes, M. n., Kimberlin, D. W., Jones, S. B., James, S. H., Pinninti, S. G., Yarbrough, A. n., Abzug, M. J., MacBrayne, C. E., Soma, V. L., Dulek, D. E., Vora, S. B., Waghmare, A. n., Wolf, J. n., Olivero, R. n., Grapentine, S. n., Wattier, R. L., Bio, L. n., Cross, S. J., Dillman, N. O., Downes, K. J., Timberlake, K. n., Young, J. n., Orscheln, R. C., Tamma, P. D., Schwenk, H. T., Zachariah, P. n., Aldrich, M. n., Goldman, D. L., Groves, H. E., Lamb, G. S., Tribble, A. C., Hersh, A. L., Thorell, E. A., Denison, M. R., Ratner, A. J., Newland, J. G., Nakamura, M. M. 2020

    Abstract

    Although Coronavirus Disease 2019 (COVID-19) is mild in nearly all children, a small proportion of pediatric patients develops severe or critical illness. Guidance is therefore needed regarding use of agents with potential activity against severe acute respiratory syndrome coronavirus 2 in pediatrics.A panel of pediatric infectious diseases physicians and pharmacists from 18 geographically diverse North American institutions was convened. Through a series of teleconferences and web-based surveys, a set of guidance statements was developed and refined based on review of best available evidence and expert opinion.Given the typically mild course of pediatric COVID-19, supportive care alone is suggested for the overwhelming majority of cases. The panel suggests a decision-making framework for antiviral therapy that weighs risks and benefits based on disease severity as indicated by respiratory support needs, with consideration on a case-by-case basis of potential pediatric risk factors for disease progression. If an antiviral is used, the panel suggests remdesivir as the preferred agent. Hydroxychloroquine could be considered for patients who are not candidates for remdesivir or when remdesivir is not available. Antivirals should preferably be used as part of a clinical trial if available.Antiviral therapy for COVID-19 is not necessary for the great majority of pediatric patients. For those rare children who develop severe or critical disease, this guidance offer an approach for decision-making regarding antivirals, informed by available data. As evidence continues to evolve rapidly, the need for updates to the guidance is anticipated.

    View details for DOI 10.1093/jpids/piaa045

    View details for PubMedID 32318706

  • Multicenter interim guidance on use of antivirals for children with COVID-19/SARS-CoV-2. Journal of the Pediatric Infectious Diseases Society Chiotos, K. n., Hayes, M. n., Kimberlin, D. W., Jones, S. B., James, S. H., Pinninti, S. G., Yarbrough, A. n., Abzug, M. J., MacBrayne, C. E., Soma, V. L., Dulek, D. E., Vora, S. B., Waghmare, A. n., Wolf, J. n., Olivero, R. n., Grapentine, S. n., Wattier, R. L., Bio, L. n., Cross, S. J., Dillman, N. O., Downes, K. J., Oliveira, C. R., Timberlake, K. n., Young, J. n., Orscheln, R. C., Tamma, P. D., Schwenk, H. T., Zachariah, P. n., Aldrich, M. L., Goldman, D. L., Groves, H. E., Rajapakse, N. S., Lamb, G. S., Tribble, A. C., Hersh, A. L., Thorell, E. A., Denison, M. R., Ratner, A. J., Newland, J. G., Nakamura, M. M. 2020

    Abstract

    Although Coronavirus Disease 2019 (COVID-19) is a mild infection in most children, a small proportion develop severe or critical illness. Data evaluating agents with potential antiviral activity continue to expand, such that updated guidance is needed regarding use of these agents in children.A panel of pediatric infectious diseases physicians and pharmacists from 20 geographically diverse North American institutions was convened. Through a series of teleconferences and web-based surveys, a set of guidance statements was developed and refined based on review of the best available evidence and expert opinion.Given the typically mild course of COVID-19 in children, supportive care alone is suggested for most cases. For children with severe illness, defined as a supplemental oxygen requirement without need for non-invasive or invasive mechanical ventilation or extra-corporeal membrane oxygenation (ECMO), remdesivir is suggested, preferably as part of a clinical trial if available. Remdesivir should also be considered for critically ill children requiring invasive or non-invasive mechanical ventilation or ECMO. A duration of 5 days is appropriate for most patients. The panel recommends against the use of hydroxychloroquine or lopinavir-ritonavir (or other protease inhibitors) for COVID-19 in children.Antiviral therapy for COVID-19 is not necessary for the great majority of pediatric patients. For children with severe or critical disease, this guidance offers an approach for decision-making regarding use of remdesivir.

