The impact of levofloxacin prophylaxis on empiric intravenous antibiotic use in pediatric hematopoietic stem cell transplant recipients.

Levofloxacin prophylaxis during periods of neutropenia in pediatric hematopoietic stem cell transplant (HSCT) may reduce the number of febrile episodes and use of empiric intravenous antibiotics (EIA); however, the literature is conflicting. This retrospective review compared EIA use before and after implementation of levofloxacin prophylaxis at a children's hospital. Levofloxacin prophylaxis was associated with reduced use of certain EIA; however, did not reduce the number of positive blood cultures or clinical deteriorations. Therefore, levofloxacin prophylaxis may have implications for the stewardship of broad-spectrum intravenous antibiotics used in pediatric HSCT.

Decreasing Misdiagnoses of Urinary Tract Infections in a Pediatric Emergency Department.

BACKGROUND AND OBJECTIVES: Urinary tract infection (UTI) is a common diagnosis in the emergency department (ED), often resulting in empirical antibiotic treatment before culture results. Diagnosis of a UTI, particularly in children, can be challenging and misdiagnosis is common. The aim of this initiative was to decrease the misdiagnosis of uncomplicated pediatric UTIs by 50% while improving antimicrobial stewardship in the ED over 4 years. METHODS: By using the Model for Improvement, 3 interventions were developed: (1) an electronic UTI diagnostic algorithm, (2) a callback system, and (3) a standardized discharge antibiotic prescription. Outcome measures included the percentage of patients with UTI misdiagnosis (prescribed antibiotics, but urine culture results negative) and antibiotic days saved. As a balancing measure, positive urine culture results without a UTI diagnosis were reviewed for ED return visits or hospitalization. Statistical process control and run charts were used for analysis. RESULTS: From 2017 to 2021, the mean UTI misdiagnosis decreased from 54.6% to 26.4%. The adherence to the standardized antibiotic duration improved from 45.1% to 84.6%. With the callback system, 2128 antibiotic days were saved with a median of 89% of patients with negative culture results contacted to discontinue antibiotics. Of 186 patients with positive urine culture results with an unremarkable urinalysis, 14 returned to the ED, and 2 were hospitalized for multiresistant organism UTI treatment. CONCLUSIONS: A UTI diagnostic algorithm coupled with a callback system safely reduced UTI misdiagnoses and antibiotic usage. Embedding these interventions electronically as a decision support tool, targeted audit and feedback, reminders, and education all supported long-term sustainability.

Social vulnerability and COVID-19: A call to action for paediatric clinicians.

The COVID-19 pandemic has had dramatic effects on the lives of children globally. However, socially vulnerable children have been particularly impacted. Certain populations have increased vulnerabilities, including children and youth experiencing homelessness. Increased infection risk due to congregant living and challenges with physical distancing are contributing factors. An urgent need exists for a wholistic approach to care with unique cross-sectoral partnerships across disciplines. A recognition of the unintended consequence of the COVID-19 pandemic on this population is urgently required by all those supporting children. Families should receive direct support in clinical settings to identify their social needs. Partnership with community agencies and advocacy for appropriate isolation facilities for patients experiencing homelessness are critical.

Utilizing Pediatric Scoring Systems to Predict Disposition During Interfacility Transport.

