Pediatric Hospital Medicine 2013

NEW ORLEANS – Intermittent spot checks are as safe as continuous pulse oximetry monitoring in children hospitalized with bronchiolitis, according to interim results from an ongoing randomized controlled trial.

Among 104 patients, the average length of stay was 1.9 days with intermittent monitoring and 2.0 days with continuous monitoring (P = .98).

There was no difference in ICU admissions and no deaths, Dr. Russell McCulloh said at the Pediatric Hospital Medicine 2013 meeting.

Patrice Wendling/IMNG Medical Media

The Choosing Wisely campaign recommends against continuous pulse oximetry use in otherwise healthy children hospitalized with bronchiolitis. Still, a variety of monitoring strategies exist for pulse oximetry in hospitalized patients, with rates of hospitalization more than tripling after institutionalization of pulse oximetry in emergency departments. Prior studies have also shown that pulse oximetry increases readmission rates and may prolong time to discharge, he said.

Dr. McCulloh and his associates in Rhode Island, Texas, and Missouri sequentially and separately randomized 104 patients within 24 hours of floor admission to continuous monitoring with a pulse oximeter in place, regardless of oxygen saturation status, or to intermittent monitoring with scheduled nursing vital signs checks every 4 hours, supplemental oxygen and continuous monitoring if blood oxygen saturation was consistently below 90%, and a return to spot checks once the patient was weaned from oxygen. Pulse oximetry was monitored at the bedside, not centrally.

The intermittent and continuous monitoring groups had similar rates of utilization of diagnostic tests including chest x-rays (58% vs. 48%, respectively), multiplex viral testing (34.6% vs. 46.2%), rapid respiratory syncytial virus testing (25% vs. 29%), and blood cultures (29% vs. 25%), said Dr McCulloh, who started the study while an infectious disease fellow at Rhode Island Hospital in Providence and is now with Children’s Mercy Hospital in Kansas City, Mo.

Therapeutic measures were also similar in the two groups, including use of IV fluids (65.4% intermittent vs. 73% continuous), supplemental oxygen (33% vs. 36.5%), bronchodilators (88.5% vs. 90.4%), and antibiotics (21.2% vs. 17.3%).

Children monitored continuously incurred no additional health care costs compared with those intermittently monitored, Dr. McCulloh said at the meeting, cosponsored by the Society of Hospital Medicine, the American Academy of Pediatrics, and the Academic Pediatric Association. The average cost of all diagnostic testing, including pulse oximetry monitoring, was similar: $203.80 for continuous monitoring and $179.80 for intermittent monitoring (P = .19). The lack of a significant difference is not surprising since the children didn’t enter the study until after they were admitted to the hospital, and much of the diagnostic testing occurs in the emergency department and not on the hospital floor, he said in an interview.

Dr. McCulloh observed that parental acceptance of the monitoring strategy varied by patient age. Parents of younger children were happier with continuous monitoring, while those with older children were more comfortable with intermittent spot checks.

At baseline, children monitored intermittently were significantly older (6.6 months vs. 3.5 months), more likely to have otitis media on admission (23% vs. 7.7%), and less likely to be admitted by a hospitalist (44.2% vs. 65%). A family history of wheeze was similar in both groups (54% vs. 40.4%), as was tobacco exposure (31% vs. 25%).

Among staff, experience played a key role in monitoring adherence and acceptance.

"We tended to have newer nurses coming on to the floor who were very uncomfortable with children of any age going onto the intermittent arm," Dr. McCulloh said. "Most of the older nurses were like, ‘Of course.’

"We’re not talking about not doing cardiac apnea monitoring if someone wants to do that; we’re just saying don’t do continuous monitoring."

Random checks on the floor and outreach with respiratory and nursing staff helped maximize adherence, he noted.

The study is expanding to include Children’s Mercy Hospital, with a goal of 266 patients and completion anticipated in spring 2014.

Dr. McCulloh reported that the study is supported by a Thrasher Research Fund Early Career Award.

[email protected]

NEW ORLEANS – Intermittent spot checks are as safe as continuous pulse oximetry monitoring in children hospitalized with bronchiolitis, according to interim results from an ongoing randomized controlled trial.

Among 104 patients, the average length of stay was 1.9 days with intermittent monitoring and 2.0 days with continuous monitoring (P = .98).

There was no difference in ICU admissions and no deaths, Dr. Russell McCulloh said at the Pediatric Hospital Medicine 2013 meeting.

Patrice Wendling/IMNG Medical Media

The Choosing Wisely campaign recommends against continuous pulse oximetry use in otherwise healthy children hospitalized with bronchiolitis. Still, a variety of monitoring strategies exist for pulse oximetry in hospitalized patients, with rates of hospitalization more than tripling after institutionalization of pulse oximetry in emergency departments. Prior studies have also shown that pulse oximetry increases readmission rates and may prolong time to discharge, he said.

Dr. McCulloh and his associates in Rhode Island, Texas, and Missouri sequentially and separately randomized 104 patients within 24 hours of floor admission to continuous monitoring with a pulse oximeter in place, regardless of oxygen saturation status, or to intermittent monitoring with scheduled nursing vital signs checks every 4 hours, supplemental oxygen and continuous monitoring if blood oxygen saturation was consistently below 90%, and a return to spot checks once the patient was weaned from oxygen. Pulse oximetry was monitored at the bedside, not centrally.

The intermittent and continuous monitoring groups had similar rates of utilization of diagnostic tests including chest x-rays (58% vs. 48%, respectively), multiplex viral testing (34.6% vs. 46.2%), rapid respiratory syncytial virus testing (25% vs. 29%), and blood cultures (29% vs. 25%), said Dr McCulloh, who started the study while an infectious disease fellow at Rhode Island Hospital in Providence and is now with Children’s Mercy Hospital in Kansas City, Mo.

Therapeutic measures were also similar in the two groups, including use of IV fluids (65.4% intermittent vs. 73% continuous), supplemental oxygen (33% vs. 36.5%), bronchodilators (88.5% vs. 90.4%), and antibiotics (21.2% vs. 17.3%).