    View details for DOI 10.1093/jpids/piaa115

    View details for PubMedID 32918548

  • Model-Informed Precision Dosing of Vancomycin in Hospitalized Children: Implementation and Adoption at an Academic Children's Hospital. Frontiers in pharmacology Frymoyer, A. n., Schwenk, H. T., Zorn, Y. n., Bio, L. n., Moss, J. D., Chasmawala, B. n., Faulkenberry, J. n., Goswami, S. n., Keizer, R. J., Ghaskari, S. n. 2020; 11: 551

    Abstract

    Model-informed precision dosing (MIPD) can serve as a powerful tool during therapeutic drug monitoring (TDM) to help individualize dosing in populations with large pharmacokinetic variation. Yet, adoption of MIPD in the clinical setting has been limited. Overcoming technologic hurdles that allow access to MIPD at the point-of-care and placing it in the hands of clinical specialists focused on medication dosing may encourage adoption.To describe the hospital implementation and usage of a MIPD clinical decision support (CDS) tool for vancomycin in a pediatric population.Within an academic children's hospital, MIPD for vancomycin was implemented via a commercial cloud-based CDS tool that utilized Bayesian forecasting. Clinical pharmacists were recognized as local champions to facilitate adoption of the tool and operated as end-users. Integration within the electronic health record (EHR) and automatic transmission of patient data to the tool were identified as important requirements. A web-link icon was developed within the EHR which when clicked sends users and needed patient-level clinical data to the CDS platform. Individualized pharmacokinetic predictions and exposure metrics for vancomycin are then presented in the form of a web-based dashboard. Use of the CDS tool as part of TDM was tracked and users were surveyed on their experience.After a successful pilot phase in the neonatal intensive care unit, implementation of MIPD was expanded to the pediatric intensive care unit, followed by availability to the entire hospital. During the first 2+ years since implementation, a total of 853 patient-courses (n = 96 neonates, n = 757 children) and 2,148 TDM levels were evaluated using the CDS tool. For the most recent 6 months, the CDS tool was utilized to support 79% (181/230) of patient-courses in which TDM was performed. Of 26 users surveyed, > 96% agreed or strongly agreed that automatic transmission of patient data to the tool was a feature that helped them complete tasks more efficiently; 81% agreed or strongly agreed that they were satisfied with the CDS tool.Integration of a vancomycin CDS tool within the EHR, along with leveraging the expertise of clinical pharmacists, allowed for successful adoption of MIPD in clinical care.

    View details for DOI 10.3389/fphar.2020.00551

    View details for PubMedID 32411000

    View details for PubMedCentralID PMC7201037

  • Reducing Piperacillin and Tazobactam Use for Pediatric Perforated Appendicitis. The Journal of surgical research Seddik, T. B., Rabsatt, L. A., Mueller, C. n., Bassett, H. K., Contopoulos-Ioannidis, D. n., Bio, L. L., Anderson, V. D., Schwenk, H. T. 2020; 260: 141–48

