Numbers and narratives: how qualitative methods can strengthen the science of paediatric antimicrobial stewardship.

Antimicrobial and diagnostic stewardship initiatives have become increasingly important in paediatric settings. The value of qualitative approaches to conduct stewardship work in paediatric patients is being increasingly recognized. This article seeks to provide an introduction to basic elements of qualitative study designs and provide an overview of how these methods have successfully been applied to both antimicrobial and diagnostic stewardship work in paediatric patients. A multidisciplinary team of experts in paediatric infectious diseases, paediatric critical care and qualitative methods has written a perspective piece introducing readers to qualitative stewardship work in children, intended as an overview to highlight the importance of such methods and as a starting point for further work. We describe key differences between qualitative and quantitative methods, and the potential benefits of qualitative approaches. We present examples of qualitative research in five discrete topic areas of high relevance for paediatric stewardship work: provider attitudes; provider prescribing behaviours; stewardship in low-resource settings; parents' perspectives on stewardship; and stewardship work focusing on select high-risk patients. Finally, we explore the opportunities for multidisciplinary academic collaboration, incorporation of innovative scientific disciplines and young investigator growth through the use of qualitative research in paediatric stewardship. Qualitative approaches can bring rich insights and critically needed new information to antimicrobial and diagnostic stewardship efforts in children. Such methods are an important tool in the armamentarium against worsening antimicrobial resistance, and a major opportunity for investigators interested in moving the needle forward for stewardship in paediatric patients.

Management and Microbiology of Perforated Appendicitis in Pediatric Patients: A 5-Year Retrospective Study.

INTRODUCTION: This study aims to assess the current epidemiology and microbiology of perforated appendicitis, how antibiotic choice and duration correlate with meaningful clinical outcomes, and whether serial white blood cell (WBC) counts provide clinical value. METHODS: Five-year retrospective cohort study, 2015-2019, among 333 consecutive children, ages 0-18 years, treated at St. Louis Children's Hospital for perforated appendicitis. Main outcomes included length of stay (LOS), postoperative abscess formation, and readmission. Statistical analysis was performed with uni- and multi-variate analyses. RESULTS: Intra-abdominal cultures most commonly grew Bacteroides fragilis (52%) and Escherichia coli (50%). Patients who initially received broad-spectrum antibiotics (meropenem, piperacillin-tazobactam, fourth-generation cephalosporins) for perforated appendicitis had greater rates of postoperative abscess formation (25% vs. 12%, p < 0.01) and LOS (7.0 vs. 5.7 days, p < 0.01). Similarly, antibiotics at time of discharge were associated with greater postoperative abscess formation (22% vs. 9%, p < 0.01) and LOS (6.4 vs. 5.6 days, p = 0.02). However, discharge with strictly oral antibiotics was not correlated with greater LOS, postoperative abscess formation, or readmission rates compared to discharge without antibiotics. Serial WBC counts had no predictive value for LOS, postoperative abscess formation, or readmission. CONCLUSIONS: Bacteroides fragilis and E. coli were the most common intra-abdominal microbes for perforated appendicitis among our cohort. In non-critically ill children, the routine use of broad-spectrum antibiotics or continuation of antibiotics beyond discharge was not correlated with improved clinical outcomes. Additionally, WBC counts were not correlated with meaningful clinical outcomes.

Resolving taxonomic and phylogenetic incongruence within species Ceratocystiopsis minuta.

Ceratocystiopsis minuta (Siemaszko) H.P. Upadhyay & W.B. Kendr., originally isolated in Poland, is the type species of genus Ceratocystiopsis H.P. Upadhyay & W.B. Kendr. Species in this genus are characterized by dark perithecia with short conical beaks, usually with convergent ostiolar hyphae and dark ascocarps, and by falcate or lunate ascospores. Work within the genus is complicated by historical inconsistencies, errors in strain identification and the absence of a holotype specimen. We used sequence data from the beta-tubulin gene, internal transcribed spacer and large subunit regions of ribosomal DNA to phylogenetically characterize 23 putative strains of Cop. minuta from Europe, Japan and North America, as well as strains from other species in genus Ceratocystiopsis. Our results show that Cop. minuta strains from Europe and Japan are monophyletic, whereas those from North American are polyphyletic and likely misidentified. This suggests that prior research groups have used misidentified strains of Cop. minuta or fungal strains that were only distantly related to the Cop. minuta strain originally described from Poland. Further our multigene phylogenetic analysis also shows that Cop. minuta strains from Europe and Japan can be segregated into three clades. This suggests the presence of several phylogenetic species that are morphologically similar to Cop. minuta, and we anticipate that this species complex will challenge researchers until such relationships are resolved.