Children monitored continuously incurred no additional health care costs compared with those intermittently monitored, Dr. McCulloh said at the meeting, cosponsored by the Society of Hospital Medicine, the American Academy of Pediatrics, and the Academic Pediatric Association. The average cost of all diagnostic testing, including pulse oximetry monitoring, was similar: $203.80 for continuous monitoring and $179.80 for intermittent monitoring (P = .19). The lack of a significant difference is not surprising since the children didn’t enter the study until after they were admitted to the hospital, and much of the diagnostic testing occurs in the emergency department and not on the hospital floor, he said in an interview.

Dr. McCulloh observed that parental acceptance of the monitoring strategy varied by patient age. Parents of younger children were happier with continuous monitoring, while those with older children were more comfortable with intermittent spot checks.

At baseline, children monitored intermittently were significantly older (6.6 months vs. 3.5 months), more likely to have otitis media on admission (23% vs. 7.7%), and less likely to be admitted by a hospitalist (44.2% vs. 65%). A family history of wheeze was similar in both groups (54% vs. 40.4%), as was tobacco exposure (31% vs. 25%).

Among staff, experience played a key role in monitoring adherence and acceptance.

"We tended to have newer nurses coming on to the floor who were very uncomfortable with children of any age going onto the intermittent arm," Dr. McCulloh said. "Most of the older nurses were like, ‘Of course.’

"We’re not talking about not doing cardiac apnea monitoring if someone wants to do that; we’re just saying don’t do continuous monitoring."

Random checks on the floor and outreach with respiratory and nursing staff helped maximize adherence, he noted.

The study is expanding to include Children’s Mercy Hospital, with a goal of 266 patients and completion anticipated in spring 2014.

Dr. McCulloh reported that the study is supported by a Thrasher Research Fund Early Career Award.

[email protected]

NEW ORLEANS – Intermittent spot checks are as safe as continuous pulse oximetry monitoring in children hospitalized with bronchiolitis, according to interim results from an ongoing randomized controlled trial.

Among 104 patients, the average length of stay was 1.9 days with intermittent monitoring and 2.0 days with continuous monitoring (P = .98).

There was no difference in ICU admissions and no deaths, Dr. Russell McCulloh said at the Pediatric Hospital Medicine 2013 meeting.

Patrice Wendling/IMNG Medical Media

The Choosing Wisely campaign recommends against continuous pulse oximetry use in otherwise healthy children hospitalized with bronchiolitis. Still, a variety of monitoring strategies exist for pulse oximetry in hospitalized patients, with rates of hospitalization more than tripling after institutionalization of pulse oximetry in emergency departments. Prior studies have also shown that pulse oximetry increases readmission rates and may prolong time to discharge, he said.

Dr. McCulloh and his associates in Rhode Island, Texas, and Missouri sequentially and separately randomized 104 patients within 24 hours of floor admission to continuous monitoring with a pulse oximeter in place, regardless of oxygen saturation status, or to intermittent monitoring with scheduled nursing vital signs checks every 4 hours, supplemental oxygen and continuous monitoring if blood oxygen saturation was consistently below 90%, and a return to spot checks once the patient was weaned from oxygen. Pulse oximetry was monitored at the bedside, not centrally.

The intermittent and continuous monitoring groups had similar rates of utilization of diagnostic tests including chest x-rays (58% vs. 48%, respectively), multiplex viral testing (34.6% vs. 46.2%), rapid respiratory syncytial virus testing (25% vs. 29%), and blood cultures (29% vs. 25%), said Dr McCulloh, who started the study while an infectious disease fellow at Rhode Island Hospital in Providence and is now with Children’s Mercy Hospital in Kansas City, Mo.

Therapeutic measures were also similar in the two groups, including use of IV fluids (65.4% intermittent vs. 73% continuous), supplemental oxygen (33% vs. 36.5%), bronchodilators (88.5% vs. 90.4%), and antibiotics (21.2% vs. 17.3%).

Children monitored continuously incurred no additional health care costs compared with those intermittently monitored, Dr. McCulloh said at the meeting, cosponsored by the Society of Hospital Medicine, the American Academy of Pediatrics, and the Academic Pediatric Association. The average cost of all diagnostic testing, including pulse oximetry monitoring, was similar: $203.80 for continuous monitoring and $179.80 for intermittent monitoring (P = .19). The lack of a significant difference is not surprising since the children didn’t enter the study until after they were admitted to the hospital, and much of the diagnostic testing occurs in the emergency department and not on the hospital floor, he said in an interview.

Dr. McCulloh observed that parental acceptance of the monitoring strategy varied by patient age. Parents of younger children were happier with continuous monitoring, while those with older children were more comfortable with intermittent spot checks.

At baseline, children monitored intermittently were significantly older (6.6 months vs. 3.5 months), more likely to have otitis media on admission (23% vs. 7.7%), and less likely to be admitted by a hospitalist (44.2% vs. 65%). A family history of wheeze was similar in both groups (54% vs. 40.4%), as was tobacco exposure (31% vs. 25%).

Among staff, experience played a key role in monitoring adherence and acceptance.

"We tended to have newer nurses coming on to the floor who were very uncomfortable with children of any age going onto the intermittent arm," Dr. McCulloh said. "Most of the older nurses were like, ‘Of course.’

"We’re not talking about not doing cardiac apnea monitoring if someone wants to do that; we’re just saying don’t do continuous monitoring."

Random checks on the floor and outreach with respiratory and nursing staff helped maximize adherence, he noted.

The study is expanding to include Children’s Mercy Hospital, with a goal of 266 patients and completion anticipated in spring 2014.

Dr. McCulloh reported that the study is supported by a Thrasher Research Fund Early Career Award.

[email protected]

NEW ORLEANS – Children admitted to the hospital on the weekend are more likely to bounce back for an unplanned readmission, according to a retrospective study of 40,961 pediatric admissions.

Being admitted to a pediatric hospital on the weekend was associated with higher odds of readmission at 30 days than a weekday admission (odds ratio, 1.14; 95% confidence interval, 1.04-1.25.)

Patrice Wendling/IMNG Medical Media

The association remained significant even after adjustment for the child’s age, gender, insurance status, race, length of stay, and primary discharge diagnosis group (OR, 1.15; CI, 1.05-1.27).