    Abstract

    Although perforated appendicitis is associated with infectious complications, the choice of antibiotic therapy is controversial. We assess the effectiveness and safety of an intervention to reduce piperacillin and tazobactam (PT) use for pediatric acute perforated appendicitis.This is a single-center, retrospective cohort study of children 18 y of age who underwent primary appendectomy for perforated appendicitis between January 01, 2016 and June 30, 2019. An intervention to decrease PT use was implemented: the first phase was provider education (April 19, 2017) and the second phase was modification of electronic antibiotic orders to default to ceftriaxone and metronidazole (July 06, 2017). Preintervention and postintervention PT exposure, use of PT ≥ half of intravenous antibiotic days, and clinical outcomes were compared.Forty children before and 109 after intervention were included and had similar baseline characteristics. PT exposure was 31 of 40 (78%) and 20 of 109 (18%) (P < 0.001), and use ≥ half of intravenous antibiotic days was 31 of 40 (78%) and 14 of 109 (13%) (P < 0.001), in the preintervention and postintervention groups, respectively. There was no significant difference in mean duration of antibiotic therapy (10.8 versus 9.8 d), mean length of stay (6.2 versus 6.5 d), rate of surgical site infection (10% versus 11%), or rate of 30-d readmission and emergency department visit (20% versus 20%) between the preintervention and postintervention periods, respectively.Provider education and modification of electronic antibiotic orders safely reduced the use of PT for pediatric perforated appendicitis.

    View details for DOI 10.1016/j.jss.2020.11.067

    View details for PubMedID 33340867

  • A multifaceted quality improvement project improves intraoperative redosing of surgical antimicrobial prophylaxis during pediatric surgery PEDIATRIC ANESTHESIA Colletti, A. A., Wang, E., Marquez, J. L., Schwenk, H. T., Yeverino, C., Sharek, P. J., Caruso, T. J. 2019; 29 (7): 705–11

    View details for DOI 10.1111/pan.13651

    View details for Web of Science ID 000478990900006

  • Dipylidium caninum Infection. The New England journal of medicine Hogan, C. A., Schwenk, H. 2019; 380 (21): e39

    View details for DOI 10.1056/NEJMicm1813985

    View details for PubMedID 31116922

  • A multifaceted quality improvement project improves intraoperative redosing of surgical antimicrobial prophylaxis during pediatric surgery. Paediatric anaesthesia Colletti, A. A., Wang, E. n., Marquez, J. L., Schwenk, H. T., Yeverino, C. n., Sharek, P. J., Caruso, T. J. 2019

    Abstract

    Accurate intraoperative antibiotic redosing contributes to prevention of surgical site infections in pediatric patients. Ensuring compliance with evolving national guidelines of weight-based, intraoperative redosing of antibiotics is challenging to pediatric anesthesiologists.Our primary aim was to increase compliance of antibiotic redoses at the appropriate time and appropriate weight-based dose to 70%. Secondary aims included a subset analysis of time compliance and dose compliance individually, and compliance based on order entry method of the first dose (verbal or electronic).At a freestanding, academic pediatric hospital, we reviewed surgical cases between May 1, 2014 and October 31, 2017 requiring antibiotic redoses. After an institutional change in cefazolin dosing in May 2015, phased interventions to improve compliance included electronic countermeasures to display previous and next dose timing, an alert five minutes prior to next dose, and weight-based dose recommendation (September 2015). Physical countermeasures include badge cards, posting of guidelines, and updates to housestaff manual (September 2015). Statistical process control charts were used to assess overall antibiotic redose compliance, time compliance, and dose compliance. The chi-square test was used to analyze group differences.3,015 antibiotic redoses were administered during 2,341 operative cases between May 1, 2014 and October 31, 2017. Mean monthly compliance with redosing was 4.3% (May 2014-April 2015) and 73% (November 2015-October 2017) (p < 0.001). Dose-only compliance increased from 76% to 89% (p < 0.001) and time-only compliance increased from 4.9 to 82% (p < 0.001). After implementation of countermeasures, electronic order entry compared with verbal order was associated with higher dose compliance, 90% vs. 86% (p = 0.015).This quality improvement project, utilizing electronic and physical interventions, was effective in improving overall prophylactic antibiotic redosing compliance in accordance with institutional redosing guidelines. This article is protected by copyright. All rights reserved.