OBJECTIVE: Determining care disposition for pediatric patients during interfacility transport is often challenging. Severity of illness scoring can assist with this process. The purpose of this retrospective study was to compare currently utilized scoring systems and their ability to reliably match pediatric transport patients' severity of illness with the level of care necessary. METHODS: The retrospective transport registry review for our region included 209 patients <18 years, transported between 2015 and 2016 and admitted to tertiary care. The Pediatric RISk of Mortality III (PRISM III); Canadian Pediatric Triage and Acuity Scale (PedCTAS); Transport Pediatric Early Warning Scores (TPEWS); and Transport Risk Assessment in Pediatrics (TRAP) scores were calculated. Descriptive statistics and binomial logistic regression were utilized to compare the scoring tools. Interrater reliability was calculated using kappa statistics. All analyses were computed using IBM SPSS Statistics for Windows, version 24. RESULTS: Patients were more likely to be admitted to pediatric intensive care unit (PICU) with PedCTAS = 1 (odds ratio [OR] = 37.2; 95% confidence interval [CI], 12.4, 111.4; p < 0.0001), TPEWS = 3 in one category or total score ≥6 (OR = 42.2; 95% CI, 17.0, 104.9; p < 0.0001), and TRAP ≥4 (OR = 7.2; 95% CI, 3.8, 13.5; p < 0.0001). PRISM scores were not predictive for PICU admissions. CONCLUSION: Elevated PedCTAS, TPEWS, and TRAP scores are strongly associated with PICU admission within the interfacility transport setting.

The Canadian Paediatric Triage and Acuity Scale algorithm for interfacility transport.

OBJECTIVE: Determining pediatric severity of illness in referring centers may be useful for establishing appropriate patient disposition and interfacility transport. For this retrospective review, the authors evaluated the Canadian Paediatric Triage and Acuity Scale (PaedCTAS) tool in regards to individual patient disposition and outcomes. METHODS: A disposition score using the PaedCTAS algorithm was retrospectively calculated from referring center data at the time our transport team was consulted. Data included children < 17 years transported to our tertiary pediatric center between April 2013 and March 2014. Patients were excluded if transported because of elective or planned interventions, investigations, and/or treatment. RESULTS: A total of 194 pediatric patients were identified, with 49 requiring a pediatric intensive care unit (PICU) admission. A PaedCTAS assessment of 1 was the only transport characteristic evaluated that was significantly associated (odds ratio [OR] 6.15; p < 0.0001) with PICU admissions, with an area under the receiver-operating characteristic curve of 0.72 (95% CI 0.64, 0.77). On multivariate analysis, a PaedCTAS assessment of 1 was also associated with a length of hospital stay greater than 3 days (OR 1.81; 95% CI 0.99, 3.31; p = 0.05). CONCLUSIONS: A PaedCTAS assessment of 1 may be a reasonable predictor for PICU admissions and longer hospitalizations when calculated in referral centers at time of pediatric transport consultation. PaedCTAS assessments may provide useful adjuvant information for specialized pediatric transport programs.

Remote Presence Robotic Technology Reduces Need for Pediatric Interfacility Transportation from an Isolated Northern Community.

BACKGROUND: Providing acutely ill children in isolated communities access to specialized care is challenging. This study aimed to evaluate remote presence robotic technology (RPRT) for enhancing pediatric remote assessments, expediting initiation of treatment, refining triaging, and reducing the need for transport. METHODS: We conducted a pilot prospective observational study at a primary/urgent care clinic in an isolated northern community. Participants (n = 38) were acutely ill children <17 years presenting to the clinic, whom local healthcare professionals had considered for interfacility transportation (IFT). Participants were assessed and managed by a tertiary center pediatric intensivist through a remote presence robot. The intensivist triaged participants to either remain at the clinic or be transported to regional/tertiary care. Controls from a pre-existing local transport database were matched using propensity scoring. The primary outcome was the number of IFTs among participants versus controls. RESULTS: Fourteen of 38 (37%) participants required transport, whereas all controls were transported (p < 0.0001). Six of 14 (43%) transported participants were triaged to a nearby regional hospital, while no controls were regionalized (p = 0.0001). All participants who remained at the clinic stayed <24 h, and were matched to controls who stayed 4.9 days in tertiary care (p < 0.001). There was no statistically significant difference in hospital length of stay between transported participants and controls (6.0 vs. 5.7 days). CONCLUSIONS: RPRT reduced the need for specialized pediatric IFT, while enabling regionalization when appropriate. This study may have implications for the broader implementation of RPRT, while reducing costs to the healthcare system.