"Higher readmission in children admitted on the weekend may indicate decreased in-hospital quality, although certainly this needs to be verified at other institutions," Dr. Katherine Auger said.

She noted that little is known about the "weekend effect" in pediatrics, although studies have shown that adults admitted to the emergency department or who have surgery on the weekend are more likely to die, and that readmissions are higher for certain acute conditions with a weekend admission.

Dr. Auger and her associates analyzed 46,187 admissions at the University of Michigan C.S. Mott Children’s Hospital, Ann Arbor, from January 2008 to December 2012. After excluding 5,226 index admissions for newborns staying less than 5 days and patients who left against medical advice, transferred out, entered hospice care, or died as an inpatient, 40,961 admissions for 24,558 patients remained. Weekend admissions accounted for 6,144 of the cases.

Planned versus unplanned readmissions were identified by hospital admitting category, which in a separate chart review of 200 readmissions demonstrated a 98% specificity for identifying unplanned readmissions and a sensitivity of 86%, said Dr. Auger, now with Cincinnati Children’s Hospital.

At the index admission, 46% of patients were female, 76% were white, 65% had private insurance, and 32.3% stayed at the hospital for 2-3 days.

The 30-day all-cause readmission rate was 14.7% and the unplanned readmission rate 10.2%.

The unplanned 30-day readmission rate was quite a bit higher than reported at national levels using chart review rather than administrative data, she observed. In a recent study (JAMA 2013;309:372-80) involving 568,845 admissions at 72 acute care pediatric hospitals, the 30-day unplanned readmission rate was just 6.5%, but the study excluded many readmissions for specific diagnoses such as when a child was readmitted after chemotherapy.

In the current analysis, unplanned readmissions peaked on Saturday and Sunday at about 11.5%, compared with about 10.5%, for example, on Monday.

Unplanned readmissions were highest in children with an index admission for chemotherapy (32.1%), diseases of the blood (21%), neoplasms (16.2%), and diseases of the gastrointestinal tract (13.2%), Dr. Auger said at the meeting, which was sponsored by the Society of Hospital Medicine, the American Academy of Pediatrics, and the Academic Pediatric Association.

Interestingly, children being discharged on Saturday or Sunday had the lowest rates of readmission. In logistic regression analyses, being discharged on the weekend was actually associated with a decreased likelihood of readmission in the unadjusted model (OR, 0.90; CI, 0.83-0.97), but this was no longer significant in the adjusted model (OR, 0.94; CI, 0.87-1.02), she said.

During a discussion of the results, Dr. Auger said follow-up analyses could be performed to stratify the data by diagnosis or by complex versus uncomplicated conditions. "Kids that are in for cancer may be very different from those in for bronchiolitis," she noted.

Dr. Auger reported salary support from the Robert Wood Johnson Foundation Clinical Scholars program. The study was funded by a grant from the Blue Cross Blue Shield of Michigan Foundation.

[email protected]

NEW ORLEANS – Children admitted to the hospital on the weekend are more likely to bounce back for an unplanned readmission, according to a retrospective study of 40,961 pediatric admissions.

Being admitted to a pediatric hospital on the weekend was associated with higher odds of readmission at 30 days than a weekday admission (odds ratio, 1.14; 95% confidence interval, 1.04-1.25.)

Patrice Wendling/IMNG Medical Media

The association remained significant even after adjustment for the child’s age, gender, insurance status, race, length of stay, and primary discharge diagnosis group (OR, 1.15; CI, 1.05-1.27).

"Higher readmission in children admitted on the weekend may indicate decreased in-hospital quality, although certainly this needs to be verified at other institutions," Dr. Katherine Auger said.

She noted that little is known about the "weekend effect" in pediatrics, although studies have shown that adults admitted to the emergency department or who have surgery on the weekend are more likely to die, and that readmissions are higher for certain acute conditions with a weekend admission.

Dr. Auger and her associates analyzed 46,187 admissions at the University of Michigan C.S. Mott Children’s Hospital, Ann Arbor, from January 2008 to December 2012. After excluding 5,226 index admissions for newborns staying less than 5 days and patients who left against medical advice, transferred out, entered hospice care, or died as an inpatient, 40,961 admissions for 24,558 patients remained. Weekend admissions accounted for 6,144 of the cases.

Planned versus unplanned readmissions were identified by hospital admitting category, which in a separate chart review of 200 readmissions demonstrated a 98% specificity for identifying unplanned readmissions and a sensitivity of 86%, said Dr. Auger, now with Cincinnati Children’s Hospital.

At the index admission, 46% of patients were female, 76% were white, 65% had private insurance, and 32.3% stayed at the hospital for 2-3 days.

The 30-day all-cause readmission rate was 14.7% and the unplanned readmission rate 10.2%.

The unplanned 30-day readmission rate was quite a bit higher than reported at national levels using chart review rather than administrative data, she observed. In a recent study (JAMA 2013;309:372-80) involving 568,845 admissions at 72 acute care pediatric hospitals, the 30-day unplanned readmission rate was just 6.5%, but the study excluded many readmissions for specific diagnoses such as when a child was readmitted after chemotherapy.

In the current analysis, unplanned readmissions peaked on Saturday and Sunday at about 11.5%, compared with about 10.5%, for example, on Monday.

Unplanned readmissions were highest in children with an index admission for chemotherapy (32.1%), diseases of the blood (21%), neoplasms (16.2%), and diseases of the gastrointestinal tract (13.2%), Dr. Auger said at the meeting, which was sponsored by the Society of Hospital Medicine, the American Academy of Pediatrics, and the Academic Pediatric Association.

Interestingly, children being discharged on Saturday or Sunday had the lowest rates of readmission. In logistic regression analyses, being discharged on the weekend was actually associated with a decreased likelihood of readmission in the unadjusted model (OR, 0.90; CI, 0.83-0.97), but this was no longer significant in the adjusted model (OR, 0.94; CI, 0.87-1.02), she said.

During a discussion of the results, Dr. Auger said follow-up analyses could be performed to stratify the data by diagnosis or by complex versus uncomplicated conditions. "Kids that are in for cancer may be very different from those in for bronchiolitis," she noted.