    View details for PubMedID 31034725

  • Reporting and Categorization of Blood Culture Contaminants in Infants and Young Children: A Scoping Review. Journal of the Pediatric Infectious Diseases Society Chappell-Campbell, L., Schwenk, H. T., Capdarest-Arest, N., Schroeder, A. R. 2018

    Abstract

    Background: Blood cultures are obtained routinely for infants and young children for the evaluation for serious bacterial infection. Isolation of organisms that represent possible contaminants poses a management challenge. The prevalence of bacteremia reported in this population is potentially biased by inconsistent contaminant categorization reported in the literature. Our aim was to systematically review the definition and reporting of contaminants within the literature regarding infant bacteremia.Methods: A search of studies published between 1986 and mid-September 2016 was conducted using Medline/PubMed. Included studies examined children aged 0 to 36 months for whom blood culture was performed as part of a serious bacterial infection evaluation. Studies that involved children in an intensive care unit, prematurely born children, and immunocompromised children or those with an indwelling catheter/device were excluded. Data extracted included contaminant designation methodology, organisms classified as contaminants and pathogens, and contamination and bacteremia rates.Discussion: Our search yielded 1335 articles, and 69 of them met our inclusion criteria. The methodology used to define contaminants was described in 37 (54%) study reports, and 16 (23%) reported contamination rates, which ranged from 0.5% to 22.8%. Studies defined contaminants according to organism species (n = 22), according to the patient's clinical management (n = 4), and using multifactorial approaches (n = 11). Many common organisms, particularly Gram-positive cocci, were inconsistently categorized as pathogens or contaminants.Conclusions: Reporting and categorization of blood culture contamination are inconsistent within the pediatric bacteremia literature, which limits our ability to estimate the prevalence of bacteremia. Although contaminants are characterized most frequently according to organism, we found inconsistency regarding the classification of certain common organisms. A standardized approach to contaminant reporting is needed.

    View details for PubMedID 30544178

  • Clinical Impact of Clostridium difficile PCR Cycle Threshold-Predicted Toxin Reporting in Pediatric Patients. Journal of the Pediatric Infectious Diseases Society Schwenk, H. T., Bio, L. L., Kruger, J. F., Banaei, N. 2018

    Abstract

    Background: Reliance on tests that detect only the presence of toxigenic Clostridium difficile can result in overdiagnosis and overtreatment of C difficile infection (CDI). The C difficile polymerase chain reaction (PCR) cycle threshold (CT) can sensitively predict the presence of free C difficile toxins; however, the clinical application for this testing strategy remains unexplored. We evaluated the impact of dual PCR and toxin result reporting, as predicted by the CT, on CDI management and outcomes in children.Methods: Before the intervention, results for C difficile testing at Lucile Packard Children's Hospital Stanford were reported as PCR positive (PCR+) or negative (PCR-) according to the GeneXpert C diff Epi tcdB PCR assay (Cepheid, Sunnyvale, California). Beginning October 5, 2016, the presence of free toxins, as predicted by the CT, was reported also. The CDI treatment rates 1 year before and 18 months after implementation of toxin reporting were compared. Demographic and treatment-related data were collected, and patient outcomes were followed up 8 weeks later.Results: CDI treatment decreased 22% after the intervention (96% [preintervention] vs 74% [postintervention]; P < .001). During the postintervention period, there were 152 PCR+C difficile results, and 94 (62%) of them were toxin positive (toxin+) according to the CT. Of the 58 PCR+/toxin-negative (toxin-) results, 38 (66%) did not result in CDI treatment. Seven (18%) of the untreated PCR+/toxin- patients underwent repeat testing within 8 weeks, and 5 (13%) of them were subsequently PCR+/toxin+ and treated. No CDI-related complications were identified.Conclusions: Addition of the CT-predicted C difficile toxin result to PCR reporting reduces the proportion of PCR+ children treated for CDI.