Dr. Auger reported salary support from the Robert Wood Johnson Foundation Clinical Scholars program. The study was funded by a grant from the Blue Cross Blue Shield of Michigan Foundation.

[email protected]

NEW ORLEANS – Children admitted to the hospital on the weekend are more likely to bounce back for an unplanned readmission, according to a retrospective study of 40,961 pediatric admissions.

Being admitted to a pediatric hospital on the weekend was associated with higher odds of readmission at 30 days than a weekday admission (odds ratio, 1.14; 95% confidence interval, 1.04-1.25.)

Patrice Wendling/IMNG Medical Media

The association remained significant even after adjustment for the child’s age, gender, insurance status, race, length of stay, and primary discharge diagnosis group (OR, 1.15; CI, 1.05-1.27).

"Higher readmission in children admitted on the weekend may indicate decreased in-hospital quality, although certainly this needs to be verified at other institutions," Dr. Katherine Auger said.

She noted that little is known about the "weekend effect" in pediatrics, although studies have shown that adults admitted to the emergency department or who have surgery on the weekend are more likely to die, and that readmissions are higher for certain acute conditions with a weekend admission.

Dr. Auger and her associates analyzed 46,187 admissions at the University of Michigan C.S. Mott Children’s Hospital, Ann Arbor, from January 2008 to December 2012. After excluding 5,226 index admissions for newborns staying less than 5 days and patients who left against medical advice, transferred out, entered hospice care, or died as an inpatient, 40,961 admissions for 24,558 patients remained. Weekend admissions accounted for 6,144 of the cases.

Planned versus unplanned readmissions were identified by hospital admitting category, which in a separate chart review of 200 readmissions demonstrated a 98% specificity for identifying unplanned readmissions and a sensitivity of 86%, said Dr. Auger, now with Cincinnati Children’s Hospital.

At the index admission, 46% of patients were female, 76% were white, 65% had private insurance, and 32.3% stayed at the hospital for 2-3 days.

The 30-day all-cause readmission rate was 14.7% and the unplanned readmission rate 10.2%.

The unplanned 30-day readmission rate was quite a bit higher than reported at national levels using chart review rather than administrative data, she observed. In a recent study (JAMA 2013;309:372-80) involving 568,845 admissions at 72 acute care pediatric hospitals, the 30-day unplanned readmission rate was just 6.5%, but the study excluded many readmissions for specific diagnoses such as when a child was readmitted after chemotherapy.

In the current analysis, unplanned readmissions peaked on Saturday and Sunday at about 11.5%, compared with about 10.5%, for example, on Monday.

Unplanned readmissions were highest in children with an index admission for chemotherapy (32.1%), diseases of the blood (21%), neoplasms (16.2%), and diseases of the gastrointestinal tract (13.2%), Dr. Auger said at the meeting, which was sponsored by the Society of Hospital Medicine, the American Academy of Pediatrics, and the Academic Pediatric Association.

Interestingly, children being discharged on Saturday or Sunday had the lowest rates of readmission. In logistic regression analyses, being discharged on the weekend was actually associated with a decreased likelihood of readmission in the unadjusted model (OR, 0.90; CI, 0.83-0.97), but this was no longer significant in the adjusted model (OR, 0.94; CI, 0.87-1.02), she said.

During a discussion of the results, Dr. Auger said follow-up analyses could be performed to stratify the data by diagnosis or by complex versus uncomplicated conditions. "Kids that are in for cancer may be very different from those in for bronchiolitis," she noted.

Dr. Auger reported salary support from the Robert Wood Johnson Foundation Clinical Scholars program. The study was funded by a grant from the Blue Cross Blue Shield of Michigan Foundation.

[email protected]

NEW ORLEANS – Escherichia coli has replaced Group B Streptococcus as the most common cause of bacteremia in febrile infants in a nationally representative, retrospective study.

Among the 183 positive blood cultures drawn from 179 febrile but otherwise healthy-appearing infants, 76 were E. coli (42%), 41 Streptococcus agalactiae (22%), 10 S. pneumoniae (5%), and 10 S. aureus (5%). Roughly half of the cultures were gram negative.

Notably, no cases of Listeria bacteremia were identified, Dr. Rianna Evans said during the plenary session at the Pediatric Hospital Medicine 2013 meeting.

"There has been a definite rise in ampicillin-resistant gram-negative pathogens, which is going to be affecting our cephalosporin resistance," she said. "There is not a national database yet on this that we know of, but we identified ampicillin-resistance patterns at several of our sites, and it’s been noted in other cities as well."

Results from the current study, conducted at six sites across the United States, are supported by prior regional studies indicating a shift in bacterial epidemiology from Group B strep toward gram-negative pathogens in young infants. A change in the types of pathogens being seen is expected given the introduction of universal Group B strep prophylaxis in pregnant mothers and several new vaccines in the past decade, said Dr. Evans, a hospitalist at Children’s Hospital of The King’s Daughters, Norfolk, Va.

The investigators analyzed positive blood cultures from infants, age up to 90 days, drawn from January 2006 through December 2012 at six sites: Illinois; Rochester and Albany, N.Y.; Virginia; Minneapolis; and Los Angeles. Cultures were excluded if they were drawn in the intensive care unit, from indwelling vascular catheters, or from infants with a history of major surgery.

In all, 79% of the infants were classified as non–low risk according to Modified Rochester Criteria, 71% were febrile at the time the culture was drawn, 49% had a concurrent urinary tract infection, and 13% had concurrent meningitis. Their average age was 39 days.

Infants with E. coli were significantly more likely to be non–low risk than low risk (P = .001), while 56% of those with S. aureus bacteremia had evidence of a skin and soft tissue infection, Dr. Evans said.

She recommended single coverage with third-generation cephalosporin in febrile, non–toxic infants and that clinicians consider S. aureus and Enterococcus spp. coverage in ill-appearing infants with evidence of skin and soft-tissue infections.

During a discussion of the results, an audience member said it was dangerous to propose practice change based on a retrospective study, even if it was multicentered. Dr. Evans agreed and said there was a lot of discussion about their recommendations.

"It’s a bold statement, and I know it’s not going to be taken universally, which is why we need a prospective study identifying this," she said. "But with our work and all of the other studies that have been done on a regional level, I think there’s good enough data to at least suggest this and take it forward with a prospective study to see if there are true differences."

Dr. Evans said they could expand the retrospective analysis to bring in other sites, possibly through coauthor Dr. Eric Biondi’s ongoing study evaluating the time to blood culture positivity.

As a result of increasing antibiotic resistance to several types of gram-negative bacilli, the Centers for Disease Control and Prevention has also set up the Multi-Site Resistant Gram-Negative Bacilli Surveillance Initiative (MuGSI) to track infections due to carbapenem-resistant organisms including E. coli, Enterobacter cloacae, Enterobacter aerogenes, Klebsiella pneumoniae, K. oxytoca, and multidrug-resistant Acinetobacter baumannii. Data from the initiative are expected this year.

In one of the regional studies from Kaiser Permanente Northern California, E. coli was identified in 56% of positive samples collected from 2005 to 2009, and again there were no cases of Listeria bacteremia (Pediatrics 2012;129:e590-6).

Clinicians should consider Listeria if the maternal history or cerebrospinal fluid is suggestive of meningitis, but may want to revise their thinking when teaching residents about the bacterial causes of serious bacterial infections, Dr. Evans suggested.

Finally, another audience member expressed concern about whether cephalosporin alone would be a safe choice, particularly by residents, given that there was a fair amount of enterococcus in the sample and residents often miss this and forget about ampicillin. Dr. Evans observed that this has been the most provocative point when discussing the results with other institutions, but she said enterococcus was present in just 4% of the study’s positive samples and prior studies have shown that only 2% of well-appearing children presenting with fever are expected to have bacteremia. "It’s still a fairly low number, and you’re seeing a higher number of kids with ampicillin-resistant gram-negative rods," she added.

The meeting was sponsored by the Society of Hospital Medicine, the American Academy of Pediatrics, and the Academic Pediatric Association. Dr. Evans and her coauthors reported having no financial disclosures.

[email protected]

NEW ORLEANS – Escherichia coli has replaced Group B Streptococcus as the most common cause of bacteremia in febrile infants in a nationally representative, retrospective study.

Among the 183 positive blood cultures drawn from 179 febrile but otherwise healthy-appearing infants, 76 were E. coli (42%), 41 Streptococcus agalactiae (22%), 10 S. pneumoniae (5%), and 10 S. aureus (5%). Roughly half of the cultures were gram negative.

Notably, no cases of Listeria bacteremia were identified, Dr. Rianna Evans said during the plenary session at the Pediatric Hospital Medicine 2013 meeting.

"There has been a definite rise in ampicillin-resistant gram-negative pathogens, which is going to be affecting our cephalosporin resistance," she said. "There is not a national database yet on this that we know of, but we identified ampicillin-resistance patterns at several of our sites, and it’s been noted in other cities as well."

Results from the current study, conducted at six sites across the United States, are supported by prior regional studies indicating a shift in bacterial epidemiology from Group B strep toward gram-negative pathogens in young infants. A change in the types of pathogens being seen is expected given the introduction of universal Group B strep prophylaxis in pregnant mothers and several new vaccines in the past decade, said Dr. Evans, a hospitalist at Children’s Hospital of The King’s Daughters, Norfolk, Va.

The investigators analyzed positive blood cultures from infants, age up to 90 days, drawn from January 2006 through December 2012 at six sites: Illinois; Rochester and Albany, N.Y.; Virginia; Minneapolis; and Los Angeles. Cultures were excluded if they were drawn in the intensive care unit, from indwelling vascular catheters, or from infants with a history of major surgery.

In all, 79% of the infants were classified as non–low risk according to Modified Rochester Criteria, 71% were febrile at the time the culture was drawn, 49% had a concurrent urinary tract infection, and 13% had concurrent meningitis. Their average age was 39 days.

Infants with E. coli were significantly more likely to be non–low risk than low risk (P = .001), while 56% of those with S. aureus bacteremia had evidence of a skin and soft tissue infection, Dr. Evans said.

She recommended single coverage with third-generation cephalosporin in febrile, non–toxic infants and that clinicians consider S. aureus and Enterococcus spp. coverage in ill-appearing infants with evidence of skin and soft-tissue infections.

During a discussion of the results, an audience member said it was dangerous to propose practice change based on a retrospective study, even if it was multicentered. Dr. Evans agreed and said there was a lot of discussion about their recommendations.

"It’s a bold statement, and I know it’s not going to be taken universally, which is why we need a prospective study identifying this," she said. "But with our work and all of the other studies that have been done on a regional level, I think there’s good enough data to at least suggest this and take it forward with a prospective study to see if there are true differences."

Dr. Evans said they could expand the retrospective analysis to bring in other sites, possibly through coauthor Dr. Eric Biondi’s ongoing study evaluating the time to blood culture positivity.

As a result of increasing antibiotic resistance to several types of gram-negative bacilli, the Centers for Disease Control and Prevention has also set up the Multi-Site Resistant Gram-Negative Bacilli Surveillance Initiative (MuGSI) to track infections due to carbapenem-resistant organisms including E. coli, Enterobacter cloacae, Enterobacter aerogenes, Klebsiella pneumoniae, K. oxytoca, and multidrug-resistant Acinetobacter baumannii. Data from the initiative are expected this year.

In one of the regional studies from Kaiser Permanente Northern California, E. coli was identified in 56% of positive samples collected from 2005 to 2009, and again there were no cases of Listeria bacteremia (Pediatrics 2012;129:e590-6).

Clinicians should consider Listeria if the maternal history or cerebrospinal fluid is suggestive of meningitis, but may want to revise their thinking when teaching residents about the bacterial causes of serious bacterial infections, Dr. Evans suggested.

Finally, another audience member expressed concern about whether cephalosporin alone would be a safe choice, particularly by residents, given that there was a fair amount of enterococcus in the sample and residents often miss this and forget about ampicillin. Dr. Evans observed that this has been the most provocative point when discussing the results with other institutions, but she said enterococcus was present in just 4% of the study’s positive samples and prior studies have shown that only 2% of well-appearing children presenting with fever are expected to have bacteremia. "It’s still a fairly low number, and you’re seeing a higher number of kids with ampicillin-resistant gram-negative rods," she added.