    View details for PubMedID 30476169

  • Liver Failure and Rash in a 6-week-old Girl PEDIATRICS IN REVIEW Mediratta, R., Schwenk, H., Rao, A., Chitkara, R. 2018; 39 (6): 315–U22

    View details for PubMedID 29858298

  • Predictors of Antimicrobial Stewardship Program Recommendation Disagreement. Infection control and hospital epidemiology Bio, L. L., Kruger, J. F., Lee, B. P., Wood, M. S., Schwenk, H. T. 2018: 1–8

    Abstract

    OBJECTIVETo identify predictors of disagreement with antimicrobial stewardship prospective audit and feedback recommendations (PAFR) at a free-standing children's hospital.DESIGNRetrospective cohort study of audits performed during the antimicrobial stewardship program (ASP) from March 30, 2015, to April 17, 2017.METHODSThe ASP included audits of antimicrobial use and communicated PAFR to the care team, with follow-up on adherence to recommendations. The primary outcome was disagreement with PAFR. Potential predictors for disagreement, including patient-level, antimicrobial, programmatic, and provider-level factors, were assessed using bivariate and multivariate logistic regression models.RESULTSIn total, 4,727 antimicrobial audits were performed during the study period; 1,323 PAFR (28%) and 187 recommendations (15%) were not followed due to disagreement. Providers were more likely to disagree with PAFR when the patient had a gastrointestinal infection (odds ratio [OR], 5.50; 95% confidence interval [CI], 1.99-15.21), febrile neutropenia (OR, 6.14; 95% CI, 2.08-18.12), skin or soft-tissue infections (OR, 6.16; 95% CI, 1.92-19.77), or had been admitted for 31-90 days at the time of the audit (OR, 2.08; 95% CI, 1.36-3.18). The longer the duration since the attending provider had been trained (ie, the more years of experience), the more likely they were to disagree with PAFR recommendations (OR, 1.02; 95% CI, 1.01-1.04).CONCLUSIONSEvaluation of our program confirmed patient-level predictors of PAFR disagreement and identified additional programmatic and provider-level factors, including years of attending experience. Stewardship interventions focused on specific diagnoses and antimicrobials are unlikely to result in programmatic success unless these factors are also addressed.Infect Control Hosp Epidemiol 2018;1-8.

    View details for DOI 10.1017/ice.2018.85

    View details for PubMedID 29708081

  • IMPLEMENTATION OF A VANCOMYCIN MODEL-BASED DOSING TOOL INTEGRATED WITHIN THE ELECTRONIC HEALTH RECORD. Goswami, S., Keizer, R., Ghaskari, S., Schneider, L., Faulkenberry, J. H., Chasmawala, B., Schwenk, H. T., Frymoyer, A. WILEY. 2018: S68
  • An Observational Study of Severe Pertussis in 100 Infants 120 Days of Age PEDIATRIC INFECTIOUS DISEASE JOURNAL Cherry, J. D., Wendorf, K., Bregman, B., Lehman, D., Nieves, D., Bradley, J. S., Mason, W. H., Sande-Lopez, L., Lopez, M., Federman, M., Chen, T., Blumberg, D., Johnston, S., Schwenk, H. T., Weintrub, P., Quinn, K. K., Winter, K., Harriman, K. 2018; 37 (3): 202–5

    Abstract

    Pertussis in young infants is a unique, severe, afebrile, cough illness that is frequently fatal.All pertussis cases ≤120 days of age admitted to a pediatric intensive care unit in California between October 1, 2013, and April 25, 2015, were evaluated.Of 100 pertussis patients ≤120 days of age admitted to pediatric intensive care unit, there were 5 deaths. The white blood cell counts in the fatal cases were significantly higher than in the nonfatal cases. Thirty-four percent of patients were intubated, 18% received inotropic and/or vasoactive support, 22% received steroid, 4% received extracorporal membrane oxygenation, and 3% underwent exchange blood transfusion. The median age at the time of illness onset in the patients who died was 23 days.These data, as well as data from previous California studies, suggest updated strategies for the management of severe pertussis. These include perform serial white blood cell counts, treat all presumptive cases with azithromycin, evaluate for pulmonary hypertension, intubate and administer oxygen for apneic episodes and administer inotropic/vasoactive agents for cardiogenic shock. Do not administer steroids or nitric oxide. Criteria for exchange blood transfusion therapy for leukocytosis with lymphocytosis are suggested.