The meeting was sponsored by the Society of Hospital Medicine, the American Academy of Pediatrics, and the Academic Pediatric Association. Dr. Evans and her coauthors reported having no financial disclosures.

[email protected]

NEW ORLEANS – Escherichia coli has replaced Group B Streptococcus as the most common cause of bacteremia in febrile infants in a nationally representative, retrospective study.

Among the 183 positive blood cultures drawn from 179 febrile but otherwise healthy-appearing infants, 76 were E. coli (42%), 41 Streptococcus agalactiae (22%), 10 S. pneumoniae (5%), and 10 S. aureus (5%). Roughly half of the cultures were gram negative.

Notably, no cases of Listeria bacteremia were identified, Dr. Rianna Evans said during the plenary session at the Pediatric Hospital Medicine 2013 meeting.

"There has been a definite rise in ampicillin-resistant gram-negative pathogens, which is going to be affecting our cephalosporin resistance," she said. "There is not a national database yet on this that we know of, but we identified ampicillin-resistance patterns at several of our sites, and it’s been noted in other cities as well."

Results from the current study, conducted at six sites across the United States, are supported by prior regional studies indicating a shift in bacterial epidemiology from Group B strep toward gram-negative pathogens in young infants. A change in the types of pathogens being seen is expected given the introduction of universal Group B strep prophylaxis in pregnant mothers and several new vaccines in the past decade, said Dr. Evans, a hospitalist at Children’s Hospital of The King’s Daughters, Norfolk, Va.

The investigators analyzed positive blood cultures from infants, age up to 90 days, drawn from January 2006 through December 2012 at six sites: Illinois; Rochester and Albany, N.Y.; Virginia; Minneapolis; and Los Angeles. Cultures were excluded if they were drawn in the intensive care unit, from indwelling vascular catheters, or from infants with a history of major surgery.

In all, 79% of the infants were classified as non–low risk according to Modified Rochester Criteria, 71% were febrile at the time the culture was drawn, 49% had a concurrent urinary tract infection, and 13% had concurrent meningitis. Their average age was 39 days.

Infants with E. coli were significantly more likely to be non–low risk than low risk (P = .001), while 56% of those with S. aureus bacteremia had evidence of a skin and soft tissue infection, Dr. Evans said.

She recommended single coverage with third-generation cephalosporin in febrile, non–toxic infants and that clinicians consider S. aureus and Enterococcus spp. coverage in ill-appearing infants with evidence of skin and soft-tissue infections.

During a discussion of the results, an audience member said it was dangerous to propose practice change based on a retrospective study, even if it was multicentered. Dr. Evans agreed and said there was a lot of discussion about their recommendations.

"It’s a bold statement, and I know it’s not going to be taken universally, which is why we need a prospective study identifying this," she said. "But with our work and all of the other studies that have been done on a regional level, I think there’s good enough data to at least suggest this and take it forward with a prospective study to see if there are true differences."

Dr. Evans said they could expand the retrospective analysis to bring in other sites, possibly through coauthor Dr. Eric Biondi’s ongoing study evaluating the time to blood culture positivity.

As a result of increasing antibiotic resistance to several types of gram-negative bacilli, the Centers for Disease Control and Prevention has also set up the Multi-Site Resistant Gram-Negative Bacilli Surveillance Initiative (MuGSI) to track infections due to carbapenem-resistant organisms including E. coli, Enterobacter cloacae, Enterobacter aerogenes, Klebsiella pneumoniae, K. oxytoca, and multidrug-resistant Acinetobacter baumannii. Data from the initiative are expected this year.

In one of the regional studies from Kaiser Permanente Northern California, E. coli was identified in 56% of positive samples collected from 2005 to 2009, and again there were no cases of Listeria bacteremia (Pediatrics 2012;129:e590-6).

Clinicians should consider Listeria if the maternal history or cerebrospinal fluid is suggestive of meningitis, but may want to revise their thinking when teaching residents about the bacterial causes of serious bacterial infections, Dr. Evans suggested.

Finally, another audience member expressed concern about whether cephalosporin alone would be a safe choice, particularly by residents, given that there was a fair amount of enterococcus in the sample and residents often miss this and forget about ampicillin. Dr. Evans observed that this has been the most provocative point when discussing the results with other institutions, but she said enterococcus was present in just 4% of the study’s positive samples and prior studies have shown that only 2% of well-appearing children presenting with fever are expected to have bacteremia. "It’s still a fairly low number, and you’re seeing a higher number of kids with ampicillin-resistant gram-negative rods," she added.

The meeting was sponsored by the Society of Hospital Medicine, the American Academy of Pediatrics, and the Academic Pediatric Association. Dr. Evans and her coauthors reported having no financial disclosures.

[email protected]

NEW ORLEANS – Escherichia coli has replaced Group B Streptococcus as the most common cause of bacteremia in febrile infants in a nationally representative, retrospective study.

Among the 183 positive blood cultures drawn from 179 febrile but otherwise healthy-appearing infants, 76 were E. coli (42%), 41 Streptococcus agalactiae (22%), 10 S. pneumoniae (5%), and 10 S. aureus (5%). Roughly half of the cultures were gram negative.

Patrice Wendling/IMNG Medical Media

Notably, no cases of Listeria bacteremia were identified, Dr. Rianna Evans said during the plenary session at the Pediatric Hospital Medicine 2013 meeting.

"There has been a definite rise in ampicillin-resistant gram-negative pathogens, which is going to be affecting our cephalosporin resistance," she said. "There is not a national database yet on this that we know of, but we identified ampicillin-resistance patterns at several of our sites, and it’s been noted in other cities as well."

Results from the current study, conducted at six sites across the United States, are supported by prior regional studies indicating a shift in bacterial epidemiology from Group B strep toward gram-negative pathogens in young infants. A change in the types of pathogens being seen is expected given the introduction of universal Group B strep prophylaxis in pregnant mothers and several new vaccines in the past decade, said Dr. Evans, a hospitalist at Children’s Hospital of The King’s Daughters, Norfolk, Va.