    View details for DOI 10.1097/INF.0000000000001710

    View details for Web of Science ID 000426088200010

    View details for PubMedID 28737623

  • A Postoperative Care Bundle Reduces Surgical Site Infections in Pediatric Patients Undergoing Cardiac Surgeries. Joint Commission journal on quality and patient safety Caruso, T. J., Wang, E. Y., Schwenk, H. n., Marquez, J. L., Cahn, J. n., Loh, L. n., Schaffer, J. n., Chen, K. n., Wood, M. n., Sharek, P. J. 2018

    Abstract

    Pediatric patients undergoing cardiac surgeries are at an increased surgical site infection (SSI) risk, given prolonged cardiopulmonary bypasses and delayed sternal closures. At one institution, the majority of cardiac patients developed SSIs during prolonged recoveries in the cardiovascular intensive care unit (CVICU). Although guidelines have been published to reduce SSIs in the perioperative period, there have been few guidelines to reduce the risk during prolonged hospital recoveries. The aim of this project was to study a postoperative SSI reduction care bundle, with a goal of reducing cardiac SSIs by 50%, from 3.4 to 1.7 per 100 procedures.This project was conducted at a quaternary, pediatric academic center with a 20-bed CVICU. Historical control data were recorded from January 2013 through May 2015 and intervention/sustainment data from June 2015 through March 2017. A multidisciplinary SSI reduction team developed five key drivers that led to implementation of 11 postoperative SSI reduction care elements. Statistical process control charts were used to measure process compliance, and Pearson's chi-square test was used to determine differences in SSI rates.Prior to implementation, there were 27 SSIs in 799 pediatric cardiac surgeries (3.4 SSIs per 100 surgeries). After the intervention, SSIs significantly decreased to 5 in 570 procedures (0.9 SSIs per 100 surgeries; p = 0.0045).This project describes five key drivers and 11 elements that were dedicated to reducing the risk of SSI during prolonged CVICU recoveries from pediatric cardiac surgery, with demonstrated sustainability.

    View details for DOI 10.1016/j.jcjq.2018.05.009

    View details for PubMedID 30170753

  • A quality improvement initiative to optimize dosing of surgical antimicrobial prophylaxis. Paediatric anaesthesia Caruso, T. J., Wang, E., Schwenk, H. T., Scheinker, D., Yeverino, C., Tweedy, M., Maheru, M., Sharek, P. J. 2017; 27 (7): 702-710

    Abstract

    The risk of surgical site infections is reduced with appropriate timing and dosing of preoperative antimicrobials. Based on evolving national guidelines, we increased the preoperative dose of cefazolin from 25 to 30 mg·kg(-1) . This quality improvement project describes an improvement initiative to develop standard work processes to ensure appropriate dosing.The primary aim was to deliver cefazolin 30 mg·kg(-1) to at least 90% of indicated patients. The secondary aim was to determine differences between accuracy of cefazolin doses when given as an electronic order compared to a verbal order.Data were collected from January 1, 2012 to May 31, 2016. A quality improvement team of perioperative physicians, nurses, and pharmacists implemented a series of interventions including new electronic medical record order sets, personal provider antibiotic dose badges, and utilization of pharmacists to prepare antibiotics to increase compliance with the recommended dose. Process compliance was measured using a statistical process control chart, and dose compliance was measured through electronic analysis of the electronic medical record. Secondary aim data were displayed as percentage of dose compliance. An unpaired t-test was used to determine differences between groups.Between January 1, 2012 and May 31, 2016, cefazolin was administered to 9086 patients. The mean compliance of cefazolin at 30 mg·kg(-1) from May 2013 to March 2014 was 40%, which prompted initiation of this project. From April 2014 to May 2016, a series of interventions were deployed. The mean compliance from September 2015 to May 2016 was 93% with significantly reduced variation and no special cause variation, indicating that the process was in control at the target primary aim. There were 649 cefazolin administrations given verbally and 1929 given with an electronic order between October 1, 2014 and May 31, 2016. During this time period, the rate of compliance of administering cefazolin at 30 mg·kg(-1) was significantly higher when given after an electronic order than when given verbally, 94% vs 76%.This comprehensive quality improvement project improved practitioner compliance with evidence-based preoperative antimicrobial dosing recommendations to reduce the risk of surgical site infections.

    View details for DOI 10.1111/pan.13137

    View details for PubMedID 28321988

  • Subacute Sclerosing Panencephalitis: The Foothold in Undervaccination JOURNAL OF PEDIATRICS Holt, R. L., Kann, D., Rassbach, C. E., Schwenk, H. T., Ritter, J. M., Rota, P. A., Elbers, J. 2016; 179: 259-262

    Abstract

    Subacute sclerosing panencephalitis (SSPE) is a fatal complication of measles infection. We present a case of a fully vaccinated 3-year-old boy who was diagnosed with and treated for autoimmune encephalitis before arriving at a diagnosis of SSPE. We discuss the challenges of diagnosing SSPE in developed countries.

    View details for DOI 10.1016/j.jpeds.2016.08.051

    View details for PubMedID 27634625

  • Anchoring Bias as a Limiting Factor in High-Value Care: A Case of Fever of Unknown Origin in a Hospitalized Child. Hospital pediatrics Festa, N., Park, K. T., Schwenk, H. 2016; 6 (11): 699-701

    View details for PubMedID 27789539

  • Fever and Renal Failure in a Child With DiGeorge Syndrome and Tetralogy of Fallot. Journal of the Pediatric Infectious Diseases Society Itoh, M., Kann, D. C., Schwenk, H. T., Gans, H. A. 2015; 4 (4): 373-375

    View details for DOI 10.1093/jpids/piv029

    View details for PubMedID 26407263

  • Bordetella petrii Sinusitis in an Immunocompromised Adolescent. Pediatric infectious disease journal Nagata, J. M., Charville, G. W., Klotz, J. M., Wickremasinghe, W. R., Kann, D. C., Schwenk, H. T., Longhurst, C. A. 2015; 34 (4): 458-?

    View details for DOI 10.1097/INF.0000000000000564

    View details for PubMedID 25760569

  • Coping with college and inflammatory bowel disease: implications for clinical guidance and support. Inflammatory bowel diseases Schwenk, H. T., Lightdale, J. R., Arnold, J. H., Goldmann, D. A., Weitzman, E. R. 2014; 20 (9): 1618-1627

    Abstract

    Studies have shown that young adults with chronic diseases, including inflammatory bowel disease (IBD), experience greater difficulty during the transition to college, reaching lower levels of educational attainment and reporting greater levels of perceived stress than their otherwise-healthy peers. We performed a qualitative study to better understand how underlying illness shapes the college experience for patients with IBD and how the college experience, in turn, impacts disease management.Fifteen college students with IBD were recruited from the Boston Children's Hospital Center for IBD. We conducted an approximately 1 hour semistructured qualitative interview with each participant, and the interviews were thematically analyzed after an iterative and inductive process.Four primary themes were identified: (1) The transition experience of college students with IBD is shaped by their health status, perceived readiness, and preparedness, (2) Elements of the college environment pose specific challenges to young adults with IBD that require adaptive strategies, (3) College students with IBD integrate their underlying illness with their individual and social identity, and (4) College students navigate health management by conceptualizing themselves, their families, and providers as serving particular roles.For young adults with IBD, college is a proving ground for demonstrating self-care and disease management practices. Future initiatives aimed at this population should recognize the evolving roles of patients, parents, and providers in disease management. Increased attention should also be paid to the promotion of patient's self-management and the unique challenges of the structural and psychosocial college environment.