The investigators analyzed positive blood cultures from infants, age up to 90 days, drawn from January 2006 through December 2012 at six sites: Illinois; Rochester and Albany, N.Y.; Virginia; Minneapolis; and Los Angeles. Cultures were excluded if they were drawn in the intensive care unit, from indwelling vascular catheters, or from infants with a history of major surgery.

In all, 79% of the infants were classified as non–low risk according to Modified Rochester Criteria, 71% were febrile at the time the culture was drawn, 49% had a concurrent urinary tract infection, and 13% had concurrent meningitis. Their average age was 39 days.

Infants with E. coli were significantly more likely to be non–low risk than low risk (P = .001), while 56% of those with S. aureus bacteremia had evidence of a skin and soft tissue infection, Dr. Evans said.

She recommended single coverage with third-generation cephalosporin in febrile, non–toxic infants and that clinicians consider S. aureus and Enterococcus spp. coverage in ill-appearing infants with evidence of skin and soft-tissue infections.

During a discussion of the results, an audience member said it was dangerous to propose practice change based on a retrospective study, even if it was multicentered. Dr. Evans agreed and said there was a lot of discussion about their recommendations.

"It’s a bold statement, and I know it’s not going to be taken universally, which is why we need a prospective study identifying this," she said. "But with our work and all of the other studies that have been done on a regional level, I think there’s good enough data to at least suggest this and take it forward with a prospective study to see if there are true differences."

Dr. Evans said they could expand the retrospective analysis to bring in other sites, possibly through coauthor Dr. Eric Biondi’s ongoing study evaluating the time to blood culture positivity.

As a result of increasing antibiotic resistance to several types of gram-negative bacilli, the Centers for Disease Control and Prevention has also set up the Multi-Site Resistant Gram-Negative Bacilli Surveillance Initiative (MuGSI) to track infections due to carbapenem-resistant organisms including E. coli, Enterobacter cloacae, Enterobacter aerogenes, Klebsiella pneumoniae, K. oxytoca, and multidrug-resistant Acinetobacter baumannii. Data from the initiative are expected this year.

In one of the regional studies from Kaiser Permanente Northern California, E. coli was identified in 56% of positive samples collected from 2005 to 2009, and again there were no cases of Listeria bacteremia (Pediatrics 2012;129:e590-6).

Clinicians should consider Listeria if the maternal history or cerebrospinal fluid is suggestive of meningitis, but may want to revise their thinking when teaching residents about the bacterial causes of serious bacterial infections, Dr. Evans suggested.

Finally, another audience member expressed concern about whether cephalosporin alone would be a safe choice, particularly by residents, given that there was a fair amount of enterococcus in the sample and residents often miss this and forget about ampicillin. Dr. Evans observed that this has been the most provocative point when discussing the results with other institutions, but she said enterococcus was present in just 4% of the study’s positive samples and prior studies have shown that only 2% of well-appearing children presenting with fever are expected to have bacteremia. "It’s still a fairly low number, and you’re seeing a higher number of kids with ampicillin-resistant gram-negative rods," she added.

The meeting was sponsored by the Society of Hospital Medicine, the American Academy of Pediatrics, and the Academic Pediatric Association. Dr. Evans and her coauthors reported having no financial disclosures.

[email protected]

NEW ORLEANS – Escherichia coli has replaced Group B Streptococcus as the most common cause of bacteremia in febrile infants in a nationally representative, retrospective study.

Among the 183 positive blood cultures drawn from 179 febrile but otherwise healthy-appearing infants, 76 were E. coli (42%), 41 Streptococcus agalactiae (22%), 10 S. pneumoniae (5%), and 10 S. aureus (5%). Roughly half of the cultures were gram negative.

Patrice Wendling/IMNG Medical Media

Notably, no cases of Listeria bacteremia were identified, Dr. Rianna Evans said during the plenary session at the Pediatric Hospital Medicine 2013 meeting.

"There has been a definite rise in ampicillin-resistant gram-negative pathogens, which is going to be affecting our cephalosporin resistance," she said. "There is not a national database yet on this that we know of, but we identified ampicillin-resistance patterns at several of our sites, and it’s been noted in other cities as well."

Results from the current study, conducted at six sites across the United States, are supported by prior regional studies indicating a shift in bacterial epidemiology from Group B strep toward gram-negative pathogens in young infants. A change in the types of pathogens being seen is expected given the introduction of universal Group B strep prophylaxis in pregnant mothers and several new vaccines in the past decade, said Dr. Evans, a hospitalist at Children’s Hospital of The King’s Daughters, Norfolk, Va.

The investigators analyzed positive blood cultures from infants, age up to 90 days, drawn from January 2006 through December 2012 at six sites: Illinois; Rochester and Albany, N.Y.; Virginia; Minneapolis; and Los Angeles. Cultures were excluded if they were drawn in the intensive care unit, from indwelling vascular catheters, or from infants with a history of major surgery.

In all, 79% of the infants were classified as non–low risk according to Modified Rochester Criteria, 71% were febrile at the time the culture was drawn, 49% had a concurrent urinary tract infection, and 13% had concurrent meningitis. Their average age was 39 days.

Infants with E. coli were significantly more likely to be non–low risk than low risk (P = .001), while 56% of those with S. aureus bacteremia had evidence of a skin and soft tissue infection, Dr. Evans said.

She recommended single coverage with third-generation cephalosporin in febrile, non–toxic infants and that clinicians consider S. aureus and Enterococcus spp. coverage in ill-appearing infants with evidence of skin and soft-tissue infections.

During a discussion of the results, an audience member said it was dangerous to propose practice change based on a retrospective study, even if it was multicentered. Dr. Evans agreed and said there was a lot of discussion about their recommendations.

"It’s a bold statement, and I know it’s not going to be taken universally, which is why we need a prospective study identifying this," she said. "But with our work and all of the other studies that have been done on a regional level, I think there’s good enough data to at least suggest this and take it forward with a prospective study to see if there are true differences."

Dr. Evans said they could expand the retrospective analysis to bring in other sites, possibly through coauthor Dr. Eric Biondi’s ongoing study evaluating the time to blood culture positivity.