    View details for DOI 10.1097/MIB.0000000000000124

    View details for PubMedID 25105948

  • Progressive multifocal leukoencephalopathy in pediatric patients: case report and literature review. Pediatric infectious disease journal Schwenk, H., Ramirez-Avila, L., Sheu, S., Wuthrich, C., Waugh, J., Was, A., DeGirolami, U., Burchett, S., Koralnik, I. J., Ahmed, A. 2014; 33 (4): e99-105

    Abstract

    Progressive multifocal leukoencephalopathy is a rare, demyelinating disease of the central nervous system caused by JC virus. Fewer than 30 cases have been reported in HIV- and non-infected children. We report the case of a 15-year-old girl with progressive multifocal leukoencephalopathy and AIDS who presented with nystagmus, dysarthria and ataxia. Following combined antiretroviral therapy, she developed immune reconstitution inflammatory syndrome, which proved fatal.

    View details for DOI 10.1097/INF.0000000000000237

    View details for PubMedID 24632669

  • Progressive multifocal leukoencephalopathy in pediatric patients: case report and literature review. Pediatric infectious disease journal Schwenk, H., Ramirez-Avila, L., Sheu, S., Wuthrich, C., Waugh, J., Was, A., DeGirolami, U., Burchett, S., Koralnik, I. J., Ahmed, A. 2014; 33 (4): e99-e105

    Abstract

    Progressive multifocal leukoencephalopathy is a rare, demyelinating disease of the central nervous system caused by JC virus. Fewer than 30 cases have been reported in HIV- and non-infected children. We report the case of a 15-year-old girl with progressive multifocal leukoencephalopathy and AIDS who presented with nystagmus, dysarthria and ataxia. Following combined antiretroviral therapy, she developed immune reconstitution inflammatory syndrome, which proved fatal.

    View details for DOI 10.1097/INF.0000000000000237

    View details for PubMedID 24632669

  • Vancomycin Use for Pediatric Clostridium difficile Infection Is Increasing and Associated with Specific Patient Characteristics ANTIMICROBIAL AGENTS AND CHEMOTHERAPY Schwenk, H. T., Graham, D. A., Sharma, T. S., Sandora, T. J. 2013; 57 (9): 4307-4313

    Abstract

    In adults with Clostridium difficile infection (CDI), enteral vancomycin is considered the preferred initial regimen for severe disease; however, patterns of antimicrobial use for children with CDI are unknown. We sought to describe trends in and predictors of vancomycin use for the treatment of children with CDI admitted to tertiary-care children's hospitals in the United States. We used a database of freestanding children's hospitals to identify patients 1 to 18 years old with CDI between January 2006 and June 2011. The first hospitalization with a diagnosis of CDI for each patient was identified, and CDI-directed therapy was assessed. Generalized estimating equations were used to identify predictors of vancomycin receipt, controlling for clustering within hospitals. Vancomycin use has increased significantly (P = 0.005), with substantial variability between hospitals (0 to 16%). In multivariate analyses, vancomycin use was more common in children age 7 to 13 years old (versus children 1 to 2 years old: adjusted odds ratio [AOR] = 1.57; 95% confidence interval [CI] = 1.13 to 2.18), 14 to 18 years old (AOR = 1.40; 95% CI = 1.11 to 1.76), in an ICU (AOR = 1.37; 95% CI = 1.05 to 1.80), or with chronic gastrointestinal conditions (AOR = 2.01; 95% CI = 1.44 to 2.81). Vancomycin use was less common in black (AOR = 0.53; 95% CI = 0.39 to 0.73) and Hispanic (AOR = 0.63; 95% CI = 0.47 to 0.84) patients and in children with malignancies (AOR = 0.57; 95% CI = 0.36 to 0.89). Despite a lack of empirical evidence to suggest superiority, vancomycin use for pediatric CDI is increasing. Furthermore, there is substantial variability in vancomycin use between hospitals. Further studies are needed to explore potential racial and ethnic differences in CDI management and to investigate clinicians' rationale for using vancomycin for initial therapy in selected populations.

    View details for DOI 10.1128/AAC.00661-13

    View details for Web of Science ID 000323285500027

    View details for PubMedCentralID PMC3754290