As a result of increasing antibiotic resistance to several types of gram-negative bacilli, the Centers for Disease Control and Prevention has also set up the Multi-Site Resistant Gram-Negative Bacilli Surveillance Initiative (MuGSI) to track infections due to carbapenem-resistant organisms including E. coli, Enterobacter cloacae, Enterobacter aerogenes, Klebsiella pneumoniae, K. oxytoca, and multidrug-resistant Acinetobacter baumannii. Data from the initiative are expected this year.

In one of the regional studies from Kaiser Permanente Northern California, E. coli was identified in 56% of positive samples collected from 2005 to 2009, and again there were no cases of Listeria bacteremia (Pediatrics 2012;129:e590-6).

Clinicians should consider Listeria if the maternal history or cerebrospinal fluid is suggestive of meningitis, but may want to revise their thinking when teaching residents about the bacterial causes of serious bacterial infections, Dr. Evans suggested.

Finally, another audience member expressed concern about whether cephalosporin alone would be a safe choice, particularly by residents, given that there was a fair amount of enterococcus in the sample and residents often miss this and forget about ampicillin. Dr. Evans observed that this has been the most provocative point when discussing the results with other institutions, but she said enterococcus was present in just 4% of the study’s positive samples and prior studies have shown that only 2% of well-appearing children presenting with fever are expected to have bacteremia. "It’s still a fairly low number, and you’re seeing a higher number of kids with ampicillin-resistant gram-negative rods," she added.

The meeting was sponsored by the Society of Hospital Medicine, the American Academy of Pediatrics, and the Academic Pediatric Association. Dr. Evans and her coauthors reported having no financial disclosures.

[email protected]

NEW ORLEANS – Escherichia coli has replaced Group B Streptococcus as the most common cause of bacteremia in febrile infants in a nationally representative, retrospective study.

Among the 183 positive blood cultures drawn from 179 febrile but otherwise healthy-appearing infants, 76 were E. coli (42%), 41 Streptococcus agalactiae (22%), 10 S. pneumoniae (5%), and 10 S. aureus (5%). Roughly half of the cultures were gram negative.

Patrice Wendling/IMNG Medical Media

Notably, no cases of Listeria bacteremia were identified, Dr. Rianna Evans said during the plenary session at the Pediatric Hospital Medicine 2013 meeting.

"There has been a definite rise in ampicillin-resistant gram-negative pathogens, which is going to be affecting our cephalosporin resistance," she said. "There is not a national database yet on this that we know of, but we identified ampicillin-resistance patterns at several of our sites, and it’s been noted in other cities as well."

Results from the current study, conducted at six sites across the United States, are supported by prior regional studies indicating a shift in bacterial epidemiology from Group B strep toward gram-negative pathogens in young infants. A change in the types of pathogens being seen is expected given the introduction of universal Group B strep prophylaxis in pregnant mothers and several new vaccines in the past decade, said Dr. Evans, a hospitalist at Children’s Hospital of The King’s Daughters, Norfolk, Va.

The investigators analyzed positive blood cultures from infants, age up to 90 days, drawn from January 2006 through December 2012 at six sites: Illinois; Rochester and Albany, N.Y.; Virginia; Minneapolis; and Los Angeles. Cultures were excluded if they were drawn in the intensive care unit, from indwelling vascular catheters, or from infants with a history of major surgery.

In all, 79% of the infants were classified as non–low risk according to Modified Rochester Criteria, 71% were febrile at the time the culture was drawn, 49% had a concurrent urinary tract infection, and 13% had concurrent meningitis. Their average age was 39 days.

Infants with E. coli were significantly more likely to be non–low risk than low risk (P = .001), while 56% of those with S. aureus bacteremia had evidence of a skin and soft tissue infection, Dr. Evans said.

She recommended single coverage with third-generation cephalosporin in febrile, non–toxic infants and that clinicians consider S. aureus and Enterococcus spp. coverage in ill-appearing infants with evidence of skin and soft-tissue infections.

During a discussion of the results, an audience member said it was dangerous to propose practice change based on a retrospective study, even if it was multicentered. Dr. Evans agreed and said there was a lot of discussion about their recommendations.

"It’s a bold statement, and I know it’s not going to be taken universally, which is why we need a prospective study identifying this," she said. "But with our work and all of the other studies that have been done on a regional level, I think there’s good enough data to at least suggest this and take it forward with a prospective study to see if there are true differences."

Dr. Evans said they could expand the retrospective analysis to bring in other sites, possibly through coauthor Dr. Eric Biondi’s ongoing study evaluating the time to blood culture positivity.

As a result of increasing antibiotic resistance to several types of gram-negative bacilli, the Centers for Disease Control and Prevention has also set up the Multi-Site Resistant Gram-Negative Bacilli Surveillance Initiative (MuGSI) to track infections due to carbapenem-resistant organisms including E. coli, Enterobacter cloacae, Enterobacter aerogenes, Klebsiella pneumoniae, K. oxytoca, and multidrug-resistant Acinetobacter baumannii. Data from the initiative are expected this year.

In one of the regional studies from Kaiser Permanente Northern California, E. coli was identified in 56% of positive samples collected from 2005 to 2009, and again there were no cases of Listeria bacteremia (Pediatrics 2012;129:e590-6).

Clinicians should consider Listeria if the maternal history or cerebrospinal fluid is suggestive of meningitis, but may want to revise their thinking when teaching residents about the bacterial causes of serious bacterial infections, Dr. Evans suggested.

Finally, another audience member expressed concern about whether cephalosporin alone would be a safe choice, particularly by residents, given that there was a fair amount of enterococcus in the sample and residents often miss this and forget about ampicillin. Dr. Evans observed that this has been the most provocative point when discussing the results with other institutions, but she said enterococcus was present in just 4% of the study’s positive samples and prior studies have shown that only 2% of well-appearing children presenting with fever are expected to have bacteremia. "It’s still a fairly low number, and you’re seeing a higher number of kids with ampicillin-resistant gram-negative rods," she added.

The meeting was sponsored by the Society of Hospital Medicine, the American Academy of Pediatrics, and the Academic Pediatric Association. Dr. Evans and her coauthors reported having no financial disclosures.

[email protected]